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Medical lessons learnt from the US and Canadian experience of treating combat casualties from Afghanistan and Iraq
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DoD LSA (Limb Salvage vs Amputation)
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The Winston Churchill Memorial Trust, established in 1965, funds Travelling Fellowships and both authors visited hospitals in Germany, Canada and the USA regarded as centres of excellence with expertise in the early care, reconstruction and rehabilitation of the combat casualties of our NATO Allies, as recipients of these Fellowships. This article presents some of the lessons learnt in the field of musculoskeletal trauma and rehabilitation from the Canadian and US military medical systems. In trauma, there were significant differences in wound debridement policy, use of external fixators for fractures, primary use of circular frames for open tibial fractures and a far more liberal use of bone morphogenetic protein in fracture treatment. Differences in soft tissue reconstruction policy regarding flaps for soft tissue cover over exposed bone, near-universal usage of topical negative pressure dressings and use of Allgower-Donati suture pattern to close all wounds were noted. Ertl amputation osteoplasty, a modified form of transtibial amputation, had also been reintroduced. In rehabilitation, the management of heterotopic ossification, in particular with imaging techniques and excision surgery, was identified. For the upper limb, we observed the patient training required to use a myoelectric hand and the future possibility of targeted muscle re-innervation to make controlling these myoelectric prostheses more natural using innate motor patterns. For the lower limb, we found we used identical above knee prostheses. For patients who have had limb reconstruction and have poor function, an energy-storing orthosis was demonstrated to compensate for the loss of range of motion and muscle power.
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Correction of Tibial Valgus Deformity
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AMP (Acute Meniscal Pathology)
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Valgus tibial malalignment may be the result of bony deformity, previous lateral meniscectomy, or lateral plateau fractures. The correction of such a problem is usually addressed through a tibial osteotomy, which affects the alignment both in flexion and extension. Two surgical options are available: medial closing wedge and lateral opening wedge. When planning a varisation osteotomy, it should be considered that the normal joint line is in 3 degrees of varus. Increasing this obliquity beyond 10 to 15 degrees ends up with increased loads on the patellofemoral joint and medial subluxation of the femur on the tibia. The aim of the present study was to discuss actual indications and contraindications for a varus-producing high tibial osteotomy and describe surgical steps of both medial closing wedge and lateral opening wedge techniques. In addition, the available literature has been searched to report functional outcomes and complications.
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1 |
Why paediatric knee surgery is not just knee surgery on small knees
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AMP (Acute Meniscal Pathology)
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Paediatric knee surgery is a developing subspecialty in the UK. The rise in early participation of children in organized competitive sports has led to an increase in knee injury presentations, and brings unique challenges. Children's knee surgery encompasses varied and complex pathologies, and combines expertise in soft tissue and arthroscopic techniques with an understanding of the unique characteristics of children, their skeleton and growth potential. Children are inherently high-risk surgical candidates due to ligamentous laxity, growth potential, difficulties in rehabilitating post-surgery and risks of re-injury. Goals of treatment include management of instability and pain, restoration of function and rehabilitation, in order to preserve the knee for the child's future. This review will focus on the commonly presenting problems of cruciate, meniscal and patellofemoral pathology.
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Treatment of non-union of the humerus using the Orthofix external fixator
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Glenohumeral Joint OA
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An Orthofix monolateral axial external fixator was used to treat 31 patients with non-union of the humeral shaft, 30 of whom had been previously treated surgically. In seven cases the non-union was hypertrophic and one of these cases had been treated by simple fixation anol compression, the others by fixation, bone grafting and decortication; in 20 cases the non-union was hypotrophic and had been treated by fixation and decortication with bone grafting. The remaining four cases had septic non-union, treated by debridement of the focus of infection and fixation, followed in three cases by a bone graft and osteomuscular decortication once the infection had been eradicated. The fracture site consolidated in all patients in a mean time of 4.9 months. Five patients required further surgery: three in the group with infected non-union and two who had had a new bone graft and application of the external fixator, one because of a refracture (the patient was receiving chronic treatment with antimitotic agents) and one because of persistent non-union. There were no major complications (e.g. radial nerve palsy, joint stiffness, deep infection), and only six cases of pin track infection (5% of the screws implanted). The authors believe that this method is reliable, effective and low risk provided that the patient is cooperative; furthermore, the monolateral axial external fixator is tolerated well and allows movement of the shoulder and elbow throughout the period of treatment.
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Accident or osteoporosis? Survey of community follow-up after low-trauma fracture
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Pediatric Supracondylar Humerus Fracture 2020 Review
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Objective: To describe the postfracture osteoporosis management of at-risk patients presenting with low-trauma fracture in a suburban community hospital setting. Design: Telephone survey. Setting: Hospital emergency department serving a retirement community in White Rock and South Surrey, BC. Participants Men and women older than 40 years of age who presented with low-trauma fracture between October 1, 2004, and April 30, 2005. Main outcome measures: The prevalence of bone mineral density testing, osteoporosis medication prescriptions, referrals to fall prevention programs, and calcium and vitamin D supplementation within 6 months of the index fracture, as well as patient perceptions of future risk of fracture and sources of osteoporosis information. Results: A total of 181 people met the eligibility criteria and 161 were contacted; 84 (52%) people responded, of whom 53 were interviewed. At the time of their index fractures, 79% (42 of 53) of patients surveyed were not taking osteoporosis medication. After the index fracture, 30% (16 of 53) received new bone mineral density testing, and 8% (4 of 53) were starting courses of new osteoporosis medication. Sixty-eight percent (36 of 53) of all patients were taking calcium supplements and 50% (26 of 53) were taking vitamin D supplements. Eight percent (4 of 53) of patients were referred to a fall prevention program and 9% (5 of 53) were prescribed hip protectors; 19% (10 of 53) of patients thought they were at risk of having another fracture. Conclusion: Osteoporosis management of patients after low-trauma fracture in this community was suboptimal; the role of the media, family and friends, and allied health professionals to prevent fractures in at-risk individuals needs to be further explored.
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The effect of electromagnetic navigation in total knee arthroplasty on knee kinematics during functional activities using flexible electrogoniometry
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Surgical Management of Osteoarthritis of the Knee CPG
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BACKGROUND: Navigated total knee arthroplasty has been shown to increase accuracy in post operative implant alignment. By contrast navigated total knee arthroplasty has not shown significant functional improvements to date, when compared with conventional surgery using subjective clinical questionnaire scores. The aim of this study was to compare the knee joint kinematics measured during functional activities using electrogoniometry 12 months after total knee arthroplasty in randomised navigated and conventional total knee arthroplasty groups. METHODS: The study design was a double blinded, randomised, prospective, controlled trial. The patients were randomised into 2 surgical groups (n=102 navigated group, n=98 conventional group; mean age navigated=67, conventional=67). Flexible electrogoniometry was used to measure patient's knee kinematics with respect to time during 12 functional activities. FINDINGS: No significant difference was found in terms of the maximum, minimum and excursion knee joint angle during any of the functional activities. However there was a statistically significant improvement in the level and slope gait cycle at the pre swing phase in the navigated group. INTERPRETATION: There were minimal functional improvements in the navigated total knee arthroplasty group 12 months after surgery. However, these are unlikely to have a significant effect on daily activity for the navigated group
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Interventions for treating bisphosphonate-related osteonecrosis of the jaw (BRONJ)
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MSTS 2018 - Femur Mets and MM
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Background: Bisphosphonate drugs can be used to prevent and treat osteoporosis and to reduce symptoms and complications of metastatic bone disease; however, they are associated with a rare but serious adverse event: osteonecrosis of the maxillary and mandibular bones. This condition is called bisphosphonate-related osteonecrosis of the jaw or BRONJ. BRONJ is diagnosed when people who are taking, or have previously taken, bisphosphonates have exposed bone in the jaw area for more than eight weeks in the absence of radiation treatment. There is currently no "gold standard" of treatment for BRONJ. The three broad categories of intervention are conservative approaches (e.g. mouth rinse, antibiotics), surgical interventions and adjuvant non-surgical strategies (e.g. hyperbaric oxygen therapy, platelet-rich plasma), which can be used in combination. Objectives: To determine the efficacy and safety of any intervention aimed at treating BRONJ. Search methods: We searched the following databases to 15 December 2015: the Cochrane Oral Health Group Trials Register, the Cochrane Breast Cancer Group Trials Register (20 September 2011), the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE via Ovid, EMBASE via Ovid, CancerLit via PubMed, CINAHL via EBSCO and AMED via Ovid. We scanned the references cited in retrieved articles and contacted experts in the field, the first authors of included papers, study sponsors, other bisphosphonates investigators and pharmaceutical companies. We searched for ongoing trials through contact with trialists and by searching the US National Institutes of Health Trials Register (clinicaltrials.gov) and the World Health Organization Clinical Trials Registry Platform. We also conducted a grey literature search to September 2015. Selection criteria: Randomised controlled trials (RCTs) comparing the effects of any treatment for BRONJ with another treatment or placebo. Data collection and analysis: Two review authors independently screened the search results, assessed the risk of bias in the included trials and extracted data. When in dispute, we consulted a third review author. Main results: One small trial at high risk of bias met the inclusion criteria. The trial randomised 49 participants, most of whom had cancer. It compared standard care (defined as surgery, antibiotics and oral rinses at the discretion of the oral-maxillofacial surgeon) to standard care plus hyperbaric oxygen therapy (2 atmospheres twice a day for 40 treatments). The trial measured the percentage of participants who improved or healed at three, six, 12 and 18 months and last contact. It also measured mean weekly pain scores. At three months, the study found that the participants in intervention group were more likely to have an improvement in their osteonecrosis than the standard care group participants (risk ratio (RR) 1.94, 95% confidence interval (CI) 1.01 to 3.74). There was no clear difference between the groups for the outcome 'healed' at three months (RR 3.60, 95% CI 0.87 to 14.82). There was no clear difference between the groups for improvement or healing when they were evaluated at six, 12 and 18 months and last contact. The study did not give any information on adverse events. Although the findings suggest adjunctive hyperbaric oxygen improved BRONJ, the quality of the evidence is very low since the only study was underpowered and was at high risk of bias due to lack of blinding, cross-over of participants between groups and very high attrition (50% at 12 months and 80% at 18 months in this study, which was designed for an intended follow-up of 24 months). Authors' conclusions: There is a lack of evidence from randomised controlled trials to guide treatment of bisphosphonate-related osteonecrosis of the jaw (BRONJ). One small trial at high risk of bias evaluated hyperbaric oxygen therapy (HBO) as an adjunct to "standard" care and could not confirm or refute the effectiveness of HBO. There are two ongoing trials of teriparatide treatment for BRONJ. We found no randomised controlled trials of any other BR
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Micrornas are related to progression of osteoarthritis (OA) in the DMM ( destablization of medial meniscus) mouse model
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Surgical Management of Osteoarthritis of the Knee CPG
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MicroRNAs (miRNAs)have emerged as key regulators of normal cellular processes and metabolic pathways in the skeleton and are associated with disease. Studies of OA tissue have identified gain and loss of miRNAs that reflect loss of the articular surface, tissue degradation, pain and inflammation. Here we addressed the temporal and spatial changes in miRNA expression from the onset and during progression to late stage of degeneration of the joint surface, not represented in samples from the terminal stage of total joint replacement. The DMM model mimics the events that occur in human disease including initial fibrillation of articular cartilage (day 10 after surgery), erosion of the cartilage matrix, active chondrocytes at the margins of degenerated tissue (days 12 - 21) and finally the beginning of sclerotic bone lesions by day 10 increasing through day 28. In n=5 mice per group (5 time points and controls), we compared expression of miRNAs using a Q-PCR array of 678 miRNAs (Fluidigm,
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Amelioration of osteoporosis and hypovitaminosis D by sunlight exposure in stroke patients
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Management of Hip Fractures in the Elderly
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BACKGROUND: The authors' previous investigations have disclosed low serum 25-hydroxyvitamin D (25-OHD) concentrations in 45 patients during long-term hospitalization following stroke (mean 5.9 ng/mL). This 25-OHD deficiency resulted from sunlight deprivation. OBJECTIVE: To evaluate the efficacy of sunlight exposure in increasing serum 25-OHD, in reducing the severity of osteoporosis in bone mineral density (BMD), and in decreasing the risk of hip fractures in chronically hospitalized, disabled stroke patients. METHODS: In a 12-month randomized and prospective study of stroke patients, 129 received regular sunlight exposure for 12 months, and the remaining 129 (sunlight-deprived) did not. RESULTS: At baseline, patients of both groups showed vitamin D deficiency. BMD increased by 3.1% in the sunlight-exposed group and decreased by 3.3% in the sunlight-deprived group (p = 0.0001). 25-OHD level increased by fourfold in the sunlight-exposed group. Six patients sustained hip fractures on the hemiplegic side in the sunlight-deprived group, and one hip fracture occurred among the sunlight-exposed group (p = 0421; odds ratio = 6.1). CONCLUSION: Sunlight exposure can increase the BMD of vitamin D-deficient bone by increasing 25-OHD concentration
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1 |
A comparative study of the therapeutic effect between long and short intramedullary nails in the treatment of intertrochanteric femur fractures in the elderly
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Hip Fx in the Elderly 2019
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PURPOSE: To compare the clinical effects of long vs. short intramedullary nails in the treatment of intertrochanteric fractures in old patients more than 65 years old.
METHODS: A retrospective analysis of 178 cases of intertrochanteric fractures of the femur (AO type A1 and A2) in the elderly was conducted from January 2008 to December 2013. There were 85 males (47.8%) and 93 females (52.2%) with the age of 65e89 (70.2+/-10.8) years. The patients were treated by closed reduction and long or short intramedullary nail (Gamma 3) fixation. The length of short nail was 180 mm and that for long nail was 320e360 mm. The general data of patients, operation time, intraoperative blood loss, length of hospital stay, preoperative hemoglobin level, blood transfusion rate, postoperative periprosthetic fractures, infections, complications, etc were carefully recorded.
RESULTS: There were 76 cases (42.7%) in the long intramedullary nail group and 102 cases (57.3%) in the short nail group. All the cases were followed up for 12e48 (21.3+/-6.8) months, during which there were 21 deaths (11.8%), mean (13.8+/-6.9) months after operation. The intraoperative blood loss was (90.7+/-50.6) ml in short nail group, greatly less than that in long nail group (127.8+/-85.9) ml (p=0.004). The short nail group also had a significantly shorter operation time (43.5 min+/-12.3 min vs. 58.5 min+/-20.3 min, p=0.002) and lower rate of postoperative transfusion (42.3% vs. 56.7%, p=0.041). But the length of hospital stay showed no big differences. After operation, in each group there was 1 case of periprosthetic fracture with a total incidence of 1.1%, 1.3% in long nail group and 0.9% in short nail group. At the end of the follow-up, all patients achieved bony union. The average healing time of the long nail group was (6.5+/-3.1) months, and the short nail group was (6.8+/-3.7) months, revealing no significant differences (p=0.09). Postoperative complications showed no great differences either.
CONCLUSION: Both the intramedullary long and short nail fixation has a good clinical effect in treating intertrochanteric femur fractures in the elderly. They showed no significant difference in terms of therapeutic effect, hospital stay and postoperative complications. The incidence of periprosthetic fractures treated by either length of nails was low. But short intramedullary nailing can obviously decrease the intraoperative blood loss, operation time and postoperative blood transfusion.
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Metalloproteinases, tissue inhibitor, and proteoglycan fragments in knee synovial fluid in human osteoarthritis
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AMP (Acute Meniscal Pathology)
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OBJECTIVE: To determine the concentrations of human stromelysin-1, collagenase, tissue inhibitor of metalloproteinases (TIMP), and proteoglycan fragments in knee synovial fluid in patients with injury to the meniscus or anterior cruciate ligament, posttraumatic osteoarthritis, primary osteoarthritis, or pyrophosphate arthritis.
METHODS: Synovial fluid samples were collected from patients with knee disease diagnosed arthroscopically and radiologically. Concentrations of stromelysin-1, collagenase, and TIMP-1 were determined by sandwich immunoassay, using monoclonal and polyclonal antibodies. Fragments of cartilage proteoglycan containing the chondroitin sulfate-binding region were determined by immunoassay with a polyclonal antibody.
RESULTS: Average concentrations of metalloproteinases, TIMP, and proteoglycan fragments in joint fluid were significantly elevated in patients from all disease groups as compared with volunteers with healthy knees (reference group). Stromelysin concentrations in disease groups averaged 15-45 times that of the reference group. The molar ratios between stromelysin and collagenase varied between 10 and 150. The molar ratio between total stromelysin and free TIMP was 0.5 in the reference group and between 1.6 and 5.3 in the disease groups.
CONCLUSION: Stromelysin concentration in joint fluid is a parameter that distinguishes diseased joints from healthy joints, with a sensitivity of 84% and a specificity of 90%. The high concentrations of metalloproteinase relative to TIMP in joint fluid from patients with the conditions studied may be associated with cartilage matrix degradation in these arthritides.
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Laparoscopic versus open pyeloplasty for ureteropelvic junction obstruction in children: A systematic review and meta-analysis
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Panniculectomy & Abdominoplasty CPG
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Purpose: To comprehensively review the available evidences in the literature on the use of laparoscopic pyeloplasty (LP) vs open pyeloplasty (OP) for the repair of ureteropelvic junction (UPJ) obstruction in children. Materials and Methods: Published studies until the end of October 2010 were searched from Medline, Embase, Web of Science, Ovid, and Cochrane databases. The literature search, quality assessment, and data extraction were independently performed by two reviewers. A systematic review and meta-analysis were performed by using Review Manager 4.2.8 software. Results: Of 1403 studies, one randomized controlled trial (RCT), two prospective comparative studies, and six retrospective observational studies were eligible for inclusion criteria, comprising 694 cases of LP and 7334 cases of OP. The OP has significantly reduced operative time (weighted mean difference [WMD]=59.00; 95% confidence interval [CI]=41.15 to 76.85; P<0.00001) and higher stent placement rate (odds ratio [OR]=5.97; 95% CI=3.17 to 11.26; P<0.00001) compared with LP, whereas the duration of hospital stay was shorter in the LP group (WMD=-0.40; 95% CI=-0.77 to -0.03; P=0.03). No difference was observed between LP and OP regarding complications (OR=0.78; 95% CI=0.46 to 1.34; P=0.37) or success rate (OR=1.76; 95% CI=0.71 to 4.36; P=0.22). Conclusions: LP is a minimally invasive, safe, and effective therapy method for UPJ obstruction in children, with shorter hospital stay and excellent outcomes, and without additional risk of postoperative complications. Because of the publishing bias, a series of RCTs are necessary to explore the efficiencies of LP in the management of UPJ obstruction in children. © 2011, Mary Ann Liebert, Inc. 2011.
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Predicting Pathologic Bone Lesions Using Scout Computed Tomography (CT) Imaging
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MSTS 2022 - Metastatic Disease of the Humerus
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The purpose of this study is to evaluate the benefit of reviewing scout CT images, obtained for routine oncologic surveillance, for the early identification of pathologic bony lesions. A retrospective review was conducted on patients who previously underwent surgical treatment by two orthopedic oncology surgeons at a tertiary care institution from 2009-2019 for pathologic lesions or fractures of the humerus or femur. Radiographic records were reviewed to identify patients in this cohort who had available scout views from CT imaging prior to official diagnosis of the bony lesion or fracture. CT scout images were assessed by two independent reviewers to identify any pathologic lesions, and radiographic reports were reviewed to identify if the lesions were noted by radiology at the time of the initial scan interpretation. One hundred and forty-four patients were identified, and thirty-nine had an available scout CT image prior to official diagnosis of the lesion. Twenty-five patients (64.1%) had lesions identified by authors on scout CT versus only 9 (23.1%) who had lesions that were documented in the initial CT radiologic report. There was a total of 29 lesions identified by the study authors on scout CT, and 19 (65.5%) were not reported in the initial radiographic interpretation with an average interval between observation by authors and official diagnosis of 202 days. Of the impending fractures, three patients (16.7%) went on to complete fracture prior to referral to orthopedics with an average interval between these missed lesions on scout CT and their presentation with fracture of 68 days. This study advocates for the careful review of all scout CT imaging as an essential part of the work up for metastatic disease and encourages all practitioners to utilize this screening tool for the identification of pathologic bony lesions which may help expedite early treatment to reduce patient morbidity.
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Long-term efficacy and safety of zoledronic acid in the treatment of skeletal metastases in patients with nonsmall cell lung carcinoma and other solid tumors: a randomized, Phase III, double-blind, placebo-controlled trial
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MSTS 2018 - Femur Mets and MM
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BACKGROUND: The authors previously reported the efficacy of a dose of 4 mg of zoledronic acid in reducing skeletal complications in patients with bone metastases secondary to lung carcinoma and other solid tumors (except carcinomas of the breast and prostate). In the current study, they update these results and report the long-term efficacy and safety of 21 months of treatment with zoledronic acid in a randomized, placebo-controlled trial.
METHODS: A total of 773 patients were randomized to receive zoledronic acid (4 mg or 8 mg) or placebo via a 15-minute infusion every 3 weeks for 21 months. The 8-mg dose later was reduced to 4 mg (8/4-mg group). The primary efficacy endpoint was the percentage of patients at 21 months with >/= 1 skeletal-related event (SRE) (pathologic fracture, spinal cord compression, radiation therapy to bone, or surgery to bone). Secondary analyses (time to first SRE, annual incidence of SREs, and multiple-event analysis) included hypercalcemia of malignancy.
RESULTS: Fewer patients treated with zoledronic acid developed at least 1 SRE at 21 months compared with patients treated with placebo (39% of those treated at the 4-mg dose [P =0.127] and 36% of those treated at the 8/4-mg dose [P = 0.023], compared with 46% of those treated with placebo). Furthermore, 4 mg of zoledronic acid significantly delayed the median time to first SRE (236 days with 4 mg vs. 155 days with placebo; P = 0.009) and significantly reduced the annual incidence of SREs (1.74 per year with the 4-mg dose vs. 2.71 per year with placebo; P = 0.012). Moreover, the 4-mg dose of zoledronic acid was found to reduce the risk of developing a skeletal event by 31% (hazard ratio of 0.693; P = 0.003). Zoledronic acid was found to be well tolerated with long-term use; the most commonly reported adverse events in all treatment groups included bone pain and the transient, acute-phase reactions of nausea, anemia, and emesis.
CONCLUSIONS: To the authors' knowledge, zoledronic acid is the first bisphosphonate to demonstrate long-term safety and efficacy in this patient population.
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0 |
History and evolution of the Sauvé-Kapandji procedure
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Distal Radius Fractures
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Arthrodesis of the distal radioulnar joint combined with the creation of a pseudarthrosis of the distal ulna is frequently referred to as the sauvé-kapandji procedure. This eponym is based on the 1936 report by Sauv and Kapandji, which is believed to be the first report of this innovative technique. There has been some controversy regarding the origin of this procedure, with similar techniques described by Berry in 1930 and Steindler in 1932. This article examines the evolution of the sauvé-kapandji procedure and sheds light on the lives of James Allan Berry, Arthur Steindler, Louis de Gonzague Sauv, and Mehmed Kapandji. © 2012 American Society for Surgery of the Hand. All rights reserved.
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Patient Satisfaction and Nipple-Areola Sensitivity After Bilateral Prophylactic Mastectomy and Immediate Implant Breast Reconstruction in a High Breast Cancer Risk Population: Nipple-Sparing Mastectomy Versus Skin-Sparing Mastectomy
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Reduction Mammoplasty for Female Breast Hypertrophy
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BACKGROUND: Prophylactic skin-sparing mastectomy (SSM) and nipple-sparing mastectomy (NSM) both are associated with major risk reduction in women with high breast cancer risk. Skin-sparing mastectomy followed by nipple-areola complex (NAC) reconstruction is standard of care, but NSM is increasingly being performed. Preservation of the NAC in NSM may increase patient satisfaction. Therefore, we measured NAC sensitivity after NSM and compared patient satisfaction as well as body image after SSM with NSM. METHODS: Women who underwent prophylactic bilateral SSM or NSM and immediate implant breast reconstruction between 2002 and 2012 were eligible. Patient satisfaction was assessed using the Breast-Q reconstruction questionnaire, body image using Hopwood's body image scale (BIS), and satisfaction with the (reconstructed) NAC using a study-specific questionnaire. In the NSM group, NAC sensitivity was assessed using Semmes Weinstein monofilaments with a 5-point scale and compared with NAC sensitivity in a nonoperated control group. RESULTS: The SSM group comprised 25 women (50 SSMs) and the NSM group 20 women (39 NSMs). Median follow-up was 65 months in the SSM group compared with 27 months in the NSM group (P < 0.01). In univariable analyses, Breast-Q scores were favorable in the SSM group compared with the NSM group with trends for higher "satisfaction with breasts" (66.2 vs 56.6; P = 0.06) and "satisfaction with outcome" (76.1 vs 61.5; P = 0.09). Mean BIS score of 7.1/30 in the SSM group and 9.3/30 in the NSM group (P = 0.35). Adjusted for follow-up, there were no significant differences in Breast-Q scores, nor in BIS scores. Interestingly, satisfaction with the (reconstructed) NAC was similar after SSM and NSM. Nipple-areola complex sensitivity was lower in the NSM group (mean score, 1.9; 95% confidence interval, 1.5-2.3) compared with the control group (mean score, 4.7; 95% confidence interval, 4.6-4.9; P < 0.01). CONCLUSIONS: Breast-Q scores regarding satisfaction with breasts and overall outcome were in favor of the SSM group. Residual NAC sensitivity after NSM was low. This suggests that SSM followed by NAC reconstruction is a balanced alternative to NSM. We observed no significant differences in body image and NAC-specific satisfaction between the NSM and SSM groups.
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Significance of C-reactive protein in osteoarthritis and total knee arthroplasty outcomes
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Surgical Management of Osteoarthritis of the Knee CPG
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BACKGROUND: The relationship between systemic inflammatory processes to total knee arthroplasty (TKA) outcomes remains unclear. This study investigates the relationship between serum high-sensitivity C-reactive protein (hs-CRP) and functional outcomes post-TKA. METHODS: A total of 31 patients with osteoarthritis (OA) who underwent TKA were enrolled in the study; 15 with hs-CRP </=1.0 mg/l (low hs-CRP group) and 16 subjects with hs-CRP >/=4.0 mg/l (high hs-CRP group). During surgery, synovium and bone sections were sequestered, formalin-fixed, and paraffin embedded for slide preparation. Tissue sections were stained with hematoxylin and eosin and analyzed using a light microscope. A total of 12 cytokines were measured in synovial fluid samples from the knee joint at time of surgery and analyzed using the Luminex Multi-Analyte Profiling System. Relationships between cytokines and hs-CRP were assessed using Spearman correlation coefficients. Student's t-tests were used to compare Short Form health outcomes survey (SF-12) health outcomes between high and low hs-CRP, and presurgical and postsurgical visits. RESULTS: Mean +/- standard deviation (SD) baseline and 1-year hs-CRP values for the low hs-CRP group were 0.55 +/- 0.23 mg/l and 1.22 +/- 1.32 mg/l, respectively (n = 15; p = 0.051) and for the high hs-CRP group were 7.86 +/- 5.98 mg/l and 14.11 +/- 38.9 mg/l, respectively (n = 13; p = 0.54). Lymphocytes were present in 10 synovium and one bone sample (all but one from high hs-CRP group). Interleukin (IL)-5 and IL-10 were significantly correlated with hs-CRP (p = 0.0137 and p = 0.0029, respectively). The low hs-CRP group exhibited significant improvement in the physical component of SF-12 at 6 and 12 months compared with baseline, whereas the high hs-CRP group exhibited significant improvement only at 6 months. Body mass index (BMI) had a significant positive correlation with presurgical hs-CRP. CONCLUSIONS: The results of this study provide support for inflammatory mechanisms contributing to the OA progression, with hs-CRP being a possible predictive variable, combined with BMI and other comorbidities, of post-TKA function
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The use of the cemented Exeter Universal femoral stem in a District General Hospital: a minimum ten-year follow-up
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Dental Implant Infection
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We describe the survivorship of the Exeter femoral component in a District General Hospital. Between 1994 and 1996, 230 Exeter Universal cemented femoral components were implanted in 215 patients who were reviewed at a mean of 11.2 years (10 to 13). We used one acetabular implant, the Elite Ogee component, in 218 of the 230 hips. During the period of this study 76 patients (79 hips) died. Of the remaining 139 patients (151 hips), 121 were able to attend for radiological analysis at a minimum of ten years. One patient was lost to follow-up. No femoral component was revised for aseptic loosening. Three hips were revised for deep infection and six acetabular components required revision, four for loosening and two for recurrent dislocation. Taking the 'worst-case scenario' including the one patient lost to follow-up, the overall survival rate was 94.4% at 13 years. Our results confirm excellent medium-term results for the Exeter Universal femoral component, implanted in a general setting. The excellent survival of this femoral component, when used in combination with the Ogee acetabular component, suggests that this is a successful pairing.
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Interrater and Intrarater Reliability of Musculoskeletal Ultrasonographic Findings for the Common Extensor Tendon of the Elbow
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PRPs for Lateral Epicondylitis/Elbow Tendinopathies
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Objectives: This retrospective case study evaluated the interrater and intrarater reliability of seven common extensor tendon pathologic features on musculoskeletal ultrasonography (MSK-US). Materials and Methods: A cohort of 50 patients were imaged due to presenting with atraumatic nonradicular lateral elbow pain. Three experienced and two novice readers rated the images on two separate occasions, and AC1 and kappa coefficients were calculated for each feature. Results: The interrater reliability was fair with respect to fascial thickening/scarring (AC1 = 0.26), tearing (AC1 = 0.35), tendon thickening (AC1 = 0.38), and intratendinous calcification (AC1 = 0.33); substantial for enthesophytes (AC1 = 0.80); and near complete for hyperemia (AC1 = 0.83) and hypoechogenicity (AC1 = 0.92). Intrarater reliability was moderate for fascial thickening/scarring (? = 0.48), tearing (? = 0.41), tendon thickening (0.47), intratendinous calcification (? = 0.56), and hypoechogenicity (? = 0.47); substantial for hyperemia (? = 0.71); and almost perfect for enthesophytes (? = 0.86). Conclusion: MSK-US may be a reliable tool to determine soft tissue changes in common extensor tendon pathology.
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1 |
Is the umbilicus truly midline? Clinical and medicolegal implications
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Panniculectomy & Abdominoplasty CPG
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A common misconception is that the umbilicus is a midline structure. To date, an anatomical survey examining whether the umbilicus is located at the midline has not been reported. This study measured the position of the umbilicus among 136 subjects, in two separate experiments. The results demonstrated that the umbilicus was not at the midline for nearly 100 percent of subjects and was more than 2 percent from the midline for more than 50 percent of subjects. This finding is of great importance for patient counseling in preoperative and postoperative settings. Because the discerning eye has repeatedly been demonstrated to be able to detect smaller asymmetries, these findings are significant and should be discussed with patients undergoing cosmetic abdominoplasty or reconstructive procedures, for preoperative informed consent. Education and preoperative demonstration can help prevent medicolegal ramifications. The umbilicus is rarely midline and, when critically analyzed, is located lateral to the midline axis more often than not.
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Pharmaceutical approval update
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OAK Recommendation 9 Articles
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Droxidopa (Northera) for neurogenic orthostatic hypotension, elosulfase alfa (Vimizim) for Morquio A syndrome, and sodium hyaluronate in phosphate-buffered saline (Monovisc) to address knee osteoarthritis
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Reverse shoulder arthroplasty for proximal humerus fracture: a more complex episode of care than for cuff tear arthropathy
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DoD SSI (Surgical Site Infections)
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Background: The purpose of this investigation is to identify the in-hospital and 30-day postoperative complications for reverse total shoulder arthroplasty (RTSA) performed because of proximal humerus fracture (PHFx) vs. cuff tear arthropathy (CTA), and determine whether acute fracture is associated with differences in complications after RTSA. Methods: The National Surgical Quality Improvement Program database was queried for RTSA performed for PHFx and CTA. This database contains surgical outcomes within 30 days after the index procedure. Patients underwent a 1:1 propensity matched based on preoperative demographics and comorbidities. Outcomes included operative time, length of stay (LOS), complications, transfusion, readmission, and discharge destination. Results: A total of 1006 patients (503 per group) were included. With a PHFx, operative time was longer (129.5 ± 54.2 vs. 96.0 ± 40.0 minutes, P < .001), and the patients were more likely to have an adverse event (19.0% vs. 8.2%, P < .001), require transfusion (15.71% vs. 3.98%, P < .001), have longer LOS (3.8 ± 3.6 vs. 2.2 ± 1.7 days, P < .001), and were more likely to be discharged to an extended care facility (27.2% vs. 10.3%, P < .001). PHFx was an independent risk factor for an adverse event after an RTSA. Conclusions: RTSA to treat PHFx is associated with longer LOS, increased complications, and discharge to an extended care facility compared with RTSA for CTA. Patients with PHFx require more health care resources than patients with CTA. It is imperative for surgeons, patients, families, governments, hospital systems, and insurance payers to recognize the differences in resource utilization for RTSA in treating PHFx compared with CTA.
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A Randomized, Double-Blind, Parallel Group, Vehicle-Controlled Study to Evaluate the Safety and Efficacy of OMS103HP-S Administered in Joint Irrigation Solution to Subjects Undergoing Arthroscopic Meniscectomy
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OAK 3 - Non-arthroplasty tx of OAK
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INTERVENTION: Product Name: OMS103HPâ?S Product Code: OMS103HPâ?S Pharmaceutical Form: Irrigation solution INN or Proposed INN: KETOPROFEN CAS Number: 22071â?15â?4 Concentration unit: mg/ml milligram(s)/millilitre Concentration type: equal Concentration number: 0.687 â? INN or Proposed INN: AMITRIPTYLINE HYDROCHLORIDE CAS Number: 549â?18â?8 Concentration unit: mg/ml milligram(s)/millilitre Concentration type: equal Concentration number: 0.227 â? INN or Proposed INN: OXYMETAZOLINE HYDROCHLORIDE CAS Number: 2315â?02â?8 Concentration unit: mg/ml milligram(s)/millilitre Concentration type: equal Concentration number: 0.215 â? CONDITION: Arthroscopic surgery ; MedDRA version: 13.1 Level: PT Classification code 10058471 Term: Arthroscopic surgery System Organ Class: 10042613 â? Surgical and medical procedures PRIMARY OUTCOME: Main Objective: To evaluate the effect of OMS103HPâ?S compared to vehicle when administered in joint irrigation fluid during arthroscopic meniscectomy on: ; â?¢ Knee symptoms as measured by the Knee Injury and Osteoarthritis Outcome Score (KOOS) Symptoms subscale through Day 30; â?¢ Safety as measured by adverse events; Primary end point(s): Primary Efficacy Measures; The primary efficacy measure is the Knee Injury and Osteoarthritis Outcome Score (KOOS) Symptoms subscale. This will be measured preâ?operatively at baseline and on Days 1, 2, 3, 7, 14, and 30. The KOOS is a validated patient reported outcome with 5 subscales: Symptoms, Pain, Sports and Recreation, Activities of Daily Living, and Quality of Life. The KOOS is a recall instrument that evaluates the prior week. (The Day 1, 2, and 3 KOOS evaluations will be performed with a modified KOOS instrument evaluating the prior day because the surgical procedure is a significant traumatic event during the prior week for those assessment time points.) The Symptoms subscale is the primary efficacy measure of this study because it evaluates symptoms that are common to meniscal injuries. Secondary Objective: To evaluate the effect of OMS103HPâ?S compared to vehicle when administered in joint irrigation fluid during arthroscopic meniscectomy on:; â?¢ Knee function as measured by the KOOS Sports and Recreation subscale through Day 30 in the subset of subjects who participate in sports; â?¢ Knee pain as measured by the KOOS Pain subscale through Day 30; â?¢ Knee quality of life as measured by the KOOS Quality of Life subscale through Day 30; â?¢ Knee function as measured by the KOOS Activities of Daily Living subscale through Day 30; â?¢ Passive flexion on Day 7; â?¢ Postoperative knee pain as measured by the Visual Analog Scale (VAS) during the day of surgery; INCLUSION CRITERIA: 1. Voluntarily provide written informed consent in accordance with governing Institutional Review Board (IRB)/Independent Ethics Committee (IEC) requirements, local regulations, and Health Insurance Portability and Accountability Act (HIPAA) Authorization (or equivalent if locally applicable) 2. In the opinion of the Investigator are able to comply with studyâ?required visits and procedures 3. 18 to 75 years of age, inclusive at the time of screening 4. Have a traumatic or degenerative meniscal cartilage injury (full thickness tear) that occurred at least 14 days prior to the day of arthroscopic surgery that is demonstrated on MRI 5. Planning to undergo unilateral arthroscopic meniscectomy 6. If female and of childbearing potential (i.e., not surgically sterilized or postâ?menopausal for longer than one year), agree to use a medically acceptable method of birth control for the duration of her study involvement 7. At minimal risk from anesthesia a
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Bone mineral density and osteoporosis risk in older patients with schizophrenia
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Management of Hip Fractures in the Elderly
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OBJECTIVE: People with schizophrenia are at a higher risk for osteoporosis. The authors investigated the prevalence of low bone density and its risk factors in older Korean patients with schizophrenia. METHOD: In cross-sectional study, 327 inpatients with schizophrenia were screened. Among them, 229 patients older than 50 years participated in this study. The control group consisted of healthy volunteers who were of similar ages (n = 125). Bone density was measured in the lumbar spine and the neck, trochanter, and ward regions of the right proximal femur by dual-energy x-ray absorptiometry. Clinical variables such as alcohol use, cigarette smoking, and fracture history were obtained. The Student t test, Pearson chi2 test, Wilcoxon rank sum test, and logistic regression analysis were used. RESULTS: The prevalence of osteoporosis was significantly higher in patients with schizophrenia compared with healthy controls (34.9% vs 18.4%, P = 0.0043). Within the schizophrenia group, female subjects had a significantly higher prevalence of osteoporosis than male subjects (48.4% vs 25.7%, P = 0.0014); however, no sex differences were identified in the healthy control group. The actual bone density and t scores in patients with schizophrenia were significantly lower in all sites than in healthy controls. Among patients with schizophrenia, smokers and alcohol abuser showed lower bone density compared with those who did not smoke or drink. The lifetime prevalence of fracture was significantly higher in patients with schizophrenia (24.0%) compared with healthy controls (5.6%; P = 0.001). CONCLUSIONS: Our results emphasize that older patients with schizophrenia are at risk for low bone density. Cigarette smoking and alcohol abuse are associated with low bone density in patients with schizophrenia
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An eclectic history of peripheral nerve surgery
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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It is hard to decide where history stops and contemporary development of peripheral nerve surgery begins. This article provides an eclectic view of the history of peripheral nerve surgery. In trying to keep the story moving, the publications of many authors have been omitted. For this, we are sorry. We have also stopped short of reporting the contemporary history of molecular biology as applied to peripheral nerve regeneration. The future of peripheral nerve repairs lies in our understanding of the molecular cascades that stimulate axon growth and guide the axon to its proper destination. We hope that this review shows the reader that researchers who got us where we are traveled a road filled with erroneous dogma, bad advice, and misleading data. We believe that the lessons learned from those who brought us back to the right path are applicable to many disciplines
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Exacerbation of rheumatoid arthritis after removal of adrenal adenoma in Cushing's syndrome
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Surgical Management of Osteoarthritis of the Knee CPG
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A 46-year-old woman with rheumatoid arthritis had been on non-steroidal antiinflammatory agents for eighteen years until she developed cushingoid features and hypertension resistant to antihypertensive drugs. She had high plasma cortisol and 24 h urinary 17-hydroxycorticosteroids (17HCS) which were not suppressed by 8 mg dexamethasone per day for two days. The circadian rhythm of plasma cortisol was absent and plasma ACTH concentrations were suppressed before and after intravenous administration of CRH. Abdominal computed tomography demonstrated a tumor (3.0 x 3.0 x 2.3 cm) in the right adrenal gland and a 131I-6 beta-19-nor-methylcholesterol scan revealed marked uptake on the same side. The patient underwent a right adrenalectomy and the diagnosis of a cortisol secreting benign adenoma was histologically confirmed. Blood pressure declined and cushingoid features regressed, but three months after the operation and while the patient was on replacement, she complained of pain on motion, marked tenderness and swelling of fingers, wrists, elbows, knees and foot joints, and had very high rheumatoid factors. Treatment with immunosuppressive drugs and oral and intraarticular administration of glucocorticoids were necessary to relieve the clinical symptoms of rheumatoid arthritis. In summary, we report a patient with rheumatoid arthritis and Cushing's syndrome due to an adrenal adenoma, in whom rheumatoid arthritis was exacerbated after curing the Cushing's syndrome. This suggests that it is imperative to follow the development and/or course of autoimmune diseases after the treatment of Cushing's syndrome
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Arthroscopic debridement of the degenerative knee - Is there still a role?
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OAK 3 - Non-arthroplasty tx of OAK
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Objectives: The role of arthroscopic debridement in the painful degenerative knee is controversial. Studies have shown that arthroscopic surgery for knee osteoarthritis provides no additional benefit to optimized physical and medical therapy. There are however, limited studies on the management of the subgroup of significantly symptomatic patients who remain refractory to maximal conservative treatment and are poor candidates for knee replacement surgery.We propose that with careful patient selection, arthroscopic debridement can provide good symptomatic relief with sustained benefits in the degenerative knee.
Methods: We performed a retrospective, single-surgeon study of 180 consecutive knee arthroscopies performed in 169 patients, aged 40 years and above, who had mechanical symptoms affecting their daily lives and underwent arthroscopic debridement after failure of a minimum 2 months of optimized medical and physical therapy. Severity of the knee osteoarthritis on plain radiographs was assessed using the Kellgren-Lawrence classification.Functional and satisfaction scores were assessed using Oxford Knee Score, Koos Knee Survey, Short Form-36, Numeric Pain Rating Scale, and questions adapted from the North American Spine Society Questionnaire.
Results: Excellent functional outcomes and patient satisfaction were reported in the majority of patients over the follow-up timeframe of 2-8 years. The mean pre-operative Kellgren-Lawrence score was 2.02 (SD 0.580). Significant improvements compared to pre-operative scores were seen across all scoring systems tested. 90% of patients reported good to excellent results.
Conclusion: Arthroscopic knee debridement can provide good symptomatic relief and sustained benefits in significantly symptomatic patients with early degenerative knees who have failed conservative management. This is most useful in patients with mechanical symptoms secondary to degenerative meniscal tears or chondral flaps, and those with symptomatic patellofemoral osteoarthritis.
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Intra-abdominal hypertension after life-threatening penetrating abdominal trauma: prophylaxis, incidence, and clinical relevance to gastric mucosal pH and abdominal compartment syndrome
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DOD - Acute Comp Syndrome CPG
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OBJECTIVE: To define the incidence, prophylaxis, and treatment of intra-abdominal hypertension (IAH) and its relevance to gut mucosal pH (pHi), multiorgan dysfunction syndrome, and the abdominal compartment syndrome (ACS).
METHODS: Seventy patients in the SICU at a Level I trauma center (1992-1996) with life threatening penetrating abdominal trauma had intra-abdominal pressure estimated by bladder pressure. pHi was measured by gastric tonometry every 4 to 6 hours. IAH (intra-abdominal pressure> 25 cm of H2O) was treated by bedside or operating room laparotomy.
RESULTS: Injury severity was comparable between patients who had mesh closure as prophylaxis for IAH (n = 45) and those who had fascial suture (n = 25). IAH was seen in 10 (22.2%) in the mesh group versus 13 (52%) in the fascial suture group (p = 0.012) for an overall incidence of 32.9%. Forty-two patients had pHi monitoring, and 11 of them had IAH. Of the 11 patients, eight patients (72.7%) had acidotic pHi (7.10 +/- 0.2) with IAH without exhibiting the classic signs of ACS. The pHi improved after abdominal decompression in six and none developed ACS. Only two patients with IAH and low pHi went on to develop ACS, despite abdominal decompression. Multiorgan dysfunction syndrome points and death were less in patients without IAH than those with IAH and in patients who had mesh closure.
CONCLUSIONS: IAH is frequent after major abdominal trauma. It may cause gut mucosal acidosis at lower bladder pressures, long before the onset of clinical ACS. Uncorrected, it may lead to splanchnic hypoperfusion, ACS, distant organ failure, and death. Prophylactic mesh closure of the abdomen may facilitate the prevention and bedside treatment of IAH and reduce these complications.
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Prevalence of pain in patients 1 year after major trauma
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DoD PRF (Psychosocial RF)
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OBJECTIVES: To describe the prevalence of pain in a large cohort of trauma patients 1 year after injury and to examine personal, injury, and treatment factors that predict the presence of chronic pain in these patients. SETTING: Sixty-nine hospitals in 14 states in the United States. PATIENTS: There were 3047 patients (10 371 weighted) aged 18 to 84 years who were admitted to the hospital because of acute trauma and survived to 12 months after injury. MAIN OUTCOME MEASURE: Pain 12 months after injury measured with the Chronic Pain Grade Scale. RESULTS: At 12 months after injury, 62.7% of patients reported injury-related pain. Most patients had pain in more than 1 body region, and the mean (SD) severity of pain in the last month was 5.5 (4.8) on a 10-point scale. The reported presence of pain varied with age and was more common in women and those who had untreated depression before injury. Pain at 3 months was predictive of both the presence and higher severity of pain at 12 months. Lower pain severity was reported by patients with a college education and those with no previous functional limitations. CONCLUSIONS: Most trauma patients have moderately severe pain from their injuries 1 year later. Earlier and more intensive interventions to treat pain in trauma patients may be needed.
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Multidisciplinary team approach in the management of popliteal artery injury
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DoD LSA (Limb Salvage vs Amputation)
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Popliteal artery injuries (PAIs) remain a challenging entity and carry the greatest risk of limb loss among traumatic lower extremity vascular injuries. Operative management of traumatic popliteal vascular injuries continues to evolve. Improved diagnostic imaging and the introduction of endovascular techniques offered alternative modalities to traditional surgical management. Despite major efforts in establishing protocols and guidelines in the management of vascular trauma, optimal strategies of traumatic PAIs are still under investigation. Herein, we discussed the role of multidisciplinary team, involving trauma and endovascular surgeons, emergency department personnel, and interventional radiologists in the management of complex PAIs.
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The clinical features and outcome of crush patients with acute kidney injury after the Wenchuan earthquake: Differences between elderly and younger adults
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DoD SSI (Surgical Site Infections)
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Background: On May 12, 2008, a devastating earthquake hit Wenchuan county of China's Sichuan province. Acute kidney injury (AKI) is one of the most lethal but reversible complications of crush syndrome after an earthquake. However, little is known about the epidemiological features of elderly crush patients with AKI. The aim of the present study is to compare clinical features and outcome of crush related AKI between elderly and younger adults in the Wenchuan earthquake. Materials and methods: A questionnaire was sent to 17 reference hospitals that treated the victims after the earthquake. Clinical and laboratory characteristics of crush patients with AKI were retrospectively analysed. Results: 228 victims experienced crush related AKI, of which 211 were adults, including 45 elderly (age = 65 years) and 166 younger adults (age, 15-64 years). Compared with the resident population, the percentage of patients was higher amongst elderly (19.7% versus 7.6%, P < 0.001). The distribution of gender was similar in elderly and younger adults. Mean systolic blood pressure was higher in elderly groups. Although no statistical differences in number of injury and injury severity score were observed between elderly and younger adults, elderly victims had lower frequency of extremities crush injury; higher incidences of thoracic traumas, limb, rib, and vertebral fractures; lower serum creatinine, potassium and creatinine kinase levels; lower incidence of oliguria or anuria; lower dialysis requirement; underwent less fasciotomies and amputations, received less blood and plasma transfusions. Mortality were 17.8% and 10.2% in elderly and younger adults, respectively (P = 0.165). Stratified analysis demonstrated the elderly receiving dialysis had higher mortality rate compared with younger patients (62.5% versus 10.5%, P < 0.001). Multivariate logistic regression analysis indicated that need for dialysis and sepsis were independent risk factors for death in the elderly patients. Conclusions: Elderly crush victims more frequently developed AKI in the Wenchuan earthquake, and they differ from younger adults in injury patterns and treatment modalities. The elderly patients with AKI requiring dialysis were at a relatively high risk of mortality. © 2010 Elsevier Ltd. All rights reserved.
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Recovery of elbow motion following pediatric lateral condylar fractures of the humerus
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The Treatment of Pediatric Supracondylar Humerus Fractures AUC
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BACKGROUND: Temporary elbow stiffness is often seen after a lateral condylar fracture of the distal end of the humerus in children. There are scant scientific data available to assess the expected time frame for return of elbow motion after these injuries. The purpose of this study is to provide a prospective, longitudinal evaluation of elbow motion in a large group of pediatric patients undergoing treatment for a lateral condylar fracture of the distal end of the humerus. METHODS: We prospectively evaluated 141 patients with lateral humeral condylar fractures at a mean age of 5.2 years and with a mean follow-up of twenty-nine weeks. The patients were treated with cast immobilization, percutaneous pinning, or open reduction and internal fixation on the basis of the initial displacement. Elbow motion was followed longitudinally at clinic visits. Relative arc of motion was calculated as a percentage of the motion of the normal, contralateral elbow. RESULTS: The mean relative arc of motion at the time of cast removal was 44%, reaching 84% by week 12. By weeks 18, 24, 36, and 48, the relative arc of motion reached 87%, 90%, 93%, and 97%, respectively. Compared with fractures treated without surgery, those treated surgically had a significantly lower absolute arc of motion from the time of cast removal (p = 0.018) and up to eighteen weeks after the injury (p < 0.001); however, no significant difference was observed at eighteen weeks or beyond. For patients treated surgically, no significant difference in relative arc of motion was observed between the patients with closed or open reductions. The age of the patient (hazard ratio = 0.87, p = 0.008), length of immobilization (hazard ratio = 0.79, p = 0.03), and severity of the fracture (hazard ratio = 0.40, p < 0.0001) were independent predictors of recovery of elbow motion after a lateral humeral condylar fracture in children. CONCLUSIONS: An initial rapid recovery in elbow motion can be expected after a lateral humeral condylar fracture in a child, with progressive improvements for up to one year after the injury. This recovery is slower if the patient is older, has a longer period of immobilization, and has a more severe injury
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Knotless Suture Anchor Fixation of a Traumatic Osteochondral Lesion of the Lateral Femoral Condyle
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Osteochondritis Dissecans 2020 Review
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Osteochondral injuries commonly occur after lateral patellar instability events. Recognition and early intervention of displaced fragments is key to maintaining the viability of the fragment and congruency of the articular surface. Multiple fixation techniques exist for achieving stable fixation of displaced osteochondral lesions, including metal or bioabsorbable screws and all suture techniques. In this Technical Note, we describe a technique for internal fixation of a displaced osteochondral fragment of the lateral femoral condyle using knotless suture anchors. This technique affords minimally invasive restoration of the native anatomy with excellent stability of the fracture fragment, allowing early range of motion and ambulation.
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Soft tissue knee injuries
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AMP (Acute Meniscal Pathology)
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Soft tissue knee injuries represent a large spectrum of pathology from the minor sprain to devastating knee dislocations. Taking a clear, focussed history and listening to the minutiae that the patient divulges give clues to the mechanism and thus the suspected patterns of injury. A thorough knee examination will allow you to narrow your differential and organize appropriate timely investigations to assist your diagnosis. This article aims to give you background information about the structure and function of the knee and diagnosis of common knee complaints.
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Poor trabecular microarchitecture at the distal radius in older men with increased concentration of high-sensitivity C-reactive protein--the STRAMBO study
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Distal Radius Fractures
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Low-grade inflammation, assessed by serum high-sensitivity C-reactive protein (hsCRP) concentration, is associated with higher fracture risk irrespective of areal bone mineral density (aBMD). We assessed the association of hsCRP with bone microarchitecture (measured by high-resolution pQCT) at the distal radius and tibia in 1,149 men, aged 19-87 years. hsCRP concentration increased with age until the age of 72, then remained stable. aBMD was not correlated with hsCRP level. After adjustment for confounders, bone microarchitecture was not associated with hsCRP level in men aged <72. After the age of 72, hsCRP >5 mg/L was associated with lower trabecular density, lower trabecular number, higher trabecular spacing, and more heterogeneous trabecular distribution (p < 0.05-0.005) at the distal radius versus hsCRP <= 5 mg/L. Similar differences were found for the fourth hsCRP quartile (>3.69 mg/L) versus the three lower quartiles combined. Cortical parameters of distal radius and microarchitectural parameters of distal tibia did not vary according to hsCRP concentration in men aged >= 72. Fracture prevalence increased with increasing hsCRP level. After adjustment for confounders (including aBMD), odds for fracture were higher in men with hsCRP >5 mg/L compared to hsCRP <1 mg/L (OR = 2.22, 95 % CI 1.29-3.82) and did not change after additional adjustment for microarchitectural parameters. The association between hsCRP level and bone microarchitecture was observed only for trabecular parameters at the radius in men aged >=72. Impaired bone microarchitecture does not seem to explain the association between elevated CRP level and higher risk of fracture.
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Femoral nerve block using 0.25% versus 0.5% bupivacaine for analgesia after arthroscopic anterior cruciate ligament reconstruction
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Surgical Management of Osteoarthritis of the Knee CPG
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Purpose/Objective: Femoral nerve block (FNB) with varying concentrations of bupivacaine is often used for postoperative analgesia after anterior cruciate ligament (ACL) reconstruction. This study investigated whether 0.5% or 0.25% bupivacaine provided better analgesia with less effect on quadriceps strengths. Materials and Methods: After ethics committee approval, one hundred patients were randomized to receive a FNB with 20 mL of 0.5% or 0.25% bupivacaine. The effectiveness of FNB was assessed before spinal block. Data regarding demographic, time to first pain, time to first analgesic, pain scores, morphine use, and recovery of sensory and motor function were recorded during the first 48 h after surgery. Results: No differences were found in demographic data, effectiveness of FNB, time to first pain and cumulative morphine consumption. Median time to first morphine requirement was 12 h in group 0.5% bupivacaine and 10 h in group 0.25% bupivacaine (P = 0.048) (Fig. 1). Pain score at 18 h was lower in group 0.5% bupivacaine compared with group 0.25% bupivacaine (P = 0.001) (Fig. 2). When specify to the patellar tendon graft subgroup, the patients requiring morphine were 70% in group 0.5% bupivacaine and 90% in group 0.25% bupivacaine (P = 0.029). The recovery of sensorimotor function was not different between groups. (Figure Presented) Conclusions: FNB with 0.5% bupivacaine provided longer time to first analgesic and lower VAS score at 18 hours after ACL reconstruction when compared to 0.25% bupivacaine. Both concentrations showed a similar effect on quadriceps strengths
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Extraction of a well fixed but fractured ceramic acetabular liner
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PJI DX Updated Search
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Ceramic fractures have been reported to occur in hip replacements, but the techniques used to extract a well fixed but fractured component are not commonly described. We present a case of ceramic liner fracture and validate a modification of a previously reported extraction technique that allowed us to save the acetabular cup and insert a polyethylene liner. With an increasing trend in ceramic bearing usage, it is likely that the number of ceramic liner fractures will increase and therefore knowledge of successful extraction techniques will be desirable
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Complications of Biliary Drainage in Patients with Malignant Biliary Obstruction
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MSTS 2022 - Metastatic Disease of the Humerus
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Purpose: Biliary tract obstruction in cancer patients is usually associated with a poor prognosis. The obstruction may cause distressing symptoms, such as pruritus. As this situation occurs mostly in advanced cancer, the primary objective of the treatment is in many cases symptom control and not prolonging life. However, some patients can be candidates for chemotherapy. To see the outcomes of stenting insertion in patients of our oncology center. Methods: A retrospective study of patients who have undergone this procedure between 1 October 2011 and 31 December 2018 was carried out. Results: Insertion of a biliary stent was performed in 171 patients. The most common diagnoses were gastric and colorectal cancers, each with 42 (24%), followed by pancreatic (34 (20%)) and biliary tract cancer (25 (14%)). Most stents (155 (91%)) were placed percutaneously. Complications were seen in 91 (53%) patients and the most common was cholangitis in 48 (53%) patients, and the median survival was 75.5 days (3–1246). A total of 168 (98%) patients were referred to palliative care. In a multivariable analysis, the ECOG performance status was associated with survival, with the ECOG 0, 1, and 2 associated with better survival and peritoneal metastases associated with lower survival. Conclusions: For many patients with advanced cancers, it may not be clear if the benefits of palliative biliary stents outweigh the risks. Therefore, the problem should be discussed with the patients and their families, making clear the goals of care and the potential benefits and risks that can be expected.
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Fracture Risk After Initiation of Use of Canagliflozin: A Cohort Study
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Hip Fx in the Elderly 2019
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Background: Sodium-glucose cotransporter-2 inhibitors promote glycosuria, resulting in possible effects on calcium, phosphate, and vitamin D homeostasis. Canagliflozin is associated with decreased bone mineral density and a potential increased risk for fracture.
Objective: To estimate risk for nonvertebral fracture among new users of canagliflozin compared with a glucagon-like peptide-1 (GLP-1) agonist.
Design: Population-based new-user cohort study.
Setting: Two U.S. commercial health care databases providing data on more than 70 million patients from March 2013 to October 2015.
Patients: Persons with type 2 diabetes who initiated use of canagliflozin were propensity score-matched in a 1:1 ratio to those initiating use of a GLP-1 agonist.
Measurements: The primary outcome was a composite end point of humerus, forearm, pelvis, or hip fracture requiring intervention. Secondary outcomes included fractures at other sites. A fixed-effects meta-analysis that pooled results from the 2 databases provided an overall hazard ratio (HR).
Results: 79 964 patients initiating use of canagliflozin were identified and matched to 79 964 patients initiating use of a GLP-1 agonist. Mean age was 55 years, 48% were female, average baseline hemoglobin A1c level was 8.7%, and 27% were prescribed insulin. The rate of the primary outcome was similar for canagliflozin (2.2 events per 1000 person-years) and GLP-1 agonists (2.3 events per 1000 person-years), with an overall HR of 0.98 (95% CI, 0.75 to 1.26). Risk for pelvic, hip, humerus, radius, ulna, carpal, metacarpal, metatarsal, or ankle fracture was also similar for canagliflozin (14.5 events per 1000 person-years) and GLP-1 agonists (16.1 events per 1000 person-years) (overall HR, 0.92 [CI, 0.83 to 1.02]).
Limitation: Unmeasured confounding, measurement error, and low fracture rate.
Conclusion: In this study of middle-aged patients with type 2 diabetes and relatively low fracture risk, canagliflozin was not associated with increased risk for fracture compared with GLP-1 agonists.
Primary Funding Source: Brigham and Women's Hospital, Division of Pharmacoepidemiology and Pharmacoeconomics.
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Comparative study of clinical and Electromyographic aspects of Chronic inflammatory demyelinating polyradiculoneuropathy idiopathic between diabetics and non diabetics
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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Background The Chronic Inflammatory Demyelinating Polyradiculoneuropathy (CIDP) is common in diabetic patients 18.9%. But a few surveys have compared the IPDC between diabetic and non- diabetic. Objective To study the IPDC between diabetic and non- diabetic. Methodology This descriptive survey examined 47 patients including 21 diabetics and 26 non-diabetics with CIDP admitted to the neurophysiology laboratory of the CHU of Limoges from January 2006 to June 2008. The diagnosis of CIDP was focused on INCAT electrophysiological criteria and distal latency greater than 9 ms. Results The clinical comparison reveals that there was no difference between the two populations as regard age, gender, presence of physical deficit disturbances, objective sensory troubles (p> 0, 05). However, the diabetic patients had more pain than non-diabetics (p = 0.006). At the electrophysiology level, there are more blocks conduction in non-diabetics (88.5%) than in diabetics (47.6%) p =0.002. At the median nerve, diabetics had less elongation of distal latency (27.8%) than non-diabetics (47.4%) p = 0.01. A comparative study of the results shows that subjects without diabetes have a higher F wave lying on the median (41.2 ms), the ulnar nerve (40.6ms) and SPE (65.8 ms) than diabetics. The reduction of nerve conduction velocity is higher in the non-diabetic on the ulnar nerve (34.3 m/sec). Conclusion These results show that diabetics may have CIDP but with different physiological and clinical aspects of non-diabetics. (copyright) 2002-2012 African Journal of Neurological Sciences. All rights reserved
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Augmentation Techniques for Meniscus Repair
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AMP (Acute Meniscal Pathology)
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Menisci display exquisitely complex structure and play an essential weight-bearing role in the knee joint. A torn meniscus is one of the most common knee injuries which can result in pain and mechanical abnormalities. Tear location is one aspect which determines the endogenous healing response; tears that occur in the peripheral densely vascularized zone of the meniscus have the potential to heal while the healing capacity is more limited in the less vascularized inner zones. Meniscectomy was once widely performed, but led to poor radiographic and patient-reported mid- and long-term outcomes. After the advent of arthroscopy, orthopaedic opinion in the 1980s has been swaying toward salvaging or repairing the torn meniscus tissue to prevent osteoarthritis rather than performing meniscectomy. Meniscus repair in young active individuals has been shown to be effective, reproducible, and reliable if indications are met; however, only a small proportion of all tears are considered repairable with available technologies. Biological augmentation techniques and meniscus tissue engineering strategies are being devised to enhance the likelihood and rate of healing in meniscus repair. Preclinical and clinical studies have shown that introduction of cellular elements of the blood, bone marrow, and related growth factors have the potential to enhance meniscus repair. This article reviews the current state of clinical management of meniscus tears (primary repair) as well as augmentation techniques to improve healing by meniscus wrapping with extracellular matrix materials, trephination, synovial rasping and abrasion, fibrin/blood clot placement, and platelet-rich plasma injections. In addition, the rationale for using polymer/autologous blood component implants to improve meniscus repair will be discussed.
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Perioperative and Modifiable Risk Factors for Periprosthetic Joint Infections (PJI) and Recommended Guidelines
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Dental Implant Infection
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PURPOSE OF REVIEW: Periprosthetic joint infection (PJI) remains a complication that is associated with high morbidity as well as high healthcare expenses. The purpose of this review is to examine patient and perioperative modifiable risk factors that can be altered to help improve rates of PJI., RECENT FINDINGS: Evidence-based review of literature shows that improved control of post-operative glycemia, appropriate management of obesity, malnutrition, metabolic syndrome, preoperative anemia, and smoking cessation can help minimize risk of PJI. Additionally, use of Staphylococcus aureus screening, preoperative evaluation of vitamin D levels, screening for urinary tract infection, and examination of dental hygiene can help with improving rates of PJI; similarly, appropriate management of perioperative variables such as limiting operating room traffic, appropriate timing, and selection of prophylactic antibiotics and surgical site preparation can help to decrease rates of PJI. In summary, PJI is a morbid complication of total joint arthroplasty. Surgeons should be vigilant of modifiable risk factors that can be improved upon to help minimize the risk of PJI.
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Utility of intraoperative frozen section in the diagnosis of periprosthetic joint infection
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PJI DX Updated Search
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PURPOSE: Intraoperative frozen section (FS) is an effective diagnostic test for periprosthetic joint infection (PJI). We evaluated the diagnostic characteristics of single- and multiplex-site intraoperative FS, and evaluated the results of single-site FS combined with those of C-reactive protein (CRP) level and erythrocyte sedimentation rate (ESR) for assessing PJI. METHODS: We studied 156 painful joint arthroplasties in 152 consecutive patients presenting for revision total joint arthroplasty due to PJI. Receiver operating characteristic analysis was used to determine the optimal cutoff values for CRP level, ESR, and intraoperative FS histopathology. Sensitivity, specificity, positive and negative predictive values, and accuracy of the diagnostic tests were assessed using a 2x2 table. RESULTS: We investigated the diagnostic utility of polymorphonuclear leukocyte number (PMN) per high-power field (HPF) on FS. Our data showed that 5 PMNs per HPF is a suitable diagnostic threshold, with a high accuracy in single- and multiplex-site FS. Five PMNs in any 1 of 5 sites had the highest sensitivity of 0.86 and a specificity of 0.96. Five PMNs in every 1 of 5 sites had greater diagnostic utility, with a specificity of 1; however, the sensitivity of this measure fell to 0.62. Five PMNs in single-site FS had a sensitivity of 0.70 and a specificity of 0.94. Five PMNs in single-site FS or CRP level >/=15 mg/L increased the sensitivity to 0.92; however, the specificity decreased to 0.79. CONCLUSION: Compared with single-site FS, any 1 positive site on multiplex-site FS may improve sensitivity, while every 1 positive site on multiplex-site FS may improve specificity. Five PMNs in any 1 of 5 sites on FS has excellent utility for the diagnosis of PJI. Additional systematic large-scale studies are needed to verify this result
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Suction lipectomy
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Panniculectomy & Abdominoplasty CPG
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Suction lipectomy is a very effective and safe method, if performed by an experienced plastic surgeon. The authors demonstrate using a group of 284 patients operated on at the University Clinic of Plastic Surgery in Prague between 1994-1998, indications, the method and complications.
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The golf ball sign: arthroscopic localization of an osteochondritis dissecans lesion of the knee
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Osteochondritis Dissecans 2020 Review
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We report on the arthroscopic treatment of a 12-year-old boy diagnosed with an osteochondral defect of the medial femoral condyle. He underwent arthroscopic fixation of the defect, and during the surgery, a blunt trocar was used to localize the lesion. The trocar created a transient dimpling effect on the cartilage overlying the osteochondral defect that resembled the surface of a golf ball. This "golf ball sign" then served as a visual guide during placement of a chondral dart. When present, it is believed that this sign can benefit arthroscopists by helping to improve intraoperative localization of an osteochondral defect.
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Correlation of Meniscal Tear with Timing of Anterior Cruciate Ligament Reconstruction in Patients without Initially Concurrent Meniscal Tear
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AMP (Acute Meniscal Pathology)
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The incidence of meniscal tear was reported to increase with the delay of anterior cruciate ligament reconstruction (ACLR). The tear may occur concurrently with the ACL injury or after the ACL injury. Few studies had focused on the patients whose meniscus is intact during ACL injury. We determined the correlation between timing of surgery and incidence of meniscal tears in ACL-deficient knees with initially intact meniscus. We retrospectively reviewed 387 patients who had undergone primary ACLR. Time of initial ACL injury, magnetic resonance imaging (MRI) examination, and surgery was recorded. The MRI was reviewed by experienced radiologic and orthopaedic doctors. Intraoperative arthroscopic images were also obtained and reviewed. The type of tear noted during surgery was classified according to the modification of International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine classification of meniscal tears. Patients were divided into early (surgery within 12 months from injury) and late surgery group (surgery at more than 12 months from injury). There were 216 patients with intact medial meniscus and 257 patients with intact lateral meniscus on the postinjury MRI study. The incidence of medial meniscus tear (MMT) was significantly higher than lateral meniscus tear (LMT) during the ACLR (33.8 vs. 19.8%, p < 0.001). The incidence of MMT is higher in late group than in early group (53.7 vs. 29.1%, p = 0.004, odds ratio= 2.815). The incidence of LMT is mildly higher in late group but without statistics significance (23.8 vs. 18.6%, p = 0.364). In both MMT and LMT, the most common injury pattern observed was a longitudinal tear. The incidence of each type is not different between early and late group. For patients without concurrent meniscal injuries with the ACL tear, the incidence of MMT significantly increased if ACLR was performed more than 12 months after injury. The medial meniscus was more prone to injury than the lateral meniscus in chronic ACL-deficient knee. ACLR should be performed earlier to reduce the risk of meniscal tears for patients without initially concurrent meniscal tear.
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Perioperative hyperglycemia and postoperative infection after lower limb arthroplasty
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PJI DX Updated Search
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BACKGROUND: One of the most serious complications after major orthopedic surgery is deep wound or periprosthetic joint infection. Various risk factors for infection after hip and knee replacement surgery have been reported, including patients' comorbidities and surgical technique factors. We investigated whether hyperglycemia and diabetes mellitus (DM) are associated with infection that requires surgical intervention after total hip and knee arthroplasty. METHODS: We reviewed our computerized database for elective primary total hip and knee arthroplasty from 2000 to 2008. Demographic information, past medical history of patients, perioperative biochemistry, and postoperative complications were reviewed. Patients were divided into two groups: infected group (101 patients who had surgical intervention for infection at our institution within 2 years after primary surgery) and noninfected group (1847 patients with no intervention with a minimum of one year follow-up. The data were analyzed using t, chi-squared, and Fisher's exact tests. RESULTS: There were significantly more diabetes patients in the infected group compared with the noninfected group (22% versus 9%, p < .001). Infected patients had significantly higher perioperative blood glucose (BG) values: preoperative BG (112 +/- 36 versus 105 +/- 31 mg/dl, p = .043) and postoperative day (POD) 1 BG (154 +/- 37 versus 138 +/- 31 mg/dl, p < .001). Postoperative morning hyperglycemia (BG >200 mg/dl) increased the risk for the infection more than two-fold. Non-DM patients were three times more likely to develop the infection if their morning BG was >140 mg/dl on POD 1, p = .001. Male gender, higher body mass index, knee arthroplasty, longer operative time and hospital stay, higher comorbidity index, history of myocardial infarction, congestive heart failure, and renal insufficiency were also associated with the infection. CONCLUSIONS: Diabetes mellitus and morning postoperative hyperglycemia were predictors for postoperative infection following total joint arthroplasty. Even patients without a diagnosis of DM who developed postoperative hyperglycemia had a significantly increased risk for the infection
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Clinical outcomes of conversion surgery from an external fixator to an iodine-supported titanium alloy plate
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DoD SSI (Surgical Site Infections)
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Background: External fixators brought a revolution in orthopaedic surgical treatment after the invention of distraction osteogenesis, which enabled treatment of various difficult diseases. However, they had some drawbacks, such as pin-site infections, psychological pain, and refracture after removal. To overcome these problems, many efforts have been made by shortening of the period of wearing them. One of those methods is conversion to locking plate, which had high risk of infection. To reduce the risk of infection, we performed conversion surgery using iodinesupported titanium plate (We named it iPlates, developed at our department). Questions/purposes: We therefore evaluated (1) Operation time, (2) whether bone union was achieved, (3) blood biochemistry, including thyroid hormone levels, (4) post-surgical complications. Patients and Methods: We assessed 28 legs. There were 13 legs after deformity correction and limb lengthening, three legs with pseudarthrosis after bone fracture, two legs after bone transport, one leg after shortening distraction, and one leg after open fracture. The mean follow-up period was 24.5 months. Results: Average operation time was 197 minutes. Bone union was achieved in all cases. Blood examinations did not find any abnormalities due to iImplant implantation, such as with thyroid hormones. One patient had superficial soft tissue infection treated with re-operation without removal of plate. Conclusions: An iPlate can reduce complications compare to previous studies. Conversion surgery with iPlate could be a new path for the future of external fixation. © 2014 Matsubara H, et al.
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Hip Fracture Surgery and Survival in Centenarians
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Hip Fx in the Elderly 2019
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BACKGROUND: Hip fracture (HF) is increasingly frequent with advancing age. Studies describing the HF incidence rate and survival after surgery in centenarians are scanty. To fill this gap, we performed a large population-based investigation on Lombardy centenarians (Italy).
METHODS: Retrospective observational cohort study based on information from the Healthcare Utilization Database. Among the cohort of 7,830 residents that reached 100 years of age between 2004 and 2011, incidence rate of HF was calculated. Two hundred fifty-nine patients were discharged alive from a hospital after HF and surgical repair (HF cohort). For each HF cohort member, a control was randomly selected from the initial cohort to be matched for gender and date of birth, and who did not experience HF from the date of their hundredth birthday until the date of hospital discharge of the corresponding HF cohort member. The survival curves and the hazard functions of HF and control cohort were calculated within 2 years.
RESULTS: Over a mean follow-up of 1.85 years, HF incidence rate was 23.1 per 1,000 centenarians per year. Survival probability was significantly lower in HF cohort than in control cohort (31.5 vs 48.1%, p < .001). Hazard functions showed an increased risk of death in HF cohort than in control cohort, especially in the 3 months after surgery.
CONCLUSION: Survival analysis exhibited an excess mortality in the first 3 months among HF cohort members, but not beyond this period. Every effort to counteract HF is warranted, including prevention of falls and high quality of care, especially in the early postsurgical time.
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Epidemiology of Operative Procedures in an NCAA Division I Football Team Over 10 Seasons
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AMP (Acute Meniscal Pathology)
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BACKGROUND: Injury rates are high for collegiate football players. Few studies have evaluated the epidemiology of surgical procedures in National Collegiate Athletic Association (NCAA) Division I collegiate football players.
PURPOSE: To determine the most common surgical procedures performed in collegiate football players over a 10-year period.
STUDY DESIGN: Descriptive epidemiological study.
METHODS: From the 2004-2005 season through the 2013-2014 season, all surgical procedures performed on athletes from a single NCAA Division I college football team during athletic participation were reviewed. Surgeries were categorized by anatomic location, and operative reports were used to obtain further surgical details. Data collected over this 10-season span included type of injury, primary procedures, reoperations, and cause of reoperation, all categorized by specific anatomic locations and position played.
RESULTS: From the 2004-2005 through the 2013-2014 seasons, 254 operations were performed on 207 players, averaging 25.4 surgical procedures per year. The majority of surgeries performed were orthopaedic procedures (92.1%, n = 234). However, there were multiple nonorthopaedic procedures (7.9%, n = 20). The most common procedure performed was arthroscopic shoulder labral repair (12.2%, n = 31). Partial meniscectomy (11.8%, n = 30), arthroscopic anterior cruciate ligament (ACL) reconstruction (9.4% n = 24), and arthroscopic hip labral repair (5.9% n = 15) were the other commonly performed procedures. There were a total of 29 reoperations performed; thus, 12.9% of primary procedures had a reoperation. The most common revision procedure was a revision open reduction internal fixation of stress fractures in the foot as a result of a symptomatic nonunion (33.33%, n = 4) and revision ACL reconstruction (12.5%, n = 3). By position, relative to the number of athletes at each position, linebackers (30.5%) and defensive linemen (29.1%) were the most likely to undergo surgery while kickers (6%) were the least likely.
CONCLUSION: In NCAA Division I college football players, the most commonly performed surgeries conducted for injuries were orthopaedic in nature. Of these, arthroscopic shoulder labral repair was the most common, followed closely by partial meniscectomy. Nonorthopaedic procedures nonetheless accounted for a sizable portion of surgical volume. Familiarity with this injury and surgical spectrum is of utmost importance for the team physician treating these high-level contact athletes.
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The nasomaxillary complex, the mandible, and sleep-disordered breathing
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Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures
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Purpose: This study aims to use clinical scales in a standardized fashion in evaluating the frequency of a high and narrow hard palate and/or small and retroplaced mandible in children with polysomnographically demonstrated sleep-disordered breathing (SDB). Methods: This is a retrospective review of clinical and polysomnographic data from children (2-17 years old) with SDB. Exclusion criteria were obesity, presence of a syndromic disorder, and incomplete chart information. Data on demographics, reason for referral, sleep history, Mallampati scale, size of the tonsils (Friedman scale), bite occlusion (dental positioning), and correlating clinical presentation and comparative physical exam of nasomaxillary and mandibular features (using subjective grading scales) were collected, as were results of pre- and post- treatment polysomnography. Results: Data from 400 children were analyzed. With increasing age, fewer referrals were made for abnormal breathing during sleep and more were made for daytime impairment and generally poor sleep. There were 290 children (72.6%) who had tonsils graded 3+ or 4+, but 373 (93.3%) had craniofacial features considered to be risk factors for SDB, including small mandible and/or high and narrow hard palate associated with a narrow nasomaxillary complex. Mean pretreatment apnea-hypopnea index (AHI) was 14.6(plus or minus)17.1 and AHI was similar in the three age groups. Initial treatment was adenotonsillectomy. Follow-up was obtained in 378 subjects, and 167 cases demonstrated residual AHI. Incomplete response to adenotonsillectomy was seen more often in children with Mallampati scale scores of 3 and 4. Conclusion: Non-obese children with SDB had different initial clinical complaints based on age. Independently of age, facial anatomic structures limiting nasal breathing and those considered to be risk factors for SDB were commonly seen in the total group. Clinical assessment of craniofacial features considered as risk factors for SDB and more particularly a Mallampati scale score of 3 or 4 can be useful in identifying children who may be more at risk for limited response to adenotonsillectomy, suggesting a subsequent need for post-surgery polysomnography. (copyright) 2011 Springer-Verlag
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Outcomes of reduction more than 7 days after injury in supracondylar humeral fractures in children
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Pediatric Supracondylar Humerus Fracture 2020 Review
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BACKGROUND: Some slightly extended type II fractures initially treated with closed reduction and casting can displace during the first 2 weeks of follow-up. Although closed reduction and percutaneous pinning are desirable for displaced supracondylar humeral fractures treated acutely, there is little or no available information regarding the surgeon's ability to obtain a satisfactory reduction when such a procedure is performed more than a week after the original injury, or the clinical outcome of it. METHODS: We reviewed the information on 143 type II pediatric supracondylar humeral fractures that were treated by closed reduction and percutaneous pinning. To determine the effect of late treatment, we compared a group of fractures that was treated within the first 7 days (group 1, n=101) with a group that was treated >7 days after the injury (group 2, n=42). RESULTS: Mean time from presentation to surgery was 2.1 days (range, 0 to 5) and 9.8 days (range, 7 to 15) for fractures in groups 1 and 2, respectively. There was no need for an open reduction in either group. An anatomic reduction was obtained in all fractures. There were no iatrogenic nerve injuries, vascular complications, or compartment syndromes in either group. Length of surgery was similar in both groups (P=0.3). There were no significant differences in final carrying angle (P=0.2) or range of motion of the treated elbow (P=0.21). Avascular necrosis of the humeral trochlea was identified in 2 fractures that were treated surgically 8 days after the original injury (group 2). CONCLUSIONS: The results of this study suggest that it is possible to obtain an anatomic reduction of a type II pediatric supracondylar humeral fracture even after 7 days from the injury. Such a delay in surgery does not appear to lead to longer surgeries, a higher incidence of open reduction, or to alter the final alignment or range of motion of the elbow. However, the risk of developing an avascular necrosis of the humeral trochlea must be considered. LEVEL OF EVIDENCE: II.
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New and emerging antiresorptive treatments in osteoporosis
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MSTS 2018 - Femur Mets and MM
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Bisphosphonates have for many years been the mainstay of antiresorptive treatment, acting predominantly by inducing apoptosis of mature osteoclasts. During recent years, an advanced understanding of the genetic and biological mechanism involved in bone resorption has revealed new therapeutic targets for antiresorptive treatments. Several of these new drugs act by targeting specific pathways within the osteoclastic cells and may reduce bone resorption without a concomitant decrease in bone formation. Such an uncoupling may result in a net bone formation, thereby causing a bone "anabolic" effect through an antiresorptive mechanism. Moreover, in contrast to bisphosphonates several of the new drugs are not deposited within bone and therefore their duration of action is related to their presence in plasma. Accordingly, their antiresorptive effect is quickly reversible, which may be advantageous if reversal of a suppressed bone turnover is warranted under certain clinical conditions such as osteonecrosis of the jaw. In this paper, we will review the pharmacological properties and clinical effects of the drugs that recently have been (denosumab, bazedoxifene, lasofoxifene), or currently are being tested in large phase III clinical trials (Catepsin K inhibitor), as well as drugs that have shown potential beneficial effects in phase I or II trials and may be tested in upcoming phase III trials (integrin antagonists, c-Src kinase inhibitor, inhibitors of the acidification process within the resorption lacuna, and glucagon-like peptide). © 2011 Bentham Science Publishers Ltd.
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The Emergency Evaluation and Management of Pediatric Extremity Fractures
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Distal Radius Fractures
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Approximately one-third of children sustain a fracture before the age of 16 years; however, their unique anatomy and healing properties often result in a good outcome. This article focuses on the diagnosis and management of pediatric extremity injuries. The article describes the anatomic features and healing principles unique to children and discusses pediatric upper and lower extremity fractures and presents evidence-based and standard practice for their management. Finally, the article describes the conditions under which emergency physicians are likely to miss pediatric fractures by highlighting specific examples and discussing the general factors that lead to these errors.
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Correlation between macroscopic changes of arthrosis and the posterior cruciate ligament histology in the osteoarthritic knee
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Surgical Management of Osteoarthritis of the Knee CPG
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BACKGROUND: There is ongoing debate about the role of the posterior cruciate ligament (PCL) in total knee arthroplasty. Advocates of PCL retention cite better soft tissue balance and improved proprioception, whereas opponents report late flexion instability. The results of knee replacement are similar whether the PCL is retained or sacrificed. The aim of the present study was to examine the PCL for histological changes that would infer its competence and correlate these with changes easily observed by the operating surgeon. METHODS: A prospective study of 50 osteoarthritic knees was performed. RESULTS: Histology of the PCL showed changes secondary to degeneration and trauma. In most of the ligaments examined, arteriosclerosis and fibrosis were present. Half of the PCL examined showed perineural fibrosis, myxoid change and hyalinization. These changes, although very frequent, did not correlate well to the changes observed in either the anterior or PCL, or in the overall severity of osteoarthrosis. CONCLUSIONS: Posterior cruciate ligaments usually show degenerative and chronic traumatic change of varying degrees on histology. The changes are not predictable from inspection of the knee at surgery. The frequency of these changes suggests that many osteoarthritic PCL are of indifferent quality and the surgeon should consider this when choosing the style of knee replacement
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Aesthetic Nonexcisional Arm Contouring
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Panniculectomy & Abdominoplasty CPG
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BACKGROUND: Surgical excision remains the gold-standard therapy for arm skin laxity. However, many patients refuse surgical treatment for fear of the prominent long scars associated with brachioplasty. OBJECTIVES: The objective of the study was to compare the aesthetic outcome of 2 energy-assisted liposuction arm-contouring techniques, radiofrequency-assisted liposuction (RFAL; Group A) and Renuvion helium subdermal coagulation (Group B), with a control group treated with VASER-assisted liposuction (VAL) alone (Group C). METHODS: This is a randomized controlled study of 176 patients seeking arm contouring, who were treated between February 2017 and December 2020. All of the patients underwent VAL, followed by either RFAL (53 patients, Group A) with the BodyTite RF platform or subdermal coagulation (66 patients, Group B) with the Renuvion platform; 57 patients in the control group (Group C) received VAL alone. Patient data, marking techniques, operative details, complications (and tips and tricks to avoid them), and aesthetic outcomes were recorded and tabulated. Surgical team, third-party, and patient satisfaction surveys were conducted 6 months postoperatively. RESULTS: The study included 176 patients (153 female and 23 male) with a mean age of 32 years (range, 20-59 years). All patients were followed up for a minimum of 6 months. In total, 96 (80.6%) patients reported their satisfaction with the overall technique. An independent plastic surgeon considered the result good to excellent in 97 of 119 cases of the studied group. CONCLUSIONS: The umbrella of nonexcisional arm contouring can be extended to include treatment of difficult cases of arm laxity with energy-producing machines. The procedure can achieve a reduction in fat deposits and significant improvements in skin laxity.
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Preoperative decolonization effective at reducing staphylococcal colonization in total joint arthroplasty patients
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PJI DX Updated Search
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Staphylococcus decolonization prior to surgery is used to prevent surgical site infections (SSIs) after total joint arthroplasty (TJA). To determine if current treatment protocols result in successful decolonization of methicillin-sensitive S. aureus (MSSA) and methicillin-resistant S. aureus (MRSA), 106 consecutive patients were screened for nasal MSSA/MRSA colonization pre-operatively and on the day of surgery. Colonized patients used intranasal mupirocin twice a day and chlorhexidine showers daily 5 days prior to surgery. Pre-operatively, 24 joints (22.0%) were positive for MSSA colonization and 5 joints (4.6%) were positive for MRSA colonization. On the day of surgery, 3 joints (2.8%) who underwent decolonization were positive for MSSA colonization and 0 joints were positive for MRSA colonization. The reduction in MSSA colonization was significant (P<0.001), while the eradication of MRSA colonization approached statistical significance (P=0.063). Current decolonization protocols using intranasal mupirocin and chlorhexidine washes are effective for reducing MRSA/MSSA colonization
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Anti-inflammatory activity of silymarin in patients with knee osteoarthritis. A comparative study with piroxicam and meloxicam
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OAK 3 - Non-arthroplasty tx of OAK
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OBJECTIVE: To evaluate the antiâ?inflammatory effect of Silymarin in patients with knee osteoarthritis (OA) in comparison with piroxicam and meloxicam. METHODS: A doubleâ?blind clinical trial was performed at the Department of Rheumatology, Baghdad Teaching Hospital, Baghdad, Iraq during the period from October 2004 to September 2005, in which 220 patients (79 males and 141 females) with painful knee osteoarthritis were randomized into 5 groups, treated with either silymarin (300 mg/day), piroxicam (20 mg/day), meloxicam (15 mg), or a combination of silymarin with piroxicam or meloxicam. Serum levels of interleukinâ?1 alpha, interleukinâ?8, and the complement proteins C3 and C4 were assessed at zero time, and after 8 weeks. RESULTS: Silymarin reduces significantly serum levels of ILâ?1 alpha and ILâ?8, C3 and C4 after 8 weeks compared to the preâ?treatment levels. Piroxicam showed no significant reduction in ILâ?1 alpha levels, while ILâ?8 decreased significantly, compared to preâ?treatment value. Meloxicam elevates serum levels of ILâ?1 alpha significantly, while ILâ?8 did not significantly change compared to the preâ?treatment value. Piroxicam or meloxicam produced slight, nonâ?significant increase in serum levels of complement proteins after the 8â?week treatment period. Adjunct use of silymarin with piroxicam results in significant reduction in both cytokines (ILâ?1 alpha and ILâ?8), and serum levels of C3 and C4. However, its adjunct use with, meloxicam did not reveal any significant changes in this respect. CONCLUSION: Silymarin reduces the elevated levels of interleukins and complement proteins, when used alone, or in combination with NSAIDs for the treatment of knee OA.
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Final results of a phase Iâ??II trial using ex vivo expanded autologous Mesenchymal Stromal Cells for the treatment of osteoarthritis of the knee confirming safety and suggesting cartilage regeneration
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OAK 3 - Non-arthroplasty tx of OAK
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Background Cellular therapies have shown encouraging results in the treatment of chronic osteoarthritis (OA). Herein, we present the final results of a phase Iâ??II clinical trial assessing the feasibility, safety and efficacy of ex vivo expanded autologous bone marrow Mesenchymal Stromal Cells (MSC, XCEL-M-ALPHA), infused intra-articularly, in patients with knee OA. Methods Fifteen patients (median age = 52 years) with grade II(9) or III(6) gonarthrosis (Kellgren & Lawrence classification) and chronic pain were treated with an intra-articular infusion of 40.9 Ã? 106 ± 0.4 Ã? 106 MSCin a phase Iâ??II prospective, open-label, single-dose, single-arm clinical trial. Endpoints were safety and tolerability. Efficacy was measured by the Visual Analogue Scale for pain, algofunctional Health Assessment Questionnaire, Quality of Life (QoL) SF-36 questionnaire, Lequesne functional index and WOMAC score. Cartilage integrity was assessed by Magnetic Resonance Imaging and quantitative T2-mapping at 0, 6 and 12 months. Results The cell-based product was well tolerated with few reported Adverse Events (mild arthralgia and low back pain). There was a relevant decrease in the intensity of pain since day 8 after the infusion, that was maintained after 12 months. The SF-36 QoL test showed improvement of parameters including bodily pain, role physical and physical functioning at month 12. The health assessment questionnaire revealed a significant decrease of incapacity. Moreover, T2 mapping showed signs of cartilage regeneration in all patients at 12 months post-treatment. Conclusions Single intra-articular infusion of XCEL-M-ALPHA is a safe and well-tolerated cell-based product, associated with a long-lasting amelioration of pain, improvement of QoL (up to four years), and signs of cartilage repair.
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Implanted vascular access device related deep vein thrombosis in oncology patients: A prospective cohort study
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MSTS 2022 - Metastatic Disease of the Humerus
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BACKGROUND: Implanted vascular access devices (IVADs) have significantly improved the management of cancer patients. These patients are at an increased risk of venous thromboembolism and IVADs are a known risk factor. We sought to assess the incidence of IVAD-related upper extremity deep vein thrombosis (IVAD-related UEDVT) associated with BioFlo R IVADs (Angiodynamics, Inc.).
METHODS: A total of 394 cancer patients were enrolled over 12months. The primary outcome was the incidence of IVAD-related UEDVT confirmed by diagnostic imaging. IVAD-related UEDVT was defined as symptomatic ipsilateral upper extremity (axillary vein or proximal) deep vein thrombosis and symptomatic pulmonary embolism (PE). Patients were followed until initiation of therapeutic anticoagulation, catheter removal, death, or up to 12months.
RESULTS: 389 patients were included in the analysis. The median age of the cohort was 58.2years; 68% (n=273) were females. Sixty-six percent had gastrointestional cancer (including pancreatic cancer) and 68% had metastases. Eighty four percent of IVADs were right sided insertions. Ninety eight percent of catheter tip placements were distal superior vena cava (n=237), cavo-atrial junction (n=67) or atrium (n=90). Overall, 5 patients had symptomatic IVAD-related UEDVT (1.29%, 95% CI 0.2 to 2.4%).
CONCLUSION: IVAD-related UEDVT is an infrequent complication in cancer patients with BioFlo R IVADs.
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Outcomes of Newer Generation Cementless Total Knee Arthroplasty: Beaded Periapatite-Coated vs Highly Porous Titanium-Coated Implants
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OAK 3 - Non-arthroplasty tx of OAK
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Background Newer generation cementless total knee arthroplasty (TKA) designs are available and have novel implant coatings. We evaluated and compared beaded periapatite (PA)-coated vs highly porous titanium-coated cementless TKAs. Specifically, we compared: (1) survivorship, (2) Knee Society Scores (KSSs) and range of motion, (3) complications, and (4) radiographic findings. Methods There were 805 TKAs with beaded PA-coated tibial and patellar components (PA group; mean age 67 years; range 41-86 years), and 219 TKAs with highly porous titanium-coated tibial and patella components (mean age 66 years; range 34-88 years). Mean follow-up was 4.4 years (range 2-9 years; median 4 years). Implant survivorship was calculated using Kaplan-Meier curves. Student t-tests and chi-square tests were used as appropriate. Radiographic evaluation was performed using Knee Society Roentgenographic Evaluation and Scoring System. Results All-cause implant survivorship in beaded PA-coated group was 99.5% (95% CI, 97.9%-99.9%) and 99.5% (95% CI, 92.7%-99.9%) in highly porous titanium-coated group. There were no significant differences in the KSS for pain and function. Improvement in flexion and extension was similar in the 2 groups. Overall, complication rate (2.2% vs 2.3%; P = .274) and number of revisions (6 [0.8%] vs 2 [0.2%]; P = .936) were similar in the 2 groups. Excluding the aseptic and septic failures, there were no progressive radiolucencies or osteolysis on radiographic evaluation. Conclusion This study has shown good clinical and patient-reported outcomes of cementless TKA for both implants. Future multicenter large scale clinical and cost-effectiveness studies are needed to determine the superiority of one cementless implant type over the other.
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Emergency department evaluation and treatment of acute hip and thigh pain
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Developmental Dysplasia of the Hip 2020 Review
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Although the incidence of hip fractures is decreasing, the overall prevalence continues to increase because of an aging population. People older than 65 suffer fractures at a rate of 0.6% per year--2% per year for persons older than 85. One in 5 patients suffering a hip fracture will die within a year. Additionally, the emergency physician must consider entities such as avascular necrosis, compartment syndrome, and muscular disruption. This article reviews patterns and complications of acute hip and thigh injuries and clinically relevant diagnostic, anesthetic, and treatment options that facilitate timely, appropriate, and effective emergency department management.
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Do we underestimate the predictive value of the ulnar styloid affection in Colles fractures?
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Distal Radius Fractures
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Various radiographic factors have been suggested as predictively important when dealing with an unstable distal radius fracture. Accordingly, many classification systems have been established in order to give an accurate description of a fracture and to grade the seriousness of the injury. In this paper, we use the classification of Colles fractures introduced by Frykman to investigate the predictive value of a concomitant fracture of the ulnar styloid. We found styloid affection to be a better predictor of a poor outcome than intra-articularity, but the combination carries the worst prognosis. We therefore suggest that a fracture of the distal radius associated with those two types of injuries should be considered for surgical treatment.
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Adjuvant therapy and prognosis in uterine carcinosarcoma
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MSTS 2022 - Metastatic Disease of the Humerus
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Purpose: To investigate the prognostic factors and impact of adjuvant treatment on uterine carcinosarcoma (UCS). Methods: A retrospective review of UCS patients treated between 2005 and 2019 was conducted. International Federation of Gynecology and Obstetrics (FIGO) 2009 staging system was used. Multivariate stepwise Cox proportional hazard regression models were used to identify the independent predictors of overall survival (OS) and progression-free survival (PFS). Results: A total of 138 patients were eligible for descriptive analysis. Excluding 12 patients without surgery, 126 patients with adequate clinicopathologic data were included for prognostic analysis. The median follow-up for survivors was 51.8 months. 5-year OS and PFS rates for FIGO stage I, II, III, IV were 64.5% and 51.8%, 60.8% and 57.7%, 47.7% and 45.9%, 5.1% and 4.1%, respectively. By multivariate analysis, six models each for PFS and OS were formulated including highly correlated variables alternatively. Adjuvant chemoradiation was consistently selected as an independent prognostic factor for OS (hazard ratio [HR] 0.10–0.22, all p < 0.001) and PFS (HR 0.12–0.23, all p < 0.001), while adjuvant chemotherapy (HR 0.33–0.41), age=58 years (HR 1.80–1.91), stage III/IV (HR 3.36–13.34), and adnexal metastasis (HR 2.06–5.02) in three to four of the six models for OS. Stratified analyses revealed that adjuvant chemoradiation significantly improved outcome compared with adjuvant chemotherapy for stage IA patients with lymphovascular space invasion and stage IB-IV, lymph node metastasis, and adnexal metastasis. Conclusion: Adjuvant chemoradiation was confirmed as an independent good prognostic factor, while older age, stage III/IV, and adnexal metastasis were associated with poor outcome in UCS.
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Clinical benefits and considerations of bisphosphonate treatment in metastatic bone disease
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MSTS 2018 - Femur Mets and MM
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Patients with metastatic bone disease are at risk for developing skeletal-related events that can negatively influence quality of life, contributing to loss of autonomy and functional capabilities. Bisphosphonates have become an important component in the treatment of patients with bone metastases as they delay the onset and reduce the risk of skeletal-related events and also palliate or control bone pain in multiple cancer types, thus preserving quality of life. Zoledronic acid has proven efficacy and safety in patients with bone lesions from breast cancer, prostate cancer, lung cancer, and other solid tumors, as well as in patients with multiple myeloma. Current data suggest that early treatment with zoledronic acid (before the onset of bone pain) may provide additional clinical benefits and also positive effects on survival in subsets of patients who have elevated levels of N-telopeptide of type I collagen (NTX), a biochemical marker of bone resorption. Studies have shown that in patients with breast cancer, prostate cancer, lung cancer, or other solid tumors, normalization of elevated levels of NTX was observed in the majority of patients who received zoledronic acid. Furthermore, normalization of NTX values correlated with extended survival. [References: 50]
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0 |
Proteinases and sialyltransferase in human breast tumors
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MSTS 2018 - Femur Mets and MM
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Proteolytic and sialyltransferase activities were determined in extracts of 65 human primary breast tumors, 6 lymph node metastases, 6 fibroadenomas and 27 normal tissues. Using proteins and synthetic selective substrates, we observed the presence of collagen-peptidases, plasminogen activator, cathepsin-B and cathepsin-D-like enzymes, and sialyltransferase. No active or trypsin-activatable type-IV collagenase activity was detected. Although individual variations between tumors were large, proteinase and sialyltransferase contents were significantly elevated in malignant breast tissues. Enzyme activities were found to be related to the epithelial volume of the tumor. No significant correlation was found between the proteinase or sialyltransferase activities and the degree of differentiation of the tumor cells, or the degree to which tumors had metastasized to regional lymph nodes. Since large variations of enzyme levels apparently reflect the heterogeneity of epithelial cell densities in tumor samples, proteolytic or sialyltransferase activities cannot therefore be used as a measure of quantitative evaluation of invasive properties in breast cancer.
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1 |
The acute compartment syndrome following fractures of the lower leg in children
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DOD - Acute Comp Syndrome CPG
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INTRODUCTION: The acute compartment syndrome (ACS) of the lower leg is a rare but serious complication following either fractures or soft tissue injuries. An acute intervention consisting of fasciotomy is indicated as ACS may cause muscle and nerve damage. The aim of the present study was to evaluate the cause, the incidence, the time to fasciotomy and the outcome of ACS of the lower leg following fractures in a paediatric population.
PATIENTS AND METHODS: A retrospective analysis of all patients with ACS following a fracture of the lower leg treated from 1998 to 2010 was performed. The time from admission to occurrence of the ACS, the kind of fracture and surgical treatment was evaluated. Accident mechanisms were recorded.
RESULTS: A total of 1028 fractures of the lower leg were treated. 31 patients (3%) with a median age of 14.6 years (range 7.3-17.1 years) developed an ACS. In the group of patients younger than 12 years the incidence was even lower (1.3%). 81% of injuries leading to ACS were caused by high-energy trauma, with motorcycle accidents being the most common (45%). External fixation was used in 45%, including all open fractures. The diagnosis of an ACS was primarily based on clinical symptoms. In 23 cases an intracompartmental pressure of median 55mmHg (range 40-100mmHg) were measured. ACS was diagnosed after 19h mean (range: 1.5-65h). There was a tendency that the ACS occurred earlier after high-energy trauma than after low energy trauma (mean 16.9 vs. mean 28h). No complications linked to the compartment syndrome were observed.
DISCUSSION: ACS can occur up to 65h after an accident and therefore clinical monitoring is fundamental in order to be able to surgically intervene as soon as possible when needed. With early decompression complications can be prevented.
Copyright © 2012 Elsevier Ltd. All rights reserved.
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1 |
Responder analysis and correlation of outcome measures: pooled results from two identical studies comparing etoricoxib, celecoxib, and placebo in osteoarthritis
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Non-Arthroplasty Treatment of Osteoarthritis of the Knee AUC
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OBJECTIVES: To determine the proportion of responders in two identical osteoarthritis (OA) trials using Outcome Measures in Arthritis Clinical Trials-Osteoarthritis Research Society International (OMERACT-OARSI) criteria and to assess the comparability and correlation of individual component measurements. METHODS: Data were pooled from two identical 26-week, double-blind, randomized, parallel, multicenter trials comparing once daily etoricoxib 30 mg (N=475), celecoxib 200 mg (N=488), and placebo (N=244) in patients with OA of the knee or hip. OMERACT-OARSI criteria were (1) improvement in pain or physical function > or =50% and an absolute change > or =20 mm on a 100-mm visual analog scale (VAS); or (2) improvement of > or =20% and with an absolute change > or =10 mm in at least two of the following three categories: pain, physical function, and patient's global assessment. Correlations were assessed between endpoints measured as time-weighted average change from baseline over 12 weeks using Pearson's correlation coefficient (r). RESULTS: There were significantly greater proportions of responders in the etoricoxib (66.2%) and celecoxib (63.5%) groups compared with the placebo group (43.0%; P<0.001). There was no difference between the two active treatment groups. There was high correlation between pain and physical function (r=0.903), pain and global assessment (r=0.778), and physical function and global assessment (r=0.820). There was high sensitivity (75-87%) and specificity (80-96%) for changes in individual component measurements to predict OMERACT-OARSI responders. CONCLUSIONS: Significantly more patients receiving etoricoxib or celecoxib than placebo were OMERACT-OARSI responders. The high correlation between individual scales composing this composite response measurement suggests some redundancies between individual components, particularly between pain and physical function
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1 |
Intraoperative Infiltration of Liposomal Bupivacaine vs Bupivacaine Hydrochloride for Pain Management in Primary Total Hip Arthroplasty: A Prospective Randomized Trial
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AAHKS (8) Anesthetic Infiltration
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BACKGROUND: Pain management after total hip arthroplasty is well studied. Nevertheless, there is no consensus regarding the "cocktail" to use in periarticular infiltration (PAI). Liposomal bupivacaine (LB) is a slow release local anesthetic that can be infiltrated during surgery. In this study, we compared LB to bupivacaine hydrochloride (HCL).
METHODS: Between September 2014 and March 2016, 181 patients were screened for this prospective randomized trial. A total of 107 patients were enrolled and studied. Patients were separated into LB and control groups. LB group (50) received PAI with LB and bupivacaine HCL with epinephrine and the control group (57) received PAI with bupivacaine HCL and epinephrine. Patient morphine equivalent consumption, pain score estimated on visual analog scale, time to first ambulation greater than 20 feet, time to discharge, drug-related side effects, and patient falls were documented. Data were collected up to 72 hours postoperation.
RESULTS: There was no significant difference in morphine equivalent consumption in any of the 12-hour time blocks, up to 72 hours. No patient falls were documented in either group. Time to first ambulation greater than 20 feet, ambulation same day as surgery, time to discharge, and drug-related side effects were not significantly different between groups.
CONLCUSION: Intraoperative PAI with LB did not result in significant differences in postoperative opioid consumption, pain scores, opioid-related side effects, time to first ambulation, and length of stay up to 72 hours following total hip arthroplasty compared to a control group.
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0 |
A 10-Year Retrospective Study of 490 Hip Fracture Patients: Reoperations, Direct Medical Costs, and Survival
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Hip Fx in the Elderly 2019
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BACKGROUND AND AIMS: Reoperations after operative treatment of hip fracture patients may be associated with higher costs and inferior survival. We examined the acute hospital costs, long-term reoperation rates, and survival of patients with a new hip fracture.
MATERIALS AND METHODS: A total of 490 consecutive new hip fracture patients treated at a single center between 31 December 2004 and 6 December 2006 were analyzed retrospectively. Fractures were classified according to Garden and AO. All medical records were checked manually. The costs of reoperations were calculated using the diagnosis-related groups (DRG)-based prices. Survival analysis was performed using the life-table method. The follow-up time was 10 years.
RESULTS: In all, 70/490 patients (14.3%) needed reoperations. Of all reoperations, 34.2% were performed during the first month and 72.9% within 1 year after the primary operation. The hemiarthroplasty dislocation rate was 8.5%, and mechanical failures of osteosynthesis occurred in 6.2%. Alcohol abuse was associated with a heightened risk of reoperation. The mean direct costs of primary fracture care were lower than the mean costs of reoperations (7500 vs 9800). The mortality rate at 10 years was 79.8% among non-reoperated patients and 62.9% among reoperated patients.
CONCLUSIONS: According to our hypothesis, the cost per patient of reoperation in acute care was 31% higher than the corresponding cost of a primary operation. Reoperations increased the overall immediate costs of index fractures by nearly 20%. One-third of all reoperations were performed during the first month and almost 75% within 1 year after the primary operation.
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Intra-articular zoledronic acid in a rat osteoarthritis model: significant reduced synovitis may indicate chondroprotective effect
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OAK 3 - Non-arthroplasty tx of OAK
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PURPOSE: The aim of this experimental study was to evaluate the effect of intra-articular application of zoledronic acid (ZA) on joint cartilage and synovial tissue following induction of knee osteoarthritis (OA) in a rat model. METHODS: An OA model was created by anterior cruciate ligament transection (ACLT) in the right knees of 48 adult Wistar albino rats. The rats were randomized into a study and control groups, each including 24 rats, and 10 μg of ZA was injected in 0.1 ml of sterile saline to 24 animals in the study group on the first day to operation and was repeated weekly until the rats were killed. The same volume of sterile saline was injected with the same schedule to the control group. Eight rats from both the study and control groups were killed, each time, on the 4th day, the 3rd week, and the 6th week after the operation. The groups were compared based on the histological scores of synovitis and cartilage destruction and the evaluation of serum markers. CONCLUSION: Intra- articular zoledronic acid may suppress synovial inflammation. Furthermore, Zoledronic Acid does not reduce cartilage degeneration in early osteoarthritis models, but may provide some chondroprotective effect in ACLT- induced knee osteoarthritis model in rats. RESULTS: Histological score indicates progression of synovitis was significantly less in the study group (p = 0.047). There was significant increase in the mean Mankin cartilage damage score in the control group (p = 0.021), while no significant change was found in the study group. When the two groups were compared over time, no statistically significant difference was detected in total histological scores, although there was a 47 % less incidence of cartilage tissue damage in the study group and better cartilage structure and tide mark integrity scores were also detected in the study group (p = 0.017 and p = 0.021, respectively).
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1 |
Graft selection in anterior cruciate ligament reconstruction--prospective analysis of patellar tendon autografts compared with allografts
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Anterior Cruciate Ligament Injuries CPG
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A prospective study of 73 arthroscopic anterior cruciate ligament reconstructions using either a patellar tendon autograft or an allograft was made to assess any difference in clinical outcome. Allocation was by availability of an allograft. There were 48 autografts and 25 allografts. Evaluation was by clinical examination and physical tests. At follow-up 2 years after operation, there were no statistically significant differences between the two groups in mobility or in physical tests, but KT-1000 evaluation showed a slightly greater anterior translation in the autografts at 6 months and one year, although at 2 years the allografts developed greater anterior laxity. Cybex testing showed greater quadriceps strength at 6 months and one year in the allografts, but at 2 years the strength was greater in the autografts. Re-rupture occurred in 3 allografts. ACL reconstruction with a patellar tendon allograft does not produce a significant functional deficit. Full quadriceps recovery takes 2 years. Allografts are not recommended as stability deteriorates with time
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1 |
Anterior cruciate ligament and meniscal injuries in sports: incidence, time of practice until injury, and limitations caused after trauma
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AMP (Acute Meniscal Pathology)
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OBJECTIVE: To analyze the incidence of ACL and meniscal injuries in a population of recreational and elite athletes from Brazil and the relation of these injuries with their sports activities.
METHODS: This was a prospective observational study of 240 patients with ACL and/or meniscal injuries submitted to surgical treatment. Data of patients and sport modality, as well as Tegner score were registered in the first clinical evaluation. The patients were divided into three groups: (1) isolated rupture of the ACL; (2) ACL injury associated with meniscal injury; (3) isolated menisci injury.
RESULTS: The majority of the patients belonged to group 1 (44.58%), followed by group 2 (30.2%) and 3 (25%). Most patients were soccer players. The mean time from sport practice to injury in group 1 was 17.81 years. In group 2, it was 17.3 years, and in group 3, 26.91 years. Soccer athletes presented ACL injury in 0.523/1000 h of practice and meniscal injury in 0.448/1000 h of practice. Before the injury, the mean Tegner score obtained for groups 1, 2, and 3 were 7.18, 7.34, and 6.53, respectively. After knee injury, those values were 3.07, 3.18, and 2.87, respectively.
CONCLUSION: Soccer was the sport that caused the majority of lesions, regardless the group. Furthermore, patients from groups 1 and 2 had less time of practice prior to the injury (17.81 and 17.3 years) than the patients of group 3 (26.91 years). Women presented a higher risk to develop ACL and meniscal injuries in 1000 h of game/practice. Running, volleyball, and weightlifting are in ascending order of risk for ACL and/or meniscal injury. Regarding the return to sport practice, the efficiency of all athletes was impaired because of the injury.
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0 |
Balneotherapy in the treatment of knee osteoarthritis: A controlled study
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OAK 3 - Non-arthroplasty tx of OAK
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Objectives: This study aims to evaluate the efficacy of combined balneotherapy and physical therapy compared to physical therapy alone in the treatment of patients with knee osteoarthritis. Patients and methods: Forty-six patients (10 males, 36 females; mean age 70.82±7.78 years; range 57 to 85 years) with knee osteoarthritis were included in this study. Patients were assigned as group 1 and 2. Patients in group 1 (n=27) were treated with physical therapy alone, while patients in group 2 (n=19) were treated with balneotherapy combined to the same physical therapy protocol. All patients had physical therapy consisting of hot pack, transcutaneous electrical nerve stimulation, and ultrasonography for knee region, 45 minutes per day, five days a week for a total duration of three weeks. On the other hand, patients in group 2 also had daily balneotherapy sessions lasting 20 minutes, five days a week, again for three weeks duration. The demographic data and clinical features of the patients were recorded. Sickness impact profile was used for the evaluation of disease severity. Evaluation parameters also included visual analog scale, Western Ontario and McMaster Universities Arthritis Index, 10-meter walking test, and the use of analgesic drugs. Tests were performed both at baseline before treatment and at the end of the third week after treatment. Results: There were no significant differences between the two groups in terms of socio-demographic features. In both groups, significant improvements were observed for all of the measured variables (all p values <0.01). Moreover, group 2 had significantly superior improvements in all of the parameters compared to group 1 (all p values <0.05). Conclusion: Combined balneotherapy and physical therapy seems to be more effective in advanced knee osteoarthritis for improving pain, physical function and walking speed, compared to physical therapy alone.
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Patient-oriented outcome measure and risk of knee replacement surgery for the Japanese knee osteoarthritis patients with kellegren-laurence graDe 4
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Surgical Management of Osteoarthritis of the Knee CPG
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Purpose: Total knee arthroplasty (TKA) is an effective therapy to control pain and improve function in subjects with severe knee osteoarthritis (OA). However, as the decision whether to have a joint replacement or not is more ambiguous, it is a judgment that has to be maDe by the physician and patient working together, and it has to take account of a disability of the patient, in addition to X-ray changes. It is also revealed that there are regional differences for the indication of TKA. For physicians, objective indicators which represent the past results of patients already received TKA are helpful to discuss with patients who are considering their decision to TKA. The use of clinical outcomes in clinical medicine is important. The Japanese Knee Osteoarthritis Measure (JKOM) was created as a patientoriented outcome measure for Japanese patients with knee OA. This measure has proven to have sufficient reliability and validity by means of statistical evaluation and comparison with the WOMAC and SF-36. The aim of this study was to examine whether the JKOM score can predict the risk for receiving TKA, and, if so, the cut-off of JKOM score can be set for receiving TKA. Methods: This study protocol was approved by the institutional review board of our university. 227 painful medial knee OA patients with K/L 4 were enrolled in this study. JKOM score was obtained from all subjects on the day that radiographs taken. The significant differences of the data were evaluated using the Mann Whitney-U test. The AUC, which is analogous to the area under the ROC curve, was estimated for the discriminative value of prediction models. Odds ratios (ORs) were calculated to evaluate the JKOM cut-off score for receiving TKA. Results: In this study, patients were followed for 6 months on average. While 63% of the patients were received TKA (OP group), remaining 37% were not (NOOP group). No gender distribution (87.2% was female in total), age (73.1 y on average) and BMI (25.4 kg/m(2)) differences were observed between OP group and NOOP group, respectively. On the other hands, JSW of medial tibio-femoral knee joint of OP group (0.4mm) was significantly reduced in comparison to that of NOOP group (0.9mm) (p < 0.001). FTA of OP group (189.0(degrees)) was significantly increased in comparison to that of NOOP group (184.5(degrees)) (p < 0.001). Pain VAS and JKOM score of OP group (72.7 and 56.5) were significantly increased in comparison to those of NOOP group (60.5 and 38.5), respectively (p < 0.001). The AUC in ROC curve of JSW and FTA were 0.25 (95% CIs; 0.16, 0.35) and 0.67 (95% CIs; 0.55, 0.78), respectively. The AUC in ROC curve of pain VAS score and JKOM score were 0.66 (0.58, 0.74) and 0.74 (0.67, 0.81), respectively. The cut-off of FTA calculated by ROC curve was found at 189(degrees) and the ORs at 189(degrees) of FTA for receiving TKA was 5.90 (95% CIs; 2.54, 13.71). The cut-off of pain VAS score calculated by ROC curve was found at 78 point and the ORs at 78 point of VAS score for receiving TKA was 3.71 (95% CIs; 1.94, 7.07). The cut-off of JKOM score calculated by ROC curve was found at 42 point and the ORs at 42 point of JKOM score for receiving TKA was 5.18 (95% CIs; 2.86, 9.36). Conclusions: The first conclusion of this study is that among severe knee OA Japanese patients with K/L graDe 4, JKOM scores were predictive of future indication for TKA. The second conclusion is that we found a cutoff point of JKOM score that relatively accurately discriminated Japanese patients who did vs did not receive TKA, as the AUCs for ROC curves were higher than 0.65 (0.74). In addition, JKOM score was more predictive than VAS score and FTA, and the ORs of JKOM score for receiving TKA was 5.18. Therefore, JKOM score would be one of the novel indicators for Japanese patients with severe knee OA which are helpful for physicians to discuss with patients who are considering their decision to TKA
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0 |
Influence of patient age on the susceptibility patterns of Streptococcus pneumoniae isolates in North America (2000-2001): Report from the SENTRY Antimicrobial Surveillance Program
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Patrick’s pharmacoepidemiology project
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Risks of developing resistance in Streptococcus pneumoniae can be greatly influenced by antimicrobial use that is often dictated by patterns of prescribing at various patient ages. The results from the SENTRY Antimicrobial Surveillance Program (2000-2001; North America) were examined for differing susceptibility profiles (25 antimicrobials) indexed by five patient age groups. All MIC results were from reference methods performed in central laboratories. Pneumococcal resistance rates in the youngest patient group (0-5 years) were significantly (p < 0.05) higher for penicillin, other �²-lactams, macrolides, tetracyclines and trimethoprim/sulfamethoxazole. In contrast, fluoroquinolone resistance in S. pneumoniae was greatest in the patients â�¥ 65 years (1.4% resistance to gatifloxacin, levofloxacin and moxifloxacin), where use of this class has been escalating. Continued local and global surveillance of resistances in common respiratory tract pathogens such as S. pneumoniae appears to be prudent practice to guide effective chemotherapy. �© 2003 Elsevier Inc. All rights reserved
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0 |
Prevalence and risk factors of radiographic vertebral fracture in postmenopausal Vietnamese women
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Management of Hip Fractures in the Elderly
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Background: Vertebral fracture is associated with an increased risk of atraumatic fracture and mortality. The prevalence of vertebral fractures among postmenopausal Caucasian women has been reported to range between 15% and 35%. Because there is no estimate of the magnitude of the problem in Vietnam, we undertook this study to estimate the prevalence and risk factors of vertebral fracture in Vietnam. Methods: Radiographs were taken from 209 postmenopausal women aged between 50 and 85 years (average 62) who were randomly sampled from various districts in Ho Chi Minh City. The presence of vertebral fracture was assessed by the Genant's semi-quantitative method with two independent readers. Bone mineral density (BMD) at the lumbar spine (LS), femoral neck (FN) and whole body was measured by DXA (Hologic QDR4500). Anthropometric and clinical data were obtained by a standardized questionnaire. Results: Among the 209 women, 48 were found to have at least one radiographic vertebral fracture, which yielded a prevalence of 23% (95%CI: 18-29%). Although fracture occurred in all vertebrae, most (83%) occurred at the L1-L5. Most fractures occurred at one vertebra, and only 12% occurred at multiple vertebrae. The prevalence increased with age such that it reached 39% among those aged 70+ years. There was no significant association between vertebral fracture and back pain, fall history, and dietary calcium intake. In simple log-binomial regression analysis, higher risk of vertebral fracture was associated with advancing age (prevalence ratio [PR] per 10 years: 1.40; 1.16-2.05) and lower lumbar spine BMD (PR per SD: 1.51; 1.18-1.92). In multivariable analysis, the two factors remained independently associated with fracture risk, with the area under the receiver operating characteristic curve being 0.66. Conclusions: These data suggest that approximately one out of 4 postmenopausal women in Vietnam have a radiographic vertebral fracture, and this prevalence is as common as in Caucasian populations. The number of women needed to screen to identify one vertebral fracture is about 4 to 5, which seems to be cost-effective. (copyright) 2009 Elsevier Inc. All rights reserved
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1 |
Predictors of posttraumatic stress disorder and symptoms in adults: a meta-analysis
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DoD PRF (Psychosocial RF)
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A review of 2,647 studies of posttraumatic stress disorder (PTSD) yielded 476 potential candidates for a meta-analysis of predictors of PTSD or of its symptoms. From these, 68 studies met criteria for inclusion in a meta-analysis of 7 predictors: (a) prior trauma, (b) prior psychological adjustment, (c) family history of psychopathology, (d) perceived life threat during the trauma, (e) posttrauma social support, (f) peritraumatic emotional responses, and (g) peritraumatic dissociation. All yielded significant effect sizes, with family history, prior trauma, and prior adjustment the smallest (weighted r = .17) and peritraumatic dissociation the largest (weighted r = .35). The results suggest that peritraumatic psychological processes, not prior characteristics, are the strongest predictors of PTSD.
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0 |
Revising Recommendations and Outcome Measurements after Complex Open Abdominal Wall Reconstruction
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Panniculectomy & Abdominoplasty CPG
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Grading systems developed by the Ventral Hernia Working Group (VHWG) for complex open abdominal wall reconstruction rely on limited outcomes: surgical site occurrence (SSO) and hernia recurrence. This does not account for the longitudinal restoration of a functional abdominal wall and the ability to correct complications. We performed a single-site, retrospective review of consecutive complex open abdominal wall reconstruction interventions with 24-month minimum follow-up to establish reoperation rates and compare long-term results to the VHWG. About 125 midline hernia repairs (>200 cm(2)) were studied. All had loss of functional domain and 47-month average follow-up. Demographics included: mean age 57 years, 47 per cent male, 63 per cent obese, and 34 per cent with contamination. Rates of SSO per VHWG grade were 9 per cent grade I, 45 per cent grade II, and 55 per cent grade III. Forty-three of 59 patients who developed complications were eventually successful after reoperation leading to an 87 per cent restoration rate. Select factors independently associated with reoperation included biological mesh and clinical history of infection. Although rates of SSO were higher than the VHWG published, we experienced high salvage rates except in patients who underwent biologic repair. We recommend restricted use of biologic mesh in contaminated and clean fields as well as modifications to the VHWG grading and recommendations.
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1 |
Glenoid component insertion in total shoulder arthroplasty: comparison of three techniques for drying the glenoid before cementation
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Glenohumeral Joint OA
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This prospective randomized study compared the immediate postoperative periglenoid radiolucencies among 3 glenoid-drying techniques used in total shoulder arthroplasty. Seventy-one consecutive patients with primary osteoarthritis underwent total shoulder arthroplasty by use of 1 prosthetic system with convex-back, keeled, polyethylene glenoid components; the same modern, instrumented pressurization technique was used to cement all glenoids. Of the shoulders, 21 had glenoid implants cemented after bony preparation with thrombin-soaked gel foam, 24 after compressed gas lavage, and 26 after saline solution lavage with sponge drying. The immediate postoperative anteroposterior radiographs were examined to evaluate the presence of periglenoid radiolucencies. Of the patients, 29 (41%) had radiolucencies evident immediately postoperatively, with all radiolucencies occurring in the faceplate zones. The mean total radiolucent line score was 0.63 (P = .94), with no significant difference among cementing preparation techniques (P = .89). Prosthetic mismatch did not differ among glenoid preparation techniques (P = .86). There was no statistical association between prosthetic mismatch and radiolucent line score either across (P = .62) or within (P = .99) the glenoid preparation groups. The associated costs in the gel foam group and compressed gas lavage group were 70 times higher than the cost in the saline solution lavage group. All radiolucencies were noted in the faceplate zones, with no radiolucency greater than 2 mm. Preparation of the glenoid surface for cementing showed no significant difference among the 3 techniques studied, although the material costs were significantly higher in the gel foam and compressed gas lavage groups compared with the saline solution lavage group.
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1 |
Comparison of ropivacaine 2 mg ml(-1) and prilocaine 5 mg ml(-1) for i.v. regional anaesthesia in outpatient surgery
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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BACKGROUND: Ropivacaine 2 mg ml(-1) (0.2%) provides longer-lasting analgesia after deflation of the tourniquet cuff, with fewer side-effects, than lidocaine 5 mg ml(-1) (0.5%) after i.v. regional anaesthesia (IVRA). Whether ropivacaine 2 mg ml(-1) also exerts this advantage over prilocaine 5 mg ml(-1), the local anaesthetic of choice in IVRA in most European countries was investigated in this study. METHODS: Sixty outpatients scheduled for forearm or hand surgery received IVRA with 40 ml of ropivacaine 2 mg ml(-1) (Ropi) or prilocaine 5 mg ml(-1) (Prilo) in a randomized, double-blinded fashion. The development and recovery of pin-prick analgesia and motor power of the hand, as well as ropivacaine and prilocaine plasma concentrations (n=30), were assessed during and after operation. RESULTS: Anaesthesia for surgery was adequate in both groups. Pin-prick analgesia was achieved at a similar rate, except in the radial nerve distribution area where at 10 min 60% of Ropi and 90% of Prilo patients had analgesia (P=0.017). At 10 min 100 and 97% had motor block of the hand in the Ropi and Prilo groups, respectively. Recovery of the sensory block in all innervation areas was already observed 2 min after the tourniquet cuff release. At 10 min after releasing the tourniquet cuff 31% of the Ropi patients and none of the Prilo patients still had analgesia in the median nerve distribution (P=0.004). At 12 min, 42% in the Ropi group and none in the Prilo group had decreased grip strength. After the release of the tourniquet, mean plasma concentrations of ropivacaine were higher than those of prilocaine. The highest individual concentration of ropivacaine was 1.65 microg ml(-1) and that of prilocaine 0.6 microg ml(-1). None of the Ropi patients experienced any symptoms of local anaesthetic toxicity. CONCLUSIONS: Compared with prilocaine 5 mg ml(-1), analgesia in IVRA with ropivacaine 2 mg ml(-1) developed slightly more slowly, while motor block developed at a similar rate. After the release of the tourniquet, sensation recovered quickly and at a similar rate in the two groups, except for a slightly slower recovery after ropivacaine in the innervation area of the median nerve, but no surgically useful extended analgesia after the cuff deflation was observed. Despite a 60% lower milligram-dose, ropivacaine plasma concentrations were markedly higher than those of prilocaine
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0 |
Older African American women's lived experiences with depression and coping behaviours
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DoD PRF (Psychosocial RF)
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Little is known about older African American women's lived experiences with depression. What does depression mean to this group? What are they doing about their depression? Unfortunately, these questions are unanswered. This study examined older African American women's lived experiences with depression and coping behaviours. The common sense model provided the theoretical framework for present study. Thirteen community-dwelling African American women aged 60 and older (M = 71 years) participated. Using qualitative phenomenological data analysis, results showed the women held beliefs about factors that can cause depression including experiences of trauma, poverty and disempowerment. Results also indicated the women believed that depression is a normal reaction to life circumstances and did not see the need to seek professional treatment for depression. They coped by use of culturally sanctioned behaviours including religious practices and resilience. It appears these women's beliefs about depression and use of culturally sanctioned coping behaviours might potentially be a barrier to seeking professional mental healthcare, which could result in missed opportunities for early diagnosis and treatment of depression among this group. Implications for research, educational and clinical interventions are discussed.
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0 |
Contribution of each leg to the control of unperturbed bipedal stance in lower limb amputees: new insights using entropy
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DoD LSA (Limb Salvage vs Amputation)
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The present study was designed to assess the relative contribution of each leg to unperturbed bipedal posture in lower limb amputees. To achieve this goal, eight unilateral traumatic trans-femoral amputees (TFA) were asked to stand as still as possible on a plantar pressure data acquisition system with their eyes closed. Four dependent variables were computed to describe the subject's postural behavior: (1) body weight distribution, (2) amplitude, (3) velocity and (4) regularity of centre of foot pressure (CoP) trajectories under the amputated (A) leg and the non-amputated (NA) leg. Results showed a larger body weight distribution applied to the NA leg than to the A leg and a more regular CoP profiles (lower sample entropy values) with greater amplitude and velocity under the NA leg than under the A leg. Taken together, these findings suggest that the NA leg and the A leg do not equally contribute to the control of unperturbed bipedal posture in TFA. The observation that TFA do actively control unperturbed bipedal posture with their NA leg could be viewed as an adaptive process to the loss of the lower leg afferents and efferents because of the unilateral lower-limb amputation. From a methodological point of view, these results demonstrate the suitability of computing bilateral CoP trajectories regularity for the assessment of lateralized postural control under pathological conditions.
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0 |
Outcomes of patients with inflammatory breast cancer by hormone receptor- and HER2-defined molecular subtypes: A population-based study from the SEER program
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MSTS 2022 - Metastatic Disease of the Humerus
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Background: The aim of this study was to evaluate the outcomes of patients with inflammatory breast cancer (IBC), with emphasis on the role of molecular subtypes and radiotherapy. Methods: A retrospective cohort study to investigate overall survival (OS) and breast cancer-specific mortality (BCSM) in patients with IBC was conducted using data obtained by the Surveillance, Epidemiology, and End Results (SEER) program from 2010-2013. Cox multivariate regression was used to calculate the adjusted Hazard Ratios (aHR). Results: 403 patients were eligible for this study. Patients in the group with hormone receptors (HR)+/HER2-subtype had an OS of 79.6% compared with 89.0 % in the group with (HR)+/HER2+ subtype and 76.8% in the HR-/HER2+ group and 62.9% in the triple-negative (TN) group. BCSM was 16.3% for the HR+/HER2-group, 9.8% for the HR+/HER2+ group, 21.7% for the HR-/HER2+ group, and 30.5% for the TN group. For distant metastases, the results showed that there was a high probability of bone metastasis in HR-positive groups, brain and liver metastasis in HER2-positive groups, and lung metastasis in the TN group. Multivariate analysis demonstrated that estrogen receptor and HER2 positivity were associated with better survival and that the TN subtype had a poorer OS and BCSM compared with other subtypes (P < 0.05). Furthermore, patients who received radiotherapy were more likely to have improved survival (P < 0.05). Conclusion: Inflammatory breast cancer appears to alter the prognosis in association with the receptor status and molecular subtypes. Radiotherapy was still considered to be a crucial treatment for patients with IBC.
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Treatment of knee osteoarthritis with acupuncture and moxibustion: a randomized controlled trial
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OAK 3 - Non-arthroplasty tx of OAK
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OBJECTIVE: To compare the difference of the efficacy on knee osteoarthritis (KOA) between the combined therapy of acupuncture and moxibustion and western medication, and explore the better therapeutic method for KOA. METHODS: One hundred and sixty patients were divided into a combined therapy group and a western medication group, 80 cases in each one according to the visit sequence, with the random number table adopted. In the combined therapy group, the main points were selected from the local painful sites, combined with the acupoints based on the syndrome differentiation and distal acupoints on the affected meridians. The lifting, thrusting or rotating technique was used and the reinforcing or reducing manipulation was applied according to the syndrome differentiation. "Duanci" or "Shuci" needling technique was used specially at the extra points and Ashi points. The needling sensation relied on the patients' tolerance. After acupuncture, the heatâ?sensitive moxibustion with pure moxa stick was applied over the local painful sites around knee joint and Shenshu (BL 23) to detect the heatâ?sensitized points. Acupuncture and moxibustion were given once every day. The treatment of 5 days made 1 session. There were 2 days at the interval between two sessions. In the western medication group, glucosamine sulfate capsules were prescribed for oral administration, 2 capsules each time, three times a day. Additionally, the joint cavity injection was combined. On the first day, sodium hyaluronate 25 mg and triamcinolone acetonide acetate 50 mg were injected. Afterwards, on the 8th, 15th, 22nd and 29th days, sodium hyaluronate injection 25 mg was used only. The treatment was for 5 weeks totally in the two groups. The efficacy was analyzed statistically in 5 weeks. The followâ?up visit was conducted in 3 months and 6 months after 5 weeks treatment, respectively. The Western Ontario and Mcmaster Universities Osteoarthritis Index (WOMAC) and visual analogue scale (VAS) were adopted to assess the recovery of joint function. RESULTS: The efficacy in 5 weeks of treatment was different significantly between the two groups (P < 0.05). The efficacy in the western medication group was better than that in the combined therapy group. The difference in the safety assessment was remarkable (P < 0.01). The result in the combined therapy group was superior remarkably to the western medication group. In 3â?month followâ?up visit after treatment, the knee joint function was not different obviously between the two groups (P > 0.05). In 6â?month followup visit after treatment, the knee joint function was different obviously between the two groups (P < 0.01). The result in the combined therapy group was better remarkably than that in the western medication group. CONCLUSION: The combined therapy of acupuncture and moxibustion achieves the safe and effective therapeutic effect with less adverse reactions in the treatment of KOA. The immediate effect in the combined therapy group is not so obvious as compared with the western medication, but the longâ?term efficacy is remarkably superior to western medication.
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Analysis of breast reduction complications derived from the BRAVO study
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Reduction Mammoplasty for Female Breast Hypertrophy
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Background: Analysis of complication data derived from the Breast Reduction Assessment: Value and Outcomes (BRAVO) study, a 9-month prospective, multicenter trial, is presented. Methods: Data derived from 179 patients were analyzed, including bivariate associations between complications and single predictor variables (Fisher's exact test or chi-square testing) or continuous variables (two-sample t test) and, finally, logistic regression. Results: The overall complication rate was 43 percent (77 patients). Simple, bivariate analysis linked preoperative breast volume, shoulder strap grooving, and a vertical incision with an increased incidence of complications (p < 0.05, 0.02, and 0.02, respectively). Delayed wound healing, the most common complication, correlated directly with average preoperative breast volume (p < 0.045), average resection weight/ breast (p < 0.027), and smoking (p < 0.029) and inversely with age (p < 0.011). Vertical incision techniques were associated with an increased complication frequency (p < 0.05) without a link to specific complications. Logistic regression analysis associated resection weight as the sole variable for increased risk of complications (p = 0.05) and with absolute number of complications [mean resection weight of 791 g for patients without complications versus 847, 882, and 1752 g for patients with one, two, and three complications, respectively (p = 0.0022)]. Each 10-fold increase in resection weight increased the risk of complication 4.8 times and increased the risk of delayed healing 11.6 times. Conclusions: Complication data revealed several significant features: (1) resection weight correlated with increased risk and absolute number of complications; (2) delayed healing correlated directly with resection weight and inversely with increasing age, anesthesia times, and preoperative Short Form-36 bodily pain score; (3) a vertical incision may be associated with increased incidence of complications but requires further analysis; and most importantly, (4) the presence of complications had no negative effect on improvement in Short Form-36 and Multidimensional Body-Self Relations Questionnaire scores.
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Diabetes-accelerated experimental osteoarthritis is prevented by autophagy activation
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OAK 3 - Non-arthroplasty tx of OAK
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Objective Type 2 Diabetes (T2D) is a risk factor for osteoarthritis (OA). Autophagy, an essential homeostasis mechanism in articular cartilage, is defective in T2D and OA. However, how T2D may influence OA progression is still unknown. We aimed to determine how diabetes affects cartilage integrity and whether pharmacological activation of autophagy has efficacy in diabetic mice (db/db mice) with OA. Design Experimental OA was performed in the right knee of 9 weeks-old C57Bl/6J male mice (Lean group, NÂ =Â 8) and of 9 weeks-old B6.BKS (D)-Leprdb male mice (db/db group, NÂ =Â 16) by transection of medial meniscotibial and medial collateral ligaments. Left knee was employed as control knee. Rapamycin (2Â mg/kg weight/day) or Vehicle (dimethyl sulfoxide) were administered intraperitoneally three times a week for 10 weeks. Histopathology of articular cartilage and synovium was evaluated by using semiquantitative scoring and synovitis grading systems, respectively. Immunohistochemistry was employed to evaluate the effect of diabetes and Rapamycin on cartilage integrity and OA biomarkers. Results Cartilage damage was increased in db/db mice compared to Lean mice after experimental OA, while no differences are observed in the control knee. Cartilage damage and synovium inflammation were reduced by Rapamycin treatment of OA-db/db mice. This protection was accompanied with a decrease in MMP-13 expression and decreased interleukin 12 (IL-12) levels. Furthermore, autophagy was increased and cartilage cellularity was maintained, suggesting that mammalian target of rapamycin (mTOR) targeting prevents joint physical harm. Conclusion Our findings indicate that diabetic mice exhibit increased joint damage after experimental OA, and that autophagy activation might be an effective therapy for diabetes-accelerated OA.
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Endoscopic management of carpal tunnel syndrome
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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This article describes a subcutaneous endoscopic operative procedure for carpal tunnel syndrome and analyzes its effectiveness using electrophysiological data. Subcutaneous transverse carpal ligament release under universal subcutaneous endoscope (USE) was performed using local anesthesia without pneumotourniquet in 54 hands of 45 patients since June 1986. The mean follow-up period was 13.8 months. Sensory disturbances began to subside immediately after the operation and disappeared within 2 months in all cases. After the disappearance of sensory disturbances, we performed postoperative electrophysiological studies in 27 patients (33 hands). Postoperative electrophysiological data were significantly improved in all cases. Patients did not suffer from any serious complications such as motor branch injuries of the median nerve, hypesthesia of the palm, or injuries of the superficial palmar arch. From these results, we conclude that the transverse carpal ligament can be safely incised by this procedure
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Aetiology and interrelationship of some common skeletal deformities. (Talipes equinovarus and calcaneovalgus, metatarsus varus, congenital dislocation of the hip, and infantile idiopathic scoliosis)
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Developmental Dysplasia of the Hip CPG
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The Edinburgh Register of the Newborn 1964-1968 and the Edinburgh Scoliosis Clinic 1964-1971 have been used to establish the population frequency in the city of the idiopathic forms of talipes equinovarus and calcaneovalgus, metatarsus varus, congenital dislocation of the hip, and infantile scoliosis. A survey of 165 patients now aged 7 to 11 years showed an aetiological relationship, but with differing environmental factors. These factors were established by comparison with the Edinburgh Register control group of 692 normal infants born over the same period, giving a unique opportunity to obtain more accurate antenatal data than has previously been possible. The principal associations were: talipes equinovarus with antepartum haemorrhage and maternal hypertension; metatarsus varus with twin pregnancies; congenital dislocation of the hip with first born children, older than average fathers, breech presentation, a significant lack of menstrual problems in the mother, and maternal upper respiratory infection during pregnancy; infantile idiopathic scoliosis with breech presentation, prematurity, and the onset of the curve in the winter months. No significant association with raised intrauterine pressure (hydramnios or oligohydramnios) was found among these simple idiopathic deformities. It is concluded that the multifactorial genetic background in likely to be similar in all, but that the additional environmental element is variable
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Pasteurella multocida infected total knee arthroplasty: A case report and review of the literature
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Surgical Management of Osteoarthritis of the Knee CPG
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Pasteurella multocida is a rare cause of prosthetic joint infection. This infection generally follows significant animal contact, usually licks and scratches. We report a case of P multocida infection that was treated with linezolid with salvage of the implant. Linezolid is generally active against Gram-positive organisms only with the exception of Pasteurella, which is Gramnegative. We extensively review the previous reported cases of implant infection with P multocida
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Computer navigated total knee arthroplasty: aspects of a single unit's experience of 777 cases
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Surgical Management of Osteoarthritis of the Knee CPG
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The use of computer navigation and conventional techniques in total knee arthroplasty remains controversial. Advocates of computer navigated techniques cite better alignment of components and reduced morbidity associated with avoidance of intramedullary instrumentation as a rationale for their use. In contrast, proponents of conventional techniques argue that better alignment does not correlate with a better functional outcome and that the conventional approach avoids the perceived risk of fracture associated with bicortical insertion of navigation tracker pins. All total knee arthoplasties performed at our institution are prospectively monitored for life in a dedicated Joint Replacement Assessment Clinic (JRAC). Patients are reviewed by physiotherapists, independent of the surgeons who performed surgery, both preoperatively and at six weeks, three and six months, and one, two and five years postoperatively (and every five years thereafter). Patients are assessed using validated outcome measures (Knee Society Score, Western Ontario and McMaster Universities (WOMAC) osteoarthritis index, Short Form SF-36 Health Survey (version 2) and a patient satisfaction score). In addition, at 6 months post surgery, a CT scan of each implanted prosthesis is performed using the Perth CT knee protocol. The findings of a single unit's experience of 777 navigated primary total knee replacements are discussed and critically compared to the body of literature that currently relates to this controversial topic
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Local tranexamic acid plus diluted epinephrine vs. Intravenous tranexamic acid for reducing bleeding in revision total hip arthroplasty
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AAHKS (8) Anesthetic Infiltration
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Background: Total joint replacement surgery is associated with large amounts of blood loss and significant rates of transfusions .Postoperative bleeding is one of the most important problems after major orthopedic surgeries including revision Total Hip Arthroplasty (THA). It has been demonstrate that Tranexamic acid is a useful agent to control the volume of blood loss. However, the more effective route of TXA administration remained controversial. Methods: In current study, we compared the effects of local and intravenous(IV) administration of TXA on need to blood transfusion and hemoglobin drop. We randomized 80 patients undergoing revision THA into two groups: local group and IV group. In group IV 40 patients was administrated TXA 4 g alone systemically and in local group 40 patients the joint was irrigated with 4 g of TXA plus 0.33mg DEP (1:200,000). Results: The level of Hb was measured before and after operation and the rate of Hb drop was compared. Also, the blood transfused were compared in two group. Results showed topical TXA plus DEP substantially reduced total blood loss, hidden blood loss and transfusion rate compared with TXA alone, without increasing the risks of hemodynamic complexity. Conclusion: We conclude that local use of TXA plus DEP was crucially effective and safe option compared with intravenous TXA alone in reducing total and hidden blood loss and transfusion rate following revision THA without considerable complications.
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Expression of tumour necrosis factor alpha and its receptors in carcinoma of the breast
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Reduction Mammoplasty for Female Breast Hypertrophy
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The expression of tumour necrosis factor alpha (TNF-alpha) and its two distinct receptors, TNF-R p55 and TNF-R p75, was assessed by immunocytochemistry in 28 primary breast cancer and three reduction mammoplasty specimens ('normal' breast tissue). Expression of TNF-alpha or TNF-R p75 was not detectable in normal breast tissue or in non-malignant breast tissue adjacent to the tumours. By contrast, TNF-R p55 was expressed by occasional stromal cells in normal tissue. TNF-alpha was expressed focally in 50% of the tumours studied, being largely localised to macrophage-like cells in the stroma. TNF-R p55 was expressed by a population of stromal cells in all the tumours examined, and a varying proportion of neoplastic cells in 75% of these tissues. TNF-R p75 was detected in about 70% of the tumours, immunoreactivity being confined mainly to cells in the stroma. In this preliminary study there was no association between the above cytokine parameters and such measures of tumour biology as lymph node status, tumour grade, proliferative activity or degree of angiogenesis. However, there was a correlation between the expression of TNF-R p55 by blood vessels and the number of leucocytes present.
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Surgical versus conservative interventions for treating ankle fractures in adults
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SR for PM on OA of All Extremities
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BACKGROUND: The annual incidence of ankle fractures is 122 per 100,000 people. They usually affect young men and older women. The question of whether surgery or conservative treatment should be used for ankle fractures remains controversial. OBJECTIVES: To assess the effects of surgical versus conservative interventions for treating ankle fractures in adults. SEARCH METHODS: We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, the Cochrane Central Register of Controlled Trials (The Cochrane Library, 2012 Issue 1), MEDLINE, EMBASE, CINAHL and the WHO International Clinical Trials Registry Platform and Current Controlled Trials. Date of last search: 6 February 2012. SELECTION CRITERIA: Randomised and quasi-randomised controlled clinical studies comparing surgical and conservative treatments for ankle fractures in adults were included. DATA COLLECTION AND ANALYSIS: Two review authors independently performed study selection, risk of bias assessment and data extraction. Authors of the included studies were contacted to obtain original data. MAIN RESULTS: Three randomised controlled trials and one quasi-randomised controlled trial were included. These involved a total of 292 participants with ankle fractures. All studies were at high risk of bias from lack of blinding. Additionally, loss to follow-up or inappropriate exclusion of participants put two trials at high risk of attrition bias. The trials used different and incompatible outcome measures for assessing function and pain. Only limited meta-analysis was possible for early treatment failure, some adverse events and radiological signs of arthritis.One trial, following up 92 of 111 randomised participants, found no statistically significant differences between surgery and conservative treatment in patient-reported symptoms (self assessed ankle "troubles": 11/43 versus 14/49; risk ratio (RR) 0.90, 95% CI 0.46 to 1.76) or walking difficulties at seven years follow-up. One trial, reporting data for 31 of 43 randomised participants, found a statistically significantly better mean Olerud score in the surgically treated group but no difference between the two groups in pain scores after a mean follow-up of 27 months. A third trial, reporting data for 49 of 96 randomised participants at 3.5 years follow-up, reported no difference between the two groups in a non-validated clinical score.Early treatment failure, generally reflecting the failure of closed reduction (criteria not reported in two trials) probably or explicitly leading to surgery in patients allocated conservative treatment, was significantly higher in the conservative treatment group (2/116 versus 19/129; RR 0.18, 95% CI 0.06 to 0.54). Otherwise, there were no statistically significant differences between the two groups in any of the reported complications. Pooled results from two trials of participants with radiological signs of osteoarthritis at averages of 3.5 and 7.0 years follow-up showed no between-group differences (44/66 versus 50/75; RR 1.05, 95% CI 0.83 to 1.31). AUTHORS' CONCLUSIONS: There is currently insufficient evidence to conclude whether surgical or conservative treatment produces superior long-term outcomes for ankle fractures in adults. The identification of several ongoing randomised trials means that better evidence to inform this question is likely to be available in future
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Routine Follow-Up Radiographs for Ankle Fractures Seldom Add Value to Clinical Decision-Making: A Retrospective, Observational Study
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DoD PRF (Psychosocial RF)
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Currently, the routine use of radiographs for uncomplicated ankle fractures represents good clinical practice. However, radiographs are associated with waiting time, radiation exposure, and costs. Studies have suggested that radiographs seldom alter the treatment strategy if no clinical indication for the imaging study was present. The objective of the present study was to evaluate the effect of routine radiographs on the treatment strategy during the follow-up period of ankle fractures. All patients aged â?¥18 years, who had visited 1 of the participating clinics with an eligible ankle fracture in 2012 and with complete follow-up data were included. The data were retrospectively analyzed. The sociodemographic and clinical characteristics and the number of, and indications for, the radiographs taken were collected from the medical records of the participating clinics. We assessed the changes in treatment strategy according to the radiographic findings. In 528 patients with an ankle fracture, 1174 radiographs were performed during the follow-up period. Of these radiographs, 936 (79.7%) were considered routine. Of the routine radiographs taken during the follow-up period, only 11 (1.2 %) resulted in changes to the treatment strategy. Although it is common practice to take radiographs routinely during the follow-up period for ankle fractures, the results from the present study suggest that routine radiographs seldom alter the treatment strategy. This limited clinical relevance should be weighed against the health care costs and radiation exposure associated with the use of routine radiographs. For a definitive recommendation, however, the results of our study should be confirmed by a prospective trial, which we are currently conducting.
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Patient's experiences of RA vs GA for orthopedic surgery
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Surgical Management of Osteoarthritis of the Knee CPG
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Introduction: The practice of evidence-based medicine stipulates the need for physicians to take into account patient preferences. Empirical research as to how patients can be meaningful engaged in their care is scarce1. It is reported that patients continue to have misgivings and fears about regional anesthesia2 (RA) despite strong evidence to support its use, compared to general anesthesia, for major orthopedic surgery. Patients who have regional anesthesia have reduced morbidity and mortality and improved pain control after surgery compared to those who have general anaesthesia3. However, variation in the use of RA continues. To date, no one has studied the experiences of patients who have undergone both types of anesthesia for hip or knee replacement as a means of understanding the patient preference implications for orthopaedic surgery. Methods: Local ethics committee approval was obtained for this study. Using descriptive qualitative methods, twelve patients were interviewed using purposeful sampling4 until the team determined that saturation had been reached. Six participants had undergone knee arthroplasty, five had undergone hip arthroplasty, and one patient had both hip and knee replacements. Two patients had undergone general anesthesia for both surgeries as a control to see if they reported differences between first and second surgeries. Following transcription of each tape, a small study team, including an anesthesiologist and a qualitative researcher, met over the course of several months to read and discuss each transcript in detail. A coding template was developed and each transcript coded and emerging themes noted4. Results: For the majority of patients we interviewed, the RA was either well tolerated or even preferred. Having a previous negative experience with general was more common than we expected, and was strongly associated with a patient's satisfaction with RA. Several patients reported that RA was nullat leastnull better than having a general, for which they reported nausea, hallucinations or feeling as one patient put it, he had suffered nullbrain damagenull from the general. Only one person reported having a problem with regional anesthesia. However, this patient's negative experience seemed linked to poor pain control after surgery rather than with the regional per se. Patients also described being highly influenced by the preference of their surgeon and/or anesthesiologist. Discussion: These findings have important implications. First, many patients were surprisingly neutral about the procedure and seemed more fearful of anesthesia in general rather than of RA specifically. This finding, combined with patient's influence by clinician preference, underscores the importance of both surgeon and anesthesiologist support for this procedure. Some participants identified one of their misgivings about RA as being fear of being awake, which is consistent with the medical literature. Our findings support the idea that from a patient perspective appropriate sedation while undergoing regional anesthesia may be important
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Outcome and risk factors after anterior cruciate ligament reconstruction: a follow-up study of 948 patients
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Anterior Cruciate Ligament Injuries CPG
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PURPOSE: The aim of the study was to assess the outcome and risk factors after anterior cruciate ligament (ACL) reconstruction in a large group of patients. TYPE OF STUDY: Case series. METHODS: Included in this retrospective study were 948 patients (323 female, 625 male) with a symptomatic unilateral ACL rupture, who underwent arthroscopic reconstruction using patellar tendon autograft and interference screw fixation at 3 Swedish hospitals. The median age of the patients at the time of the index operation was 26 years (range, 14 to 53 years). The patients underwent surgery at a median of 12 months (range, 0.5 to 360 months) after their injury. Independent physiotherapists performed the follow-up examinations at a median of 32 months (range, 21 to 117 months) postoperatively. RESULTS: Of the 948 patients, 550 (58%) underwent meniscal surgery before, during, or after the ACL reconstruction. The median Tegner activity level was 8 (range, 2-10) before injury, 3 (range, 0-9) preoperatively, and 6 (range, 1-10) at follow-up (P < .0001 preoperative v follow-up). At follow-up, the median Lysholm score was 90 points (range, 14-100), the median KT-1000 anterior side-to-side laxity difference was 1.5 mm (range, -6 to 13 mm), and the median 1-leg hop test quotient was 95% (0% to 167%) compared with the contralateral normal side. At follow-up, 69.3% of the patients were classified as normal or nearly normal according to the International Knee Documentation Committee evaluation system. However, 36% of the patients were unable to or had severe problems performing the knee-walking test. Inferior results correlated with increased time period between the index injury and reconstruction and concomitant joint damage found at the index operation. CONCLUSIONS: Overall, the results were good after ACL reconstruction using patellar tendon autograft and interference screw fixation. Concomitant joint damage and a long time period between the injury and reconstruction are major risk factors for inferior outcome after ACL reconstruction. LEVEL OF EVIDENCE: Level IV, case series
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The use of galantamine in the treatment of post-traumatic oculomotor and trochlear nerve palsy
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Upper Eyelid and Brow Surgery
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To assess the suitability of galantamine for the symptomatic treatment of post-traumatic oculomotor (III) and trochlear (IV) nerve palsy. The routine ophthalmic and strabological examination was performed in five patients (4 females and 1 male) at the age of 31 to 57 years (mean 40.7) with the post-traumatic ophthalmic complications. Due to the unilateral oculomotor and trochlear nerve palsy, which had not resolved within 2-6 (mean duration of 4 months) months following traffic accident, galantamine was used. Nivalin and Reminyl were administered in iontophoresis and orally, respectively, for 10-18 months (mean duration of 14 months). The ocular muscle motion exercises and prism correction were also used. The increased range of ocular motion (100%), reducing of the angle of strabismus horizontally (40%) and vertically (60%), statistically significant extension of palpebral fissure (60%), and regression of diplopia (80% total without correction) were observed. The binocular vision after treatment in the free- and instrument-space environment were also improved (100% simultaneous perception, fusion 80%, stereopsis 60%). The early galantamine administration in patient with n. III and n. IV post-traumatic palsy accelerates the resolution of post-traumatic ophthalmic symptoms. It is an effective treatment which offers the elimination of strabismus, diplopia and ptosis, at the same time improvings ocular movements and binocular vision. galantamine, post-traumatic nerve palsy, oculomotor and trochlear nerves.
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A review of fractures in the proximal femur treated with the Zickel nail
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Management of Hip Fractures in the Elderly
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The Zickel intramedullary fixation device was used to treat 26 patients with subtrochanteric or impending subtrochanteric fractures. The use of this device has advantages over traditional traction methods as well as nail plate fixation. Twenty-two patients were ambulatory within one month following surgery. Healing of the fracture by roentenogram required an average of 4.9 months and had a high union rate, 17 out of 18 patients was apparent with the use of the Zickel device. There is no classification of fractures at present which has a prognostic value when intramedullary fixation is used. Traumatic and pathologic fractures were treated with similar results. There was no appliance failure in this series
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Loss to follow-up and social background in an inception cohort of patients with severe traumatic brain injury: Results from the Paris-TBI study
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DoD PRF (Psychosocial RF)
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Objectives: To assess determinants of loss to follow-up (FU) at 2 time points of an inception traumatic brain injury (TBI) cohort. Design and Participants: The Paris-TBI study consecutively included 504 adults with severe TBI on the accident scene (76% male, mean age 42 years, mean Glasgow Coma Scale 5). No exclusion criteria were used. Main Measure: Loss to FU at 1 and 4 years was defined among survivors as having no outcome data other than survival status. Results: Among 257 1-year survivors, 118 (47%) were lost to FU at 1 year and 98 (40%) at 4 years. Main reasons for loss to FU were impossibility to achieve contact (109 at 1 year, 52 at 4 years) and refusal to participate (respectively 5 and 24). At 1 year, individuals not working preinjury or with nonaccidental traumas were more often lost to FU in univariate and multivariable analyses. At 4 years, loss to FU was significantly associated with preinjury alcohol abuse and unemployment. Relationship with injury severity was not significant. Conclusions: Socially disadvantaged persons are underrepresented in TBI outcome research. It could result in overestimation of outcome and biased estimates of sociodemographic characteristics' effects. These persons, particularly unemployed individuals, require special attention in clinical practice.
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