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Resiliency among individuals with childhood sexual abuse and HIV: perspectives on addressing sexual trauma
DoD PRF (Psychosocial RF)
This study examined how resiliency (represented by optimism, social support, religiosity, and finding growth and meaning), within the context of perceived impact of sexual trauma and HIV-related stress, was linked to perspectives on addressing trauma among individuals (N=266) with HIV and childhood sexual abuse (CSA). Structural equation modeling analyses indicated that lower resiliency and greater HIV-related stress were related to negative feelings about addressing trauma, whereas greater resiliency and higher perceived impact of sexual trauma were associated with positive feelings about addressing trauma. Findings suggest that multiple factors influence perspectives on addressing trauma among individuals with HIV and CSA, and that resiliency might influence these attitudes.
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AFM-Nanomechanical Test: An Interdisciplinary Tool That Links the Understanding of Cartilage and Meniscus Biomechanics, Osteoarthritis Degeneration, and Tissue Engineering
AMP (Acute Meniscal Pathology)
Our objective is to provide an in-depth review of the recent technical advances of atomic force microscopy (AFM)-based nanomechanical tests and their contribution to a better understanding and diagnosis of osteoarthritis (OA), as well as the repair of tissues undergoing degeneration during OA progression. We first summarize a range of technical approaches for AFM-based nanoindentation, including considerations in both experimental design and data analysis. We then provide a more detailed description of two recently developed modes of AFM-nanoindentation, a high-bandwidth nanorheometer system for studying poroviscoelasticity and an immunofluorescence-guided nanomechanical mapping technique for delineating the pericellular matrix (PCM) and territorial/interterritorial matrix (T/IT-ECM) of surrounding cells in connective tissues. Next, we summarize recent applications of these approaches to three aspects of joint-related healthcare and disease: cartilage aging and OA, developmental biology and OA pathogenesis in murine models, and nanomechanics of the meniscus. These studies were performed over a hierarchy of length scales, from the molecular, cellular to the whole tissue level. The advances described here have contributed greatly to advancing the fundamental knowledge base for improved understanding, detection, and treatment of OA.
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Reducing costly falls of total knee replacement patients
AAHKS (9/10) Regional Nerve Blocks
The objective of this study was to determine whether the use of a knee immobilizer brace reduces patient falls associated with the recent use of femoral nerve blocks for pain control after total knee arthroplasty (TKA). The authors conducted a retrospective study to investigate fall rates before and after the introduction of an immobilizer brace. The demographics of patients and total cost of care were examined. Of the 600 TKA patients who did not receive a knee immobilizer, 22 (3.7%) experienced a fall. In contrast, of the 502 patients who received knee immobilizers, only 8 patients (1.6%) fell. This difference achieves statistical significance (P = .04). Given the considerable costs associated with hospital falls and the significant reduction of these falls related to knee immobilizer use shown in this study, the authors recommend that knee immobilizers be given to TKA patients as standard practice.
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Risk factors related to surgical site infection in orthopedic prosthesis surgery
DoD SSI (Surgical Site Infections)
Objective: to identify the risk factors for surgical site infections (SSI) in patients with surgical management fractures with internal fixation or prosthetic material. Materials and Methods: a cross-sectional study was conducted in a tertiary institution in Armenia-Colombia in 2008 and 2009 in 223 patients. Results: The superficial incisional infection frequency was 9,4% (n: 21), and deep incisional infection was 7,6% (n: 17); there were no organ/space SSI.; the highest rates of infection were observed in patella fractures (50%), acromio-clavicular joint (25%), and femur (23,7%). The infections were caused by: S. aureus, Enterobacter gergoviae y Enterobacter aerogenes. There was an association with clean-contaminated wounds compared to clean wounds (OR 2,2), comminuted fractures (OR 2,1) multiple fractures (OR 2,9) and patella surgery (OR 3,1). Conclusions: the severity of the fracture and the degree of contamination were predisposing factors to infection.
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Reliability and validity of the EQ-5D-5L compared to the EQ-5D-3L in patients with osteoarthritis referred for hip and knee replacement
Surgical Management of Osteoarthritis of the Knee CPG
PURPOSE: To assess the test-retest reliability of the EQ-5D-5L (5L) and compare the validity of the 5L and EQ-5D-3L (3L) in osteoarthritis patients referred to an orthopaedic surgeon for total joint replacement. METHODS: We mailed questionnaires to 306 consecutive patients following referral and a second questionnaire after 2 weeks to assess reliability. Questionnaires included the 5L, EQ-VAS, Short Form-12, Oxford hip and knee scores, pain VAS, and the 3L. We compared the ceiling effect, redistribution properties, convergent and discriminant validity, and discriminatory power of the 5L and 3L. RESULTS: We obtained 176 respondents (response rate 58 %), 60 % female, 64 % knee patients, mean age 65 years (SD 11), with no significant differences between responders versus non-responders. Intraclass correlation coefficients were 0.61-0.77 for the 5L dimensions and 0.87 for the 5L index. For the 3L, most patients used level 2 (some/moderate problems) for mobility (87 %), usual activities (78 %), and pain/discomfort (71 %). In comparison, 5L responses were spread out with only 52, 42, and 50 %, respectively, using the middle level. All convergent validity coefficients were stronger with the 5L (Spearman coefficients 0.51-0.75). Absolute informativity (Shannon's index) showed higher results for all dimensions of the 5L compared with the 3L (average difference 0.74). Relative informativity (Shannon's evenness index) showed an increase from the 3L to the 5L in mobility, usual activities, and pain/discomfort. CONCLUSIONS: The 5L provided stronger validity evidence than the 3L, especially for dimensions relevant to this patient population-mobility, usual activities, and pain/discomfort
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Clinical feasibility of simultaneous multislice acceleration in knee MRI
AMP (Acute Meniscal Pathology)
PURPOSE: To find the best simultaneous multislice (SMS) accelerated setting for clinical application in knee MRI. MATERIAL AND METHODS: Thirty-three patients (mean age, 54 years; 21 women) who underwent knee MRI (conventional/SMS sequences) between June and October 2020 were enrolled. Two radiologists retrospectively evaluated sagittal T1- and T2-weighted conventional (2-fold parallel acquisition technique [PAT-2]) and SMS (SMS-2 [PAT-2 with 2-fold SMS], SMS-3, and SMS-4) images. For qualitative analysis, artifacts (zebra/residual aliasing) and diagnostic confidence for internal derangement of knee (bone marrow, cartilage, meniscus, anterior cruciate ligament, and synovium abnormalities) were evaluated. For quantitative analysis, contrast-to-noise ratios of bone marrow, meniscus, joint effusion, and ligament were evaluated. RESULTS: Compared to PAT-2 (2 min 32 s), mean acquisition time was reduced by 47% in SMS-2; 64%, SMS-3; and 70%, SMS-4. In qualitative analysis, zebra artifacts were only seen on T2-weighted SMS images. The more SMS was applied, the more zebra and residual aliasing artifacts were seen and the lower diagnostic confidence was for internal derangement. However, qualitative analysis showed acceptable image quality in SMS-2 and SMS-3 images, but not in SMS-4 images. In quantitative analysis, SMS-4 images showed the lowest contrast-to-noise ratios and there were no significant differences among PAT-2, SMS-2, and SMS-3 images. CONCLUSION: Applying SMS-3 to knee MRI reduced scan time and showed acceptable image quality compared to conventional (PAT-2). However, when evaluating SMS images, radiologists should know that when more SMS is applied, more zebra and residual aliasing artifacts appear.
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Rehabilitation (exercise and strength training) and osteoarthritis: A critical narrative review
OAK 3 - Non-arthroplasty tx of OAK
Rehabilitation is widely recommended in national and international guidelines for managing osteoarthritis (OA) in primary care settings. According to the 2014 OA Research Society International (OARSI) recommendations, rehabilitation is even considered the core treatment of OA and is recommended for all patients. Rehabilitation for OA widely includes land- and water-based exercise, strength training, weight management, self-management and education, biomechanical interventions, and physically active lifestyle. We performed a critical narrative review of the efficacy and safety of rehabilitation for managing OA and discuss evidence-based international recommendations. The process of article selection was unsystematic. Articles were selected based on authors' expertise, self-knowledge, and reflective practice. For the purpose of the review, we focused on land- and water-based exercise and strength training for knee, hip and hand OA. Other aspects of rehabilitation in OA are treated elsewhere in this special issue. Exercise therapy is widely recommended for managing knee, hip and hand OA. However, the level of evidence varies according to OA location. Overall, consistent evidence suggests that exercise therapy and specific strengthening exercise or strength training for the lower limb reduce pain and improve physical function in knee OA. Evidence for other OA sites are less consistent. Therefore, because of the lack of specific studies, recommendations for hip and hand OA are mainly derived from studies of knee OA. In addition, no recommendations have been established regarding the exercise regimen. The efficacy and safety of exercise therapy and strength training need to be further evaluated in randomized controlled trials of patients with hip and hand OA. The optimal delivery of exercise programs also has to be more clearly defined.
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Multiple myeloma
MSTS 2018 - Femur Mets and MM
Multiple myeloma is characterised by clonal proliferation of malignant plasma cells, and mounting evidence indicates that the bone marrow microenvironment of tumour cells has a pivotal role in myeloma pathogenesis. This knowledge has already expanded treatment options for patients with multiple myeloma. Prototypic drugs thalidomide, bortezomib, and lenalidomide have each been approved for the treatment of this disease by targeting both multiple myeloma cells and the bone marrow microenvironment. Although benefit was first shown in relapsed and refractory disease, improved overall response, duration of response, and progression-free and overall survival can be achieved when these drugs are part of first-line regimens. This treatment framework promises to improve outcome not only for patients with multiple myeloma, but also with other haematological malignancies and solid tumours. © 2009 Elsevier Ltd. All rights reserved.
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Prevention of Post-Traumatic Elbow Stiffness Using Botulinum Toxin
Pediatric Supracondylar Humerus Fracture 2020 Review
Background: Approximately 30% of all upper extremity fractures are elbow fractures. This may lead to elbow stiffness and heterotopic ossification resulting in limited range of motion which is a challenging problem. A sufficient functional arc of motion is stated for flexion�extension 130�°�30�°�0�° and for pronation/ supination 50�°�0�°�50�°. Aim: To investigate the efficacy of Botulinum Toxin (Botox) injections to prevent postoperative elbow stiffness after trauma, we performed a study in three steps. Methods: All patients were included who presented to a single surgeon with distal humerus fracture, Monteggia fracture, or olecranon fracture. The study was developed in three steps: 1) prospective comparative pilot study to demonstrate the safeness of use and dosage of Botox between 1999 and 2003, 2) double�blinded prospective, randomized study between 2003 and 2007 to evaluate the functional outcome scores and range of motion and finally, 3) a retrospective study between 2007 and 2017 to assess clinical impact and the functional outcome after elbow fracture. For the prospective group, the Disabilities of the Arm, Shoulder, and Hand (DASH) score, Visual Analogue Scale for pain as well as the range of motion (ROM) were assessed after three months, six months and one year. For the retrospective study, range of motion measurements were recorded and analyzed using a paired t�test. Results: In total, 79 patients were included, 32 patients (44%) received Botox injections and 47 patients (54%) were in the control group. The pilot study reported that Botox is a safe and effective method to prevent posttraumatic elbow stiffness, lasting six months, with an optimal dosage of 100 units each for the brachialis muscle and biceps brachii. In the prospective randomized study, a significant difference (p<0.05) in VAS score and high positive trend in DASH score after 1 year (p =0.06) between the botulinum (VAS 1.2�±5.2; DASH 11.18�±11.0) and control group (VAS 5.7�±21.9; DASH 54.46�±7.59) could be identified. For ROM, a positive trend especially for extension could be identified in Monteggia and significant difference in Intercondylar fracture (p<0.05) 6�weeks postoperatively. Conclusions: Botulinum toxin is a safe and promising treatment to prevent post�traumatic elbow stiffness. Our study demonstrates improved early range�of�motion, and better functional outcome like VAS and DASH score.
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Mortality, morbidity, and psychosocial outcomes of persons spinal cord injured more than 20 years ago
DoD PRF (Psychosocial RF)
Mortality, morbidity, health, functional, and psychosocial outcomes were examined in 834 individuals with long term spinal cord injuries. All were treated at one of two British spinal injury centres: the National Spinal Injuries Centre at Stoke Mandeville Hospital or the Regional Spinal Injuries Centre in Southport; all were 20 or more years post injury. Using life table techniques, median survival time was determined for the overall sample (32 years), and for various subgroups based on level and completeness of injury and age at injury. With the number of renal deaths decreasing over time, the cause of death patterns in the study group as it aged began to approximate those of the general population. Morbidity patterns were found to be associated with age, years post injury, or a combination of these factors, depending upon the particular medical complication examined. A current medical examination of 282 of the survivors revealed significant declines in functional abilities associated with the aging process. Declines with age also were found in measures of handicap and life satisfaction, but three quarters of those interviewed reported generally good health and rated their current quality of life as either good or excellent.
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Early periprosthetic femoral bone remodelling using different bearing material combinations in total hip arthroplasties: a prospective randomised study
Management of Hip Fractures in the Elderly
The present study was performed to test the hypothesis that different bearing materials have an impact on femoral bone remodelling within the first year after a total hip arthroplasty. A total of 225 patients with osteoarthrosis of the hip or avascular necrosis of the femoral head were included in this randomised prospective study. All patients had an identical hybrid total hip arthroplasty (cemented BiMetric stem and cementless RingLoc acetabular cup) except for the bearing materials: polyethylene-on-zirconia (n = 78), CoCr-on-CoCr (n = 71), or alumina-on-alumina (n = 76). Bone mineral density (BMD) was measured with Dual-energy X-ray absorptiometry (DEXA) in seven Gruen zones adjacent to the femoral implant. The DEXA scan was performed within one week after surgery and was repeated one year postoperatively. There was no significant difference in periprosthetic BMD change between the three groups. After twelve months the relative BMD decrease was highest in the proximal part of the femur, - 6.2% in the greater trochanter region and - 12.7% in the lesser trochanter region. In the distal zones the relative BMD decrease was -5.3, -4.2, -2.1, -2.3, and -5.6%, respectively. The use of different bearing materials had no significant impact on femoral bone remodelling adjacent to the cemented hip stem within one year after surgery
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The biphasic bioresorbable scaffold (Trufit(®)) in the osteochondral knee lesions: long-term clinical and MRI assessment in 30 patients
Osteochondritis Dissecans 2020 Review
BACKGROUND: Chondral or osteochondral defects have been reported in 60-67 % of patients in studies reporting knee arthroscopies. The surgical management of chondral and osteochondral defects (OCD's) of the articular surface of the knee joint remains a controversial topic. Osteochondral injuries can be treated with transfer cartilage procedure and with implantation of biodegradable scaffolds. For patients over 50 years old with largest osteochondral lesions, we prefer to use the biodegradable scaffold, like Trufit(®) plug (Smith & Nephew, Andover, MA). The purpose of this study is to evaluate the outcome of this series of surgical procedure with Trufit. METHODS: In our institute, the Trufit was used for the treatment of one or more focal osteochondral lesions of the femoral condyles positive MRI with or without concomitant ligamentous or meniscal pathology. We reviewed 30 patients with mean age of 60.57 years (range 32-79 years) with a clinical and imaging control at 6, 12, 24 and 48 months of follow-up. RESULTS: The clinical evaluation has shown the good outcome. The MRI conducted has shown the progressive partial integration of the scaffolds. CONCLUSIONS: The results obtained indicate a clear improvement of the clinical symptoms and slowing joint degeneration. The clinical and imaging results confirm that the Trufit constitutes a valid surgical alternative in case of focal osteochondral.
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Patient-related risk factors for periprosthetic joint infection and postoperative mortality following total hip arthroplasty in medicare patients
MSTS 2022 - Metastatic Disease of the Humerus
Background: The patient-related risk factors for periprosthetic joint infection and postoperative mortality in elderly patients undergoing total hip arthroplasty are poorly understood. The purpose of this study was to identify the specific patient comorbidities that are associated with an increased risk of periprosthetic joint infection and of ninety-day postoperative mortality in U.S. Medicare patients undergoing total hip arthroplasty. Methods: The Medicare 5% sample claims database was used to calculate the relative risk of periprosthetic joint infection and of ninety-day postoperative mortality as a function of preexisting comorbidities in 40,919 patients who underwent primary total hip arthroplasty between 1998 and 2007. The impact of twenty-nine comorbid conditions on periprosthetic joint infection and on postoperative mortality was examined with use of Cox regression, controlling for age, sex, census region, public assistance, and all other baseline comorbidities. The adjusted hazard ratios for all comorbid conditions were evaluated, and the Wald chi-square statistic was used to rank the degree of association of each condition with periprosthetic joint infection and with postoperative mortality. The Bonferroni-Holm method was used to adjust for the multiple comparisons resulting from the number of comorbid conditions analyzed. Results: Comorbid conditions associated with an increased adjusted risk of periprosthetic joint infection (in decreasing order of significance, p < 0.05 for all comparisons) were rheumatologic disease (hazard ratio [HR] = 1.71), obesity (HR = 1.73), coagulopathy (HR = 1.58), and preoperative anemia (HR = 1.36). Comorbid conditions associated with an increased adjusted risk of ninety-day postoperative mortality (in decreasing order of significance, p < 0.05 for all comparisons) were congestive heart failure (HR = 2.11), metastatic cancer (HR = 3.14), psychosis (HR = 1.85), renal disease (HR = 1.98), dementia (HR = 2.04), hemiplegia or paraplegia (HR = 2.62), cerebrovascular disease (HR = 1.40), and chronic pulmonary disease (HR = 1.32). Conclusions: We identified specific patient comorbidities that were independently associated with an increased risk of periprosthetic joint infection and of ninety-day postoperative mortality in Medicare patients who had undergone total hip arthroplasty. This information is important when counseling elderly patients regarding the risks of periprosthetic joint infection and mortality following total hip arthroplasty, as well as for risk adjustment of publicly reported total hip arthroplasty outcomes. Level of Evidence: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence. Copyright © 2012 by The Journal of Bone and Joint Surgery, Incorporated.
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Parafoveal letter recognition at reduced contrast in normal aging and in patients with risk factors for AMD
Upper Eyelid and Brow Surgery
BACKGROUND: Patients with early age-related maculopathy (ARM) do not necessarily show obvious morphological signs or functional impairment. Many have good visual acuity, yet complain of decreased visual performance. The aim of this study was to investigate the aging effects on performance of parafoveal letter recognition at reduced contrast, and defects caused by early ARM and normal fellow eyes of patients with unilateral age-related macular degeneration (nfAMD). METHODS: Testing of the central visual field (8 degrees radius) was performed by the Macular Mapping Test (MMT) using recognition of letters in 40 parafoveal target locations at four contrast levels (5, 10, 25 and 100%). Effects of aging were investigated in 64 healthy subjects aged 23 to 76 years (CTRL). In addition, 39 eyes (minimum visual acuity of 0.63;20/30) from 39 patients with either no visible signs of ARM, while the fellow eye had advanced age-related macular degeneration (nfAMD; n = 12), or early signs of ARM (eARM; n = 27) were examined. Performance was expressed summarily as a "field score" (FS). RESULTS: Performance in the MMT begins to decline linearly with age in normal subjects from the age of 50 and 54 years on, at 5% and 10% contrast respectively. The differentiation between patients and CTRLs was enhanced if FS at 5% was analyzed along with FS at 10% contrast. In 8/12 patients from group nfAMD and in 18/27 from group eARM, the FS was statistically significantly lower than in the CTRL group in at least one of the lower contrast levels. CONCLUSION: Using parafoveal test locations, a recognition task and diminished contrast increases the chance of early detection of functional defects due to eARM or nfAMD and can differentiate them from those due to aging alone.
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Primary Total Hip Arthroplasty for Charcot Arthropathy is Associated With High Complications but Improved Clinical Outcomes
Hip Fx in the Elderly 2019
BACKGROUND: Neuropathic (Charcot) arthropathy of the hip is rare but can lead to joint destruction, bone loss, and dysfunction. While total hip arthroplasty (THA) may be considered a treatment option, only very limited data in the form of case reports are available on the results of THA. The goal of this study was to analyze the outcomes of primary THA for Charcot arthropathy with emphasis on implant survivorship, complications, and clinical outcomes. METHODS: Eleven patients undergoing 12 primary THAs for Charcot arthropathy from 2007 to 2014 were retrospectively reviewed. All patients had a severe underlying neuropathy and clear radiographic evidence of Charcot arthropathy. Mean age was 54 years with 4 patients being female. Mean follow-up was 5 years. RESULTS: Survivorship free of any revision was 75% at both 2 and 5 years. Three THAs (3/12) were revised: 2 for recurrent instability and 1 for femoral component loosening. Survivorship free of any reoperation was 67% at both 2 and 5 years. One additional THA underwent open reduction and internal fixation of a Vancouver B<sub>1</sub> periprosthetic fracture. The overall complication rate (including revisions and reoperations) was high at 58% with 3 recurrent dislocations, 2 periprosthetic fractures, 1 femoral component loosening, and 1 delayed wound healing. Harris Hip Scores improved from a mean of 43 preoperatively to 81 postoperatively (P < .001). CONCLUSION: In this study, the largest to date, we found that patients undergoing primary THA for Charcot arthropathy have a significant improvement in clinical outcomes but that there was a high risk of early complications and revisions, mostly related to recurrent instability. Specific precautions to avoid early complications, namely utilization of components that provide robust fixation and strategies that provide enhanced hip stability, should be considered. LEVEL OF EVIDENCE: Level IV.
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Classification, clinical findings and operative treatment of degenerative and posttraumatic shoulder disease: what do we really need to know from an imaging report to establish a treatment strategy?
Glenohumeral Joint OA
Successful patient care involves interdisciplinary Cupertino. Images allow an interpretation of a static dimension, but may not be sufficient to develop a surgical treatment strategy, since many shoulder problems have its origin in a dynamic pathology. This article outlines dynamic clinical tests of shoulder pathology, classifies various degenerative and posttraumatic shoulder problems and stresses key facts an imaging report should include in order to plan surgery. This article conveys basic knowledge of those tests and the dynamic background of shoulder pathology. Basic surgical treatment principles are summarised briefly. [References: 26]
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Total knee arthroplasty in patients with stiff knees
PJI DX Updated Search
The purpose of this study was to evaluate the clinical outcome of total knee arthroplasty and analyze the prognostic factors in patients with stiff knees. Thirty-two patients (39 knees) with severe knee arthritis and an arc of motion of 50° or less were treated by total knee arthroplasty. The mean follow-up period was 58 months (range, 24-123 months). The mean arc of motion improved from 35° before the operation to 94° at the time of the latest follow-up (P<.05). Improvement in knee motion after postoperative 3 months was insignificant. The most important factor related to the final arc of knee motion was preoperative arc of knee motion. The V-Y quadricepsplasty was associated with an inferior clinical outcome. Total knee arthroplasty in patients with stiff knees has substantially improved in the clinical outcome and the arc of motion. © 2012 Elsevier Inc
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Translation and cultural adaptation of the Brief Michigan Hand Questionnaire to Brazilian Portuguese language
Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
PURPOSE: The use of patient-reported outcome questionnaires is recommended in orthopedic studies. However, validated tools are necessary to ensure the comparability of results across different studies, centers, and countries. The Brief Michigan Hand Questionnaire (BMHQ) can be used for outcome measures in self-evaluation after carpal tunnel release. This study aimed to translate the BMHQ to Portuguese to permit cross-cultural adaptation to Brazilians patients. METHODS: We translated the Brief Michigan Hand Questionnaire from the original version (English) to Brazilian Portuguese. The translation and cultural adaptation of the content of this tool consisted of six stages, according to the methodology proposed by medical literature: (1) initial translation of the questionnaire by two independent translators; (2) synthesis of translations and reconciliation; (3) back-translation to English of the reconciled version; (4) verification of the cultural equivalence process by an expert committee; (5) pre-testing in a sample of patients to verify understanding of the items; and (6) development of a final version of the BMHQ. RESULTS: The pre-final version of the tool was applied to 43 patients to verify its understanding. Pre-testing showed that the questions and options were satisfactorily understood. The number of items from the original English version was maintained in the Brazilian Portuguese version of BMHQ. DISCUSSION: The Brazilian Portuguese version of the BMHQ is easily understood by patients and will be useful to clinicians and researchers
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Hip arthroplasty in a patient with congenital pubic diastasis and bladder exstrophy
PJI DX Updated Search
We report a total hip arthroplasty performed for arthritis and osteonecrosis in a patient with congenital pubic diastasis and bladder exstrophy. A satisfactory outcome was achieved after appropriate consideration of the technical and biomechanical issues involved. © Wichtig Editore, 2009
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The Charnley stem: Clinical, radiological and survival data after 11-14 years
PJI DX Updated Search
Background: The Charnley stem provides good outcome for 10 years, but several studies find deteriorating results thereafter. However, study populations, techniques and data analysis vary widely. We have studied 240 Charnley stems in a homogeneous group of patients providing clinical, radiological and survival data after 11-14 years. Hypothesis: The clinical and radiological outcome of the Charnley stem is not as good than previously thought. Patients and methods: Five surgeons implanted 240 femoral stems in a community hospital in Norway using antibiotic impregnated cement and third generation cementing techniques. The Charnley stems were implanted with a Charnley cup in 120 cases and an uncemented hemispherical cup (Duraloc™) in 120 cases. The mean age of the patients was 65.5 years and the mean Body Mass Index (BMI) was 26.8. All patients received low molecular weight heparin and antibiotic prophylaxis. Patients were assessed after 10 years by means of Harris Hip Score (HHS) and radiographic evaluation. Implant survival studies were performed after 11-14 years. Results: One hundred and fifty-eight patients were available for clinical and radiographic evaluation after 10 years. HHS improved from 48.4 (95% CI: 46.6-50.2) preoperatively to 87.9 (95% CI: 86.6-89.3) after 6 months and 87.6 (95% CI: 85.3-89.8) at 10 years. Thirty-one stems had been revised, the reasons for revision were loosening (21), infection (five), instability (four) and late perisprosthetic fracture (one). Forty-one stems had one or more signs of loosening. Stem survival was 83.6% using any revisions as end point, and mean estimated stem survival was 12.7 years (12.2-13.3 years). Discussion: Other studies report survival at mid-term from 83-96%. Our results are in the low-end. Even though our rate of infection was high (2%), the main cause of the poor results is aseptic loosening. We do not know the reason for this high-rate of loosening. As we believe that our technique is adequate and patient population average, we suspect that this rate of loosening is a characteristic of the implant. Results from this prospective cohort study add to the evidence that the Charnley stem should not be used hip arthroplasty unless patient life expectancy is less than 10 years. Level of evidence: Level 2 prospective clinical study. © 2010
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Osteomyelitis following palatoplasty: A rare complication
Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures
Objectives: Raise awareness of potential serious complications of oropharyngeal surgery such as osteomyelitis and discuss the role of perioperative antibiotics in such operations. Explore the events leading up to the development of osteomyelitis in a 13-month-old boy following palatoplasty. Discuss the role of perioperative antibiotics in oropharyngeal surgery. Study Design: Single case report with chart and literature review. Methods: We present the case of a 13-month-old boy who underwent palatoplasty, received perioperative antibiotics, and subsequently developed group A streptococcal bacteremia along with osteomyelitis of the right calcaneus. A literature review was done to explore the role of antibiotics in oropharyngeal surgery. Results: The patient underwent treatment with antibiotics, and the osteomyelitis resolved. Conclusions: Surgeons and clinicians should maintain a high level of suspicion for bone and joint infections in any child presenting postoperatively with fevers, bacteremia, and musculoskeletal symptoms. The role of perioperative antibiotics in the prevention of severe postoperative infections such as osteomyelitis is unclear. In the era of evidence-based medicine there is a movement to temper, if not eliminate, the once standard practice of discharging children on a short course of prophylactic antibiotics following palate repair. It should therefore be noted that even when these antibiotics are given, rare infectious complications may still occur
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Local and systemic consequences of severe ischemia and reperfusion of the skeletal muscle. Physiopathology and prevention
DOD - Acute Comp Syndrome CPG
Revascularization of a limb after a severe and prolonged period of ischemia may be associated with high rates of mortality and amputation, because of the development of a postrevascularization syndrome, regardless the cause of occlusion (ischemia, trauma, iatrogenic) or the methods used to achieve reperfusion (fibrinolysis, surgery, resuscitative therapy). This "revascularization" syndrome includes several complications, both local (explosive swelling of the limb, compartment syndrome and skeletal muscle infarction (rhabdomyolysis) and general (acidosis, hypercalcemia, hypovolaemic shock, renal, hepatointestinal and pulmonary failures, arrhythmias and cardiac arrest (multiple organ dysfunction). Current therapies are directed against complications after they occurred, once revascularization is completed: fasciotomy, mannitol and diuretics administration for forced diuresis, fluid administration to correct hypovolaemia, use of resins, insulin and glucose or haemodialysis to deal with hypercalcemia, administration of buffers (THAM, bicarbonate) to correct acidosis, control of hypercalcaemia with orthophosphates and calcitonin.... Nevertheless, a substantial percentage of the injury is generated upon reperfusion and the muscle may remain viable after prolonged period of ischemia. Intra and extraacellular swelling, tissue acidosis, free radical mediated damage, loss of adenine nucleotide precursors, and intracellular calcium overload have been suggested to be the mechanisms responsible for reperfusion injury. Careful control of both the composition and the physical conditions of the initial reperfusion (controlled reperfusion) may result, in selected cases, in improvements in the metabolism, structure and function of the limb after reperfusion. [References: 62]
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Neck rejuvenation
Panniculectomy & Abdominoplasty CPG
Rejuvenation of the neck is an important aspect of facial rejuvenation that is often overlooked. Careful evaluation of all aspects of the aging neck and the a proper assessment of the patient's needs and expectations are required to arrive at a desirable outcome. With advances in technology and a push for noninvasive, no downtime procedures, the nonsurgical treatments have increased in number and efficacy. By offering the patient a comprehensive list of options for treating the skin, fat, and deeper tissues of the neck, the cosmetic surgeon can provide fantastic results to a happy patient. © 2005 Elsevier Inc. All rights reserved.
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Arthroscopically assisted treatment for Schatzker type I-V tibial plateau fractures
DoD SSI (Surgical Site Infections)
Objective: To report the clinical outcome of arthroscopically assisted treatment for tibial plateau fractures. Methods: A total of 39 patients with tibial plateau fractures were treated by arthroscopic fixation from February 2002 to December 2005, including 11 patients with bony avulsion of the anterior cruciate ligament and 19 with meniscal injury. There were 4 cases of type I fracture, 12 type II, 9 type III, 12 type IV and 2 type V according to Schatzker criteria. Firstly, the combined injuries were treated. Then the plateau fractures with the displacement over 3 mm or more were reduced and fixed. Finally, the internal fixation was observed by X-ray equipment. Postoperative management was early motion and delayed weight bearing. Results: All the fractures healed in 3 or 4 months. All patients were followed up for 1 to 5 years after operation. No case had severe complications, such as poor wound healing, infection, osteofascial compartment syndrome and osteoarthritis. According to the Rasmussen scoring system, 36 cases obtained excellent or good results and the other 3 cases had moderate clinical results. The average score was 26 ±3. Conclusions: As an adjuvant treatment of intraarticular fractures such as tibial plateau fracture, arthroscopy has many advantages. It can treat associated intraarticular soft tissue components, visualize the chondral surface reduction, lavage the hematoma and smaller loose fragments, decrease soft tissue dissection, reduce the risk of scarring and promote rapid recovery.
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Patients with drug-eluting stents and management of their anticoagulant therapy in cutaneous surgery
Reconstruction After Skin Cancer
Whether a patient has a drug-eluting stent (DES) implanted may not seem to be an immediate concern for a dermatologist. However, the clinician needs to consider a patient's risk of bleeding if a patient is to undergo a cutaneous surgical procedure. Patients with skin cancer are generally older with a higher risk of comorbidities such as cardiovascular disease with history of cardiac stent implantation. After DES placement, patients are typically on long-term dual antiplatelet therapy, which increases the risk of bleeding. However, stopping antiplatelet therapy prematurely can lead to serious thrombotic complications. Thus, when performing a dermatologic procedure in a patient with a DES, the physician must weigh the risks of bleeding complications with continuing antiplatelet therapy against the risk of thrombotic complications associated with stopping antiplatelet therapy. The aim of this review is to identify the issues for the dermatologist and the dermatologic surgeon surrounding the perioperative treatment of patients with a DES and to discuss the treatment of patients with an implanted DES.
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Improvement in osteoporosis detection in a fracture liaison service with integration of a geriatric hip fracture care program
Hip Fx in the Elderly 2019
INTRODUCTION: Care gaps have been identified in the treatment of osteoporosis after the occurrence of a fragility hip fracture. HiROC (High Risk Osteoporosis Clinic) is a fracture liaison service implemented at our institution. In ProvenCare geriatric hip fracture care program at our institution pre-set orders for the inpatient HiROC consults were prescribed. We hypothesized that there will be a significant increase in the rate of enrollment of patients in the HiROC program after the integration of the pre-set orders. PATIENTS AND METHODS: The trauma database at a level-I trauma center was reviewed retrospectively for the charts of patients >50 years of age with fragility intertrochanteric fractures. Patients not treated under the geriatric hip fracture care program and patients treated under the geriatric hip fracture care program were identified and reviewed for the enrollment in HiROC and subsequent follow up. RESULTS: Out of 589 patients treated before the implementation of ProvenCare, 443 patients (75%) were enrolled in HiROC at the index consult. In comparison, out of 153 patients treated after the implementation of ProvenCare, 131 patients (85.6%) were enrolled in HiROC at the index consult. The difference between the two groups was statistically significant (p=0.008). CONCLUSION: Our experience shows that the occurrence of a fragility intertrochanteric fracture can be effectively utilized for the detection and initiation of treatment of osteoporosis. With the implementation of pre-set orders in the geriatric hip fracture care program significantly better enrollment can be achieved.
0
Dissociation between the growing opioid demands and drug policy directions among the U.S. older adults with degenerative joint diseases
OAK 3 - Non-arthroplasty tx of OAK
We aim to examine temporal trends of orthopedic operations and opioid-related hospital stays among seniors in the nation and states of Oregon and Washington where marijuana legalization was accepted earlier than any others.As aging society advances in the United States (U.S.), orthopedic operations and opioid-related hospital stays among seniors increase in the nation.A serial cross-sectional cohort study using the healthcare cost and utilization project fast stats from 2006 through 2015 measured annual rate per 100,000 populations of orthopedic operations by age groups (45-64 vs 65 and older) as well as annual rate per 100,000 populations of opioid-related hospital stays among 65 and older in the nation, Oregon and Washington states from 2008 through 2017. Orthopedic operations (knee arthroplasty, total or partial hip replacement, spinal fusion or laminectomy) and opioid-related hospital stays were measured. The compound annual growth rate (CAGR) was used to quantify temporal trends of orthopedic operations by age groups as well as opioid-related hospital stays and was tested by Rao-Scott correction of Ï? for categorical variables.The CAGR (4.06%) of orthopedic operations among age 65 and older increased (Pâ??<â??.001) unlike the unchanged rate among age 45 to 64. The CAGRs of opioid-related hospital stays among age 65 and older were upward trends among seniors in general (6.79%) and in Oregon (10.32%) and Washington (15.48%) in particular (all Pâ??<â??.001).Orthopedic operations and opioid-related hospital stays among seniors increased over time in the U.S. Marijuana legalization might have played a role of gateway drug to opioid among seniors.
1
Treatment outcomes of sorafenib for first line or cytokinerefractory advanced renal cell carcinoma in Japanese patients
MSTS 2018 - Femur Mets and MM
The objective of the present study was to document the treatment efficacy and safety of sorafenib in Japanese patients with advanced renal cell carcinoma (RCC). A retrospective analysis of 50 consecutive patients with metastatic RCC between January 2005 and December 2009 was carried out. Patients received sorafenib after failed cytokine therapy or first-line sorafenib treatment. All received 400 mg of sorafenib orally twice daily. Five of 14 patients with bone metastases were also given bisphosphonates. Tumor response was evaluated every 1-2 months according to the Response Evaluation Criteria in Solid Tumors. Adverse events (AE) were evaluated at each visit during and after treatment, and were recorded according to the National Cancer Institute's Common Terminology Criteria for Adverse Events version 3.0. Dose modification of sorafenib was permitted if grade 3 or 4 AE occurred. Treatment continued until disease progression or treatment intolerance occurred. Partial response, and stable disease as best objective responses were observed in 11 (22%) and 23 (46%) patients, respectively. Median progression-free survival was 7.3 months and median overall survival was 11.9 months. All patients experienced AE and one or more grade 3/4 AE occurred in 43 of 50 (86%) patients. Although it requires close monitoring, sorafenib treatment seemed to be effective in the present study population. © 2010 The Japanese Urological Association.
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High Survivorship With Cementless Stems and Cortical Strut Allografts for Large Femoral Bone Defects in Revision THA
PJI DX Updated Search
BACKGROUND: Numerous studies have investigated the clinical and radiographic results of revision THAs with use of cementless stems and cortical strut allografts. However, to our knowledge, no long-term followup studies have evaluated patients undergoing revision THA with use of cortical strut allografts where the allografts provided the primary stability for extensively coated femoral stems in the presence of extensive femoral diaphyseal bone defects. QUESTION/PURPOSES: We performed this study to determine (1) validated outcomes scores; (2) radiographic signs of fixation and allograft healing; (3) frequency of complications; and (4) survivorship of the components after use of cortical strut onlay allografts in Types IIIB and IV femoral diaphyseal bone defects. METHODS: Between 1994 and 2003, we performed 140 revision THAs in 130 patients with Paprosky Types IIIB and IV femoral diaphyseal defects. The patients were treated using extensively coated femoral stems and cortical strut allografts because primary axial or rotational stability could not be achieved without grafting. Ten of the patients (10 hips; 7.7%) were lost to followup or died before 10 years; the remaining 120 patients (130 hips) represent the study group in this retrospective study. There were 66 men and 54 women. Their mean age at the time of index surgery was 59 +/- 18 years (range, 36-67 years). The primary diagnosis was predominantly osteonecrosis of the femoral head (53%). The most common reason for revision was aseptic loosening (97%), followed by periprosthetic fracture (3%). The mean time from primary to revision THA was 12 years (range, 8-27 years). The mean duration of followup was 16.1 years (range, 12-20 years). RESULTS: The mean Harris hip score was 39 +/- 10 points before revision and improved to 86 +/- 14 points at 16 years followup (p = 0.02). The mean preoperative WOMAC score was 62 +/- 29 (41-91) points and improved to 22 +/- 19 (11-51) points at 16 years followup (p = 0.003). Of the 130 stems, 113 (87%) had bone ingrowth, five (4%) had stable fibrous ingrowth, and 12 (9%) were unstable. All allografts were incorporated. Four hips (3%) had a displaced femoral shaft fracture at the stem tip; four (3%) had a postoperative dislocation; and six (5%) had early postoperative infection. Kaplan-Meier survivorship analysis, with revision or radiographic failure as the endpoint, revealed that the 16-year rate of survival of the components was 91% (95% CI, 0.88%-0.96%). CONCLUSION: Supportive cortical strut onlay allografts provided high survivorship beyond 12 years of followup in revision THAs. Future studies might compare this approach with allograft-prosthesis composites, proximal femoral replacement, or modular fluted, tapered stems. LEVEL OF EVIDENCE: Level IV, therapeutic study
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Do bone loss and reconstruction procedures differ at revision of cemented unicompartmental knee prostheses according to the use of metal-back or all-polyethylene tibial component?
Surgical Management of Osteoarthritis of the Knee CPG
INTRODUCTION: Results of unicompartmental knee arthroplasty (UKA) revision are known but the severity of bone loss and the need for reconstruction are not detailed for different tibial implants. HYPOTHESIS: Metal-backing UKA revision exposes the patient to more severe tibial bone loss and requires more substantial reconstruction procedures than cemented polyethylene UKA revision. MATERIALS AND METHODS: This retrospective series of 23 revisions of UKA to total knee arthroplasty (TKA) compared 11 all-polyethylene UKAs with 12 metal-backing UKAs. Factors that contributed to failure were aseptic loosening (n=12) and osteoarthritis evolution (n=11). Both groups were similar regarding the demographic and clinical features. We reported bone loss and the reconstruction procedure to fill it according to the initially used tibial implant. The results were evaluated with the IKS score to a follow-up of 37 months (range, 24-67 months). RESULTS: There were more tibial segmental bone loss (10 versus 3) and more metal wedges (8/12 versus 2/11) in metal-backing UKA revision (P<0.05). Tibial stems were more often used in metal-backing UKA revision (12/12 versus 7/11) (P=0.04). The results of TKA at follow-up did not differ according to whether the revised tibial implant was all polyethylene (IKS=155 [range, 107-195]) or metal-back (IKS=155 [range, 127-172]). DISCUSSION: This study suggests that metal-backing UKA revision exposes the patient to more severe tibial bone loss requiring more substantial reconstruction. These results must be confirmed on a larger population, but surgeons should be alerted to this kind of revision surgery, which warrants having available a revision knee prothesis. LEVEL OF EVIDENCE: Level III, case-control study
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Amyloid deposits in human knee and hip joints
Management of Hip Fractures in the Elderly
A systematic search for articular amyloidosis was carried out on both knees of 53 autopsy cases and on 26 femoral heads resected during surgery for hip prosthesis. Typical amyloid deposits exhibiting green apple birefringence following Congo red staining and thioflavin T fluorescence were found in 58.5% and 29% of the cases, in the knee and hip joint respectively. They occurred more frequently in articular cartilage than in the synovium, and in elderly subjects more than young ones. In the knee joint, the osteoarthritic changes and to a minor extent synovial inflammation appear to be positively correlated for the presence of intraarticular amyloid deposits. Such a correlation was not observed for the presence of calcium pyrophosphate dihydrate crystal deposits
0
Infective complications in tumour endoprostheses implanted after pathological fracture of the limbs
DoD PRF (Psychosocial RF)
Introduction Pathological fractures represent an adverse prognostic factor in primary and metastatic bone tumours. The purpose of this study was to evaluate the results of tumour silverâ?coated prosthesis implanted after pathological fractures. Materials and methods A retrospective analysis was conducted on 30 patients with pathological limb fracture after primary or metastatic bone tumours treated by the same surgeon with wide margin resection and tumour prosthesis implant between 2005 and 2015. Silverâ?coated prostheses were implanted in 17 patients and uncoated prostheses were implanted in 13 patients. The primary outcome of the study was to evaluate the infective risk, the secondary outcomes were survival and functional level (visual analogue scale [VAS], 36-Item Short Form Health Survey [SF 36], and Musculoskeletal Tumour Society [MSTS] score) obtained at the longest followâ?up available. A multivariate analysis was performed considering age, sex, tumour histology, grading and location, resection size, concomitant radiotherapy/chemotherapy, use of mesh for soft tissue reconstruction and local complications (dislocation, relapse, implant breakage). Scanning electron microscopy (SEM) analysis of explanted prosthesis was performed to study the residual silver-coating. Results The average age of patients in the study was 56.2 years (range 12â??78 years). Silverâ?coated prostheses were implanted in 56.7% of patients, and uncoated tumour prostheses were used in the remaining 43.3%. The mean follow-up was 40.7 months. A total of 26.7% of patients died at a median time of 28.6 months after surgery. The overall rate of complications was 30%, with 16.7% due to infection. A total of 11.8% of the patients treated with silverâ?coated implants developed infection compared with 23.1% of the patients treated with uncoated tumour prostheses. There were no cases of early infection in the silver-coated prosthesis group, whereas early infection occurred in 66.7% of patients in the uncoated prosthesis group. All the functional outcomes were significantly improved after surgery. None of the other parameters analysed can be considered a significant negative prognostic factor for infection. The SEM analyses showed severe silver-coating degradation 2 years after first implant. No case of silver toxicity was demonstrated. Discussion There are few papers in the literature about infective complications in tumour prosthesis after pathological fracture. Silver-coated implants showed a protective action against early infection. Late infection rate was similar between the groups, thereby indicating a reduction of antimicrobial activity for the silver-coating over time. Conclusions Silver-coated prostheses are a protective factor against early infections in limb salvage surgery after pathological fractures, so may represent the first-choice of implants in this type of surgery.
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Interventions for treating proximal humeral fractures in adults
Pediatric Supracondylar Humerus Fracture 2020 Review
- Background Fracture of the proximal humerus, often termed shoulder fracture, is a common injury in older people. The management of these fractures varies widely. This is an update of a Cochrane Review first published in 2001 and last updated in 2012. Objectives To assess the effects (benefits and harms) of treatment and rehabilitation interventions for proximal humeral fractures in adults. Search methods We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, and other databases, conference proceedings and bibliographies of trial reports. The full search ended in November 2014. Selection criteria We considered all randomised controlled trials (RCTs) and quasi�randomised controlled trials pertinent to the management of proximal humeral fractures in adults. Data collection and analysis Both review authors performed independent study selection, risk of bias assessment and data extraction. Only limited meta�analysis was performed. Main results We included 31 heterogeneous RCTs (1941 participants). Most of the 18 separate treatment comparisons were tested by small single�centre trials. The main exception was the surgical versus non�surgical treatment comparison tested by eight trials. Except for a large multicentre trial, bias in these trials could not be ruled out. The quality of the evidence was either low or very low for all comparisons except the largest comparison. Nine trials evaluated non�surgical treatment in mainly minimally displaced fractures. Four trials compared early (usually one week) versus delayed (three or four weeks) mobilisation after fracture but only limited pooling was possible and most of the data were from one trial (86 participants). This found some evidence that early mobilisation resulted in better recovery and less pain in people with mainly minimally displaced fractures. There was evidence of little difference between the two groups in shoulder complications (2/127 early mobilisation versus 3/132 delayed mobilisation; 4 trials) and fracture displacement and non�union (2/52 versus 1/54; 2 trials). One quasi�randomised trial (28 participants) found the Gilchrist�type sling was generally more comfortable than the Desault�type sling (body bandage). One trial (48 participants) testing pulsed electromagnetic high�frequency energy provided no evidence. Two trials (62 participants) provided evidence indicating little difference in outcome between instruction for home exercises versus supervised physiotherapy. One trial (48 participants) reported, without presentable data, that home exercise alone gave better early and comparable long�term results than supervised exercise in a swimming pool plus home exercise. Eight trials, involving 567 older participants, evaluated surgical intervention for displaced fractures. There was high quality evidence of no clinically important difference in patient�reported shoulder and upper�limb function at one� or two�year follow�up between surgical (primarily locking plate fixation or hemiarthroplasty) and non�surgical treatment (sling immobilisation) for the majority of displaced proximal humeral fractures; and moderate quality evidence of no clinically important difference between the two groups in quality of life at two years (and at interim follow�ups at six and 12 months). There was moderate quality evidence of little difference between groups in mortality in the surgery group (17/248 versus 12/248; risk ratio (RR) 1.40 favouring non�surgical treatment, 95% confidence interval (CI) 0.69 to 2.83; P = 0.35; 6 trials); only one death was explicitly linked with the treatment. There was moderate quality evidence of a higher risk of additional surgery in the surgery group (34/262 versus 16/261; RR 2.06, 95% CI 1.18 to 3.60; P = 0.01; 7 trials). Although there was moderate evidence of a higher risk of adverse events after surgery, the 95% confidence intervals for adverse events also included the potential for a great r risk of adverse events after non�surgical treatment. Different methods of surgical management were tested in 12 trials. One trial (57 participants) comparing two types of locking plate versus a locking nail for treating two�part surgical neck fractures found some evidence of slightly better function after plate fixation but also of a higher rate of surgically�related complications. One trial (61 participants) comparing a locking plate versus minimally invasive fixation with distally inserted intramedullary K�wires found little difference between the two implants at two years. Compared with hemiarthroplasty, one trial (32 participants) found similar results with locking plate fixation in function and re�operation rates, whereas another trial (30 participants) reported all five re�operations occurred in the tension�band fixation group. One trial (62 participants) found better patient�rated (Quick DASH) and composite shoulder function scores at a minimum of two years follow�up and a lower incidence of re�operation and complications after reverse shoulder arthroplasty (RSA) compared with hemiarthroplasty. No important between�group differences were found in one trial (120 participants) comparing the deltoid�split approach versus deltopectoral approach for non�contact bridging plate fixation, and two trials (180 participants) comparing 'polyaxial' and 'monaxial' screws in locking plate fixation. One trial (68 participants) produced some preliminary evidence that tended to support the use of medial support locking screws in locking plate fixation. One trial (54 participants) found fewer adverse events, including re�operations, for the newer of two types of intramedullary nail. One trial (35 participants) found better functional results for one of two types of hemiarthroplasty. One trial (45 participants) found no important effects of tenodesis of the long head of the biceps for people undergoing hemiarthroplasty. Very limited evidence suggested similar outcomes from early versus later mobilisation after either surgical fixation (one trial: 64 participants) or hemiarthroplasty (one trial: 49 participants). Authors' conclusions There is high or moderate quality evidence that, compared with non�surgical treatment, surgery does not result in a better outcome at one and two years after injury for people with displaced proximal humeral fractures involving the humeral neck and is likely to result in a greater need for subsequent surgery. The evidence does not cover the treatment of two�part tuberosity fractures, fractures in young people, high energy trauma, nor the less common fractures such as fracture dislocations and head splitting fractures. There is insufficient evidence from RCTs to inform the choices between different non�surgical, surgical, or rehabilitation interventions for these fractures. Plain language summary Interventions for treating shoulder fractures in adults Background Fracture of the top end of the upper arm bone (proximal humerus) is a common injury in older people. It is often called a shoulder fracture. The bone typically fractures (breaks) just below the shoulder, usually after a fall. Most of these fractures occur without breaking the skin lying over the fracture. The injured arm is often supported in a sling until the fracture heals sufficiently to allow shoulder movement. More severe (displaced) fractures may be treated surgically. This may involve fixing the fracture fragments together by various means. Alternatively, the top of the fractured bone may be replaced (half 'shoulder' replacement: hemiarthroplasty). More rarely, the whole joint, thus including the joint socket, is replaced (total 'shoulder' replacement). Physiotherapy is often used to help restore function. Results of the search We searched medical databases up to November 2014 and included 31 randomised studies with a total of 1941 participants. Most of the 18 treatment comparisons were tested by one study only. The best evidence was from eight studies, one of which was a relatively large multicentre study these investigated whether surgery gave a better result than non�surgical treatment for displaced fractures. Key results Nine trials evaluated non�surgical treatment in usually less severe fractures. One trial found a type of arm sling was generally more comfortable than a type of body bandage. There was some evidence that early mobilisation (within one week), compared with delayed mobilisation (after three weeks), resulted in less pain and faster recovery in people with 'stable' fractures. Two studies provided weak evidence that many patients could generally achieve a satisfactory outcome when given sufficient instruction to pursue exercises on their own. Eight studies, involving 567 participants with displaced fractures, compared surgical versus non�surgical treatment. Pooled results from the five most recent trials showed that there were no important differences between the two approaches for patient�reported measures of function and quality of life at 6, 12 and 24 months. There was little difference between the two groups in mortality. Twice as many surgical group patients had additional or secondary surgery. More surgical group patients had adverse events. Twelve trials (744 participants) tested different methods of surgical treatment. There was weak evidence of some differences (e.g. in complications) between some interventions (e.g. different devices or different ways of using devices). There was very limited evidence suggesting similar outcomes for early versus delayed mobilisation after either surgical fixation or hemiarthroplasty. Quality of the evidence Most of the 31 studies had weaknesses that could affect the reliability of their results. We considered that the evidence was either of high or moderate quality for the results of the surgical versus non�surgical treatment comparison, which means that we are pretty certain these results are reliable. We considered that the evidence for other comparisons was of low or very low quality, which means we are unsure of these results. Conclusions Surgery does not result in a better outcome for the majority of people with displaced proximal humeral fractures and is likely to result in a greater need for subsequent surgery. Otherwise, there is not enough evidence to determine the best non�surgical or, when selected, surgical treatment for these fractures.
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Peripheral Nerve Block as a Supplement to Light or Deep General Anesthesia in Elderly Patients Receiving Total Hip Arthroplasty
AAHKS (8) Anesthetic Infiltration
Background: Peripheral nerve block combined with general anesthesia is a preferable anesthesia method for elderly patients receiving hip arthroplasty. The depth of sedation may influence patient recovery. Therefore, we investigated the influence of peripheral nerve blockade and different intraoperative sedation levels on the short-term recovery of elderly patients receiving total hip arthroplasty. Methods: Patients aged 65 years and older undergoing total hip arthroplasty were randomized into 3 groups: a general anesthesia without lumbosacral plexus block group, and 2 general anesthesia plus lumbosacral plexus block groups, each with a different level of sedation (light or deep). The extubation time and intraoperative consumption of propofol, sufentanil, and vasoactive agent were recorded. Postoperative delirium and early postoperative cognitive dysfunction were assessed using the Confusion Assessment Method and Mini-Mental State Examination, respectively. Postoperative analgesia was assessed by the consumption of patient-controlled analgesics and visual analog scale scores. Discharge time and complications over a 30-day period were also recorded. Results: Lumbosacral plexus block reduced opioid intake. With lumbosacral plexus block, intraoperative deep sedation was associated with greater intake of propofol and vasoactive agent. In contrast, patients with lumbosacral plexus block and intraoperative light sedation had lower incidences of postoperative delirium and postoperative cognitive decline, and earlier discharge readiness times. The 3 groups showed no difference in complications within 30 days of surgery. Conclusions: Lumbosacral plexus block reduced the need for opioids and offered satisfactory postoperative analgesia. It led to better postoperative outcomes in combination with intraoperative light sedation (high bispectral index).
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The relationship between obesity and fractures
Pediatric Supracondylar Humerus Fracture 2020 Review
There has been very limited analysis of the relationship between obesity and fractures in the orthopaedic literature. It has been established for some years that underweight individuals are at greater risk of proximal femoral fractures but recently there has been interest in the susceptibility of obese post-menopausal females to fracture. We have undertaken an analysis of 4886 adult patients who presented with a fracture and had their BMI assessed. Analysis has confirmed the relationship between underweight individuals and proximal femoral fractures but there is also a negative association between obesity and clavicle fractures in males and females and with calcaneal fractures in females. There is a positive relationship between obesity and proximal humeral, finger phalangeal and ankle fractures in males and with humeral diaphyseal, carpal and ankle fractures in females. There was no relationship found between open or multiple fractures and obesity.
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Isolation of adipose tissue derived regenerative cells from human subcutaneous tissue with or without the use of an enzymatic reagent
Panniculectomy & Abdominoplasty CPG
Freshly isolated, uncultured, autologous adipose derived regenerative cells (ADRCs) have emerged as a promising tool for regenerative cell therapy. The Transpose RT system (InGeneron, Inc., Houston, TX, USA) is a system for isolating ADRCs from adipose tissue, commercially available in Europe as a CE-marked medical device and under clinical evaluation in the United States. This system makes use of the proprietary, enzymatic Matrase Reagent for isolating cells. The present study addressed the question whether the use of Matrase Reagent influences cell yield, cell viability, live cell yield, biological characteristics, physiological functions or structural properties of the ADRCs in final cell suspension. Identical samples of subcutaneous adipose tissue from 12 subjects undergoing elective lipoplasty were processed either with or without the use of Matrase Reagent. Then, characteristics of the ADRCs in the respective final cell suspensions were evaluated. Compared to non-enzymatic isolation, enzymatic isolation resulted in approximately twelve times higher mean cell yield (i.e., numbers of viable cells/ml lipoaspirate) and approximately 16 times more colony forming units. Despite these differences, cells isolated from lipoaspirate both with and without the use of Matrase Reagent were independently able to differentiate into cells of all three germ layers. This indicates that biological characteristics, physiological functions or structural properties relevant for the intended use were not altered or induced using Matrase Reagent. A comprehensive literature review demonstrated that isolation of ADRCs from lipoaspirate using the Transpose RT system and the Matrase Reagent results in the highest viable cell yield among published data regarding isolation of ADRCs from lipoaspirate.
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Calciotropic hormones and markers of bone remodeling in age-related (type II) femoral neck osteoporosis: alterations consistent with secondary hyperparathyroidism-induced bone resorption
Management of Hip Fractures in the Elderly
BACKGROUND: Both a decrease in bone formation and the skeletal consequences of secondary hyperparathyroidism have been implied in the pathogenesis of age-related femoral neck osteoporosis. However, studies using biochemical indices of bone remodeling in hip fracture patients have yielded conflicting results. Similarly, secondary hyperparathyroidism has not been a consistent finding in this population. Some of these inconsistencies might reflect differences in the assays used as well as in the timing of the sampling. Moreover, measurements were mostly performed in a limited number of patients. In this regard, the aim of the present study was to analyze potential alterations in bone metabolism in a large population of elderly hip fracture patients. METHODS: Circulating concentrations of 25-hydroxyvitamin D [25(OH)D], 1,25-dihydroxyvitamin D [1,25(OH)2D3], intact parathyroid hormone (PTH), and calcitonin were measured in 117 elderly women (within a few hours after sustaining a fracture of the proximal femur) and in 117 healthy age-matched controls. In addition, serum osteocalcin and urinary excretion of (deoxy)pyridinoline were determined as markers of bone formation and resorption, respectively. RESULTS: Serum levels of 25(OH)D and 1,25(OH)2D3 were decreased in hip fracture patients. When correcting for differences in serum vitamin D binding protein, serum 25(OH)D was still significantly lower in patients than in controls, whereas serum 1,25(OH)2D3 was not. Moreover, 25(OH)D deficiency in hip fracture patients was associated with an increase in circulating PTH and urinary excretion of (deoxy)pyridinoline. Serum osteocalcin, on the other hand, was significantly decreased in fracture patients. There was no statistically significant difference in calcitonin. CONCLUSION: These data suggest that there is reduced bone formation and increased bone resorption in patients with hip fracture. Although limited by its cross-sectional design, the present study emphasizes the role of secondary hyperparathyroidism-induced bone resorption in the pathogenesis of age-related osteoporosis, mainly due to a lack of 25(OH)D
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Histopathology grading systems for characterisation of human knee osteoarthritis--reproducibility, variability, reliability, correlation, and validity
Surgical Management of Osteoarthritis of the Knee CPG
OBJECTIVE: To determine the reliability, reproducibility, variability and validity of the Osteoarthritis Cartilage Histopathology (OACH) assessment system and Mankin Histological-Histochemical Grading System (HHGS) when applied to the characterisation of the osteoarthritic human knee. METHOD: Osteoarthritic knees of 10 patients undergoing unilateral knee arthroplasty were assessed, and assigned Kellgren-Lawrence and Line Drawing Atlas (LDA) radiology scores. The tibial plateaux were scored using the Modified Collins (MC) and Societe Francaise d'Arthroscopie (SFA). Three observers twice scored both the OACH and HHGS across a single complete medial and lateral tibial plateau transect taken to include the region with the most severe osteoarthritis (OA) lesion. Intra- and inter-observer reliability, reproducibility, variability and validity were assessed, and the correlation between the two histopathology scoring systems was calculated. RESULT: Both histopathology scoring systems were determined to be reliable and reproducible exhibiting similar variability, when applied to characterise OA specimens sampled from a well defined patient group with knee OA. A strong correlation between the mean OACH and mean HHGS scores was identified (Spearman's rho 0.980, P<0.0001). CONCLUSION: Both scoring systems implemented provide useful measures in the characterisation of knee osteoarthritis. It is of note that an additional parameter within the OACH score over the HHGS defines the extent of the disease, where the HHGS is a grade attributed to the most representative level of the biological aggression within the OA lesions. This study has confirmed the OACH system's utility in human knee OA and is supported by a significant correlation with the established HHGS
1
Clinical benefit of intra-articular saline as a comparator in clinical trials of knee osteoarthritis treatments: A systematic review and meta-analysis of randomized trials
OAK 3 - Non-arthroplasty tx of OAK
OBJECTIVES: Hyaluronic acid and corticosteroids are common intra-articular (IA) therapies widely used for the management of mild to moderate knee osteoarthritis (OA). Many trials evaluating the efficacy of IA administered therapies commonly use IA saline injections as a placebo comparator arm. Using a systematic review and meta-analysis, our objective was to assess the clinical benefit associated with use of IA saline in trials of IA therapies in the treatment of patients with painful knee OA. METHODS: MEDLINE and Embase databases were searched for articles published up to and including August 14th, 2014. Two reviewers assessed the eligibility of potential reports and the risk of bias of included trials. We analyzed short (<=3 months) and long-term (6-12 months) pain reduction of the saline arm of included trials using standardized mean differences (SMDs; estimated assuming a null effect in a comparator group) that were combined and weighted using a random effects model. Treatment-related adverse events (AEs) were tabulated and presented using descriptive statistics. RESULTS: From 40 randomized controlled trials (RCTs) eligible for inclusion only 38 provided sufficient data to be included in the meta-analysis. Based on data with moderate inconsistency IA saline was found to significantly improve short-term knee pain in 32 studies involving 1705 patients (SMD = -0.68; 95% CI: -0.78 to -0.57; P < 0.001; I(2) = 50%). Long-term knee pain was significantly decreased following IA injection with saline in 19 studies involving 1445 patients (SMD = -0.61; 95% CI: -0.76 to -0.45; P < 0.001) with a substantial degree of inconsistency (I(2) = 74%). Overall, 29 of the included trials reported on adverse events, none of which found any serious treatment-related AEs following IA injection with saline. CONCLUSIONS: Pain relief observed with IA saline should prompt health care providers to consider the additional effectiveness of current IA treatments that use saline comparators in clinical studies, and challenges of identifying IA saline injection as a "placebo."
0
Meniscotibial ligament strains: a prospective survey
AMP (Acute Meniscal Pathology)
Medial knee pain is an increasingly common presentation in sports medicine practice. A prospective review was undertaken of 72 patients, mean age 48 years, seen in 1986-1987. The physical findings which were most diagnostic were a loss of some degrees of flexion which was painful medially when forced, and tenderness over the posteromedial joint line. Treatment was either injection of local steroid, or physiotherapy, together with emphasis on quadriceps exercise. Five patients failed to respond and were referred for arthroscopy. Nine patients relapsed once but no subsequent episode has occurred. Meniscotibial ligament strain is a common cause of knee pain in middle-aged sports people.
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Efficacy of Radial Shockwave Therapy for Treatment of Pain in Knee Osteoarthritis
OAK 3 - Non-arthroplasty tx of OAK
� Prospective, placebo controlled randomized and double�blind study. � Treatment Method: Radial extracorporeal shockwaves will be applied using the Swiss Dolorclast (EMS Electro Medical Systems, Switzerland), generated by pneumatic waves. Intervention: � Group 1 � Intervention group Patients will receive 2,000 impulses of radial shockwave per week, with pressure of 2.5bar to 4.0bar, at the frequency of 8Hz. The impulses will be applied at the most painful site of the knee joint interface on manual palpation, for three consecutive weeks. � Group 2 � Control Group: Patients will receive 2,000 impulses of placebo radial shockwave per week, without any energy flow intensity. Frequency of 8Hz will appear in the screen. The impulses will be applied at the most painful site of the knee joint interface on manual palpation, for three consecutive weeks. Post application program for both groups: Three consecutive days of: 1. Hot packs (superficial heat) applied on the application site for 20 minutes; 2. Simple analgesics, when needed (Acetaminophen 500mg every 6 hours, or analogue in case of allergy). Outcome Evaluation: The evaluation of pain intensity will be done according to the VAS (Visual Analog Scale) The influence of pain on the functional capacity of patients will be measured with WOMAC (Western Ontario and McMaster Osteoarthritis Index) for knee evaluation. Another evaluation criteria will be the level of tolerance of pressure on several muscles and other parts as the pes anserinus and patellar tendon, the knee joint interface, and the supraspinal of L1 to S1 also on the dermatomal from T12 to S2. These measures will be done by the Fisher algometry. The evaluations will be carried out before the treatment, immediately after the treatment and 3 months after the end of the treatment. Analgesia drut will be prescribed, if patients feel pain during the days after the application.
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Antibiotic-Loaded MMT/PLL-Based Coating on the Surface of Endosseous Implants to Suppress Bacterial Infections
Dental Implant Infection
BACKGROUND: Bone infections remain one of the most common and serious complications of orthopedic surgery, posing a tremendous economic burden to society and patients. This is because bacteria colonize and multiply on the surface of the implant. The (MMT/PLL)8 multilayer films have been shown to effectively release antibiotics depending on the changes in the microenvironment. Here, vancomycin was loaded into the (MMT/PLL)8 multilayer films, which were prepared to be used as a local delivery system for the treatment of bone infections., METHODS: We used the layer-by-layer self-assembly method to prepare VA-loaded coatings (MMT/PLL-VA)8 consisting of montmorillonite (MMT), poly-L-lysine (PLL), and VA. The thickness and surface morphology of coatings were characterized using spectroscopic ellipsometry and scanning electron microscopy (SEM). In order to evaluate the drug release behavior from coatings in different media, we measured the size of the zone of inhibition. Additionally, in vitro antibacterial activity was assessed using the shake-flask culture method and SEM images, while that of in vivo was evaluated by establishing an animal model of bone infection., RESULTS: Our findings revealed that small-molecule antibiotics were successfully loaded into the (MMT/PLL-VA)8 multilayer film structure during the hierarchical self-assembly process and subsequently the multilayer film structure depicted linear growth behavior. The PLL in the multilayer films was progressively degraded which triggered the VA release when contacted with CMS or bacterial infections. The release of VA from multilayer film structure depends on the concentration changes of CMS. Notably, the multilayer films presented great in vitro cell compatibility. Moreover, the prepared antibacterial multilayer films showed excellent antibacterial property by killing more than 99.99% of S. aureus in 24 h. More importantly, we found that multilayer film exhibits good sterilization effect and biocompatibility under the stimulation of bacterial liquid both in vitro and in vivo antibacterial ability tests., CONCLUSION: Altogether, this study shows that (MMT/PLL-VA)8 multilayer films containing CMS and bacteria-responsive drug release properties posess high bactericidal activity and good biocompatibility. This finding provides a novel strategy for the treatment of bone infections. Copyright © 2021 Yu et al.
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Is manipulative therapy more effective than sham manipulation in adults?: A systematic review and meta-analysis
SR for PM on OA of All Extremities
Background: Manipulative therapy is widely used in the treatment of spinal disorders. Manipulative techniques are under debate because of the possibility of adverse events. To date, the efficacy of manipulations compared to sham manipulations is unclear. The purpose of the study is: to assess the efficacy of manipulative therapy compared to sham in adults with a variety of complaints.Study design: Systematic review and meta-analysis.Methods: Bibliographic databases (PubMed, EMBASE, CINAHL, PEDro, Central) along with a hand search of selected bibliographies were searched from inception up to April 2012.Two reviewers independently selected randomized clinical trials (RCTs) that evaluated manipulative therapy compared to sham manipulative therapy in adults, assessed risk of bias and extracted data concerning participants, intervention, kind of sham, outcome measures, duration of follow-up, profession, data on efficacy and adverse events. Pooled (standardized) mean differences or risk differences were calculated were possible using a random effects model. The primary outcomes were pain, disability, and perceived recovery. The overall quality of the body of evidence was evaluated using GRADE.Results: In total 965 references were screened for eligibility and 19 RCTs (n = 1080) met the selection criteria. Eight studies were considered of low risk of bias. There is moderate level of evidence that manipulative therapy has a significant effect in adults on pain relief immediately after treatment (standardized mean difference [SMD] - 0.68, 95% confidence interval (-1.06 to -0.31). There is low level of evidence that manipulative therapy has a significant effect in adults on pain relief (SMD - 0.37, -0.69 to -0.04) at short- term follow-up. In patients with musculoskeletal disorders, we found moderate level of evidence for pain relief (SMD - 0.73, -1.21 to -0.25) immediate after treatment and low level of evidence for pain relief (SMD - 0.52, -0.87 to -0.17) at short term-follow-up. We found very low level of evidence that manipulative therapy has no statistically significant effect on disability and perceived (asthma) recovery. Sensitivity analyses did not change the main findings. No serious adverse events were reported in the manipulative therapy or sham group.Conclusions: Manipulative therapy has a clinical relevant effect on pain, but not on disability or perceived (asthma) recovery. Clinicians can refer patients for manipulative therapy to reduce pain. (copyright) 2013 Scholten-Peeters et al.; licensee BioMed Central Ltd
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Surgery for femoroacetabular impingement using a minimally invasive anterolateral approach: analysis of 118 cases at 2.2-year follow-up
PJI DX Updated Search
INTRODUCTION: Treatment of femoroacetabular impingement (FAI) has progressed over time from using long incisions and dislocation to using arthroscopic surgery. Minimally invasive treatment has rarely been evaluated and a minimally invasive, anterolateral approach has not been used up to now for this indication. A prospective, on-going study was performed to evaluate surgical treatment of FAI with a minimally invasive, anterolateral approach. HYPOTHESIS: Femoral neck, acetabulum and labrum abnormalities can be corrected without significant morbidity using a minimally invasive, anterolateral approach without dislocation. PATIENTS AND METHODS: Treatment of 120 FAI cases (108 patients, 16 women, 92 men, 12 bilateral cases during one surgical session), average age: 34 years (18.9-63.5 years), was done prospectively and in an uninterrupted series. Two cases were lost to follow-up; 106 patients (118 FAI cases) were evaluated with a follow-up of at least 1 year. Assessments consisted of the Non-Arthritic Hip Score (NAHS), WOMAC, measurement of internal rotation with 90 degrees flexion and the Notzli alpha angle on an A/P radiograph in 45 degrees of flexion, 45 degrees abduction and 30 degrees external rotation. RESULTS: Blood loss averaged 1.2g/dl (range 0.5 to 2.7g/dl) and the average operative time was 44.9 minutes (range 30 to 65). With an average follow-up of 2.2 years (range 12 to 54 months), the NAHS changed by 32.5 points (P<0.0001), internal rotation by 19.0 degrees (P<0.0001) and the alpha angle by -24.9 degrees (P<0.0001). Eight surgical revisions were required (6.8%) (four haematomas, two capsular debridement, two additional procedures on the acetabulum) and these had a good outcome; there were no nerve-related or infection-related complications. Four failures (3.5%) were revised by arthroplasty (two patients experienced residual pain and two patients rapidly progressed to osteoarthritis). Eighteen cases progressed by only one Tonnis stage. Brooker stage II and III ossification were observed in 12 cases (10.2%) but these did not affect the functional score and range of motion improvement. DISCUSSION: This approach, which can be learned and performed quickly, does not require any specific materials and yields a reliable surgical procedure without major complications. This short-term study, where the central cartilaginous compartment was not explored and the labrum was not sutured, comprised a consecutive, non-selected series of patients (independent of age, weight, osteoarthritis stage) and had encouraging results. LEVEL OF EVIDENCE: Level III, prospective study, no control group
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Pediatric Sports Injuries
Distal Radius Fractures
With increasing pediatric participation in organized sport and the early specialization of children in single sports, the number of injuries seen in the pediatric and adolescent athletic population continues to increase. Children experience acute traumatic injuries during practice and competition as well as chronic overuse injuries secondary to the repetitive stress on their developing bodies. The unique nature of the pediatric patient often requires a different diagnostic, prognostic, and treatment approach to sports injuries compared with their adult counterparts.
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In vivo kinematics comparison of fixed- and mobile-bearing total knee arthroplasty during deep knee bending motion
OAK 3 - Non-arthroplasty tx of OAK
Purpose: The in vivo kinematics of fixed-bearing and mobile-bearing total knee prostheses remains unclear, particularly for knee flexion over 120°. The purpose of this study was to compare the in vivo kinematics of fixed-bearing and mobile-bearing posterior-stabilized prosthesis during deep knee bending with knee flexion exceeding 120° under weight-bearing conditions. Methods: In vivo kinematics was analysed for 20 patients implanted with either a fixed-bearing posterior-stabilized or mobile-bearing posterior-stabilized prosthesis. Under fluoroscopic surveillance, each patient performed weight-bearing deep knee bending. Motion between each component was analysed using a two- to three-dimensional registration technique, which uses computer-assisted design models to reproduce the spatial positions of the femoral and tibial components from single-view fluoroscopic images. Results: Patients who had fixed-bearing prostheses experienced posterior femoral rollback at a mean of 1.4 mm (SD 1.6) of the medial condyle, whereas patients who had mobile-bearing prostheses experienced 0.8 mm (SD 1.2). The posterior femoral rollback of the femoral lateral condyle in patients with a fixed-bearing prosthesis was a mean of 6.4 mm (SD 1.7) motion in the posterior direction, whereas patients who had a mobile-bearing prosthesis had 6.5 mm (SD 2.4) motion. The mean tibial internal rotation was 7.5° (SD 2.1) for fixed-bearing prosthesis and 9.2° (SD 3.2) for mobile-bearing prosthesis. Conclusions: The present results demonstrated that the fixed-bearing and mobile-bearing posterior-stabilized designs had similar posterior condylar translation and tibial axial rotation during weight-bearing deep knee flexion exceeding 120°. Level of evidence: Retrospective comparative study, Level III. © 2012 Springer-Verlag Berlin Heidelberg.
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Wrist pain, distal radial physeal injury, and ulnar variance in the young gymnast
Distal Radius Fractures
In gymnastics, the wrist joint is subjected to repetitive loading in a weightbearing fashion. In this setting, chronic wrist pain is quite common. Because gymnasts ordinarily enter the sport at very young ages and train for several years before skeletal maturity is attained, the growth plates of the wrist are at risk for injury. In addition, imaging studies have identified evidence of injury to the distal radial physis and the development of positive ulnar variance. Recent studies provide more information on the relationships between these findings, as well as factors that may predispose some gymnasts to wrist pain. This article provides a comprehensive review of these issues and offers suggestions for management, preventive measures, and future research. [References: 84]
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Fluvastatin Prevents Lung Adenocarcinoma Bone Metastasis by Triggering Autophagy
MSTS 2018 - Femur Mets and MM
Bone is one of the most preferred sites of metastasis in lung cancer. Currently, bisphosphonates and denosumab are major agents for controlling tumor-associated skeletal-related events (SREs). However, both bisphosphonates and denosumab significantly increase the risk for jaw osteonecrosis. Statins, 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitors and the most frequently prescribed cholesterol-lowering agents, have been reported to inhibit tumor progression and induce autophagy in cancer cells. However, the effects of statin and role of autophagy by statin on bone metastasis are unknown. In this study, we report that fluvastatin effectively prevented lung adenocarcinoma bone metastasis in a nude mouse model. We further reveal that fluvastatin-induced anti-bone metastatic property was largely dependent on its ability to induce autophagy in lung adenocarcinoma cells. Atg5 or Atg7 deletion, or 3-methyadenine (3-MA) or Bafilomycin A1 (Baf A1) treatment prevented the fluvastatin-induced suppression of bone metastasis. Furthermore, we reveal that fluvastatin stimulation increased the nuclear p53 expression, and fluvastatin-induced autophagy and anti-bone metastatic activity were mostly dependent on p53.
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Breast reduction trend among plastic surgeons: A national survey
Reduction Mammoplasty for Female Breast Hypertrophy
BACKGROUND: A number of breast reduction techniques have been developed over the years, but debate over which technique is better for patients continues to grow. The authors' goal was to survey members of the American Society of Plastic Surgeons to identify their preferences and practices and report their opinion regarding issues related to the various breast reduction techniques. METHODS: In the fall of 2006, a one-page anonymous survey was sent to 5112 plastic surgeons who were members of the American Society of Plastic Surgeons. A follow-up survey was sent 2 weeks after the first mailing as a friendly reminder. The questionnaires were then collected over a 6-week period. RESULTS: Of the 5112 plastic surgeons surveyed, 2665 (52 percent) responded to the survey. The majority of the respondents (69 percent) use the inferior pedicle breast reduction technique. Ninety-two percent of the respondents use intraoperative deep venous thrombosis prophylaxis. Sixty-one percent of respondents performed over 75 percent of their cases on an outpatient basis and 97 percent of respondents use general anesthesia. Ninety-three percent of the respondents use preoperative antibiotics. Over 70 percent of the respondents do not think breast reduction should be a cosmetic procedure. CONCLUSIONS: In conclusion, the inferior pedicle technique has traditionally been the procedure of choice and remains so today. However, there has been an increase in the use of the newer techniques. Plastic surgeons are becoming more cognizant of the risk of deep venous thrombosis among their patients. The majority of breast reductions are now performed as outpatient procedures. Copyright © 2008 by the American Society of Plastic Surgeons.
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Compositional MRI techniques for evaluation of cartilage degeneration in osteoarthritis
OAK 3 - Non-arthroplasty tx of OAK
Osteoarthritis (OA), a leading cause of disability, affects 27 million people in the United States and its prevalence is rising along with the rise in obesity. So far, biomechanical or behavioral interventions as well as attempts to develop disease-modifying OA drugs have been unsuccessful. This may be partly due to antiquated imaging outcome measures such as radiography, which are still endorsed by regulatory agencies such as the United States Food and Drug Administration (FDA) for use in clinical trials. Morphological magnetic resonance imaging (MRI) allows unparalleled multi-feature assessment of the OA joint. Furthermore, advanced MRI techniques also enable evaluation of the biochemical or ultrastructural composition of articular cartilage relevant to OA research. These compositional MRI techniques have the potential to supplement clinical MRI sequences in identifying cartilage degeneration at an earlier stage than is possible today using morphologic sequences only. The purpose of this narrative review is to describe compositional MRI techniques for cartilage evaluation, which include T2 mapping, T2* Mapping, T1 rho, dGEMRIC, gagCEST, sodium imaging and diffusion weighted imaging (DWI). We also reviewed relevant clinical studies that have utilized these techniques for the study of OA. The different techniques are complementary. Some focus on isotropy or the collagen network (e.g., T2 mapping) and others are more specific in regard to tissue composition, e.g., gagCEST or dGEMRIC that convey information on the GAG concentration. The application and feasibility of these techniques is also discussed, as they will play an important role in implementation in larger clinical trials and eventually clinical practice.
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The peril of order? IPV, injury, and order in Mongolian families
DoD PRF (Psychosocial RF)
Despite its consistent and latent appearance in feminist accounts of intimate partner violence (IPV), the characterization of IPV as an elaborately ordered relationship whose norms are backed up by force is notably absent from the empirical IPV literature. Drawing on Emeryâ??s typology of IPV, we hypothesized a curvilinear relationship between order and IPV injury. We developed a measure of relationship order and implemented it in a representative, randomly selected cluster sample of 250 families from Ulaanbaatar, Mongolia. Controlling for the severity of the IPV, higher levels of order, but not lower levels, are associated with higher numbers of reported IPV injuries. Theoretical and practical implications of order as a risk factor are discussed. (PsycINFO Database Record (c) 2016 APA, all rights reserved)
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Effect of low appendicular lean mass, grip strength, and gait speed on the functional outcome after surgery for distal radius fractures
Distal Radius Fractures
Patients with low appendicular lean mass plus slow gait speed or weak grip strength are at risk for poor functional recovery after surgery for distal radius fracture, even when they have similar radiologic outcomes. INTRODUCTION: Loss of skeletal muscle mass and consequent loss in muscle function associate with aging, and this condition negatively impacts the activities of daily living and increases elderly individuals' frailty to falls. Thus, patients with low appendicular lean mass would show different functional recovery compared to those without this condition after surgery for distal radius fracture (DRF). This study compares the functional outcomes after surgery for DRF in patients with or without low appendicular lean mass plus slowness or weakness. METHODS: A total of 157 patients older than 50 years of age with a DRF treated via volar plate fixation were enrolled in this prospective study. A definition of low appendicular lean mass with slowness or weakness was based on the consensus of the Asian Working Group for Sarcopenia. The researchers compared functional assessments (wrist range of motion and Michigan Hand Questionnaire [MHQ]) and radiographic assessments (radial inclination, volar tilt, ulnar variance, and articular congruity) 12 months after surgery between patients with and without low appendicular lean mass plus slowness or weakness. Multivariable regression analyses were performed to determine whether appendicular lean mass, grip strength, gait speed, patient demographic, or injury characteristics accounted for the functional outcomes. RESULTS: Patients with low appendicular lean mass plus slowness or weakness showed a significantly lower recovery of MHQ score than those in the control group throughout 12 months. There was no significant difference in the range of motion between the groups. The radiologic outcomes showed no significant difference between groups in terms of volar tilt, radial inclination, or ulnar variance. According to multivariable regression analysis, the poor recovery of MHQ score was associated with an increase in age, weak grip strength, and lower appendicular lean mass, and these three factors accounted for 37% of the variation in the MHQ scores. CONCLUSION: Patients with low appendicular lean mass plus slowness or weakness are at risk for poor functional recovery after surgery for DRF, even when they have similar radiologic outcomes.
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Surgical capability and surgical pathology in Papua New Guinea in the year 2000
DoD SSI (Surgical Site Infections)
BACKGROUND: Papua New Guinea (PNG) is a country of 4.5 million people with an annual health budget of only 96 million Kina (1K = US$0.35). There are 19 hospitals in the country and national surgeons are now staffing most of these hospitals. This review aims to describe the surgical pathology in the year 2000 and the capability of PNG surgeons to manage it. METHODS: A review of publications, reports and surgical audit data on surgery in PNG was conducted. Surgical audit has been computerized for over 5 years. The review also draws on personal experience and data from MMed theses submitted to the University of Papua New Guinea. RESULTS: Surgical pathology Surgical practice in PNG remains very general. Late presentation and advanced disease are common. Trauma, infection, malignancy and congenital anomalies dominate the surgical scene. The pattern of disease is different from what is found in the West. Western diseases are emerging with the incidence of appendicectomy rising from 5/100,000 to 75/100,000 in the past 30 years. The incidence of diabetes and gallstones has also risen. Osteoporosis, Colles' and neck of femur fractures are rare. Surgical capability The standard of surgical care is acceptable with a low wound infection rate for clean and clean-contaminated abdominal surgery of 0.9% and an anastomotic leak rate of 1.6%. Transurethral prostatectomy is also being performed to a satisfactory standard for head injuries admitted with a Glasgow Coma Score of 6-8 and a good outcome is achieved in over 70% of cases. Hospital mortality for surgical admissions is 3.7%. Subspecialties in orthopaedics, urology and head and neck surgery have been established. Neurosurgery, paediatric and cardiac surgery are being developed. Priorities for the next decade Papua New Guinea needs to continue to develop surgical subspecialties, particularly paediatric and neurosurgery, while maintaining a broad competence in general surgery. Services for burns, spinal injuries, rehabilitation and oncology need to be improved. Surgeons need to be more involved in rural health and teaching basic skills to primary health-care workers. Acquisition, maintenance and repair of surgical equipment needs to be improved so that PNG's well-trained surgeons can have the right tools for their trade. CONCLUSIONS: Papua New Guinea offers a wide range of surgical pathology. The standard of surgery in PNG is reasonable but there are many areas that need development during the period of the next national health plan, 2001-2010. Australasian surgery has many opportunities to assist surgeons in PNG to achieve their objectives. [References: 53]
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Calcaneal Fractures: Update on Current Treatments
DOD - Acute Comp Syndrome CPG
Calcaneal fractures represent 2% of all fractures and account for approximately 60% of all tarsal injuries. Motor vehicle collisions and falls are the major causes of these large force compression injuries, causing widening of the heel, loss of heel height, and articular surface displacement. A correlation has been shown between restoration of normal anatomy and satisfactory functional outcome. Once the basic principles of calcaneal fractures are understood, including the anatomy, the radiographic findings, and the challenges that these complicated fractures present, the physician can then be ready with the armamentarium that allows for a patient-specific and injury-specific plan. © 2012 Elsevier Inc.
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Quadratus lumborum block for postoperative analgesia after full abdominoplasty: a randomized controlled trial
Panniculectomy & Abdominoplasty CPG
Background and aims The quadratus lumborum block (QLB) provides regional analgesia of the anterior abdominal wall, theoretically matching the postoperative pain after postbariatric standard full abdominoplasty. We investigated the effectiveness of a QLB as an addition to the current multimodal analgesia regimen in postbariatric patients treated with standard full abdominoplasty. Methods Randomized, placebo-controlled, triple blinded study (n = 50). All patients received perioperative paracetamol and intraoperative local anesthetic infiltration. QLB was administered bilaterally before induction of general anesthesia with 2 x 20 mL of either ropivacaine 3.75 mg/mL (n = 25) or placebo (saline 9 mg/mL) (n = 25). Patients received intravenous patient controlled opioid analgesia postoperatively. The primary endpoint was opioid use during the first 24 postoperative hours. Secondary endpoints were acute and chronic postoperative pain, postoperative nausea and vomiting, and other side effects. Results Patient characteristics were similar between groups. The primary endpoint in morphine equivalent units was similar between groups during the first 24 h with mean (SD) of 26 (25) vs. 33 (33) mg (p = 0.44) in the ropivacaine and placebo group, respectively. The observed effect was smaller, and SD larger than assumed in the sample size estimation. Linear mixed effects modeling indicated a minimal inter-group difference. No differences were found for secondary endpoints. Conclusions The QLB did not provide significant additional benefit in terms of reduced opioid requirements or secondary endpoints when administered as part of a multimodal pain regimen to postbariatric patients undergoing standard full abdominoplasty. A minimal difference of little clinical importance the first 12 postoperative hours may have been missed. Implications Including the QLB in the current multimodal pain regimen cannot be recommended based on these findings. The study does not preclude QLB use in individual cases where the multimodal regimen is inadequate or contraindicated. The effectiveness of the QLB for supraumbilical pain remains undocumented.
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The treatment of displaced supracondylar fractures of the humerus in children. A comparison of three methods
The Treatment of Pediatric Supracondylar Humerus Fractures AUC
This retrospective study compares the long-term results of the treatment of 135 children with displaced extension-type supracondylar fractures of the humerus using 3 different methods. Closed reduction and percutaneous fixation was superior with excellent and good results in 87% and had the lowest incidence of poor results (8%). Open reduction and wire fixation, and closed reduction with a plaster cast gave excellent and good results in 74% and 60% respectively. Closed reduction and wire fixation is recommended as the treatment for grades II and III supracondylar fractures
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Fresh meniscal allograft transplantation and autologous ACL/PCL reconstruction in a patient with complex knee trauma following knee dislocation - A case report
Surgical Management of Osteoarthritis of the Knee CPG
Instability of the knee joint, particularly in combination with the loss of one meniscus, regularly leads to the early development of arthritis. This paper describes the case of a 19-year-old male with ruptures of the anterior (ACL) and posterior cruciate ligament (PCL) along with the loss of the medial meniscus due to knee dislocation. Combined, time-delayed reconstruction of both the ACL and PCL and the allogenic fresh meniscal transplantation of the medial meniscus without bone plugs were performed. The control arthroscopy performed 6 months post-transplantation revealed good vitality and integration of the grafts as assessed both macroscopically and histologically. A small portion of the posterior horn had to be refixated, and the anterior horn was atrophic. At 24 months after trauma and 13 months following meniscal transplantation, the patient achieved a Lysholm score of 88 points and clinical examination indicated a stable knee. Fresh meniscal allograft transplantation, in combination with autologous ACL and PCL reconstruction, constitutes - in specialized centers - an alternative treatment option for complex trauma of the knee joint with loss of a meniscus
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Magnetic resonance evaluation of TruFit® plugs for the treatment of osteochondral lesions of the knee shows the poor characteristics of the repair tissue
Osteochondritis Dissecans 2020 Review
BACKGROUND: Treatment of osteochondral lesions of the knee with synthetic scaffolds seems to offer a good surgical option preventing donor site morbidity. The TruFit® plug has frequently been shown to not properly incorporate into. OBJECTIVE: To evaluate the relationship between MRI findings and functional scores of patients with osteochondral lesions of the knee treated with TruFit®. METHODS: Patients were evaluated with MOCART score for magnetic resonance imaging assessment of the repair tissue. KOOS, SF-36 and VAS were used for clinical evaluation. Correlation between size of the treated chondral defect and functional scores was also analyzed. RESULTS: Fifty-seven patients with median follow-up of 44.8 months (range 24-73) were included. KOOS, SF-36 and VAS improved from a mean 58.5, 53.9 and 8.5 points to a mean 87.4, 86.6 and 1.2 at last follow-up (p<0.001). Larger lesions showed less improvement in KOOS (p=0.04) and SF-36 (p=0.029). Median Tegner values were restored to preinjury situation (5, range 2-10). Mean MOCART score was 43.2 ± 16.1. Although the cartilage layer had good integration, it showed high heterogeneity and no filling of the subchondral bone layer. CONCLUSIONS: TruFit® failed to restore the normal MRI aspect of the subchondral bone and lamina in most cases. The appearance of the chondral layer in MRI was partially re-established. This unfavourable MRI appearance did not adversely influence the patient's outcome in the short time and they restored their previous level of activity. There was an inverse linear relationship between the size of the lesion and the functional scores. LEVEL OF EVIDENCE: Therapeutic case series; level 4.
0
Carpal tunnel syndrome in children
Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
BACKGROUND: Carpal tunnel syndrome or median neuropathy at the wrist is a rare condition in children. Of the reported patients with carpal tunnel syndrome, mucopolysaccharidoses and the mucolipidoses are the most common causes. PATIENTS: We report 13 patients between the ages of 2 and 17 years of age with carpal tunnel syndrome. RESULTS: Mucopolysaccharidoses was the cause in one child. In other children, trauma to the median nerve, malformations of the wrist, brachial plexopathy, obesity, inherited susceptibility to pressure palsies (PMP 22 gene deletion), and family history of median neuropathy at the wrist were identified. All patients had hand pain, numbness, and paresthesias in their hands. The nerve conduction studies showed prolongation of median sensory nerve latency and distal motor latency in median nerve. CONCLUSIONS: Carpal tunnel syndrome occurs in children and a variety of risk factors predispose to its occurrence
1
Better interprofessional teamwork, higher level of organized care, and lower risk of burnout in acute health care teams using care pathways: a cluster randomized controlled trial
Hip Fx in the Elderly 2019
BACKGROUND: Effective interprofessional teamwork is an essential component for the delivery of high-quality patient care in an increasingly complex medical environment. The objective is to evaluate whether the implementation of care pathways (CPs) improves teamwork in an acute hospital setting. DESIGN AND MEASURES: A posttest-only cluster randomized controlled trial was performed in Belgian acute hospitals. Teams caring for patients hospitalized with a proximal femur fracture and those hospitalized with an exacerbation of chronic obstructive pulmonary disease, were randomized into intervention and control groups. The intervention group implemented a CP. The control group provided usual care. A set of team input, process, and output indicators were used as effect measures. To analyze the results, we performed multilevel statistical analysis. RESULTS: Thirty teams and a total of 581 individual team members participated. The intervention teams scored significantly better in conflict management [beta=0.30 (0.11); 95% confidence interval (CI), 0.08 to 0.53]; team climate for innovation [beta=0.29 (0.10); 95% CI, 0.09 to 0.49]; and level of organized care [beta=5.56 (2.05); 95% CI, 1.35 to 9.76]. They also showed lower risk of burnout as they scored significantly lower in emotional exhaustion [beta=-0.57 (0.21); 95% CI, -1.00 to -0.14] and higher in the level of competence (beta=0.39; 95% CI, 0.15 to 0.64). No significant effect was found on relational coordination. CONCLUSIONS: CPs are effective interventions for improving teamwork, increasing the organizational level of care processes, and decreasing risk of burnout for health care teams in an acute hospital setting. Through this, high-performance teams can be built.
1
Limiting spread of COVID-19 in an orthopaedic department-a perspective from Spain
Coronavirus Disease 2019 (COVID-19)
Besides national and international recommendations, orthopaedic departments face significant changes in daily activity and serious issues to maintain their standards in musculoskeletal care during the pandemic Covid-19 crisis that we are facing. This report retrospectively addresses measures that were progressively put in place to modify in a week time the activity of a busy orthopaedic department in a large tertiary university hospital in face of the pandemic. Surgical priorities and surgical outcomes are key aspects to consider. The experience may offer some insight to areas where the spread of the disease may be slower or delayed. Abrupt stop of scheduled surgery and clinics is useful to adapt an orthopaedic department to the overall hospital resource reorganization. Orthopaedic surgeons need to be aware of the risks to patients and personnel in view of underdiagnosed cases, which make pre-operative Covid-19 evaluation mandatory for all surgical cases.
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Iliopsoas Tendonitis Caused by Overhang of a Collared Femoral Prosthesis
PJI DX Updated Search
Pain after total hip arthroplasty can be due to a variety of causes, one of the less common being iliopsoas tendonitis. We report an unusual case of iliopsoas tendonitis caused by overhang of the femoral calcar by a collared femoral prosthesis resulting in impingement on the iliopsoas tendon. An ultrasound-guided corticosteroid and local anesthetic diagnostic injection to the site of impingement confirmed the diagnosis with temporary symptom relief. Revision of the femoral stem to a collarless prosthesis resulted in immediate and complete resolution of symptoms. © 2011 Elsevier Inc
1
Neurolysis in the treatment of carpal tunnel syndrome. A preliminary report
Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
Partial external and internal neurolysis of the median nerve as an adjunct to release of the transverse carpal ligament restored nerve conduction at a more rapid rate than has been appreciated. No evidence is obtained to indicate deleterious effects of internal neurolysis
0
Retained Sponge: A Rare Complication in Acetabular Osteosinthesis
DoD SSI (Surgical Site Infections)
Retained sponges after a surgical treatment of polytrauma may cause a broad spectrum of clinical symptoms and present a difficult diagnostic problem. We report a case of retained surgical sponge in a 35-year-old man transferred from another hospital, that sustained a open acetabular fracture. The fracture was reduced through a limited ilio-inguinal approach. After 4 days, he presented massive wound dehiscence of the surgical approach. An abdominal CT scan showed, lying adjacent to the outer aspect of the left iliac crest, a mass of 10 cm, identified as probable foreign body. The possibility of this rare complication should be in the differential diagnosis of any postoperative patient who presents with pain, infection, or palpable mass.
1
Evolution of pain at 3 months by oral resveratrol in knee osteoarthritis (ARTHROL): protocol for a multicentre randomised double-blind placebo-controlled trial
OAK 3 - Non-arthroplasty tx of OAK
INTRODUCTION: Osteoarthritis (OA) pathophysiology is driven in part by joint inflammation. Resveratrol has in vitro anti-inflammatory properties. We aim to assess the efficacy of oral resveratrol for knee pain at 3 months in people with knee OA. METHODS AND ANALYSIS: We will conduct a randomised double-blind placebo-controlled trial. Overall, 164 individuals with knee OA fulfilling 1986 American College of Rheumatology criteria will be recruited in three tertiary care centres in France and randomised to receive oral resveratrol, 40 mg (two caplets) two times per day for 1 week, then 20 mg (one caplet) two times per day or a matching placebo for a total of 6 months. Randomisation will be centralised and stratified by centre. The allocation ratio of assignments will be 1:1. The primary outcome will be the mean change from baseline in knee pain on a self-administered 11-point pain Numeric Rating Scale at 3 months. Secondary outcomes will be the mean change in knee pain at 6 months, the function subscore of the Western Ontario and McMaster Universities Arthritis Index score, patient global assessment, proportion of responders according to the Osteoarthritis Research Society International-Outcome Measures in Rheumatology criteria at 3 and 6 months, and self-reported number of intra-articular injections of corticosteroids or hyaluronic acid and consumption of analgesics and non-steroidal anti-inflammatory drugs since the last contact. Other interventions will be allowed and self-reported. Adherence will be monitored by capsule counts and a booklet and adverse events recorded at 3 and 6 months. Statisticians, treating physicians and participants will be blinded to the allocated treatment. ETHICS AND DISSEMINATION: The oral resveratrol in knee osteoarthritis (ARTHROL) trial has been authorised by the AgenceNationale de Securite du Medicament et des Produits de Sante and ethics were approved by the Comite deProtection des Personnes Ile-de-France III. The findings of the study will be published in a peer-reviewed journal and disseminated at conferences. The design of ARTHROL will warrant the translation of its findings into clinical practice. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov identifier: NCT02905799. Pre-results. First received: 14 September 2016. Last updated: 16 September 2016. Status: not yet recruiting.
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Determination of the minimum initial intrathecal dose of isobaric 0.5% bupivacaine for the surgical repair of a proximal femoral fracture: A prospective, observational trial
Hip Fx in the Elderly 2019
BACKGROUND: Femoral neck fractures usually require operative fixation. Spinal anaesthesia is the preferred technique for many anaesthetists, although single-shot spinal anaesthesia may have severe haemodynamic side-effects. OBJECTIVE: To determine the initial minimum intrathecal dose of 0.5% isobaric bupivacaine required in order to achieve surgical anaesthesia within 15 min. DESIGN: Prospective controlled trial using the Dixon and Massey up-and-down method. SETTING: Patients awaiting surgery for proximal femoral fractures at Cork University Hospital were recruited between September 2012 and December 2012. PATIENTS: With institutional ethics approval and having obtained written informed consent from each, American Society of Anesthesiologists' physical status I to III patients aged more than 60 years were recruited. Twenty-three patients were recruited to the study, of which 22 were managed as per protocol. One patient was excluded because of the inability to insert an intrathecal catheter. INTERVENTION: A 22-guage spinal catheter was inserted between the L3 and L5 vertebral levels. An initial dose of 1 ml 0.5% isobaric bupivacaine was arbitrarily chosen as a starting point. The dose in subsequent patients was determined by the outcome of the preceding spinal block and adjusted by 0.1 ml until data on six independent pairs of patients with successful block/failed block were acquired. MAIN OUTCOME MEASURES: The minimum effective local anaesthetic dose of intrathecal 0.5% isobaric bupivacaine to achieve surgical anaesthesia was defined as the primary outcome. RESULTS: The minimum effective local anaesthetic dose of 0.5% bupivacaine was 0.24 ml (95% confidence interval 0.18 to 0.68). CONCLUSION: Our findings may influence clinicians' initial dose selection for spinal anaesthesia when a spinal catheter is used. The dose may be less than previously thought. TRIAL REGISTRATION: Clinicaltrials.gov identifier: NCT01680120.
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Acute pain after total hip arthroplasty does not predict the development of chronic postsurgical pain 6 months later
AAHKS (8) Anesthetic Infiltration
PURPOSE: Much remains unknown about the relationship between acute postoperative pain and the development of pathologic chronic postsurgical pain (CPSP). The purpose of this project was to identify the extent to which maximum pain scores on movement over the first two days after total hip arthroplasty predicted the presence of chronic pain 6 months later after controlling for potentially important covariates. METHODS: The sample comprised 82 of 114 patients who participated in a double-blinded randomized controlled trial in which all patients received acetaminophen 1 g p.o., celecoxib 400 mg p.o., and dexamethasone 8 mg i.v., 1-2 h preoperatively. In addition, patients received gabapentin (GBP) 600 mg (G2) or placebo (G1 and G3) 2 h prior to surgery [G1: placebo/placebo (n = 38); G2: GBP/placebo (n = 38); G3: placebo/GBP (n = 38)]. In the PACU, patients received gabapentin 600 mg (G3) or placebo (G1 and G2). Follow-up data from the 82 patients who were contacted by telephone 6 months postsurgery were used for the current study. RESULTS: Maximal movement-evoked pain intensity over the first two postoperative days (P = 0.38) failed to predict the presence of CPSP 6 months later after controlling for age (P = 0.09), treatment group (P = 0.91), and cumulative morphine consumption (P = 0.8) (multivariate logistic regression likelihood ratio test against the intercept only model P = 0.59). CONCLUSION: Neither maximum movement-evoked acute pain, nor any other factor measured, predicted the presence of CPSP at 6 months. Further research is needed to identify risk factors for CPSP after total hip arthroplasty.
1
Unilateral and bilateral neurogenic dislocation of the hip joint--which deformity is more difficult to treat?
Developmental Dysplasia of the Hip CPG
BACKGROUND: Authors present and compare the results of treatment of spastic hip dislocation in a group of patients with unilateral or bilateral dislocation. MATERIAL AND METHODS: We analyzed a group of 77 patients (109 hips) with a dislocated hip joint (MP>80%). The patients were divided into Group 1 (47 hip joints, 47 patients) with unilateral dislocation and Group 2 (62 hips, 31 patients) with bilateral dislocation. The mean duration of follow-up was 2.5 years (range 1.2-7.5) in Group 1 and 3.4 years (1.2-10.2) in Group 2. The hips were evaluated clinically and radiographically in the pre- and post-operative period. The relation of the femoral head to the acetabulum was described as the Acetabular Index (AI) and Reimers' migration percentage (MP). The Pelvic Femoral Angle (PFA) was used to measure the degree of windblown deformity. RESULTS: There were three cases of post-operative redislocation (MP>80%) and four cases of severe subluxation (MP>50%) in Group 1 compared to no dislocations in Group 2. In Group 1, AI improved from 31.3 degrees (20 degrees -50 degrees ) to 22.7 degrees (3 degrees -50 degrees ) and MP improved from 98.8% (85%-100%) to 23.4% (0%-100%). In Group 2, AI improved from 30.5 degrees (10 degrees -62 degrees ) to 19.9 degrees (4 degrees -40 degrees ) and MP improved from 98.8% (82%-100%) to 9.6% (0%-60%). In Group 1, PFA before surgery was -10.3 degrees (-40 degrees to 10 degrees ) for the dislocated side and 6.6 degrees (-16 degrees to 55 degrees ) for the non-dislocated side and after surgery it was -5.7 degrees (-46 to 45) for the treated side and 5.6 degrees (-18 degrees to 45 degrees ) for the untreated side. In Group 2, PFA was -3.1 degrees (-22 degrees to 9 degrees ) before surgery and -0.15 degrees (-18 degrees to 25 degrees ) after surgery. We found improved ranges of motion for the movements investigated. CONCLUSION: The clinical and radiological results of operative treatment presented in this paper allow for the conclusion that patients with unilateral dislocations run a higher risk of redislocation, subluxation, and windblown deformity
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Combination therapy with thalidomide, incadronate, and dexamethasone for relapsed or refractory multiple myeloma
MSTS 2018 - Femur Mets and MM
The feasibility and efficacy of a combination of thalidomide, incadronate, and dexamethasone (TID) were studied in 12 patients with relapsed or refractory multiple myeloma. The protocol, consisting of 300 mg/day of thalidomide administered orally, intravenous incadronate (10 mg/day) administered weekly, and 12 mg/day dexamethasone for 4 days, was repeated every 3 weeks. Evaluations of efficacy and toxicity were carried out every 3 weeks and were continued for 3 cycles. Three patients were excluded during the study because of apnea, severe somnolence, and pancytopenia. Of 9 evaluated patients, the partial responses achieved in 3 patients and the minor responses achieved in 4 patients corresponded to a response rate of 78% according to the criteria of the European Group for Blood and Marrow Transplantation. In addition, painful osteolytic symptoms improved rapidly after 1 cycle of TID therapy in the 10 patients evaluated. These data suggest that TID is a feasible and promising therapeutic approach for refractory and relapsed multiple myeloma.
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Transcriptional profiling and muscle cross-section analysis reveal signs of ischemia reperfusion injury following total knee arthroplasty with tourniquet
OAK 3 - Non-arthroplasty tx of OAK
Total knee arthroplasty (TKA) is the most common and cost-effective treatment for older adults with long-standing osteoarthritis. Projections indicate that nearly 3.5 million older adults will undergo this procedure annually by the year 2030. Thus, understanding the factors that lead to optimal outcomes is of great clinical interest. In the majority of cases, tourniquet is applied during surgery to maintain a clear surgical field, however, there is debate as to whether this intervention is completely benign. In particular, muscle atrophy is a significant factor in preventing full functional recovery following surgery, and some evidence suggests that tourniquet application and the associated ischemia-reperfusion injury that results contributes to muscle atrophy. For this reason, we examined tissue level changes in muscle in TKA patients following surgery and found that there was a significant increase in cross-sectional area of muscle fibers of all types. Furthermore, to detect changes not evident at the tissue level, we performed NextSeq analysis to assess the transcriptional landscape of quadriceps muscle cells following TKA with tourniquet and found 72 genes that were significantly upregulated. A large proportion of those genes regulate cell stress pathways, suggesting that muscle cells in our cohort of older adults were capable of mounting a significant response to cell stress. Furthermore, factors related to complement were upregulated, suggesting tourniquet may play a role in priming cells to ischemia reperfusion injury. Therefore, our analysis reveals potential harms of tourniquet during TKA, thus suggesting that surgeons should consider limiting its use.
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An unusual cause of carpal tunnel syndrome
Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
Tuberculosis is an uncommon cause of carpal tunnel syndrome. We report a patient with systemic lupus erythematosus who developed hand numbness. Ultrasonic, operative and microbiological findings supported the diagnosis of median nerve compression secondary to a tuberculous abscess. The symptoms resolved with surgical excision and antituberculous chemotherapy
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Developing an engineered antimicrobial/prophylactic system using electrically activated bactericidal metals
PJI DX Updated Search
The increased use of Residual Hardware Devices (RHDs) in medicine combined with antimicrobial resistant-bacteria make it critical to reduce the number of RHD associated osteomyelitic infections. This paper proposes a surface treatment based on ionic emission to create an antibiotic environment that can significantly reduce RHD associated infections. The Kirby-Bauer agar gel diffusion technique was adopted to examine the antimicrobial efficacy of eight metals and their ionic forms against seven microbes commonly associated with osteomyelitis. Silver ions (Ag(+)) showed the most significant bactericidal efficacy. A second set of experiments, designed to identify the best configuration and operational parameters for Ag(+) based RHDs addressed current and ionic concentrations by identifying and optimizing parameters including amperage, cathode and anode length, separation between anode and cathode, and surface charge density. The system demonstrated an unparalleled efficacy. The concept was then implemented during in vitro testing of an antimicrobial hip implant, RHD
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Bone quality, as measured by trabecular bone score in patients with adrenal incidentalomas with and without subclinical hypercortisolism
Management of Hip Fractures in the Elderly
Patients with adrenal incidentalomas (AIs) and subclinical hypercortisolism (SH) have increased risk of fracture independent of bone mineral density (BMD) and possibly due to reduced bone quality. The trabecular bone score (TBS) has been proposed as a index of bone microarchitecture. The aim of the study was to investigate TBS in AI. In 102 AI patients, SH was diagnosed in the presence of at least two of the following: (1) urinary free cortisol >70 (mu)g/24 h (193.1 nmol/L); (2) cortisol after 1-mg dexamethasone suppression test (1-mg DST) >3.0 (mu)g/dL (82.8 nmol/L); or (3) adrenocorticotropic hormone (ACTH) <10 pg/mL (<2.2 pmol/L). In patients and in 70 matched controls, BMD was measured at lumbar spine (LS) and femur (neck [FN] and total [FT]) by dual X-ray absorptiometry and TBS was assessed in the region of LS-BMD; BMD and TBS data were reported as Z-scores. In patients, vertebral deformities were assessed by radiograph. Patients with SH (n = 34) had lower LS-BMD (-0.31 (plus or minus) 1.17), FT-BMD (-0.29 (plus or minus) 0.91), and TBS (-3.18 (plus or minus) 1.21) than patients without SH (n = 68, 0.31 (plus or minus) 1.42, p = 0.03; 0.19 (plus or minus) 0.97, p = 0.01; -1.70 (plus or minus) 1.54, p < 0.0001, respectively) and controls (0.42 (plus or minus) 1.52, p = 0.02; 0.14 (plus or minus) 0.76, p = 0.02; -1.19 (plus or minus) 0.99, p < 0.0001, respectively). TBS was inversely correlated with 1-mg DST ((beta) = -0.26, t = -2.79, p = 0.006) regardless of age, LS-BMD, body mass index (BMI), and gender. The presence of fracture was associated with low TBS alone (odds ratio [OR], 4.8; 95% confidence interval [CI], 1.85-12.42, p = 0.001) and with the cluster low TBS plus low LS-BMD (OR, 4.37; 95% CI, 1.71-11.4, p = 0.002), after adjustment for age, BMI, and gender. Low TBS plus low LS-BMD showed a good specificity (79%) for predicting fractures, whereas normal TBS (ie, > -1.5) plus normal LS-BMD high specificity (88.1%) for excluding fractures. Finally, TBS predicted the occurrence of a new fracture in 40 patients followed for 24 months (OR, 11.2; 95%CI, 1.71-71.41, p = 0.012) regardless of LS-BMD, BMI, and age. In SH, bone quality, as measured by TBS, is altered. TBS is useful in detecting AI patients at risk of fractures. (copyright) 2012 American Society for Bone and Mineral Research
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Effectiveness of an Internet-Delivered Exercise and Pain-Coping Skills Training Intervention for Persons With Chronic Knee Pain: A Randomized Trial
OAK 3 - Non-arthroplasty tx of OAK
Background: Effective, accessible biopsychosocial treatments are needed to manage chronic knee pain on a population level. Objective: To evaluate the effectiveness of Internet-delivered, physiotherapist-prescribed home exercise and pain-coping skills training (PCST). Design: Pragmatic parallel-group randomized, controlled trial. (Australian New Zealand Clinical Trials Registry: ACTRN12614000243617). Setting: Community (Australia). Patients: 148 persons aged 50 years or older with chronic knee pain. Intervention: The intervention was delivered via the Internet and included educational material, 7 videoconferencing (Skype [Microsoft]) sessions with a physiotherapist for home exercise, and a PCST program over 3 months. The control was Internet-based educational material. Measurements: Primary outcomes were pain during walking (11-point numerical rating scale) and physical function (Western Ontario and McMaster Universities Osteoarthritis Index) at 3 months. Secondary outcomes were knee pain, quality of life, global change (overall, pain, and functional status), arthritis self-efficacy, coping, and pain catastrophizing. Outcomes were also measured at 9 months. Results: Of participants enrolled, 139 (94%) completed primary outcome measures at 3 months and 133 (90%) completed secondary outcome measures at 9 months; multiple imputation was used for missing data. The intervention group reported significantly more improvement in pain (mean difference, 1.6 units [95% CI, 0.9 to 2.3 units]) and physical function (mean difference, 9.3 units [CI, 5.9 to 12.7 units]) than the control group at 3 months, and improvements were sustained at 9 months (mean differences, 1.1 units [CI, 0.4 to 1.8 units] and 7.0 units [CI, 3.4 to 10.5 units], respectively). Intervention participants showed significantly more improvement in most secondary outcomes than control participants. At both time points, significantly more intervention participants reported global improvements. Limitation: Participants were unblinded. Conclusion: For persons with chronic knee pain, Internet-delivered, physiotherapist-prescribed exercise and PCST provide clinically meaningful improvements in pain and function that are sustained for at least 6 months. Primary Funding Source: National Health and Medical Research Council.
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Non-sporeforming anaerobic bacteria in clean surgical wounds--air and skin contamination
Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures
The contamination of clean surgical wounds with anaerobic and aerobic bacteria was studied in 52 hip operations. In addition to wound samples, samples from air and the patients' skin were taken. The median of the total number of bacteria isolated from the wounds was 26 colony-forming units (cfu). The median percentage of anaerobic bacteria in the wound counts was 30. Propionibacterium spp. were found in 71 per cent of the wounds and anaerobic or microaerophilic cocci, most often Peptococcus spp., were found in 23 per cent. In six of 43 patients the same bacterial flora was seen in the skin samples and wounds. The geometric mean of the total number of bacteria in the air was 70.3 cfu/m3. Of these the median percentage of anaerobic bacteria was 30.3. When operating clothing of a disposable fabric (Barrier 450, Johnson & Johnson) was used, the counts of airborne bacteria were a little less than half those found when conventional cotton clothing was worn. Probably because of the overall low air counts in the operating theatre and the great variability in the individual bacterial counts from the operation wounds, a significant decrease in wound contamination was not observed. A positive correlation was found between the duration of operation and wound contamination
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Mechanic characteristics of modified external fixator for the treatment of transcervical fracture
Management of Hip Fractures in the Elderly
Background: T-type or linear type external fixator is applied in transcervical fracture in the elderly. Because its fixing force is weak, so it is difficult to avoid the aggravation of complication due to long term lay up in severe osteoporosis. Based on this reason, percutaneous penetrating arch tri-claw external fixator is designed to treat elderly transcervical fracture with strong fixing force for the realization of early restoration to the active status before injury to reduce complication. Objective: To design percutaneous penetrating arch tri-claw external fixator for the treatment of elderly transcervical fracture for the investigation of its feasibility. Design: A self-controlled study by employing patients as subjects. Setting: Department of orthopedic surgery of the first affiliated hospital of a university. Participants: Thirty-one cases of elderly transcervical fracture including 18 males and 13 females aged between 71 and 86 years old with an average age of 79 years were admitted by the Department of Orthopedics of the First Affiliated Hospital of Nanhua University between December 2002 and June 2004. Methods: Percutaneous penetrating arch tri-claw external fixator was applied in the treatment of 31 cases with elderly transcervical fracture for the observation of its clinical effects, and the force-bearing situation and stability of the external fixator during application were analyzed by theoretical mechanics. Main outcome measures: 1 The functional effects of percutaneous penetrating arch tri-claw external fixator applied in the therapy of transcervical fracture(sub-femoral head type, transcervical type and femoral basilar type); 2 The force-bearing situation and the stability of the fixing point on the fixator; 3 The restoration of activity in hip joint and fracture union time Results: 1 Patients could sit and stand immediately after the application of the fixator, and its fixing reinforce was analyzed by theoretic mechanics during standing(the force on upper fixing point A, B or C was 1/22, 1/2 or 1/2 of the lower fixing point). The unidirectional flexion and extension activity of the hip joint overcame hip-inversion and rotational disposition at the distal end of the fracture. The hip-joint axial compression board caused compact embedment and insertion of the fracture end and vertical crush to simulate fracture union by stability and compressive strain. 2 The stability of percutaneous penetrating arch tri-claw external fixator: No disposition was found during the application except rotational disposition during activity in sub-femoral head type fracture. The fixation was stable, the operative trauma was less, and the operation was simple with good accommodation. No complication was found due to long-term lay up and no re-disposition due to the loosening of the external fixator was found. 3 The hip-joint flexion-extension function was restored within 7 days averagely and fracture healing time was about 2 to 3 months, average of 2. 4 months. Conclusion: No re-injury is found after the application of percutaneous penetrating arch tri-claw external fixator, which has small force bearing at upper fixing point with strong stability. There is strain stimulation on the cross section of the fracture to promote fracture healing. The articular function status before injury could be restored at early stage
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How does elective laparoscopic abdominal aortic aneurysm repair compare to endovascular aneurysm repair?
DOD - Acute Comp Syndrome CPG
A best evidence topic in surgery was written according to a structured protocol. The question addressed was how elective laparoscopic abdominal aortic aneurysm (AAA) repair compared to endovascular aneurysm repair (EVAR) in terms of survival. There were 229 papers found using the reported search, with 8 papers (5 prospective studies, 1 retrospective study, 1 randomized trial and 1 systematic review) representing the best evidence to answer the question proposed. Current evidence suggests that EVAR is the preferred surgical approach for AAA repair, due to shorter hospital stay and lower perioperative morbidity and mortality rates, as opposed to an open surgical approach. Despite this, EVAR is subject to a number of limitations, including device restrictions in patients with anatomical variations as well as increased risk of future complications stemming from device implantation. We discuss a key study that showed that complications in the EVAR group commonly included endoleak type II and graft thrombosis. More importantly, there were similar rates of complications between those patients receiving EVAR and those receiving minimally invasive aortic surgery. The evidence suggests that elective laparoscopic AAA repair has a favourable safety profile comparable with that of EVAR, with low conversion rates as well as similar mortality and morbidity rates. This has been illustrated in several studies. We discuss a prospective randomized trial of 100 patients, which compared EVAR with hand-assisted laparoscopic surgery. This study showed no deaths in either group after the procedure or at follow-up after 12 months, with similar complication rates between the groups. While the evidence suggests that EVAR is less invasive, it does not always significantly alter the postoperative course or length of hospital stay for patients. We conclude from the evidence available that elective laparoscopic AAA repair may have a role in those patients who are unsuitable for EVAR. Unfortunately, few studies exist directly comparing these two techniques, and those that do are subject to limitations, for example, study population bias, small sample sizes and a lack of comparison in the literature between the common AAA repair techniques. © 2014 The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.
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Median nerve injuries associated with supracondylar fractures of the humerus in children
The Treatment of Pediatric Supracondylar Humerus Fractures AUC
If not specifically examined for median nerve function, partial injury associated with supracondylar fracture of the humerus in children will go unrecognized. These injuries occur in as high as 5% of supracondylar fractures of the humerus in children. The 6 patients reported here as well as many cases described in the orthopedic literature present evidence that special exercises and supportive care are important as soon as the fracture is healed. Functional return may be seen as long as 4 to 5 months following supracondylar fracture, and exploration should be delayed at least that long in this type of peripheral nerve injury
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Propofol patient-controlled sedation during hip or knee arthroplasty in elderly patients
AAHKS (9/10) Regional Nerve Blocks
PURPOSE: Little information is available regarding the use of patient-controlled sedation (PCS) among the elderly. This study evaluated the safety and efficacy of propofol PCS among elderly patients undergoing hip or knee arthroplasty. METHODS: Forty patients, aged 65-78 yr, undergoing hip or knee arthroplasty under regional anaesthesia were randomized to receive propofol PCS (dose = 0.3 mg.kg-1, delay = three min; n = 20) or anaesthetist-administered midazolam-fentanyl sedation (n = 20). Sedation, anxiety and discomfort visual analogue scores (VAS) were measured, by an independent observer, preoperatively, immediately at the end of surgery and one hour following admission to the postanaesthetic care unit (PACU). Cognition was evaluated, using an abbreviated Mini Mental Status Examination, preoperatively and in the PACU. Patient satisfaction, based on VAS and a brief questionnaire, was measured in the PACU. The incidence of intraoperative complications was also compared. RESULTS: Patient satisfaction was high in each group. Sedation and anxiety VAS were similar in each group. A high incidence of pain with drug injection was noted among patients receiving propofol (80%). Transient deeper levels of sedation (6 vs 1; P = 0.05) were observed more commonly in the propofol PCS group. CONCLUSION: Propofol PCS provides effective sedation. Using a propofol dose of 0.3 mg.kg-1, transient episodes of deeper sedation were noted more frequently among patients receiving PCS. These episodes did not require intervention but, suggest that this propofol PCS dose approaches the limit of safety and should be further reduced for some elderly patients.
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MRI analysis of extra-capsular ganglia at the gastrocnemius origin and their association with osteoarthritis
AMP (Acute Meniscal Pathology)
AIM: To evaluate the prevalence, clinical relevance, and magnetic resonance imaging (MRI) features of extra-capsular ganglia at the gastrocnemius origin and to assess their association with internal derangement and osteoarthritis of the knee. MATERIALS AND METHODS: One hundred consecutive knee MRI examinations, obtained within a 6-month period from patients with no history of recent knee trauma, recent injections, inflammatory arthritis, infection, or tumours, were evaluated retrospectively for the presence of ganglia at the gastrocnemius origin. The lesions were divided into two groups: an intra-capsular and an extra-capsular group. Cyst morphology (size, shape, and internal septa), internal derangement of the knee (cartilage lesion, cruciate ligament injury, meniscal tear, and corner injury on MRI, and osteoarthritis of the knee on radiographs) were evaluated. The chi-square, Fisher's exact, and t-tests were used to compare the two groups, in addition to multivariate stepwise logistic regression analysis. RESULTS: Thirty-nine ganglia with an extra-capsular location were identified on 100 knee MRI (39 %). Rounded shape and internal septa were more common in the extra-capsular than in the intra-capsular group (p<0.001). Frequencies of high-grade cartilage, meniscal tear, and high-grade osteoarthritis significantly differed between the groups (p<=0.038). In multivariate analysis, the only significant association was between high-grade osteoarthritis and the extra-capsular group. CONCLUSION: Extra-capsular ganglia at the gastrocnemius origin were not uncommon on knee MRI and had features typical of ganglia found at other sites. High-grade osteoarthritis was significantly associated with extra-capsular ganglia.
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Internal fixation or hemiarthroplasty for undisplaced fractures of the femoral neck in octogenarians
Management of Hip Fractures in the Elderly
We compared the reoperation rate after internal fixation for minimally displaced or impacted intracapsular fractures of the femoral neck in patients aged 80 years and above with that in similar patients aged 65 to 79 years. We also compared the results of internal fixation with those of hemiarthroplasty for displaced intracapsular fracture in an age- and sex-matched group of elderly patients. We found that a significantly greater proportion of the older patients treated by internal fixation required reoperation than either the younger group or the age-matched group treated by hemiarthroplasty. Our results indicate that internal fixation may not be the best treatment for extremely elderly patients with minimally displaced or impacted intracapsular fractures of the femoral neck
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Effect of dietary lipid structure in early postnatal life on mouse adipose tissue development and function in adulthood
Reduction Mammoplasty for Female Breast Hypertrophy
Obese individuals have more (hyperplastic) and larger (hypertrophic) adipocytes in their white adipose tissue (WAT) than normal-weight individuals. The difference in cell number emerges early in childhood, suggesting that this is a critical period for being susceptible to obesity. Breast-feeding has been shown to be protective against obesity, and we have previously shown in mice that the physical structure of lipids in human milk may contribute to this protective effect. In the present study, we investigated how differences in the physical structure of lipids in the early diet may modulate adipose tissue development. Male mice were fed a diet containing control infant milk formula (Control IMF; Danone Research) or Nuturis(R) (Concept IMF with large phospholipid-coated lipid droplets; Danone Research) from postnatal day (PN)16 to 42. Subsequently, mice were challenged with a moderate Western-style diet (WSD) until PN98, and body composition was monitored by dual-energy X-ray absorptiometry. Epididymal WAT was analysed for adipocyte size, number and gene expression of metabolic transcription factors. Early Concept IMF exposure reduced fat accumulation during the WSD challenge by 30 % compared with the Control IMF. It reduced adipocyte size without affecting adipocyte number in adult mice. The Concept IMF decreased the expression of PPARgamma, CCAAT/enhancer-binding protein and retinoid X receptor alpha in WAT in adulthood, key regulators of metabolic activity. In conclusion, Concept IMF exposure in early life reduced susceptibility to obesity in adult life, by preventing adipocyte hypertrophia upon adult dietary challenge without affecting adipogenesis. These data emphasise the importance of the physical properties of dietary lipids in early life in obesity risk later in life.
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Comparison of lipidocolloid and chlorhexidine-impregnated tulle gras dressings following microscopically controlled surgery
Reconstruction After Skin Cancer
OBJECTIVE: Modified microscopically controlled surgery (MCS) is a staged and margin-controlled excision; after MCS, the selection of an appropriate initial wound dressing plays an important role in wound healing. A wide range of dressings is available for temporary wound coverage; however, data comparing different types of wound dressings after MCS are lacking. The aim of this study was to compare two commonly used and commercially available types of wound dressings. METHOD: We assessed pain levels, wound adherence, bleeding upon dressing removal and signs of infection, with chlorhexidine-impregnated tulle gras and a lipidocolloid dressing used for primary wound dressing following MCS. RESULTS: A total of 42 patients were included. Adherence of the dressing to the wound (p<0.001) and bleeding after removal (p=0.001) were significantly higher in the chlorhexidine-impregnated tulle gras dressing group. Pain during removal of wound dressing had a higher visual analogue scale score (1.9 +/- 2.2) in the chlorhexidine-impregnated tulle gras dressing group compared to 0.7 +/- 1.0 in the lipidocolloid dressing group (p=0.022). CONCLUSION: The results indicate that the lipidocolloid dressing, when compared with the chlorhexidine-impregnated tulle gras dressing, offers a significant benefit during removal in terms of less pain, less wound adherence and less wound bleeding. DECLARATION OF INTEREST: The authors have no conflict of interest to declare.
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Quality of life issues among women with physical disabilities or breast cancer
DoD PRF (Psychosocial RF)
OBJECTIVE: The purpose of this study was to assess quality of life (QOL) and life satisfaction among women with physical disabilities or breast cancer, and to identify factors predictive of QOL and life satisfaction for women and men. QOL and life satisfaction differences were examined between women and men with physical disabilities and cancer, and between women with traumatic and chronic physical conditions. DESIGN: A cross-sectional design employing several QOL and life satisfaction measures was used. SAMPLE: Two hundred sixteen outpatient subjects (99 women, 117 men) with physical disabilities or cancer were studied. INSTRUMENTS: The Health Status Questionnaire-Short-Form 36 (SF-36), Functional Assessment of Cancer Therapy (FACT), Functional Living Index-Cancer (FLIC), and the Satisfaction With Life Scale (SWLS). RESULTS: Women with traumatic conditions (amputation, spinal cord injury) reported poorer physical functioning and well-being, whereas women in the chronic (postpolio, breast cancer) group reported poorer health status. No significant gender differences were found with respect to QOL or life satisfaction. Whereas functional and emotional well-being were the strongest predictors of overall QOL for both men and women, self-perceived general health significantly predicted QOL for women (p < .05) and social well-being significantly predicted QOL for men (p < .01). Among men, life satisfaction was best predicted by marital status (p < .05), general health (p < .05), and social well-being (p < .01). The resulting QOL models had adjusted R2 values of .77 and .76 for women and men, respectively. Among women with traumatic conditions, functional well-being best predicted QOL (p < .01). Life satisfaction for women with chronic conditions was best predicted by age, education, and spiritual well-being. CONCLUSION: QOL as measured by the impact of illness on an individual is best predicted by physical and functional well-being. Satisfaction with one's life was best predicted by functional ability. Although functional and physical ability were the best predictors for both QOL and life satisfaction, social functioning made significant and substantive contributions to these constructs. Spinal cord injury had the most impact on physical functioning, whereas prostate cancer had the least. Psychosocial functioning was most affected by amputation and least affected by prostate cancer.
0
Haemophiliac hands--a three year follow-up study
DOD - Acute Comp Syndrome CPG
The total absence of literature regarding the affects of haemophilia on the hand prompted this three year study at the Israel National Haemophilia Centre. The hands of all haemophiliacs were examined and X-rayed at the time of their annual check-up. Apart from a number of established Volkmann's contractures in elderly patients and multiple bone cysts of the carpus, surprisingly little pathology was found. When considering the extensive damage done to the musculoskeletal system by this haemarthritic pathogenesis it is astounding how the hand, with its multiple small joints, constant movement and trauma, escapes significant damage.
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The role of bone allografts in the treatment of angular malunions of the distal radius
Distal Radius Fractures
PURPOSE: Two cohorts of patients who had corrective osteotomies and volar platings for malunited fractures of the distal radius were compared retrospectively to determine whether the time to union and the outcome were affected by bone allograft. METHODS: Patients in the first group (n = 14) did not receive any bone graft; patients in the second group (n = 14) had allograft bone chips following volar plating. Indications for surgery, surgical technique, and postoperative rehabilitation were the same in both groups. Volar cortical contact was maintained using a volar locking plate in all patients. Radiographic parameters of deformity correction, time to union, wrist and forearm range of motion, grip strength, patient-rated wrist evaluation and Disabilities of the Arm, Shoulder, and Hand questionnaire were used to evaluate the outcome before and after the surgery. Average follow-up time was 36 weeks. Patients who had diabetes, who smoked, who had a body mass index of more than 35, and who required lengthening for deformity correction were excluded from the study. RESULTS: Osteotomies in both groups healed without loss of surgical correction. Final outcome and time to union revealed no significant differences, clinically or statistically, between the 2 groups. The Disabilities of the Arm, Shoulder, and Hand score was improved in both groups. CONCLUSIONS: When volar cortical contact was maintained using a volar locked plate, bone allograft at the osteotomy site did not improve the final outcome. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic III.
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Guidelines for the diagnosis and treatment of cutaneous squamous cell carcinoma and precursor lesions. Guidelines
Reconstruction After Skin Cancer
These guidelines are based on the guidelines formulated under the aegis of the French Society of Dermatology (Société Française de Dermatologie) and validated in May 2009. These professional guidelines have received the joint INCa-HAS guarantee of quality. This guarantee means that the guidelines have been elaborated according to the procedures and methodological rules recommended by the INCa and the HAS. Any query as to the contents should be directed to the promotor. © 2009 Elsevier Masson SAS.
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Use of prophylactic antibiotics in the prevention of infective endocarditis and prosthesis infection
Dental Implant Infection
In the field of antimicrobial therapy, few areas have created more debate and controversy than the subject of antibiotic prophylaxis for infective endocarditis. Firstly, there still exists considerable controversy about the efficacy of prophylactic antibiotics for prevention of bacterial endocarditis. Secondly, dental surgeons, orthopaedic surgeons, cardiologists and endoscopists have differing opinions regarding indications for pre-procedural prophylactic antibiotics against infective endocarditis. The British have a different set of recommendations from the Americans although the basic tenets on which these recommendations are founded are similar. This article summarises the updated recommendations issued by the American Heart Association (AHA) as well as those from the British Society for Antimicrobial Chemotherapy. A short discussion of the use of prophylactic antibiotics prior to endoscopy and surgery for patients with non-valvular prosthetic devices has been included in this paper. Practitioners should also be reminded that these recommendations are issued as guidelines and clinical judgement must be exercised when dealing with individual patients.
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New-onset synovial chondromatosis after total knee arthroplasty
Surgical Management of Osteoarthritis of the Knee CPG
Total joint arthroplasty is commonly recommended as a definitive treatment for synovial chondromatosis refractory to other treatment. We describe a unique case of synovial chondromatosis developing after total joint arthroplasty in a patient presenting 5 years after total knee arthroplasty for osteoarthritis. This case illustrates that the diagnosis of synovial chondromatosis cannot be excluded in a patient with chronic, painful swelling of a joint, even after total joint arthroplasty
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Pamidronate prevents skeletal complications and is effective palliative treatment in women with breast carcinoma and osteolytic bone metastases: long term follow-up of two randomized, placebo-controlled trials
MSTS 2018 - Femur Mets and MM
BACKGROUND: Pamidronate therapy previously has been shown to reduce skeletal complications effectively for up to 12 months in breast carcinoma patients with bone metastases. The current study data provide further follow-up results regarding the effects of long term (up to 24 months) pamidronate treatment in women with breast carcinoma and osteolytic metastases. METHODS: Follow-up results from two prospective, multicenter, randomized, double-blind, placebo-controlled intervention trials conducted at academic and community oncology centers were combined to provide a large data set with which to evaluate the long term efficacy and safety of pamidronate therapy. Seven hundred fifty-four women with Stage IV breast carcinoma and osteolytic metastases were randomized to the 2 treatment arms of the trial. Three patients were excluded from the intent-to-treat population for the analysis. A total of 751 evaluable patients were randomized to receive either a 90-mg intravenous pamidronate infusion (367 patients) or a placebo infusion (384 patients) every 3-4 weeks. The primary outcome measures were skeletal morbidity rate (events/year), proportion of patients developing a skeletal complication, and time to first skeletal complication. RESULTS: Of the 367 women receiving pamidronate, 115 (31.3%) completed the trial and 81 (22.1%) discontinued the study due to adverse events. Of the 384 women who received placebo, 100 (26.0%) completed the study and 76 (19.8%) discontinued the study due to adverse events. The skeletal morbidity rate was 2.4 in the pamidronate group and 3.7 in the placebo group (P < 0.001). In the pamidronate group, 186 of the 367 patients (51%) had skeletal complications compared with 246 of the 384 patients in the placebo group (64%) (P < 0.001). The median time to first skeletal complication was 12.7 months in the pamidronate group and 7 months in the placebo group (P < 0.001). Six patients treated with pamidronate discontinued treatment due to drug-related adverse events. Pain and analgesic scores were significantly worse in the placebo group compared with those patients in the pamidronate group. CONCLUSIONS: In the current study, monthly infusions of 90 mg of pamidronate as a supplement to antineoplastic therapy were found to be well tolerated and superior to antineoplastic therapy alone in preventing skeletal complications and palliating symptoms for at least 24 months in breast carcinoma patients with osteolytic bone metastases.
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Predictors of in-hospital mortality following operative management of hip fractures
Management of Hip Fractures in the Elderly
OBJECTIVE: To identify predictors of in-hospital mortality and hospital stay following hip fractures. DESIGN: Retrospective cohort study of 185 consecutive patients. SETTING: Tertiary Care University Hospital. PARTICIPANTS: Individuals requiring operative treatment of a proximal femoral fracture excluding those individuals < 50 years old, with femoral head or subtrochanteric fractures, and significant co-morbidity. OUTCOMES: In-hospital mortality and length of hospital stay (days). RESULTS: 116 patients met the inclusion criteria. Predictors of in-hospital mortality from logistic regression analysis included male gender (odds ratio with 95% CI: 5.5, 1.5-20.5), admission from a long term care facility (5.5, 1.4-22.6), age greater than 90 years (4.5, 0.9-22.1), and living at home with support (0.2, 0.03-0.9). Predictors of hospital stay from multivariate regression analysis in order of magnitude included presence of a post-operative complication (odds ratio with 95% CI: 14.1, 4.7-44), living at home with support (3.4, 1.3-8.9) and older age (> 85 years) (2.7, 1.0-7.3). Moreover, confusion, urinary tract infections and decubitus ulcers accounted for greater than 50% of all complications encountered. A trend between the number of positive predictors and length of hospital stay was observed. CONCLUSIONS: Elderly individuals admitted from a long term care facility are at high risk of mortality following operative fixation of hip fractures. Early recognition and aggressive management of post-operative complications such as confusion, urinary tract infections and decubitus ulcers through careful patient monitoring may decrease hospital stays in those that survive
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Acupuncture and neuropathic pain management
Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
Background: Treatment of neuropathic pain remains challenging because of the difficulty in achieving adequate pain control. Objective: This review focuses on the neurobiological basis of acupuncture and clinical evidence for acupuncture's efficacy for neuropathic pain management. Methods: A search was conducted for preclinical and clinical studies published in English since February 2011. The search included articles in
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Medial epicondyle fractures of the humerus: how to evaluate and when to operate
Pediatric Supracondylar Humerus Fracture 2020 Review
The fundamental principles of fracture care apply to medial epicondyle fractures in that the goals of treatment are to obtain fracture healing and to promote a return of appropriate motion, strength, and stability. Recent studies have revealed limitations of some classically described evaluation methods and have revealed more precise methods of measuring displacement. The authors of this manuscript describe established principles of care and incorporate recent evidence-based articles to help the clinician study the issues relative to the clinical evaluation and the operative and nonoperative treatment of medial epicondyle fractures.
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Tibial Plafond Fractures: Changing Principles of Treatment
DoD SSI (Surgical Site Infections)
Tibial plafond fractures from axial loading are high-energy injuries with significant associated soft-tissue damage. New classification methods include detailed anatomic subgroupings and highlight the soft-tissue injury. The traditional treatment of this intra-articular fracture with open reduction and internal fixation resulted in high rates of wound breakdown and infection. Treatment of these complications is lengthy and costly and not infrequently results in a poor outcome. Newer techniques using external fixation minimize disturbance of the soft-tissue envelope and have decreased these complications. Because the long-term outcome with all techniques is variable and often depends on factors beyond the surgeon's control, it is particularly important to avoid complications of initial treatment. Longer follow-up will determine whether patients treated with these techniques have a different rate of arthrosis.
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Horizontal Forehead Lines: A Reflection of Eyelid Ptosis or Blepharodermachalasia
Upper Eyelid and Brow Surgery
BACKGROUND: In his facial aesthetics practice, the senior author (B.G.) observed that many patients presenting with horizontal forehead lines also demonstrated upper eyelid ptosis or enough blepharodermachalasia to require compensation. This study was conducted to investigate this observation. METHODS: Photographs of patients presenting for facial rejuvenation were retrospectively reviewed for the presence of forehead lines, ptosis, brow ptosis, and blepharodermatochalasia. Patient age, gender, and race were reported. Only patients over age 50 were included. Patients who had previous eyelid or forehead surgery, congenital abnormalities, or post-traumatic deformities were excluded. Ptosis was defined as more than 1.5-mm overlap between the upper eyelid and the iris. Patients were divided into two groups based on presence of forehead lines for comparative analysis. RESULTS: One hundred sixty patients, including 100 patients with and 60 patients without horizontal forehead lines, were included. Patients with forehead lines were likely to be older (age 61.56 +/- 8.93 vs. 58.58 +/- 7.59; P = 0.0337), male (36 vs. 11.67%; P = 0.0008), have ptosis (90 vs. 76.67%; P = 0.0377), and have blepharodermatochalasis (20 vs. 5%; P = 0.0097). All 28 patients with unilateral forehead lines (17 left, 11 right) had ipsilateral ptosis. CONCLUSIONS: Ptosis and blepharodermatochalasis may result in the development of horizontal forehead lines through compensatory frontalis activation. Whenever horizontal forehead rhytids are noted, it is imperative to search for ptosis or blepharodermachalasia in repose. Otherwise, forehead rejuvenation may fail to eliminate these compensatory forehead lines, and chemodenervation may have significant adverse effects on the visual field by forcibly blocking frontalis compensation. LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
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The management of nonunion and malunion of the distal humerus-A 30-year experience
The Treatment of Pediatric Supracondylar Humerus Fractures AUC
This personal series of nonunions of the distal humerus reviews unique features of this problem, categorizes them according to unique anatomic features, and presents pitfalls and pearls in the management of these complex reconstructive problems. (copyright) 2008 Lippincott Williams & Wilkins
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Analgesic efficacy of ultrasound-guided adductor canal blockade after arthroscopic anterior cruciate ligament reconstruction: a randomised controlled trial
Surgical Management of Osteoarthritis of the Knee CPG
CONTEXT: Anterior cruciate ligament (ACL) reconstruction surgery is associated with moderate to severe postoperative pain, which may be ameliorated by peripheral nerve blocks. The adductor canal block (ACB) is an almost exclusively sensory nerve block that has been demonstrated to reduce pain and opioid consumption after major knee surgery. OBJECTIVES: To investigate the analgesic effect of ACB in patients receiving a basic analgesic regimen of paracetamol and ibuprofen after arthroscopic ACL reconstruction under general anaesthesia. DESIGN: Randomised, double-blind, placebo-controlled, parallel groups. SETTING: Day Case Surgery, University of Copenhagen, Glostrup Hospital, Denmark, June 2010 to March 2012. PATIENTS: Fifty patients, aged 18 to 70 years, scheduled for arthroscopic ACL reconstruction. INTERVENTIONS: Patients were randomised to receive ACB with either 30 ml ropivacaine 7.5 mg ml (n = 25) or 30 ml 0.9% saline (n = 24). MAIN OUTCOME MEASURES: Primary outcome was pain score (0 to 100 mm) during standing at 2 h after surgery. Secondary outcomes were pain at rest, during standing and after walking 5 m, opioid consumption and opioid-related side effects for 24 h after surgery. RESULTS: Median (interquartile range) pain scores for the primary outcome were 20 (12 to 36) mm in the ropivacaine and 20 (10 to 44) mm in the control group (P = 0.84, 95% confidence interval for difference of -9 to 12 mm). No significant differences were observed in any of the secondary outcomes. CONCLUSION: An analgesic regimen with paracetamol and ibuprofen provides acceptable postoperative pain control after arthroscopic ACL reconstruction. ACB did not confer further benefit in our patients. TRIAL REGISTRATION: Clinicaltrials.gov Identifier: NCT01212666
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Cryotherapy decreases synovial Doppler activity and pain in knee arthritis: A randomized-controlled trial
OAK 3 - Non-arthroplasty tx of OAK
OBJECTIVE: To measure and compare the effects of 2 local cryotherapy techniques on synovial power Doppler activity (primary outcome) and pain in non-septic knee arthritis without any concurrent treatment. METHODS: 30 patients were randomized (ice: 30min, n=15 or cold CO<sub>2</sub>: 2min, n=15 both applied twice at 8h interval). Contralateral non-treated arthritic knees were used as paired controls (n=11 and n=10 respectively). The PDUS semi-quantitative score (0-3) and pain visual analogic scale were evaluated before/after each cold application, 2min, 2h, 24h after the first application. PDUS scores were checked in double-blind by 2 ultrasonographists. RESULTS: The inter-class effect size of local cryotherapy on the power Doppler score remained significant the day after treatment in local cryotherapy-treated compared to contralateral non-treated knees (Global difference: -1 [95% confidence interval: -1.23; -0.77]; ice: -0.73 [-1.06; -0.4]; CO<sub>2</sub>: -0.7 [-1.18; -0.22]). Both techniques significantly and to the same extent reduced the power Doppler score and pain visual analogic scale at all evaluation times and globally throughout the 24 hour-study period. No dropout nor adverse event was reported. In multivariate analysis, the Power Doppler score decrease was associated with pain decrease, while pain decrease was associated with the female sex and ice technique. CONCLUSION: Local ice and cold CO<sub>2</sub> applied twice equally reduced synovial Power Doppler activity and pain over 24h in knee arthritis. These effects remained significant the day after treatment. ClinicalTrials.gov identifier: NCT02573298.
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Xanthogranulomatous reaction to a ruptured galactocele
Reduction Mammoplasty for Female Breast Hypertrophy
We describe a case of a 34-year-old, healthy, lactating female with a 2-month history of breast pain and an enlarging, tender mass on her right nipple. Her right breast was firm and mildly engorged without mass, warmth or erythema. A tender, yellow nodule was located on the superior aspect of the nipple, obstructing the flow of milk from this portion of the nipple. A biopsy showed epidermal erosion, sheets of cells with massively distended, foamy cytoplasm in the dermis, and a hypertrophied and occluded glandular duct, consistent with reactive squamous metaplasia. Immunostaining for CD68 confirmed the foamy cells were macrophages, and anti-human milk fat globulin-1 (HMFG1) labeled the substance within the macrophages consistent with human breast milk. Therefore, the lesion could be identified as a xanthogranulomatous reaction to a ruptured galactocele.
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Effects of hook plate on shoulder function after treatment of acromioclavicular joint dislocation
Glenohumeral Joint OA
INTRODUCTION: Internal fixation with hook plate has been used to treat acromioclavicular joint dislocation. This study aims to evaluate the effect of its use on shoulder function, to further analyze the contributing factors, and provide a basis for selection and design of improved internal fixation treatment of the acromioclavicular joint dislocation in the future. METHODS: A retrospective analysis was performed on patients treated with a hook plate for acromioclavicular joint dislocation in our hospital from January 2010 to February 2013. There were 33 cases in total, including 25 males and 8 females, with mean age of 48.27 +/- 8.7 years. There were 29 cases of Rockwood type III acromioclavicular dislocation, 4 cases of type V. The Constant-Murley shoulder function scoring system was used to evaluate the shoulder function recovery status after surgery. Anteroposterior shoulder X-ray was used to assess the position of the hook plate, status of acromioclavicular joint reduction and the occurrence of postoperative complications. RESULTS: According to the Constant-Murley shoulder function scoring system, the average scores were 78 +/- 6 points 8 to 12 months after the surgery and before the removal of the hook plate, the average scores were 89 +/- 5 minutes two months after the removal of hook plate. Postoperative X-ray imaging showed osteolysis in 10 cases (30.3%), osteoarthritis in six cases (18.1%), osteolysis associated with osteoarthritis in four cases(12.1%), and steel hook broken in one case (3%). CONCLUSION: The use of hook plate on open reduction and internal fixation of the acromioclavicular joint dislocation had little adverse effect on shoulder function and is an effective method for the treatment of acromioclavicular joint dislocation. Osteoarthritis and osteolysis are the two common complications after hook plate use, which are associated with the impairment of shoulder function. Shoulder function will be improved after removal of the hook plate.