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Extended release local anesthetic agents in a postoperative arthritic pain model
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AAHKS (8) Anesthetic Infiltration
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Local anesthetics play an important role in postoperative pain management in orthopedic joint procedures. The aim of this study was to determine the effect of an intraoperative extra-articular injection of poly(DL-lactic acid co castor oil 3:7), p(DLLA:CO) 3:7 loaded with 15% bupivacaine, for postoperative analgesia following knee arthroplasty. Prolonged release local anesthetic formulation was synthesized by mixing p(DLLA:CO) 3:7 with bupivacaine base. Under anesthesia, the knee joint of Sprague-Dawley rats was exposed, a hole drilled in the femoral trochlea. 0.2 mL of either 15% polymer-bupivacaine formulation or plain bupivacaine (control) was injected locally and compared with a nonsurgery control group. Mechanical hyperalgesia was determined by counting the vocalizations and leg withdrawal after joint squeezing. Behavioral assessments over a day postoperative period revealed a reduction in rearing and ambulation in an open-field apparatus in animals of both experimental groups compared with the nonsurgery control. The vocalizations during the hyperalgesia test increased compared with the control at 24 h. At 48 h, 3.667 ± 0.5138, p = 0.0076 vocalizations were recorded for the plain bupivacaine group versus 1.417 ± 0.5138, p < 0.0001 in the 15% polymer-bupivacaine formulation. Bupivacaine encapsulated in p(DLLA:CO) 3:7 extended the duration of the analgesia compared with plain drug in rats and could represent effective postoperative analgesic in orthopedic joint procedures. © 2013 Wiley Periodicals, Inc. and the American Pharmacists Association J Pharm Sci 103:185-190, 2014 © 2013 Wiley Periodicals, Inc. and the American Pharmacists Association.
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Proï¬쳌le of Patients Diagnosed with Developmental Dysplasia of the Hip
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Developmental Dysplasia of the Hip 2020 Review
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Objective â??To describe the proï¬le of patients with developmental dysplasia of the hip (DDH) diagnosed by physical and ultrasound examination, with the implementation of a protocol for the treatment and follow-up of DDH. Methods â??A cross-sectional study with DDH patients born between January 2014 and December 2016, in the city of Pelotas, Southern Brazil. Ethnicity, gender, birth weight, fetal presentation, affected side of the hip, gestational age, maternal age and family history were considered. The data on the medical records were compared with the characteristics of the general population described on the Brazilian National Information System on Live Births (Sistema de Informação sobre Nascidos Vivos [SINASC]). Results â??A total of 33 DDH patients were identiï¬ed, mostly female, with a four-fold higher probability of having the condition ( p â??<â??0.001); the left was the most affected side. No statistically signiï¬cant association was found regarding the following factors: birth weight, gestational age, ethnicity, and maternal age. The newborns in breech presentation had a 15-fold higher probability of presenting DDH ( p â??<â??0.001). A total of 21 newborns required immediate treatment of the hips, since the ultrasound showed a Graf classiï¬cation of IIb or higher, or the radiography showed dislocation in DDH patients older than 6 months of age. Conclusion â??Screening for DDH is essential in all newborns; physical examinations revealing alterations must be complemented with ultrasound imaging to avoid the delayed diagnosis of the condition.
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1 |
The effect of clopidogrel and aspirin on blood loss in hip fracture surgery
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Management of Hip Fractures in the Elderly
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INTRODUCTION: Anti-platelet drugs are commonly used for primary and secondary prevention of thrombo-embolic events and following invasive coronary interventions. Their effect on surgery-related blood loss and perioperative complications is unclear, and the management of trauma patients treated by anti-platelets is controversial. The anti-platelet effect is over in nearly 10 days. Notably, delay of surgical intervention for hip fracture repair for >48 h has been reported to increase perioperative complications and mortality. PATIENTS AND METHODS: Intra-operative and perioperative blood loss, the amount of transfused blood and surgery-related complications of 44 patients on uninterrupted clopidogrel treatment were compared with 44 matched controls not on clopidogrel (either on aspirin alone or not on any anti-platelets). RESULTS: The mean perioperative blood loss was 899+/-496 ml for patients not on clopidogrel, 1091+/-654 ml for patients on clopidogrel (p=0.005) and 1312+/-686 ml for those on combined clopidogrel and aspirin (p=0.0003 vs. all others). Increased blood loss was also associated with a shorter time to operation (p=0.0012) and prolonged surgical time (p=0.0002). There were no cases of mortality in the early postoperative period. CONCLUSIONS: Patients receiving anti-platelet drugs can safely undergo hip fracture surgery without delay, regardless of greater perioperative blood loss and possible thrombo-embolic/postoperative bleeding events
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Use of systemic glucocorticoids and the risk of major osteoporotic fractures in patients with sarcoidosis
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Hip Fx in the Elderly 2019
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Summary: This study revealed the risk of major osteoporotic fracture in patients with sarcoidosis exposed to glucocorticoids. Current use of glucocorticoids was associated with a risk of fracture, with no difference between patients with and without sarcoidosis. Sarcoidosis per se was not associated with an increased fracture risk. Introduction: Sarcoidosis is a multi-organ, chronic inflammatory, granulomatous disorder that most frequently affects the lungs, lymph nodes, skin, eyes, and liver, but may occur in any organ, including the bones. While oral glucocorticoids (GCs) are commonly used as initial treatment, little is known about the risk of major osteoporotic fractures in patients with sarcoidosis exposed to GCs. Methods: A case-control study was conducted using the Danish National Hospital Discharge Registry (NHDR) between January 1995 and December 2011. Conditional logistics regression models were used to derive adjusted odds ratios (OR) of major osteoporotic fractures in subjects with and without sarcoidosis stratified by average daily and cumulative dose exposures. Results: A total of 376,858 subjects with a major osteoporotic fracture and the same number of subjects without this event were identified (mean age 64.2 ± 19.5 years, 69% female). In patients with sarcoidosis (n = 124), current use of GC was associated with an increased risk of major osteoporotic fracture (adjusted (adj.) OR 1.74; 95% CI 1.17â??2.58), which dropped to baseline levels after discontinuation. In subjects without sarcoidosis, this risk was comparable (adj. OR 1.36; 95% CI 1.32â??1.40). In sarcoidosis patients, cumulative dose 1.0â??4.9 g and >10 g prednisolone equivalents were associated with increased risk of major osteoporotic fracture (adj. OR 2.75; 95% CI 1.06â??7.14 and 2.22; 95% CI 1.17â??4.22, respectively), whereas a cumulative dose of <1.0 g and 5.0â??9.9 g was not associated with major osteoporotic fracture risk. Conclusion: Both in subjects with and without sarcoidosis, current expose to GC is associated with increased risk of major osteoporotic fractures, with no between-group difference. Sarcoidosis per se was not associated with increased fracture risk. Having sarcoidosis per se, i.e., if not treated with GC, is not a risk factor for fracture, and such patients may only need risk assessment when they commence GC therapy.
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Fasciotomies of the limbs: how to do it?
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DOD - Acute Comp Syndrome CPG
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The compartment syndrome has been defined as an elevation of the interstitial pressure in a closed osteofascial compartment resulting in microvascular compromise. The only effective treatment is early decompression of the involved compartment. In acute conditions, this decompression can only be established if skin and fascia are incised over the muscular part of the compartment. A good knowledge of the anatomy and importance of the fascia generalis, communis and propria is necessary for successful and complete decompression. Classic and more recent anatomical and clinical data are selected from the surgical literature to provide comprehensive and anatomically based guidelines for fasciotomies of the upper and lower limbs.
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Posterior root tear of the medial meniscus in multiple knee ligament injuries
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AMP (Acute Meniscal Pathology)
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The purposes of the present study were to examine the frequency and characteristics of root tears of the medial meniscus associated with ligament injuries of the knee and to evaluate the effectiveness of pull-out repair for restoring meniscus function. We retrospectively analyzed the 9 patients (10 knees) with posterior root tears of the medial meniscus and ligament injuries of the knee treated between August 2004 and February 2007. All the patients were male, with average age of 29.8 years, and the mean follow-up period was 29.7 months. The pull-out suture technique was used to repair the root tears. Clinical outcomes were evaluated using the Lysholm, IKDC, and Tegner scores, as well as the McMurray and Apley tests. The mean follow-up period was 41.1 months (range, 30 to 63 months). The incidence of root tears of the medial meniscus with ligament injuries was 2.74% (10 cases in 365 ligament surgeries). All clinical results showed significant improvement. At the final follow-up, McMurray test showed one positive and nine negative cases, and the Apley test revealed two positive and eight negative cases. There were no positive findings in anterior drawer test, posterior drawer test, valgus and varus stress test, and posterolateral instability test. Healing of the root tear was confirmed by arthroscopy in five patients and by MR in four patients. Root tears of the medial meniscus may occur in multiple knee ligament injuries. It is important not to miss them. Our results indicate that pull-out repair provides satisfactory results and evidence of healing.
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Staged multidisciplinary step-up management for necrotizing pancreatitis
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DOD - Acute Comp Syndrome CPG
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BACKGROUND: Some 15 per cent of all patients with acute pancreatitis develop necrotizing pancreatitis, with potentially significant consequences for both patients and healthcare services.
METHODS: This review summarizes the latest insights into the surgical and medical management of necrotizing pancreatitis. General management strategies for the treatment of complications are discussed in relation to the stage of the disease.
RESULTS: Frequent clinical evaluation of the patient's condition remains paramount in the first 24-72h of the disease. Liberal goal-directed fluid resuscitation and early enteral nutrition should be provided. Urgent endoscopic retrograde cholangiopancreatography is indicated when cholangitis is suspected, but it is unclear whether this is appropriate in patients with predicted severe biliary pancreatitis without cholangitis. Antibiotic prophylaxis does not prevent infection of necrosis and antibiotics are not indicated as part of initial management. Bacteriologically confirmed infections should receive targeted antibiotics. With the more conservative approach to necrotizing pancreatitis currently advocated, fine-needle aspiration culture of pancreatic or extrapancreatic necrosis will less often lead to a change in management and is therefore indicated less frequently. Optimal treatment of infected necrotizing pancreatitis consists of a staged multidisciplinary 'step-up' approach. The initial step is drainage, either percutaneous or transluminal, followed by surgical or endoscopic transluminal debridement only if needed. Debridement is delayed until the acute necrotic collection has become 'walled-off'.
CONCLUSION: Outcome following necrotizing pancreatitis has improved substantially in recent years as a result of a shift from early surgical debridement to a staged, minimally invasive, multidisciplinary, step-up approach.
Copyright © 2013 BJS Society Ltd. Published by John Wiley & Sons Ltd.
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Subject-specific finite element modeling of the tibiofemoral joint based on CT, magnetic resonance imaging and dynamic stereo-radiography data in vivo
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AMP (Acute Meniscal Pathology)
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In this paper, we present a new methodology for subject-specific finite element modeling of the tibiofemoral joint based on in vivo computed tomography (CT), magnetic resonance imaging (MRI), and dynamic stereo-radiography (DSX) data. We implemented and compared two techniques to incorporate in vivo skeletal kinematics as boundary conditions: one used MRI-measured tibiofemoral kinematics in a nonweight-bearing supine position and allowed five degrees of freedom (excluding flexion-extension) at the joint in response to an axially applied force; the other used DSX-measured tibiofemoral kinematics in a weight-bearing standing position and permitted only axial translation in response to the same force. Verification and comparison of the model predictions employed data from a meniscus transplantation study subject with a meniscectomized and an intact knee. The model-predicted cartilage-cartilage contact areas were examined against "benchmarks" from a novel in situ contact area analysis (ISCAA) in which the intersection volume between nondeformed femoral and tibial cartilage was characterized to determine the contact. The results showed that the DSX-based model predicted contact areas in close alignment with the benchmarks, and outperformed the MRI-based model: the contact centroid predicted by the former was on average 85% closer to the benchmark location. The DSX-based FE model predictions also indicated that the (lateral) meniscectomy increased the contact area in the lateral compartment and increased the maximum contact pressure and maximum compressive stress in both compartments. We discuss the importance of accurate, task-specific skeletal kinematics in subject-specific FE modeling, along with the effects of simplifying assumptions and limitations.
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Thrombolysis for deep venous thrombosis
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DOD - Acute Comp Syndrome CPG
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The key questions addressed in this summary are whether clot removal should be part of the preferred therapy for patients with acute deep venous thrombosis (DVT), and whether there is evidence that a strategy of thrombus removal offers better outcomes for patients than anticoagulation alone. Evidence is defined as an outward sign or something that furnishes proof. Evidence in medicine is not limited to direct, blinded comparisons of one form of treatment compared with another but rather the body of knowledge that provides insight to clinicians to offer patient care. Evidence-based medicine follows from information available to form the foundation for the use of a treatment for a specific disease. Reports of strategies of thrombus removal for acute DVT, especially in patients with iliofemoral DVT, consistently demonstrate improved outcomes relative to postthrombotic morbidity. This summary reviews the evidence supporting this strategy as the preferred initial management of patients with extensive proximal DVT. © 2012 Society for Vascular Surgery.
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Focal osteoporosis defects play a key role in hip fracture
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Hip Fx in the Elderly 2019
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BACKGROUND: Hip fractures are mainly caused by accidental falls and trips, which magnify forces in well-defined areas of the proximal femur. Unfortunately, the same areas are at risk of rapid bone loss with ageing, since they are relatively stress-shielded during walking and sitting. Focal osteoporosis in those areas may contribute to fracture, and targeted 3D measurements might enhance hip fracture prediction. In the FEMCO case-control clinical study, Cortical Bone Mapping (CBM) was applied to clinical computed tomography (CT) scans to define 3D cortical and trabecular bone defects in patients with acute hip fracture compared to controls. Direct measurements of trabecular bone volume were then made in biopsies of target regions removed at operation.
METHODS: The sample consisted of CT scans from 313 female and 40 male volunteers (158 with proximal femoral fracture, 145 age-matched controls and 50 fallers without hip fracture). Detailed Cortical Bone Maps (c.5580 measurement points on the unfractured hip) were created before registering each hip to an average femur shape to facilitate statistical parametric mapping (SPM). Areas where cortical and trabecular bone differed from controls were visualised in 3D for location, magnitude and statistical significance. Measures from the novel regions created by the SPM process were then tested for their ability to classify fracture versus control by comparison with traditional CT measures of areal Bone Mineral Density (aBMD). In women we used the surgical classification of fracture location ('femoral neck' or 'trochanteric') to discover whether focal osteoporosis was specific to fracture type. To explore whether the focal areas were osteoporotic by histological criteria, we used micro CT to measure trabecular bone parameters in targeted biopsies taken from the femoral heads of 14 cases.
RESULTS: Hip fracture patients had distinct patterns of focal osteoporosis that determined fracture type, and CBM measures classified fracture type better than aBMD parameters. CBM measures however improved only minimally on aBMD for predicting any hip fracture and depended on the inclusion of trabecular bone measures alongside cortical regions. Focal osteoporosis was confirmed on biopsy as reduced sub-cortical trabecular bone volume.
CONCLUSION: Using 3D imaging methods and targeted bone biopsy, we discovered focal osteoporosis affecting trabecular and cortical bone of the proximal femur, among men and women with hip fracture.
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Cost-effectiveness analysis of screening for osteoporosis in postmenopausal Japanese women
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Management of Hip Fractures in the Elderly
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Osteoporosis-related hip fracture is an important cause of mortality and morbidity in older people. In an aging society such as Japan's, prevention and treatment of osteoporosis is of paramount importance in reducing the risk of hip fracture. To determine the efficiency of screening by dual-energy X-ray absorptiometry for reducing the incidence of hip fracture, a cost-effectiveness analysis was conducted using a state-transition model. We compared the following four strategies in a hypothetical cohort of postmenopausal Japanese women: (1) no intervention; (2) hormone replacement therapy (HRT) for patients with osteoporosis after screening; (3) HRT for patients with osteopenia and osteoporosis after screening; and (4) universal HRT. Epidemiological and economic data were collected from published articles. HRT for patients with osteoporosis after screening was the most cost-effective strategy, with the marginal cost-effectiveness being 5.36 million yen/quality-adjusted life year (QALY). The ratios for other strategies exceeded 10 million yen/QALY. Sensitivity analyses showed that the drug effect and treatment cost of HRT had a significant influence on the results. Screening postmenopausal Japanese women and treating patients with osteoporosis may be an acceptable strategy, but its cost-effectiveness ratio seems only fair at present
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Characterization of initial microfracture defects in human condyles
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Surgical Management of Osteoarthritis of the Knee CPG
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Microfracture (MFX) is a cartilage repair technique that depends on cell migration from marrow-rich trabecular bone cavities into the cartilage lesion. This study tested the hypothesis that MFX awls with distinct geometry generate different hole shapes and variable bone marrow access in condyles with Grade III to IV lesions. Lateral and medial condyles from total knee arthroplasty (N = 24 male and female patients, 66 (plus or minus) 9 years) were systematically microfractured ex vivo to 2 and 4 mm deep and the bone holes analyzed by micro-computed tomography. Subchondral bone in lesional condyles showed different degrees of sclerosis up to 2 mm deep ("porous," sclerotic, extremely dense). MFX holes ranged from 1.1 to 2.0 mm in diameter, and retained the awl shape with evidence of slight bone elastic rebound and bone compaction lining the holes that were increased by wider awl diameter and deeper MFX. Marrow access was significantly diminished by sclerosis for all three awls, with an average marrow access varying from 70% (nonlesional bone) to 40% (extremely dense bone). This study revealed that subchondral bone sclerosis can reach a critical limit beyond which MFX creates bone compaction and fissures instead of marrow access. Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA
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Extracorporeal Shock Wave Therapy reduces upper limb spasticity and improves motricity in patients with chronic hemiplegia: A case series
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Pediatric Supracondylar Humerus Fracture 2020 Review
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BACKGROUND: Extracorporeal Shock Wave Therapy (ESWT) has been proposed for treatment of abnormal muscle tone only in the last years. The effects on motor impairment are unknown. OBJECTIVE: To assess the long-term effects of ESWT on muscle tone and motricity in upper limb in patients with chronic hemiplegia. METHODS: Twelve patients were selected and treated with two sessions of ESWT. Participants were assessed at baseline, after the treatment, and at 3 and 6 months. Muscle tone of shoulder adductors, elbow, wrist and finger flexors was evaluated at all assessment points using the Modified Ashworth Scale (MAS), while motricity, passive range of motion (PROM) and pain sub-scores of upper extremity part of the Fugl-Meyer scale were used to assess motor recovery. The degree of perceived benefit from treatment was assessed on a visual analogue scale. RESULTS: MAS showed a significant reduction of spasticity and Fugl-Meyer scores improved immediately after treatment. Persistent effects were observed at 3 and 6 months for MAS, and for motricity and PROM subscores of the Fugl-Meyer scale. Clinical improvement was not correlated to the patients' perceived benefit. CONCLUSIONS: Two sessions of ESWT seem to have long-term effects in reducing muscle tone and enhancing motor impairment. © 2013 - IOS Press and the authors. All rights reserved.
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Function versus position of the wrist following distal radial fracture
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Distal Radius Fractures
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INTERVENTION: Patients with distal radial fractures undergoing reduction and kâ?wire fixation are randomised to dorsi or palmar flexion in plaster of Paris (POP). Upon removal of POP, grip test is measured using a Jamar Dynamometer. At 8 weeks, grip strength is measured again and the test is repeated at 17 weeks. CONDITION: Injury, Occupational Diseases, Poisoning: Radial fracture ; Injury, Occupational Diseases, Poisoning ; Radial fracture PRIMARY OUTCOME: 1. Grip strength; 2. Range of motion; 3. Radiological outcomes SECONDARY OUTCOME: Not provided at time of registration INCLUSION CRITERIA: Consecutive patients with displaced distal radial fracture undergoing reduction and kâ?wire fixation.
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Humeral amputation following total elbow arthroplasty
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MSTS 2022 - Metastatic Disease of the Humerus
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PURPOSE: Total elbow arthroplasty (TEA) is associated with a relatively high complication rate, and exceptionally catastrophic complications might lead to amputation. The purpose of this study was to determine the incidence and aetiology of amputation performed at our institution in upper extremity limbs with a prior TEA.
METHODS: Between 1973 and 2018, 1906 consecutive TEAs were performed at our institution. Upper extremity amputation was performed in seven (0.36%) elbows with five transhumeral amputations and two shoulder disarticulations. The group consisted of five females and two males with a mean age of 64 years (range, 37-80). The index TEA had been performed for rheumatoid arthritis (n = 2), rheumatoid arthritis with acute fracture (n = 2), radiation associated nonunion (n = 2), and metastatic cancer (n = 1). Mean follow-up after amputation was three years (range, 3 months-5 years).
RESULTS: Mean time between amputation and TEA was 5 years (range, 2 months-13 years). The indications for amputation included uncontrolled deep infection in six (86%) elbows and tumor recurrence in one (14%) elbow. Only one elbow (14%) was fitted with a prosthesis. Six (86%) patients died at a mean of three years (range, 3 months-5 years) after amputation.
CONCLUSION: The results of this study highlight a low incidence of amputation after TEA. Most amputations were the direct result of TEA complications, with infection being the most common cause of amputation. Outcomes after amputation are concerning, with poor overall survival and few patients being fit for a prosthesis.
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Acellular human dermis implantation in 153 immediate two-stage tissue expander breast reconstructions: determining the incidence and significant predictors of complications
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Acellular Dermal Matrix
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BACKGROUND: Little information exists on the incidence of complications after acellular human dermis implantation in two-stage tissue expander breast reconstruction. The purpose of this study was to evaluate the incidence of postoperative adverse events and identify significant predictors of complications in acellular human dermis tissue expander breast reconstruction. METHODS: This study accrued all patients from January of 2004 through April of 2008 undergoing two-stage immediate tissue expander breast reconstruction using acellular human dermis. A total of 153 expanders were placed. Complications were assessed. Univariate and multivariate logistic regression modeling was performed. Comparison of complication rates using the traditional (non-acellular human dermis) technique from concurrent (2004 to 2008) and consecutive time periods (2001 to 2003) for 2910 and 1170 expanders, respectively, is provided. RESULTS: A total of 153 expanders were implanted in 96 women: 39 unilateral and 57 bilateral. Eleven (7.2 percent) were removed due to infection (n = 5, 3.3 percent), exposure (n = 4, 2.6 percent), or patient preference (n = 2, 1.3 percent). Other complications included cellulitis (3.9 percent), seroma (7.2 percent), hematoma (2.0 percent), mastectomy flap necrosis (4.6 percent), and leak/failed expansion (0.0 percent); 92.8 percent were successfully expanded and exchanged for a permanent implant. Eleven seromas (7.2 percent) were identified; nine underwent aspiration. None of these resulted in infection or reconstructive failure. Univariate analysis revealed age, body mass index, axillary dissection, and postoperative chemotherapy to be associated with reconstructive failure (p < 0.05). Multivariate analysis revealed that age, body mass index, and axillary dissection are independent risk factors for developing complications (p < 0.05). CONCLUSION: Acellular human dermis is a useful adjunct for intraoperative pocket development in immediate tissue expander reconstruction but can result in an increased risk of complications, in particular, seroma and reconstructive failure.
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Comparison of patient outcomes in periarticular and intraarticular local anaesthetic infiltration techniques in total knee arthroplasty
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AAHKS (8) Anesthetic Infiltration
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BACKGROUND: The use of local infiltration analgesia in the setting of knee arthroplasty is well established. There are no studies to date which have directly compared differences in infiltration techniques. The purpose of this study is to establish if a difference in patient outcomes exists when the infiltrate is injected into the periarticular tissues or directly into the joint.
METHODS: One hundred and forty-two consecutive patients waitlisted for primary total knee arthroplasty were enrolled after primary exclusion criteria were applied. These included the following: allergy to study drugs, inability to receive spinal anaesthesia, and planned bilateral surgery. Patients were divided into two groups, a periarticular infiltration group (group A) and an intraarticular infiltration group (group B). Secondary exclusion criteria of regular opioid use, psychiatric illness, and serious medical comorbidity left a total of 47 patients in group A and 54 patients in group B. Both groups received a combination of 30 mg ketorolac, 500 mug of adrenaline, and 300 mg of ropivacaine, and normal saline. This was either injected into the periarticular tissues during surgery (group A) or intraarticularly after closure of the wound (group B). Primary outcome measures included opioid consumption during the first 24 h postoperatively and over the total admission, and visual analogue scales (VAS) on postoperative day 1 and at discharge. Secondary measures included Oxford Knee Score, knee flexion, length of stay, haemoglobin drop, and transfusion requirement. Ethics approval was granted by the hospital review board. The trial is registered in the Australian New Zealand Clinical Trials Registry, registration ACTRN12615000488505 .
RESULTS: No statistically significant differences in postoperative analgesic use were observed between the two groups. However, there was a trend toward decreased postoperative patient-controlled analgesia use in the periarticular group (mean 53.1 vs 68.3 mg morphine equivalents; p=0.093), as well as a statistically significant reduction in postoperative visual analogue pain scores. No statistically significant differences were observed for haemoglobin drop, range of motion, or pre- to 6-week postoperative Oxford Score difference.
CONCLUSIONS: Our study is the first we are aware of to directly compare a periarticular to intraarticular injection technique when using local infiltration analgesia for total knee arthroplasty. Our results show no clear statistically significant benefit with either technique. The periarticular group showed a statistically significant reduction in postoperative VAS pain scores alongside a trend in that group toward reduced overall opioid use.
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Arthroscopic transtibial single-bundle posterior cruciate ligament reconstruction using patellar tendon graft compared with hamstring tendon graft
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OAK 3 - Non-arthroplasty tx of OAK
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PURPOSE: The purpose of this study was to compare the outcomes of arthroscopic transtibial single-bundle posterior cruciate ligament reconstruction using autologous patellar tendon and hamstring tendon grafts.
METHODS: From 1998 to 2007, 59 patients with symptomatic isolated posterior cruciate ligament injury were included in this retrospective study. Twenty-five knees were reconstructed using bone-patellar tendon-bone graft, and 34 knees were reconstructed using hamstring graft. In both groups, surgical techniques were similar, except material of fixation screws. Patients were evaluated pre-operatively and post-operatively at the latest follow-up with several parameters, including symptoms, physical examination, outcome satisfaction, functional scores, radiography and complications.
RESULTS: Average follow-up period was 51.6 months in patellar tendon group and 51.1 months in hamstring tendon group. Significantly more kneeling pain (32 vs. 3 %), squatting pain (24 vs. 3 %), anterior knee pain (36 vs. 3 %), posterior drawer laxity and osteoarthritic change were shown in patellar tendon group than in hamstring tendon group post-operatively. No significant differences were found in other parameters between both groups.
CONCLUSIONS: Several shortcomings, including anterior knee pain, squatting pain, kneeling pain and osteoarthritic change, have to be concerned when using patellar tendon autograft. In conclusion, hamstring tendon autograft may be a better choice for transtibial tunnel PCL reconstruction.
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Incidence of Skeletal-related Events Over Time from Solid Tumour Bone Metastases Reported in Randomised Trials Using Bone-modifying Agents
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MSTS 2018 - Femur Mets and MM
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Aims: Skeletal-related events (SREs) in patients with bone metastases decrease a patient's quality of life and functional status. Although bone-modifying agents have been found to reduce the time to first on-trial SRE and decrease the total incidence of SREs in randomised clinical trials, standard practice in the management of bone metastases has changed concurrently. The purpose of this study was to investigate if advances in bone-targeted therapies have decreased the incidence of individual types of SREs and to delineate the trend of SREs. Materials and methods: A literature review was conducted in MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials to identify phase III, randomised bisphosphonate and other bone-targeted therapy trials from 1980 to September 2011. For all studies, a mean year of enrolment ([start of enrolment+end of enrolment]/2) was calculated. The incidences of SREs were tabulated and expressed as percentages of on-trial patients. Generalised linear mixed models were used to search for the trends of SREs over time for all placebo and intervention arms. Regression coefficients were interpreted as the odds ratio, which was calculated using the exponential of the slope. Ninety-five per cent confidence intervals were also calculated. Results: In total, 20 eligible studies were identified that reported SRE data from phase III trials, of which 11 were suitable for the quantitative analysis. Most of the articles included patients with breast cancer and the remaining involved patients with prostate, renal cell, bladder and lung cancer or other solid tumours. Enrolment periods for all included data ranged from 1990 to 2009. Statistically significant overall downward trends in pathological fractures and the need for surgery were seen over time. Also significant differences between intervention and placebo were seen with all SREs. Conclusion: The decrease in SREs over time may not only be a result of the development of new generation bone-targeted agents, but also due to better systemic management and awareness of events associated with bone metastases. © 2013 The Royal College of Radiologists.
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Review of Artificial Intelligence Techniques in Imaging Data Acquisition, Segmentation and Diagnosis for COVID-19
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Coronavirus Disease 2019 (COVID-19)
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The pandemic of coronavirus disease 2019 (COVID-19) is spreading all over the world. Medical imaging such as X-ray and computed tomography (CT) plays an essential role in the global fight against COVID-19, whereas the recently emerging artificial intelligence (AI) technologies further strengthen the power of the imaging tools and help medical specialists. We hereby review the rapid responses in the community of medical imaging (empowered by AI) toward COVID-19. For example, AI-empowered image acquisition can significantly help automate the scanning procedure and also reshape the workflow with minimal contact to patients, providing the best protection to the imaging technicians. Also, AI can improve work efficiency by accurate delineation of infections in X-ray and CT images, facilitating subsequent quantification. Moreover, the computer-aided platforms help radiologists make clinical decisions, i.e., for disease diagnosis, tracking, and prognosis. In this review paper, we thus cover the entire pipeline of medical imaging and analysis techniques involved with COVID-19, including image acquisition, segmentation, diagnosis, and follow-up.
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Carpal arch alteration and related clinical status after endoscopic carpal tunnel release
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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One hundred eight endoscopic carpal tunnel releases were performed by a modification of the technique described by Chow. Eighty-seven of the 108 cases were evaluated for quantitative postoperative widening of the transverse carpal arch. The average postoperative widening of the transverse carpal arch was 0.17 cm (7%), with a range of 0 to 0.5 cm. Seventy percent of the patients showed 0% to 10% widening, 26% showed 10% to 20% widening, and 4% showed more than 20% widening of the transverse carpal arch. Preliminary findings show that 3 weeks after endoscopic carpal tunnel release, pinch strength was at 102% and grip strength at 86% of preoperative values. Six weeks after surgery, pinch strength was 106% and grip strength was 121% of preoperative values. The complication rate in this series was 3%. The transverse dimension of the carpal arch generally widens after endoscopic carpal tunnel release but to a lesser degree than has been reported for open carpal tunnel release. The rate of improvement of pinch and grip strength after endoscopic release is faster than that reported in the literature after open release
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Corrigendum to â??Blockade of vascular endothelial growth factor receptor-1 (Flt-1), reveals a novel analgesic for osteoarthritis-induced joint painâ?쳌 (Gene Reports (2018) 11 (94â??100), (S2452014418300244) (10.1016/j.genrep.2018.03.008))
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OAK 3 - Non-arthroplasty tx of OAK
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As the principal investigator and senior author for the above-mentioned publication (Das et al., 2018, GENE REPORTS 11, 94â??100), it has been brought to my attention that a portion of 2.4. Surgical procedure for OA induction in the Materials and Methods section in this publication contains inaccurate description. Hence, we are respectfully requesting to publish a corrigendum to replace the surgical procedure with proper description and references as below: 2.4 Surgical procedure for OA induction All the surgical operations were performed under a microscope in an aseptic setting. Mice were placed in a supine position and anesthetized with 1.5% isoflurane (Abbott Laboratories, North Chicago, IL, USA) in oxygen via a facemask at a rate of 1 L/min. The toe or tail pinch with toothed forceps was used to assess the depth of anesthesia, and flick responses were interpreted as inadequate anesthesia. After confirming adequate anesthesia, a 1 cm left knee incision was made with a #15 scalpel blade. The knee joint was identified from the tibia and femur; and the medial meniscotibial ligament was identified using anatomic landmarks. To induce partial medial meniscectomy (PMM), which destabilizes the ligaments, a microscalpel at a depth of 0.5 mm was used to remove meniscus at midline (Knights et al., 2012; Kroin; et al., 2016; Das et al., 2018). The skin incision will be then closed with 4-0 vicryl suture. Below two references need to be added: (i) Kroin, J.S., Kc, R., Li, X., Hamilton, J.L., Das, V., van Wijnen, A.J., Dall O.M., Shelly, D.A., Kenworth T., Im, H.J. (2016). Intraarticular slow-release triamcinolone acetate reduces allodynia in an experimental mouse knee osteoarthritis model. Gene 591, 1â??5. doi: https://doi.org/10.1016/j.gene.2016.06.049. Epub 2016 Jun 26.(ii) Knights C.B., Gentry C., Bevan S. (2012). Partial medial meniscectomy produces osteoarthritis pain-related behavior in female C57BL/6/mice. Pain 2012, 153, 281â??292. doi: https://doi.org/10.1016/j.pain.2011.09.007. Epub 2011 Oct 15.(iii) Das V, Kc R, Li X, Varma D, Qiu S, Kroin JS, Forsyth CB, Keshavarzian A, van Wijnen AJ, Park TJ, Stein GS, O-Sullivan I, Burris TP, Im HJ. (2018). Pharmacological targeting of the mammalian clock reveals a novel analgesic for osteoarthritis-induced pain. Gene 655, 1â??12. doi: https://doi.org/10.1016/j.gene.2018.02.048. Epub 2018 Feb 20.The authors would like to apologise for any inconvenience caused.
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Agreement on and predictors of long-term psychosocial development 16 years post-childhood traumatic brain injury
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DoD PRF (Psychosocial RF)
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Childhood traumatic brain injury (CTBI) is one of the most common causes of childhood mortality and morbidity, with psychosocial impairment being among the most debilitating persisting consequences. Child and adolescent survivors of CTBI have fewer friends and lower self-esteem with a higher risk of developing a psychiatric disorder. In most research to date, findings in the psychosocial domain have been based on parent reports, with the child or adolescent only consulted infrequently. If there is a discrepancy identified between parent and child reported symptoms and behaviors, this is generally interpreted as resulting from impaired self-awareness in the child. The aim of this study was to 1) examine the agreement between self- and proxy-reported long-term psychosocial outcomes and 2) investigate the predictors of outcome 16 years post-CTBI. Thirty-three young adults (mean, 21.36 years; standard deviation, 2.75), with a CTBI sustained between 1 and 7 years of age, and a significant other completed questionnaires assessing the young adults' social and psychological functioning. Young adults and their significant other had good-to-excellent agreement on communication as well as alcohol and drug use scales. There was poorer agreement for the overall internalizing symptoms, anxious/depressed, withdrawn, thought, and rule-breaking behaviors. On the scales with poor agreement, there was no consistent contribution identified for any injury or preinjury factors. Preinjury adaptive behavior partly predicted withdrawn and overall internalizing symptoms, with a trend to also partly predict anxious/depressed and rule-breaking behavior reported by the significant other. Because young adults and significant others had poor agreement on the less-overt symptoms, these young adults may be at a higher risk of developing more-severe symptoms or disorders if it is not identified in time.
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0 |
Anterior cruciate ligament reconstruction with autogenous patellar tendon graft in patients with articular cartilage damage
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Surgical Management of Osteoarthritis of the Knee CPG
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To test if anterior cruciate ligament reconstruction with autogenous patellar tendon can alleviate symptoms and functional limitations and increase activity levels in patients with advanced articular cartilage damage, we looked at 53 patients with arthroscopically documented cartilage damage. In this group, a mean of 7.5 years had elapsed between the original injury and the reconstruction, and 90 prior operative procedures had been done. Postoperatively, all patients had immediate motion and early functional rehabilitation. The results were assessed with the Cincinnati Knee Rating System. At followup (mean, 27 months), significant improvements were found for pain, swelling, giving way, functional limitations with daily and sports activities, and the overall rating score. Forty-two patients (79%) had returned to some type of athletic activity. Only three patients (6%) had failed results. In the patients' own ratings of the overall knee condition, 8 of 51 (16%) rated their knees as normal, 28 (55%) as very good, 7 (14%) as good, 5 (10%) as fair, and 3 (6%) as poor. We concluded that the majority of patients benefited from the arthroscopically assisted anterior cruciate ligament reconstruction because it decreased episodes of giving way with daily activities and increased activity without aggravating the preexisting arthrosis
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0 |
Correlation between synovial vascular endothelial growth factor, clinical, functional and radiological manifestations in knee osteoarthritis
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OAK 3 - Non-arthroplasty tx of OAK
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Aim of the work: To correlate between synovial vascular endothelial growth factor (VEGF), clinical, functional and radiological findings in knee osteoarthritis (KOA) patients. Patients and methods: Twenty patients with primary KOA were clinically examined and the modified Ritchie articular index (RAI) recorded. The knees were examined and knee pain evaluated by the visual analog scale (VAS) and tenderness by the knee subscale of the RAI. The Western Ontario Mc Master scale (WOMAC) was recorded and the Kellgren-Lawrence grading used to assess radiographic severity. The synovial level of VEGF was assessed using ELISA. Results: The mean age was 56.15 ± 7.77 years and body mass index 28.1 ± 4.04. All patients had knee effusion; 40% were bilateral and 60% unilateral. The mean duration of knee pain was 3.01 ± 1.43 years; duration of morning stiffness was 15.75 ± 3.72 min. The mean WOMAC was 44.22 ± 11.46 and modified RAI 5.45 ± 2.94. The mean knee subscale of RAI was 2.9 ± 1.16 and VAS for knee pain 5.7 ± 2.92. The mean synovial VEGF level was 693.71 ± 314.63 pg/ml. There was a significant increase in the synovial VEGF compared to the reference value (p = 0.0001). There was a significant correlation between the synovial VEGF and patients' age (p = 0.04), knee pain duration (p = 0.025), morning stiffness (p < 0.0001), modified RAI (p = 0.0001), knee subscale of RAI (p < 0.0001), VAS for knee pain (p < 0.0001) and WOMAC (p = 0.0001). There was a significant negative correlation between synovial VEGF and muscle strength grading (p = 0.0001) and a significant correlation with the radiological assessment (p = 0.0001). Conclusion: Synovial VEGF significantly correlated with clinical manifestations, functional impact, as well as radiological changes of KOA.
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Descriptive analysis and short-term follow-up clinical results of osteochondral lesions of the distal tibia based on data of the German Cartilage Register (Knorpelregister(®) DGOU)
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Osteochondritis Dissecans 2020 Review
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INTRODUCTION: An increasing number of ankle injuries with osteochondral lesions (OCL) also include lesions of the distal tibia. Therefore, the German Cartilage Society database is used to describe and examine the characteristics of these lesions and, early on, the results of different surgical therapies on the clinical outcome. MATERIALS AND METHODS: Forty-seven patients out of 844 registered in the German Cartilage Society database met the inclusion criteria showing an OCL of the distal tibia (OLDT). Sixteen of them also presented a 1-year follow-up regarding the Foot and Ankle Ability Measure (FAAM). Further evaluations were included in the follow-up, such as the Foot and Ankle Outcome Score (FAOS) and the Visual Analogue Scale for pain (VAS). RESULTS: The patients' mean age was 35?±?11 with a mean BMI in the range of overweight (26/27?±?5 kg/m(2)). The lesions were equally distributed on the articular surface of the distal tibia. Most patients were operated using anterior ankle arthroscopy [n(T) 34 (72%); n(S) 13 (81%)], while some (n(T) 9; n(S) 4) converted to open procedures. Almost 90% staged III and IV in the ICRS classification. Debridement, bone marrow stimulation, solid scaffolds, and liquid filler were the treatment choices among the subgroup. All therapies led to a clinical improvement between pre-op and 1-year follow-up but not to a significant level. CONCLUSION: This study presents baseline data of OLDT based on data from a large database. BMS and scaffolds were the treatment of choice but did not present significant improvement after a 1-year follow-up.
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1 |
Early surgical site infection in adult appendicular skeleton trauma surgery: a multicenter prospective series
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DoD SSI (Surgical Site Infections)
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INTRODUCTION: Surgical site infections (SSI) studies rely on an imprecise and debatable definition. The term "wound healing problems" (WHP), not necessarily septic, is also frequently cited. This study had the objectives of determining the frequency of early SSIs in traumatology, these terms eventual correlation, and the factors influencing onset.
PATIENTS AND METHODS: A multicenter prospective observational study was conducted in 12 centers. The exclusion criteria were open lesions as well as multiple injuries and multiple fractures (more than two fractures treated surgically). All patients were followed for the first three postoperative months until there was clinical certainty of healing and absence of infection. The presence of any WHP or SSI required a minimum follow-up of 1 year. WHP and SSI risk factors were determined using logistical regression adjusted on the centers.
RESULTS: Out of 1617 cases, 103 were complicated by a WHP and 22 by a SSI. The SSIs were mainly secondary to Staphylococcus infections. The factors predisposing the patients to WHP and SSI (p<=0.05) were age; the NNIS, ASA, and Parker scores; alcoholism; antiaggregant use; and the locoregional aspect at the time of injury. The 522 subcutaneous osteosyntheses "near the skin" resulted in 58 WHPs (11%) and 14 SSIs (2.7%); 13 of the 58 WHPs (22%) resulted in one SSI. Out of 707 deep osteosyntheses, 24 (3.4%) presented a WHP and seven (1%) a SSI; Four SSIs originated from a WHP. The 352 fractures of the trochanter were complicated by a WHP in 15 cases (5.5%) and a SSI in one case (0.4%) after interlocked nailing and two WHPs and two SSIs (2.5%) after screw and plate fixation. Of the 388 first-line arthroplasties, only the prostheses implanted for a proximal femur fracture presented complications: 21 WHPs (6%) and one SSI (0.02%). Of the 103 WHPs of the entire series, 18 became SSIs. In absence of WHP, the SSI rate was 0.2%, whereas the probability of a WHP evolving toward a SSI was 100 times higher. The only factor significantly associated with a WHP becoming a SSI was osteosynthesis material exposure.
DISCUSSION: This prospective study can be criticized on several points: the deliberately limited inclusion criteria, the short follow-up, and the possible subjectivity of the data collection. The SSI rates reported are for the most part in agreement with the literature. This study is innovative in traumatology given the large number of patients and the notion of WHP that was preferred over superficial infection. It demonstrates the relations between WHP and SSI, in particular for osteosyntheses near the skin.
LEVEL OF EVIDENCE: Level III.
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0 |
Treatment of unreduced elbow dislocations with hinged external fixation
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Glenohumeral Joint OA
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Background: The results of operative treatment of an unreduced elbow dislocation have been regarded with pessimism. Suggested procedures have included tendon-lengthening, tendon transfer, or reconstruction of ligament or bone. Methods: Three women and two men (average age, forty-nine years) with an unreduced dislocation of the elbow without associated fractures were treated with open relocation of the joint and hinged external fixation at an average of eleven weeks (range, six to thirty weeks) after the initial injury. The lateral soft tissues, including the origin of the lateral collateral ligament complex, were reattached to the lateral epicondyle in three patients, but no attempt was made to reconstruct the ligaments, tendons, or bone. A passive worm gear incorporated into a hinged external fixator was used to mobilize the elbow initially, and active mobilization was gradually introduced. The hinge was removed at an average of five weeks after the procedure. Results: At an average of thirty-eight months (range, twelve to ninety-eight months), a stable, concentric reduction had been maintained in all five patients, with radiographic signs of mild arthrosis in four. The average arc of flexion was 123°, and all patients had full forearm rotation. The average score on the Mayo Elbow Performance Index was 89 points, with two excellent and three good results. The average scores on the Disabilities of the Arm, Shoulder and Hand (DASH) and American Shoulder and Elbow Surgeons outcome instruments (13 and 92 points, respectively) reflected mild residual pain and disability. Conclusions: Treatment of unreduced elbow dislocations with open reduction and hinged external fixation as much as thirty weeks after the injury can restore a stable, mobile joint without the need for tendon-lengthening or transfer, ligament reconstruction, or deepening of the trochlear notch of the ulna.
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Recurrent acute otitis media in infants: analysis of risk factors
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Reduction Mammoplasty for Female Breast Hypertrophy
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OBJECTIVE: Recurrence acute otitis media (RAOM) may cause a considerable morbidity and a great parental concern. The aim of this study was to analyze the risk factors that are likely to be responsible for RAOM in infants, and their impact on treatment failure. METHODS: A retrospective study on 340 infants with RAOM was conducted. Data were collected from hospital charts. A 10 days course of amoxicillin/clavulanate was used for treatment of recurrence, while surgical management in the form of adenoidectomy and/or myringotomy was reserved for patients with persistent disease. We analyzed various risk factors that may affect the prognosis of RAOM, including: age, prematurity, upper respiratory tract infections (URTI), duration of breastfeeding, use of pacifiers, parental smoking, seasonality, the presence of siblings (family size), gender, adenoid hypertrophy, allergy, and craniofacial abnormalities. RESULTS: Use of pacifiers, short duration of breastfeeding, older infantile age, winter season, URTI and presence of adenoid hypertrophy were identified as risk factors for RAOM. Treatment failure may be due to adenoid hypertrophy, short duration of breastfeeding and it is more common in older age infants. We did not find a significant association between RAOM and gender, prematurity, exposure to passive smoking, the presence of siblings, allergy, craniofacial abnormalities. CONCLUSIONS: Factors that may cause recurrence of the disease in infant population are use of pacifiers, short duration of breastfeeding, older infantile age, winter season, upper respiratory tract infections and adenoid hypertrophy. Also, treatment failure may be caused by adenoid hypertrophy and short duration of breastfeeding. Good understanding of these factors may help to decrease the recurrence rate and to improve the treatment of the disease.
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0 |
Clinical Management in Early OA
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AAHKS (2) Corticosteroids
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Knee osteoarthritis affects an important percentage of the population throughout their life. Several factors seem to be related to the development of knee osteoarthritis including genetic predisposition, gender, age, meniscal deficiency, lower limb malalignments, joint instability, cartilage defects, and increasing sports participation. The latter has contributed to a higher prevalence of early onset of knee osteoarthritis at younger ages with this active population demanding more consistent and durable outcomes. The diagnosis is complex and the common signs and symptoms are often cloaked at these early stages. Classification systems have been developed and are based on the presence of knee pain and radiographic findings coupled with magnetic resonance or arthroscopic evidence of early joint degeneration. Nonsurgical treatment is often the first-line option and is mainly based on daily life adaptations, weight loss, and exercise, with pharmacological agents having only a symptomatic role. Surgical treatment shows positive results in relieving the joint symptomatology, increasing the knee function and delaying the development to further degenerative stages. Biologic therapies are an emerging field showing early promising results; however, further high-level research is required.
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Interleukin-8 (IL-8) in synovial fluid of rheumatoid and nonrheumatoid joint effusions
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AMP (Acute Meniscal Pathology)
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IL-8 was measured in knee joint synovial fluid of 60 patients with rheumatoid arthritis, 8 with gout, 6 with osteoarthritis and 4 with meniscus lesions. IL-8 could be demonstrated in most SF samples. The highest levels were observed in rheumatoid joint effusions, yet mean levels were not significantly different between the different subgroups (mean +/- SE; RA 1537 +/- 3049 pg/ml, gout 570 +/- 952 pg/ml, OA/ML 178 +/- 188 pg/ml). In RA patients, IL-8 levels could not be related to various serological, clinical or radiological parameters. However, a correlation was observed between SF levels of IL-8 with those of lactate, LDH, beta 2-microglobulin and glucose. These observations suggest that next to the laboratory parameters IL-8 will be a parameter of the activity of the local inflammatory process. The results also demonstrate that IL-8 is not a disease-specific marker of joint inflammation.
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Does the postoperative dressing regime affect wound healing after hip or knee arthroplasty?
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PJI DX Updated Search
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OBJECTIVE: The aim of this literature review is to enable practitioners to make informed decisions about how to manage patients with hip or knee arthroplasty wounds. METHOD: A systematic critique of the evidence in relation to how the postoperative dressing regime may affect wound healing after hip or knee arthroplasty, was undertaken. RESULTS: No single treatment emerged as the ideal postoperative dressing regime for hip and knee arthroplasty wounds. CONCLUSION: A selection of dressings is recommended for hip and knee arthroplasty wounds, on the basis of reducing the incidence of postoperative blistering and wound infection
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Femoral Shaft Fractures
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Hip Fx in the Elderly 2019
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Fractures of the femoral shaft are one of the most common injuries treated by orthopedic surgeons. These fractures are often associated with polytrauma and can be life-threatening. They commonly result from high energy mechanisms such as motor vehicle collisions (MVC) with sequelae of limb shortening and deformities if not treated appropriately. Femoral shaft fractures (FSF) typically occur in a bimodal distribution, high-energy trauma in the young population, and lower energy trauma in the elderly population. FSFs are also associated with other comorbidities necessitating a thorough advanced trauma life support (ATLS) assessment and interdisciplinary care. Intramedullary nailing (IMN) is the most common treatment of physiologically stable patients. The goal of fixation is early healing and long-term functional recovery. Treatment of modern-day femoral shaft fractures results in excellent outcomes. <b> Anatomy </b> Proximally, the femur is composed of a specialized metaphyseal region consisting of the head, neck, and greater and lesser trochanters. Distally, the femur comprises the metaphyseal flare, which continues into the medial and lateral femoral condyles, separated by the intercondylar notch. The shaft, or diaphysis, is the segment inferior to the lesser and ending at the metaphyseal flair and condyles. Classically the first 5 cm distal to the lesser trochanter is termed the subtrochanteric region and is considered a separate fracture pattern. These fractures are challenging to manage secondary to the muscular deforming forces. They will not be discussed in this article.[1] According to the Arbeitsgemeinschaft fur Osteosynthesefragen (AO) classification of fractures, the femoral shaft begins at the inferior border of the lesser trochanter. It ends proximal to the condyles at a distance equal to the greatest width of the femoral condyles.[2] The diaphysis is a smooth cylinder with differences in cortical thickness throughout its length, which may aid in assessing intraoperative femoral rotation. The femur is bowed anteriorly with an average radius of curvature 120 cm (+/- 36 cm); the shorter the radius, the greater the bow.[3] The linea aspera is the major cortical thickening along the posterior aspect of the femur and is an attachment site for muscles and the medial and lateral intermuscular septa and acts as a compressive cortical strut.[4] Three abundant muscular compartments envelop the femur. The anterior or extensor compartment is responsible for knee extension and houses the femoral nerve. The posterior or flexor compartment is responsible for knee flexion and houses the sciatic nerve. The medial compartment houses the adductor muscles. In FSF, the sciatic nerve and specifically the peroneal division are at the highest risk to injury because they lay close to the femoral shaft. The adductor compartment houses the obturator nerve. The gluteal muscles also surround and attach to the proximal femur and shaft; they include the gluteus maximus, medius, and minimus and cover the superior and inferior gluteal nerves. In FSF, the muscles are deforming forces on the fracture fragments depending on the location of the fracture. Generally, the proximal segment is flexed, abducted, and externally rotated by the iliopsoas and hip abductors. The distal segment is pulled proximally (shortened) by the quadriceps and hamstrings and adducted by the adductor muscles. The main blood supply to the femur derives from the femoral artery, a continuation of the external iliac artery. The femoral artery passes under the mid-portion of the inguinal ligament and divides into the superficial femoral artery (SFA) and deep femoral artery (DFA), also known as the profunda femoris. The SFA supplies the tissues below the knee, and the DFA supplies the femoral shaft and the surrounding soft tissues. Multiple branches arise from the DFA, most notably the perforating arteries that encircle the femur. One or multiple nutrient arteries arise from the DFA or its branches to supply the inner 2/3 of the cortex and bone marrow. They anastomose w
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Postoperative delirium in old patients with femoral neck fracture: a randomized intervention study
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Management of Hip Fractures in the Elderly
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BACKGROUND AND AIMS: Delirium is a common postoperative complication in elderly patients which has a serious impact on outcome in terms of morbidity and costs. We examined whether a postoperative multi-factorial intervention program can reduce delirium and improve outcome in patients with femoral neck fractures.METHODS: One hundred and ninety-nine patients, aged 70 years and over (mean age+/-SD, 82+/-6, 74% women), were randomly assigned to postoperative care in a specialized geriatric ward or a conventional orthopedic ward. The intervention consisted of staff education focusing on the assessment, prevention and treatment of delirium and associated complications. The staff worked as a team, applying comprehensive geriatric assessment, management and rehabilitation. Patients were assessed using the Mini Mental State Examination and the Organic Brain Syndrome Scale, and delirium was diagnosed according to DSM-IV criteria.RESULTS: The number of days of postoperative delirium among intervention patients was fewer (5.0+/-7.1 days vs 10.2+/-13.3 days, p=0.009) compared with controls. A lower proportion of intervention patients were delirious postoperatively than controls (56/102, 54.9% vs 73/97, 75.3%, p=0.003). Eighteen percent in the intervention ward and 52% of controls were delirious after the seventh postoperative day (p<0.001). Intervention patients suffered from fewer complications, such as decubitus ulcers, urinary tract infections, nutritional complications, sleeping problems and falls, than controls. Total postoperative hospitalization was shorter in the intervention ward (28.0+/-17.9 days vs 38.0+/-40.6 days, p=0.028).CONCLUSIONS: Patients with postoperative delirium can be successfully treated, resulting in fewer days of delirium, fewer other complications, and shorter length of hospitalization
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Relationship between Tibial Bone Defect and Extent of Medial Release in Total Knee Arthroplasty
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Surgical Management of Osteoarthritis of the Knee CPG
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PURPOSE: To understand the relationship between tibial bone defect and extent of medial release in total knee arthroplasty. MATERIALS AND METHODS: We evaluated 32 knees in 22 patients with variable degrees of tibial bone defect on medial plateau has undergone total knee arthroplasty. In this study, 31 cases had been diagnosed as degenerative osteoarthritis and 1 case was osteonecrosis. We excluded cases with infection, traumatic arthritis, or neuropathic joints. With regard to gender, 29 cases were female and 3 cases were male. The following relationships were analyzed: preoperative degrees of tibial bone defect and varus deformity; the femorotibial angle of both weight-bearing whole extremity radiogram, distractive stress radiogram, and the extent of medial release. RESULTS: Average tibial bone defect was 9.8+/-4.1 mm. Average femorotibial angle on weight-bearing whole extremity radiograph was varus 10.0 degrees +/-6.2 degrees . Average femorotibial angle on distractive stress radiograph was varus 0.7 degrees +/-4.6 degrees . Statistically the extent of medial release showed no significant relationship with the degree of tibial bone defect and femoro-tibial angle of whole extremity radiogram. However, it revealed a statistically significant relationship with the femorotibial angle on distractive radiogram (r=0.465, p=0.007). CONCLUSIONS: Preoperative distractive stress radiograph might be a useful method to predict the extent of intraoperative medial release during total knee arthroplasty
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Ophthalmic and visual profile of guide dog owners in Scotland
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Upper Eyelid and Brow Surgery
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BACKGROUND/AIMS: Out of an estimated 90,000 visually impaired people in Scotland, 509 make use of a guide dog. Initial research in Northern Ireland suggests that the ophthalmic profile of guide dog owners (GDOs) is highly specific. The aim of this study was to compare the ophthalmic and visual characteristics of Scottish GDOs with other groups of visually impaired people. METHODS: A random sample of GDOs from central and northern Scotland (n = 82) underwent a detailed assessment of residual vision (distance and near acuity, visual fields, contrast, and glare sensitivity). Comparative data were obtained from two populations of visually impaired non-GDOs-one group attending hospital ophthalmic and low vision clinics (n = 50) the other social services rehabilitation clients (n = 35). All participants completed a questionnaire to elicit ophthalmic history, age, and registration details. RESULTS: GDOs were found to be significantly younger and more profoundly visually impaired than non-GDOs. The main causes of visual impairment were retinitis pigmentosa (23%), optic atrophy (15%), and retinopathy of prematurity (7%). Ninety nine per cent of GDOs were registered blind and had been visually impaired for an average of 39 years. Only 31% were totally blind. CONCLUSION: GDOs represent a unique minority of the visually impaired population. Epidemiological registration trends would suggest that the numbers of young profoundly visually impaired people are unlikely to increase relative to their elderly counterparts. This has implications on the future demand for guide dog ownership.
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Total femur replacement: A limb-saving strategy for patients with primary malignant femoral tumors
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MSTS 2018 - Femur Mets and MM
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Objective: The treatment of primary malignant tumors with skip or extensive bone destruction in the femur is a major challenge. We investigated the clinical effects of total femur replacement (TFR) in patients with primary malignant femoral tumors. Methods: Eleven cases of primary malignant femoral tumors treated with TFR between June 2005 and January 2015 were retrospectively reviewed. The lesions were located throughout the majority of the femur in seven cases, and the remaining four cases had skip lesions. Ten cases were in stage IIB and one case was in stage III with lung metastasis according to the Enneking system. Results: After surgery, hip dislocation occurred in one patient, and one patient suffered from transient common peroneal nerve palsy. During follow-up, local recurrence was observed in one patient, two patients died from pulmonary metastasis, and two patients died from systemic multi-metastasis. No periprosthetic infections or aseptic loosening occurred. The mean Musculoskeletal Tumor Society score was 76% (range, 56-92%). Conclusion: TFR is a reliable and effective strategy for managing primary malignant femoral tumors.
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Systematic review and meta-analysis of bearing dislocation in lateral meniscal bearing unicompartmental knee replacement: Domed versus flat tibial surface
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AMP (Acute Meniscal Pathology)
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BACKGROUND: Bearing dislocation is a problem following mobile bearing Oxford lateral Unicompartmental Knee Replacement (UKR). Therefore, the design of the tibial component was changed from a flat tibial surface to a domed tibial surface with a biconcave bearing to increase bearing entrapment. This systematic review compared the dislocation and revision rates of the two designs.
METHODS: Two authors independently searched MEDLINE, EMBASE and ISI Web of Science, reference lists of retrieved articles, and the internet. Randomised, cohort, case-control and case studies of adult patients with lateral knee osteoarthritis treated with flat or domed Oxford lateral UKR and their outcomes were included. The overall dislocation rate and the annual revision rate (per 100 component years) were determined.
RESULTS: Nine studies (937 knees) met the inclusion criteria (3 flat, 6 domed). Four studies (all domed) had a low risk of bias and five had a high risk (3 flat, 2 domed), so data should be interpreted with caution. The bearing dislocation rate decreased from 17% (flat) to 3.7% (domed). Dislocations occurred on average at 16 months and medial dislocations were most common. The revision rate excluding dislocation decreased from 1.1%pa to 0.7%pa. PROSPERO registration: CRD42019139250.
CONCLUSION: Modifying the tibial component from a flat to a domed shape decreased the bearing dislocation rate to 3.7% and increased the 10 year survival rate excluding dislocation to 93%. The dislocation rate is still relatively high so bearing stability should be assessed intra-operatively and if unacceptable, a fixed bearing version of the Oxford lateral tibial component can be inserted.
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The prevention and treatment of osteoporosis: A review CME
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HipFx Supplemental Cost Analysis
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Osteoporosis is a disorder characterized by reduced bone strength, diminished bone density, and altered macrogeometry and microscopic architecture. Adult bone mass is the integral measurement of the bone mass level achieved at the peak minus the rate and duration of subsequent bone loss. There is clearly a genetic predisposition to attained peak bone mass, which occurs by a person's mid-20s. Bone loss with age and menopause are universal, but rates vary among individuals. Both peak bone mass and subsequent bone loss can be modified by environmental factors, such as nutrition, physical activity, and concomitant diseases and medications. Osteoporosis prevention requires adequate calcium and vitamin D intake, regular physical activity, and avoiding smoking and excessive alcohol ingestion. Risk of fracture determines whether medication is also warranted. A previous vertebral or hip fracture is the most important predictor of fracture risk. Bone density is the best predictor of fracture risk for those without prior adult fractures. Age, weight, certain medications, and family history also help establish a person's risk for osteoporotic fractures. All women should have a bone density test by the age of 65 or younger (at the time of menopause) if risk factors are present. Guidelines for men are currently in development. Medications include both antiresorptive and anabolic types. Antiresorptive medications - estrogens, selective estrogen receptor modulators (raloxifene), bisphosphonates (alendronate, risedronate, and ibandronate) and calcitonins - work by reducing rates of bone remodeling. Teriparatide (parathyroid hormone) is the only anabolic agent currently approved for osteoporosis in the United States. It stimulates new bone formation, repairing architectural defects and improving bone density. All persons who have had osteoporotic vertebral or hip fractures and those with a bone mineral density diagnostic of osteoporosis should receive treatment. In those with a bone mineral density above the osteoporosis range, treatment may be indicated depending on the number and severity of other risk factors. (copyright) 2005 Medscape
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Epidural morphine injection after combined spinal and epidural anaesthesia
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Surgical Management of Osteoarthritis of the Knee CPG
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BACKGROUND AND OBJECTIVE: Although combined spinal and epidural anaesthesia is efficient and easy to perform, the technique can be a double-edged sword having the potential risk that an increased flux of drugs across the meninges through the hole made in it may lead to severe adverse effects. The aim was to compare the incidence of adverse events when an epidural injection of morphine was given after combined spinal and epidural anaesthesia or after epidural anaesthesia. METHODS: Fifteen patients had an epidural catheter inserted at the L2-3 interspace, and then a spinal block administered via the L3-4 interspace. Another 15 patients only had an epidural catheter inserted. After the onset of spinal or epidural anaesthesia had been confirmed, morphine 2 mg was injected into the epidural space, and a continuous epidural infusion of morphine was started. At the end of the operation and at 4, 8 and 12 h after the administration of epidural morphine and on the next day, the following variables were examined: blood pressure, heart rate, respiratory rate, arterial blood-gas analysis, visual analogue scale pain scores, nausea/vomiting scores, and pruritus scores. RESULTS: In the study population, the epidural injection of morphine was not associated with a significantly higher incidence of adverse events when given after spinal anaesthesia than after epidural anaesthesia. CONCLUSIONS: The adverse effects associated with epidural morphine given after spinal anaesthesia did not increase significantly when a 27-G Whitacre needle was used. Thus, the morphine flux through the meningeal hole into the cerebrospinal fluid was trivial
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1 |
Risk factors for revision after shoulder arthroplasty: 1,825 shoulder arthroplasties from the Norwegian Arthroplasty Register
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Glenohumeral Joint OA
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BACKGROUND AND PURPOSE: Previous studies on shoulder arthroplasty have usually described small patient populations, and few articles have addressed the survival of shoulder implants. We describe the results of shoulder replacement in the Norwegian population (of 4.7 million) during a 12-year period. Trends in the use of shoulder arthroplasty during the study period were also investigated.
PATIENTS AND METHODS: 1,531 hemiprostheses (HPs), 69 total shoulder replacements (Neer type TSR), and 225 reversed total shoulder replacement (reversed TSR) operations were reported to the Norwegian Arthroplasty Register between 1994 and 2005. Kaplan-Meier failure curves were drawn up for particular subgroups of patients, and revision rates were calculated using Cox regression analysis.
RESULTS: The 5- and 10-year failure rates of hemiprostheses were 6% (95% CI: 5-7) and 8% (95% CI: 6-10), and for reversed total shoulder replacements they were 10% (95% CI: 5-15) and 22% (95% CI: 10-33), respectively. For hemiprostheses, the risk of revision for patients who were 70 years or older was half that of those who were younger (RR = 0.47, CI: 0.28-0.77), while the risk of revision was highest for patients with sequelae after fracture compared to those with acute fractures (RR = 3.3, CI: 1.5-7.2). No differences in prosthesis survival were found between the different hemiprosthesis brands. The main reasons for revision of hemiprostheses were pain and luxation. For reversed total prostheses, the risk of revision was less for women than for men (RR = 0.26, CI: 0.11-0.63), and the main cause of revision was aseptic loosening of the glenoid component. During the study period, the incidence of shoulder arthroplasty increased for all diagnostic groups except inflammatory arthritis, for which a decrease was seen.
INTERPRETATION: We found good results in terms of 5-year prosthesis failure rate, with the use of hemiarthroplasty for patients with inflammatory arthritis, osteoarthritis, and acute fractures. Reversed total shoulder replacement was associated with a rather poor prognosis.
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Palliative Management of Nonoperative Femoral Neck Fractures With Continuous Peripheral Indwelling Catheters: Case-Control Series
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Hip Fx in the Elderly 2019
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Introduction: This case-control study evaluates the success of indwelling pain catheters in nonoperatively treated femoral neck fractures (FNFs) for end-of-life pain management.
Methods: Patients older than 65 years with nonoperatively treated FNFs were retrospectively identified at a level 1 trauma center between March 2012 and September 2015. Twenty-three received indwelling continuous peripheral pain catheters (experimental) and 10 received traditional pain control modalities (control). Pain scores 24 hours before/after pain management interventions, ambulation status at admission and discharge, mortality at 30 days/1 year, and length of hospital stay (LOS) were compared between treatment groups.
Results: The experimental and control groups were similar with respect to demographics, differing only in pre-fracture ambulatory status (P = .03). The 30-day mortality was 52% versus 50% (odds ratio, OR: 1.1 [95% confidence interval, CI: 0.25-4.82], P = .99) and 1-year mortality was 87% versus 80% (OR: 1.67 [95% CI: 0.23-11.9], P = .63) for experimental and control groups, respectively. The LOS did not statistically significantly differ for experimental and control groups (5.3 +/- 3.56 days vs 3.8 +/- 1.81 days, P = .15), respectively. The experimental group experienced twice the improvement in ambulation status (1.0 +/- 0.56 vs 0.5 +/- 0.71, P = 0.03) and greater improvement in pain scores (4.5 +/- 2.19 vs 1.2 +/- 2.72, P = .002).
Discussion: Operative management of FNFs may not be indicated in patients with advanced age and comorbidities. Regardless, these patients require pain palliation and early mobilization while minimizing hospital LOS and opiate consumption.
Conclusion: This case-control study demonstrates significant improvement in both pain level and ambulatory status for patients treated with indwelling continuous peripheral catheters. Future studies should further evaluate with a larger sample size; however, this study provides an excellent launching point for palliative management of this complex population.
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1 |
Comparative analysis of the surgical treatment results for multiple myeloma bone disease of the spine and the long bone/soft tissue
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MSTS 2018 - Femur Mets and MM
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The present retrospective study was designed to compare the pain relief, surgery duration, life quality, survival time and relative prognostic factors in multiple myeloma (MM) bone disease patients with different surgical sites. A total of 65 cases were enrolled and divided into two groups. Group A included patients with lesions located in the spine, while Group B included patients with lesions located in the long bone or soft tissue. Pain relief was measured by the visual analogue scale (VAS), neurological impairment was determined according to Frankel classification, and survival was assessed by the Kaplan-Meier method. Cox regression analysis was also used to estimate the effect of factors on the prediction of survival. The hospitalization time, preoperative duration of symptoms, method of surgery, complications, recurrence and survival time were evaluated and compared retrospectively. Pain relief and improvement of life quality were observed in all the patients in groups A and B. No significant differences were detected for the majority of parameters compared between groups A and B, with the exception of the surgery duration, as well as the postoperative VAS score at 1 and 6 months after surgery. The multivariate Cox regression analysis revealed several risk factors significantly associated with survival, including the preoperative VAS score, postoperative chemotherapy, prothrombin time activity (PTA), albumin, lactate dehydrogenase and urine protein level. In conclusion, surgical treatment was an effective therapeutic method in patients with MM. Postoperative analgesic use should be individualized according to the different surgical sites and postoperative periods. Furthermore, preoperative pain, PTA, albumin, urine protein level and postoperative chemotherapy are associated with prognosis.
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0 |
MRI of fractures of the distal radius: comparison with conventional radiographs
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Distal Radius Fractures
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OBJECTIVE: To compare the evaluation of fractures of the distal radius with MRI and conventional radiographs. To demonstrate the ability of MRI to detect unsuspected soft tissue derangement accompanying this common injury.
DESIGN AND PATIENTS: Twenty-one consecutive inpatients admitted following fracture of the distal radius underwent preoperative evaluation with both conventional radiographs and MRI. In each case, analysis was made of both the osseous and soft tissue injury. MRI findings were compared with those identified on conventional radiographs and at subsequent surgical fixation.
RESULTS: Of 21 patients with fractures of the distal radius, 20 had extension to the radiocarpal articulation, 14 had distal radio-ulnar joint extension and 5 had avulsion of the ulnar styloid. Occult carpal bone fractures accompanying fracture of the distal radius were identified in two patients: one of the capitate and the other of the second metacarpal base. Ten patients (48%) had associated soft tissue injury: six patients had scapholunate ligament rupture, two patients had disruption of the triangular fibrocartilage, one patient had extensor carpi ulnaris tenosynovitis and one patient had a tear of a dorsal radiocarpal ligament. Of five patients with ulnar styloid avulsions, none had evidence of triangular fibrocartilage tears.
CONCLUSION: MRI affords better evaluation of osseous injury accompanying distal radial fractures than conventional radiographs. Intra-articular soft tissue injury accompanies distal radial fractures in almost 50% of cases. Scapholunate ligament disruption commonly accompanies intraarticular fracture through the lunate facet of the distal radius. Fracture of the ulnar styloid is infrequently associated with tear of the triangular fibrocartilage.
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0 |
Androgen deprivation therapy: Evidence-based management of side effects
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MSTS 2022 - Metastatic Disease of the Humerus
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What's known on the subject? and What does the study add? The benefits of androgen deprivation therapy (ADT) are well recognized and a multitude of studies have documented the benefits of ADT in conjunction with other therapies. Given the widespread use of ADT due to its important clinical implications, it is imperative that clinicians understand the side effects to limit treatment-related morbidity. There are numerous well recognized adverse effects of ADT, including vasomotor flushing, loss of libido and impotence, fatigue, gynaecomastia, anaemia, osteoporosis and metabolic complications, as well as effects on cardiovascular health and bone density. Present study focuses on the most recent evidence-based treatment options for various side effects of ADT. Objective To familiarize clinicians with the various side effects of androgen deprivation therapy (ADT). The present study focuses on the most recent evidence-based treatment strategies for the common side effects of ADT. Methods A PubMed database search was conducted from 2000 to 2012. All prospective clinical studies were selected, including randomized and non-randomized clinical trials, as well as meta-analysis studies concerning preventive and therapeutic interventions for various side effects of ADT. 'The Oxford 2011 Levels of Evidence' classification system for treatment benefits was used to categorize selected studies. Results Gabapentin shows moderate efficacy for the long-term treatment of hot flashes in a dose-dependent manner. A combined resistance/aerobic exercise programme leads to significant improvement in fatigue, sexual function and cognitive function. A home-based/group exercise programme also improves fatigue and unfavourable metabolic changes. Denosumab increases lumbar spine, hip and radius bone mass density, and also reduces the risk of vertebral fractures in men receiving ADT for non-metastatic prostate cancer. Metformin coupled with lifestyle intervention is a safe, well-tolerated intervention for adverse metabolic changes. Toremifene improves the lipid profile. Intermittent ADT improves early side effects, such as hot flashes, sexual activity, fatigue, and quality of life, although its effect on long-term side effects remains inconclusive. Conclusion Despite significant improvement in management strategies for the side effects of ADT, the best way of preventing side effects is to use ADT only when it is absolutely indicated. © 2013 BJU International.
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Periprosthetic fractures of the femur after hip and knee replacement
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Management of Hip Fractures in the Elderly
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Objective: To present the clinical and radiological results of treatment of periprosthetic fractures of the femur after hip and knee replacements. Subjects and Methods: Thirty-four patients (8 males and 26 females) with 34 fractures of the femur complicating hip and knee replacements are the subjects of this report. In 21 cases, the fracture affected the femur after hip replacement, and in 13 cases after knee replacement. Fractures around the hip replacement were classified according to Vancouver classification, and those around the knee replacement were classified according to Rorabeck. Location of fracture was defined as metaphyseal or diaphyseal. Arbitrary classification of fracture union was used. Fractures were considered to be either united or to have delayed union, after radiology. Conservative treatment and different methods of fixation were used. Clinical correlations between location of fracture and outcome were analyzed. Results: All 21 metaphyseal fractures after hip and knee replacements united. Eight diaphyseal fractures (6 after hip replacement and 2 after knee replacement) united. Five diaphyseal fractures after hip replacement had delayed union, and 4 fractures united after bone graft. In 1 case, fracture did not unite, the treatment was discontinued and the patient was lost to follow-up. Conclusion: Our data show that metaphyseal fractures, regardless of type of implant, had better healing potential and did not require additional surgery. Diaphyseal fractures of the femoral shaft around the stem of femoral component of the hip or knee prosthesis required a bone graft and had less favorable outcomes. Women were more frequently affected by periprosthetic femoral fractures. Copyright (copyright) 2009 S. Karger AG, Basel
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Do large pragmatic randomised trials change clinical practice?: Assesing the impact of the Distal Radius Acute Fracture Fixation Trial (DRAFFT)
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Distal Radius Fractures
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Aims: Our aim, using English Hospital Episode Statistics data before during and after the Distal Radius Acute Fracture Fixation Trial (DRAFFT), was to assess whether the results of the trial affected clinical practice. Patients and Methods: Data were grouped into six month intervals from July 2005 to December 2014. All patient episodes in the National Health Service involving emergency surgery for an isolated distal radial fracture were included. Results: Clinical practice in England had not changed in the five years before DRAFFT: 75% of patients were treated with plate fixation versus 12% with Kirschner (K)-wires. After the publication of the trial, the proportion of patients having K-wire fixation rose to 42% with a concurrent fall in the proportion having fixation with a plate to 48%. The proportion of 'other' procedures stayed the same. Take home message. It appears that surgeons in the United Kingdom do change their practice in response to large, pragmatic, multicentre clinical trials in musculoskeletal trauma.
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Chromosome 1q21 gains confer inferior outcomes in multiple myeloma treated with bortezomib but copy number variation and percentage of plasma cells involved have no additional prognostic value
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MSTS 2018 - Femur Mets and MM
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Chromosome 1q21 aberrations have not been yet been made part of routine clinical tests and their effect in multiple myeloma is still under investigation. The prognostic value of copy number variation and percentage of plasma cells involved have remained unclear. In the present study, we analyzed the prognostic value of 1q21 in a series of 290 cases of newly diagnosed multiple myeloma treated in a prospective, non-randomized clinical trial (BDH 2008/02). We found that incidence of 1q21 aberration increased at relapse, but its copy numbers and proportion of cells involved did not change. Gains of 1q21 had no impact on survival in patients receiving thalidomide-based treatment but conferred a significantly inferior prognosis in patients under bortezomib-based chemotherapy and was an independent adverse prognostic factor for progression free survival (HR 3.831; 95%CI: 2.125-6.907; P<0.001) and overall survival (HR 3.245; 95%CI: 1.555-6.773; P=0.002). Strikingly, our results showed that the copy number variation and clone size harboring 1q21 gains carried no additional prognostic value and patients with 1q21 gains did not benefit significantly from regimens incorporating bortezomib. Our results indicate that three copies of 1q21 and 20% of plasma cells with this abnormality were enough to confer bortezomib resistance. Therefore, chromosome 1q21 gains should be considered a high-risk feature in multiple myeloma receiving bortezomib therapy. © 2013 Ferrata Storti Foundation.
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Treatment of melanoma metastases in a limb by isolated limb perfusion and isolated limb infusion
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DOD - Acute Comp Syndrome CPG
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In-transit melanoma metastases are often confined to a limb. In this circumstance, treatment by isolated limb perfusion or isolated limb infusion can be a remarkably effective regional treatment option. Copyright © 2011 Wiley-Liss, Inc.
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Evaluation of Herbert screw fixation for the treatment of displaced scaphoid nonunions
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Distal Radius Fractures
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Ten cases of unstable scaphoid nonunions treated with Herbert screw fixation were compared to nine cases treated with Herbert screw fixation supplemented with a single Kirschner wire (K-wire) across the fracture site. Corticocancellous bone graft from the distal radius was used in all cases to reconstruct the scaphoid. The age of the patients and duration of the nonunions were similar in both groups. Postoperative radiographs demonstrated that only 5 of 10 patients with Herbert screw fixation alone healed, while 8 of 9 patients with Herbert screw and K-wire fixation healed. The time to union averaged 4.9 months in the patients supplemented with a K-wire and 7.8 months in those patients without the K-wire.
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1 |
Treatment of massive rotator-cuff tears with a polyester ligament (Dacron) augmentation: clinical outcome
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Optimizing the Management of Full-Thickness Rotator Cuff Tears
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We describe the clinical outcome of a technique of surgical augmentation of chronic massive tears of the rotator cuff using a polyester ligament (Dacron) in 21 symptomatic patients (14 men, seven women) with a mean age of 66.5 years (55.0 to 85.0). All patients had MRI and arthroscopic evidence of chronic massive tears. The clinical outcome was assessed using the Constant and Murley and patient satisfaction scores at a mean follow-up of 36 months (30 to 46). The polyester ligament (500 mm x 10 mm) was passed into the joint via the portal of Neviaser, medial to the tear through healthy cuff. The two ends of the ligament holding the cuff were passed through tunnels made in the proximal humerus at the footprint of the insertion of the cuff. The ligament was tied with a triple knot over the humeral cortex. All the patients remained free from pain (p < 0.001) with improvement in function (p < 0.001) and range of movement (p < 0.001). The mean pre-operative and post-operative Constant scores were 46.7 (39.0 to 61.0) and 85.4 (52.0 to 96.0), respectively (p < 0.001). The mean patient satisfaction score was 90%. There were two failures, one due to a ruptured ligament after one year and the other due to deep-seated infection. The MR scan at the final follow-up confirmed intact and thickened bands in 15 of 17 patients. This technique of augmentation gives consistent relief from pain with improved shoulder movement in patients with symptomatic massive tears of the rotator cuff
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1 |
Periarticular injections with continuous perfusion of local anaesthetics provide better pain relief and better function compared to femoral and sciatic blocks after TKA: a randomized clinical trial
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AAHKS (8) Anesthetic Infiltration
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PURPOSE: Combined femoral and sciatic nerve blocks for post-operative pain management following total knee arthroplasty (TKA) improve patient satisfaction, decrease narcotic consumption and improve pain. However, accompanying motoric weakness can cause falls and related complications. We wonder whether peri-capsular injections in combination with intra-articular perfusion of local anaesthetics would result in equal or less pain without the related complications of nerve blocks. The objective of the study was to verify these aspects in a prospective randomized trial comparing both treatments.
METHODS: Fifty TKA patients randomly received either a femoral (continuous) and a sciatic (single-shot) nerve block (CFNB group, 25 knees) or periarticular infiltrations and a continuous post-operative intra-articular infusion (PIAC group, 25 knees). VAS for pain, pain medication consumption, functional assessment, straight leg raising as well as KSS were recorded post-operatively for 6 days.
RESULTS: VAS (p < 0.001) and KSS (p = 0.05) were significantly better for PIAC. There was increased pain following CFNB compared to PIAC. Catheters stayed for 4 days, a pain 'rebound' occurred after removing in CFNB but not after PIAC. There was no difference in regard to knee function (n.s.), but straight leg raising was significant better following PIAC. There were two falls in patients with CFNB.
CONCLUSION: Peri-capsular injections combined with an intra-articular catheter provide better pain control, no rebound pain with better function and might decrease the risk of complications related to motor weakness.
Level of evidence: I.
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Arthroplasty patients with diabetes mellitus have higher bone pentosidine levels and greater immunohistochemical rage and mmp-1 than patients without diabetes
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Surgical Management of Osteoarthritis of the Knee CPG
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We previously identified a higher rate of total joint replacement surgeries (arthroplasty) in patients diagnosed with diabetes mellitus compared to patients without diabetes mellitus in a Veterans Affairs database.1 The purpose of the present study was to identify an effect, if any, of diabetes on joint tissue metabolism. With IRB-approval, cartilage and bone tissues were obtained as surgical wastes from total knee arthroplasty surgeries of osteoarthritis patients diagnosed with diabetes (N=10) or not diagnosed with diabetes (N=10). Osteochondral cores (5 mm dia.) were taken from the tibia plateau and either separated to cartilage and bone samples for collagen analysis or fixed whole for histology. Levels of collagen cross-links (HP, LP, and pentosidine) and total collagen were measured using HPLC. Osteochondral thinsections were probed with monoclonal antibodies for RAGE or MMP-1. Overall, cartilage had higher pentosidine levels than bone in both groups (P < 0.001). Bone pentosidine levels were higher in the group with diabetes compared to the group without diabetes (9.153 x 10(-3) mol pentosidine/mol collagen vs. 6.945 x 10(-3), P < 0.05). Cartilage pentosidine levels were higher, but not statistically significant, in the diabetes group (2.624 x 10(-2) mol pentosidine/mol collagen vs. 2.167 x 10(-2), P = 0.075). There were no differences between groups in the levels of HP or LP in bone or cartilage (P > 0.05). Immunostaining for RAGE was greater in the thin-sections obtained from the diabetes group. Immunostaining for MMP-1 was also greater in the diabetes group. Furthermore, the cells positive for RAGE and MMP-1 were located in the same regions, the cartilage superficial and mid zones and at the bone-cartilage interface. These results support the hypothesis that hyperglycemia leads to increased pentosidine and other advanced glycation end-products in diabetes mellitus patients and that AGE-RAGE signaling causes inflammatory events such as increased MMP activity.2 We propose that this hypothesis is applicable to the joint tissues and may be a factor (along with others such as BMI) in the increased rates of arthroplasty surgeries
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Reverse total shoulder arthroplasty: a review of results according to etiology
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Glenohumeral Joint OA
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BACKGROUND: Reverse total shoulder arthroplasty provides a surgical alternative to standard total shoulder arthroplasty for the treatment of selected complex shoulder problems. The purpose of the present study was to evaluate the effects of etiology on the results of reverse total shoulder arthroplasty.
METHODS: Between May 1995 and June 2003, 240 consecutive reverse total shoulder arthroplasties were performed in 232 patients with an average age of 72.7 years. Patients were grouped according to etiology, and the clinical and radiographic outcomes for each group were measured and compared.
RESULTS: One hundred and eighty-six patients with 191 retained reverse total shoulder arthroplasty prostheses were followed for an average of 39.9 months. Overall, the average Constant score improved from 23 points before surgery to 60 points at the time of follow-up and 173 of the 186 patients were satisfied or very satisfied with the result. Although substantial clinical and functional improvement was observed in all etiology groups, patients with primary rotator cuff tear arthropathy, primary osteoarthritis with a rotator cuff tear, and a massive rotator cuff tear had better outcomes, on average, than patients who had posttraumatic arthritis and those managed with revision arthroplasty. Dislocation (fifteen cases) and infection (eight cases) were the most common complications among the 199 shoulders that were followed for two years or were revised prior to the minimum two-year follow-up. Patients who received the reverse prosthesis at the time of a revision arthroplasty had a higher complication rate than did those who received the reverse prosthesis at the time of a primary arthroplasty.
CONCLUSIONS: The reverse total shoulder arthroplasty prosthesis can produce good results when used for the treatment of a number of other complex shoulder problems in addition to cuff tear arthropathy. Patients with posttraumatic arthritis and those undergoing revision arthroplasty may have less improvement and higher complication rates in comparison with patients with other etiologies. The advanced age of the patients in the present series and the relatively short duration of follow-up suggest that the prosthesis should continue to be used judiciously.
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Single-stage Abdominoplasty Using Groin Flaps Without Osteotomies: Management of Exstrophy-epispadias Complex
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Panniculectomy & Abdominoplasty CPG
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BACKGROUND AND OBJECTIVE: The optimal treatment for children born with exstrophy-epispadia complex is still a matter of debate.(1,2)(,)(3) We demonstrate the Single-Stage Abdominoplasty using Groin Flap technique to close the abdominal wall of children with classic bladder exstrophy (CBE) without osteotomy neither radical soft tissue mobilization. Advantages over current techniques are less risk of penile tissue loss and avoidance of osteotomies. MATERIAL AND METHODS: Abdominal wall repair consists in using the hypogastric skin, rectus, and obliquus externus abdominalis muscle fascial flaps. These groin flaps are rotated medially resulting in a very strong abdominal wall support. Groin flaps are made of rectus anterior fascia rotated medially, flipped over, and sutured with Prolene sutures to close the defect. By rotating the fascial flaps medially, complete reinforcement of the abdominal wall to the level of the pubic bone is achieved. This permits abdominal closure maintenance without tension. RESULTS: Groin flap was applied to 128 patients with CBE referenced from all over the country. Most of these patients returned to their home areas making difficult their follow up. However, we have 44 cases that have regular clinical visits. Mean follow-up was 10.3 +/- 4.5 years (2 years 8 months-16 years). Successful closure was achieved in 43 patients (97.7%) as a single procedure; one patient had a complete wound dehiscence and needed another reconstruction (2.2%). Four patients (9.1%) presented abdominal hernias that needed surgical management. When continence is evaluated, we present similar literature rates (60%).(4) CONCLUSION: Abdominal reconstruction using Groin flaps has advantages over the traditional approaches to CBE. It reduces the surgical steps and facilitates the closure of the abdominal wall without the need of osteotomies and consequent immobilization during the postoperative period. It is feasible at any age and can be also very useful as a salvage technique even after previous failed procedures. Finally, it minimizes the number of surgeries.
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Successful prevention of bacterial endophthalmitis in eyes with the Boston keratoprosthesis
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Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures
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PURPOSE: To determine the influence of topical vancomycin prophylaxis on the incidence of bacterial endophthalmitis in eyes with a Boston Keratoprosthesis (KPro). METHODS: A retrospective chart review was performed for 255 eyes of 231 patients who received a KPro between March 1990 and December 2006. Preoperative diagnoses were burn, ocular cicatricial pemphigoid (OCP), Stevens-Johnson Syndrome (SJS), and graft failure/other. Patients used topical antibiotic prophylaxis for the duration of the KPro: polymyxin-trimethoprim or a quinolone in the 1990s, or a quinolone with or without vancomycin beginning in late 1999. For each KPro eye, the follow-up interval was divided into months on or off vancomycin (vancomycin versus no-vancomycin group). The incidence of endophthalmitis was calculated with Kaplan-Meier survival curves. RESULTS: The 255 eyes were followed for 673.6 patient-years (mean, 2.64 years; range, 1 week to 13 years). There were 18 cases of bacterial endophthalmitis; 17 occurred at least 6 weeks postoperatively (range, 1.5 to 46 months). Gram-positive cocci caused over 80% of cases. Only 1 case, due to an atypical mycobacterium, occurred in a patient using vancomycin.The incidence of bacterial endophthalmitis was lower in the vancomycin group than in the no-vancomycin group: 0.35% versus 4.13% per patient-year (P = 0.001). It was also lower in SJS eyes using vancomycin versus no vancomycin: 1.76% versus 18.39% per patient-year (P = 0.009). In eyes with preoperative diagnoses of burn, OCP, or graft failure/other, the incidence in the vancomycin group was zero. CONCLUSION: Topical vancomycin plus a quinolone is effective in preventing bacterial endophthalmitis in KPro eyes
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Relationship between undercarboxylated osteocalcin and osteoprotegerin in knee osteoarthritis
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OAK 3 - Non-arthroplasty tx of OAK
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Objective: The purpose of the present study was to evaluate the possible association between the serum levels of undercarboxylated osteocalcin (ucOC) and osteoprotegerin (OPG) in patients with knee osteoarthritis (OA). Methods: Twenty patients (10 men and 10 women) diagnosed to have knee OA, and twenty healthy subjects of matching age, sex, and BMI as a control group, were enrolled in this study. Serum levels of ucOC and OPG, were assayed using the corresponding human ELISA kits. Results: Patients with knee OA, showed a statistically significant elevation in serum levels of ucOC (P<0.001), and a statistically significant reduction in that of OPG (P<0.0001), as compared to the control group. Also, there is significant negative correlation (r=-0.554, p= 0.0113) between the serum levels of ucOC and OPG in knee OA patients. Conclusion: there is possible association between the serum levels of ucOC and OPG in patients with knee OA.
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0 |
High-risk surgically resected pediatric melanoma and adjuvant interferon therapy
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Reconstruction After Skin Cancer
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Background. Pediatric patients with high-risk surgically resected melanoma are at risk for relapse, yet little is known about these young patients and how they tolerate high-dose interferon therapy. Procedure. We reviewed medical records of patients (�18 years) with high-risk melanoma referred to the University of Michigan Pediatric Hematology-Oncology service between January 1989 and July 2003. Results. Fourteen patients were identified with high-risk resected melanoma. The median age at diagnosis was 8.5 years. The median time to establish diagnosis was 9 months. Primary lesions were diagnosed as unequivocal melanoma, atypical epithelioid melanocytic proliferations, or atypical Spitz tumor with indeterminate malignant potential. Twelve patients had a positive sentinel lymph node (SLN) biopsy or a palpable regional lymph node and underwent regional lymph node dissection (LND). Two patients with unequivocal melanoma with Breslow depth >4 mm had negative SLN biopsies. Twelve patients received adjuvant high-dose interferon. The following toxicities were observed: constitutional symptoms, gastrointestinal symptoms, depression or neuropsychiatric symptoms, myelosuppression, elevated AST or ALT, hypothyroidism, and hypertension. Grade 3 or 4 toxicities were uncommon with exception of neutropenia, resulting in modification of therapy in one patient. All patients are alive and free of disease at follow-up (median 24.5 months). Conclusions. Invasive melanoma can occur in very young children. Despite early signs of malignancy, there is often a delay in diagnosis. Histologically, diagnosis may be difficult because of overlap with Spitz nevi. Pediatric patients tolerated adjuvant high-dose interferon well and may be less likely than adults to require therapy modification secondary to toxicities. © 2004 Wiley-Liss, Inc.
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Real-life experience with the specific reversal agent idarucizumab for the management of emergency situations in dabigatran-treated patients: a series of 11 cases
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Hip Fx in the Elderly 2019
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Non-vitamin K antagonist oral anticoagulants (NOACs) have a favorable benefit-risk profile compared with vitamin K antagonists. However, the lack of specific reversal agents has made the management of some patients receiving long-term treatment with NOACs problematic in emergency situations such as major bleeding events or urgent procedures. Idarucizumab, a fully humanized Fab antibody fragment that binds specifically and with high affinity to dabigatran, was recently approved for use in adult patients treated with dabigatran when rapid reversal of its anticoagulant effect is required. Clinical experience with idarucizumab is currently limited. We report 11 real-life clinical cases in which idarucizumab was used after multidisciplinary consultation in a variety of emergency situations including severe postoperative bleeding, emergency high-bleeding-risk surgery (hip/spine surgery and neurosurgery), invasive diagnostic testing (lumbar puncture), intracranial bleeding (pre-pontine subarachnoid hemorrhage and lobar intracerebral hemorrhage) and thrombolysis with recombinant tissue plasminogen activator for acute ischemic stroke. This case series illustrates the role of idarucizumab in improving patient safety in rare emergency situations requiring rapid reversal of the anticoagulant effect of dabigatran, while highlighting the importance of information and education about the availability and appropriate use of this recently approved specific reversal agent.
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1 |
Medial neck femoral fractures: algorithm of treatment and the use of f.g.L. TM memory shape stem
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Hip Fx in the Elderly 2019
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BACKGROUND AND AIM OF THE WORK: We treat undisplaced or minimally displaced medial neck femoral fractures with screws in both young and elderly patients with good activity of daily living, without severe comorbidity. Total hip replacement is preferred in middle-advanced age, with good level of functional activity. Bipolar hemiarthroplasty is performed on patients who may require early mobilization to avoid deterioration due to existing comorbidities. Bipolar hemiarthroplasty with memory shape stem (F.G.L. TM) is our preferred mode of surgery for high risk patients (ASA classification). In fact, higher perioperative mortality from cardiopulmonary complications has been attributed to the use of cement during arthroplasty. This stem in its metaphyseal region has 10 tabs, made of a Nitinol TM alloy, that facilitate the restoration of the implant to its original enlarged shape at physiological temperature. This enables a strong fit in the metaphyseal region.
METHODS: We report the clinical and radiological results of 24 patients (mean follow-up: 14 months) who underwent surgical procedure of bipolar hemiarthroplasty with F.G.L. TM stem in our department between March 2008 and December 2009.
RESULTS: No perioperative complications were observed and the results were comparable to those of patients who underwent standard cemented bipolar hemiarthroplasty.
CONCLUSIONS: A significant advantage to the use of F.G.L. TM stem is that it allows immediate primary stability without using cement. A limiting consideration is the higher cost associated with the implant & procedure in comparison with standard cemented bipolar hemiarthroplasty. This implant may thus be most suitable for patients with pre-existing cardio-pulmonary complications for whom the use of cement is a major risk factor.
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0 |
Predictors of lower extremity arterial injury after total knee or total hip arthroplasty
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DoD LSA (Limb Salvage vs Amputation)
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OBJECTIVE: Lower extremity arterial injury is a rare complication following total knee (TKA) or total hip arthroplasty (THA). To date, no multi-institutional study has identified preoperative factors that may portend increased risk for these injuries. We queried a large clinical database for the incidence and predictors of arterial injury and/or compromise following lower extremity arthroplasty. METHODS: Prospectively collected preoperative and postoperative data by the National Surgical Quality Improvement Program (NSQIP) of the Veterans Affairs Medical Centers were analyzed. All patients from 1996 to 2003 in the NSQIP database who underwent TKA or THA were identified via CPT codes. NSQIP defined, 30-day, postoperative outcomes were analyzed. Data were compared using bivariable analysis, as well as limited multivariable logistic regression. RESULTS: A total of 41,633 arthroplasties (24,029 TKA, 2077 redo-TKA, 13,494 THA, 2033 redo-THA) were identified in the NSQIP database. A total of 34 (0.08%) lower extremity arterial injuries were recognized (0.08% TKA, 0.19% redo-TKA, 0.04% THA, 0.20% redo-THA). Eighteen injuries were repaired on the same day of surgery (seven intraop, 11 postop), eight between postoperative days 1 and 5, and 8 between days 6 and 30. Only two patients underwent lower extremity amputation (overall limb loss rate of 5.9% of patients who had arterial injury). Statistically significant predictors of lower extremity arterial injury identified on logistic regression analysis included redo procedure (odds ratio [OR] 2.7, 95% confidence interval [CI] 1.2-6.0, P = .013) and African American race (OR 2.5, 95% CI 1.2-5.3, P = .02). CONCLUSION: Lower extremity arterial injury was exceedingly rare after total knee or total hip arthroplasty. There is an increased incidence in African American patients and those undergoing redo arthroplasty. Among patients who sustain vascular injury, excellent limb salvage rates can be achieved with close postoperative surveillance to achieve early detection and repair of injuries.
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1 |
Health-economic evaluation of meniscus tear treatments: a systematic review
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AMP (Acute Meniscal Pathology)
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PURPOSE: To evaluate the overall evidence of published health-economic evaluation studies on meniscus tear treatment.
METHODS: Our systematic review focuses on health-economic evaluation studies of meniscus tear treatment interventions found in PubMed and Embase databases. A qualitative, descriptive approach was used to analyze the studies' results and systematically report them following PRISMA guidelines. The health-economic evaluation method for each included study was categorized following one of the four approaches: partial economic evaluation (PEE), cost-effectiveness analysis (CEA), cost-benefit analysis (CBA), or cost-utility analysis (CUA). The quality of each included study was assessed using the Consensus on Health Economic Criteria (CHEC) list. Comparisons of input variables and outcomes were made, if applicable.
RESULTS: Sixteen studies were included; of these, six studies performed PEE, seven studies CUA, two studies CEA, and one study combined CBA, CUA, and CEA. The following economic comparisons were analyzed and showed the respective comparative outcomes: (1) meniscus repair was more cost-effective than arthroscopic partial meniscectomy (meniscectomy) for reparable meniscus tear; (2) non-operative treatment or physical therapy was less costly than meniscectomy for degenerative meniscus tear; (3) physical therapy with delayed meniscectomy was more cost-effective than early meniscectomy for meniscus tear with knee osteoarthritis; (4) meniscectomy without physical therapy was less costly than meniscectomy with physical therapy; (5) meniscectomy was more cost-effective than either meniscus allograft transplantation or meniscus scaffold procedure; (6) the conventional arthroscopic instrument cost was lower than laser-assisted arthroscopy in meniscectomy procedures.
CONCLUSION: Results from this review suggest that meniscus repair is the most cost-effective intervention for reparable meniscus tears. Physical therapy followed by delayed meniscectomy is the most cost-effective intervention for degenerative meniscus tears. Meniscus scaffold should be avoided, especially when implemented on a large scale.
LEVEL OF EVIDENCE: Systematic review of level IV studies.
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0 |
Pseudoptosis Correction With the 270 degrees Pedicle Reduction Mammoplasty: An Anatomic and Clinical Study
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Reduction Mammoplasty for Female Breast Hypertrophy
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Background: Reduction mammoplasty techniques have evolved considerably. Today, aesthetically pleasing results and preservation of nipple sensation and vascularity are emphasized. Achieving the aforementioned goals for the patient with pseudoptosis remains challenging. Objective: We present 270 degrees pedicle reduction mammoplasty as a safe and direct technique for treatment of pseudoptosis to reduce size and improve breast shape. Methods: Circumareolar subcutaneous dissection of 10 breasts (5 cadavers) was performed to identify the nerves from the chest wall to the nipple. The trajectory of the nerves to the nipple was identified and dissected to their origin of penetration of the chest fascia. This information provides the basis for lateral chest wall tissue preservation for preserved nipple-areolar innervation, which is incorporated into this technique. Retrospective review of a single surgeon's experience with the 270 degrees pedicle technique for reduction mammoplasty over a 1-year period was performed. Results: Anatomic dissection identified 3 to 5 branches of the fourth intercostal nerve to primarily innervate the nipple on 8 of 10 breast dissections. Accessory innervation from the fifth intercostal nerve provided lateral branches to the nipple in 5 of 10 specimens. Five patients underwent reduction mammoplasty with the 270 degrees pedicle technique. No complications were identified. Excellent aesthetic outcomes were achieved on the basis of patient-reported satisfaction and the surgeon's judgment. All patients demonstrated normal nipple sensation at postoperative follow-up. Follow-up at 1 year did not demonstrate recurrence of ptosis/pseudoptosis or change in nipple position. Conclusions: The 270 degrees technique for pedicle reduction mammoplasty yields aesthetically pleasing results and symptomatic relief from macromastia and preserves nipple sensation.
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Use of orexigenic medications in geriatric patients
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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Background: The loss of appetite, anorexia, is commonly observed in older persons and associated with adverse outcomes. It is becoming increasingly apparent that anorexia is the chief factor in producing weight loss in older adults. Although common and expected in acute illness, anorexia is also frequently associated with chronic diseases and leads to inadequate nutrient intake. Objective: The aim of this paper was to review clinical studies on the use of orexigenic drugs to stimulate appetite. Methods: Clinical trials were identified related to improving appetite and/or weight gain in older persons. Articles were identified by Ovid search using terms nutrition, anorexia, cachexia, weight loss, orexigenic drugs, and by searching references from retrieved papers. Results: Environmental and nutritional interventions to improve intake should be the first intervention. When these fail to produce adequate intake, orexigenic drugs should be considered. No drug has received approval from the US Food and Drug Administration for geriatric anorexia. Conclusions: In the presence of adequate food, weight loss most often is due to cytokine-associated cachexia and anorexia. Assessment of changes in appetite is essential to evaluating older persons with weight loss. When anorexia is identified, a search for reversible causes should be instituted. Intervention should first be aimed at the provision of adequate calories and protein, often in the form of high-density nutritional supplements. Failure to respond to adequate nutrition or supplements should trigger a concern for cachexia. Orexigenic drugs have been reported to improve appetite and produce weight gain. The mechanism is unknown, but it may relate to suppression of proinflammatory cytokines. (copyright) 2011 Elsevier HS Journals, Inc. All rights reserved
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Effects of nerve growth factor (NGF) in rats with basal forebrain lesions
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DoD PRF (Psychosocial RF)
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Effects of nerve growth factor (NGF) on the basal forebrain (BF) lesion-induced amnesia in rats were investigated. When NGF infusion was begun immediately after the formation of BF lesions, NGF ameliorated amnesia in a water maze task and showed a tendency to increase choline acetyltransferase (CAT) activity in the fronto-parietal cortex. The amnesia and the decrease of CAT activity were not ameliorated when NGF infusion was begun 4 weeks after BF lesion formation. These observations suggest that NGF may act as a trophic and/or a protective factor on partially damaged cholinergic neurons and that the efficacy of NGF was influenced by the phase of neuronal damage.
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Complications of Total Hip Arthroplasty: Standardized List, Definitions, and Stratification Developed by The Hip Society
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PJI DX Updated Search
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BACKGROUND: Reporting of complications after total hip arthroplasty (THA) is not standardized, and it is done inconsistently across various studies on the topic. Advantages of standardizing complications include improved patient safety and outcomes and better reporting in comparative studies. QUESTIONS/PURPOSES: The purpose of this project was to develop a standardized list of complications and adverse events associated with THA, develop standardized definitions for each complication, and stratify the complications. A further purpose was to validate these standardized THA complications. METHODS: The Hip Society THA Complications Workgroup proposed a list of THA complications, definitions for each complication, and a stratification scheme for the complications. The stratification system was developed from a previously validated grading system for complications of hip preservation surgery. The proposed complications, definitions, and stratification were validated with an expert opinion survey of members of The Hip Society, a case study evaluation, and analysis of a large administrative hospital system database with a focus on readmissions. RESULTS: One hundred five clinical members (100%) of The Hip Society responded to the THA complications survey. Initially, 21 THA complications were proposed. The validation process reduced the 21 proposed complications to 19 THA complications with definitions and stratification that were endorsed by The Hip Society (bleeding, wound complication, thromboembolic disease, neural deficit, vascular injury, dislocation/instability, periprosthetic fracture, abductor muscle disruption, deep periprosthetic joint infection, heterotopic ossification, bearing surface wear, osteolysis, implant loosening, cup-liner dissociation, implant fracture, reoperation, revision, readmission, death). CONCLUSIONS: Acceptance and use of these standardized, stratified, and validated THA complications and adverse events could advance reporting of outcomes of THA and improve assessment of THA by clinical investigators. LEVEL OF EVIDENCE: Level V, therapeutic study
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Induced human gestational hypoprolactinemia: Lack of action on fetal adrenal androgen synthesis
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Reduction Mammoplasty for Female Breast Hypertrophy
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To investigate the possible role of PRL in the control of fetal adrenal function, blood samples were collected from maternal peripheral and cord blood from six women at delivery, who had received treatment with bromocriptine (3.75-35 mg daily) for the entire gestation. A group of eight untreated parturients served as control. Parameters measured were PRL and dehydroepiandrosterone, the latter as an indicator of fetal adrenal function. PRL was significantly suppressed (P < 0.002), whereas dehydroepiandrosterone was not influenced by bromocriptine treatment. The results indicate that the control of fetal production of androgenic substrate by the adrenal is not specifically PRL dependent.
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Nightshift work and fracture risk: the Nurses' Health Study
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Management of Hip Fractures in the Elderly
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SUMMAYR: Nightshift work suppresses melatonin production and has been associated with an increased risk of major diseases including hormonally related tumors. Experimental evidence suggests that light at night acts through endocrine disruption likely mediated by melatonin. To date, no observational study has addressed the effect of night work on osteoporotic fractures, another condition highly sensitive to sex steroid exposure. Our study, to our knowledge, the first to address this question, supports the hypothesis that nightshift work may negatively affect bone health, adding to the growing list of ailments that have been associated with shift work. INTRODUCTION: We evaluated the association between nightshift work and fractures at the hip and wrist in postmenopausal nurses. METHODS: The study population was drawn from Nurses' Health Study participants who were working full or part time in nursing in 1988 and had reported their total number of years of rotating nightshift work. Through 2000, 1,223 incident wrist and hip fractures involving low or moderate trauma were identified among 38,062 postmenopausal women. We calculated multivariate relative risks (RR) of fracture over varying lengths of follow-up in relation to years of nightshift work. RESULTS: Compared with women who never worked night shifts, 20+ years of nightshift work was associated with a significantly increased risk of wrist and hip fractures over 8 years of follow-up [RR = 1.37, 95% confidence interval (CI), 1.04-1.80]. This risk was strongest among women with a lower body mass index (<24) who never used hormone replacement therapy (RR = 2.36; 95% CI, 1.33-4.20). The elevated risk was no longer apparent with 12 years of follow-up after the baseline single assessment of nightshift work. CONCLUSIONS: Long durations of rotating nightshift work may contribute to risk of hip and wrist fractures, although the potential for unexplained confounding cannot be ruled out
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Single photon emission computed tomography in planning unicompartmental knee arthroplasty. A prospective study examining the association between scan findings and intraoperative assessment of osteoarthritis
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Surgical Management of Osteoarthritis of the Knee CPG
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The aim of this study was to determine the relationship between preoperative single photon emission computed tomography (SPECT) scan findings and intraoperative assessments of knee osteoarthritis (OA) in patients undergoing tibiofemoral unicompartmental knee arthroplasty (UKA). Fifty knees in 46 patients undergoing UKA were investigated preoperatively with a SPECT scan to confirm unicompartmental disease. There were 38 men and 12 women in the cohort with an average age of 63 years (range 44-78). The SPECT scan uptake in each compartment of the knee was graded by a single radiologist and these findings were compared with intraoperative assessments of OA (size and grade of lesion), made by two experienced surgeons, blinded to the scan findings. Significant association was demonstrated between scan findings and OA in all compartments of the knee (p<0.05), and this was strongest in the medial compartment and weakest in the patellofemoral compartment and lateral tibial plateau. We conclude that SPECT scan is a useful imaging modality in the planning of medial tibiofemoral UKA to confirm unicompartmental disease. The lower degree of association between scan findings and OA encountered in the patellofemoral compartments and lateral tibial plateau indicates that greater vigilance should be exercised in the intraoperative assessment of these areas
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0 |
Triclosan can select for an AdeIJK-overexpressing mutant of Acinetobacter baumannii ATCC 17978 that displays reduced susceptibility to multiple antibiotics
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Patrick’s pharmacoepidemiology project
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In order to determine if triclosan can select for mutants of Acinetobacter baumannii ATCC 17978 that display reduced susceptibilities to antibiotics, we isolated a triclosan-resistant mutant, A. baumannii AB042, by serial passaging of A. baumannii ATCC 17978 in growth medium supplemented with triclosan. The antimicrobial susceptibility of AB042 was analyzed by the 2-fold serial dilution method. Expression of five different resistance-nodulation-division (RND) pump-encoding genes (adeB, adeG, adeJ, A1S-2818, and A1S-3217), two outer membrane porin-encoding genes (carO and oprD), and the MATE family pump-encoding gene abeM was analyzed using quantitative reverse transcriptase (qRT) PCR. A. baumannii AB042 exhibited elevated resistance to multiple antibiotics, including piperacillin-tazobactam, doxycycline, moxifloxacin, ceftriaxone, cefepime, meropenem, doripenem, ertapenem, ciprofloxacin, aztreonam, tigecycline, and trimethoprim-sulfamethoxazole, in addition to triclosan. Genome sequencing of A. baumannii AB042 revealed a (116)Gââ? â??V mutation in fabI, the gene encoding the target enzyme for triclosan. Expression analysis of efflux pumps showed overexpression of the AdeIJK pump, and sequencing of adeN, the gene that encodes the repressor of the adeIJK operon, revealed a 73-bp deletion which would cause a premature termination of translation, resulting in an inactive truncated AdeN protein. This work shows that triclosan can select for mutants of A. baumannii that display reduced susceptibilities to multiple antibiotics from chemically distinct classes in addition to triclosan resistance. This multidrug resistance can be explained by the overexpression of the AdeIJK efflux pump
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1 |
Sex differences in carpal tunnel syndrome: comparison of surgical and non-surgical populations
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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Carpal tunnel syndrome (CTS) patients are known to show gender-related differences in severity. The main aim of this cross-sectional study was to determine whether these differences between women and men may be related to age, education or body mass index (BMI) in two populations, one with idiopathic CTS not treated surgically and the other with idiopathic CTS treated by surgical decompression. A secondary aim was to check differences in surgical results between the genders in the surgical population. The non-surgical population consisted of 172 subjects (126 women and 46 men, mean age 55.1 years) whose data were obtained at electrophysiological examination. The surgical population consisted of 219 patients (177 women and 42 men, mean age 55.1 years) whose data were obtained before surgery. Age, education, BMI, duration of symptoms, electrophysiological and clinical severity of CTS (with ordinal scales), and the self-administered Boston Questionnaire (BQ) of symptoms and functional status of hands were considered. There were no differences in age or clinical and electrophysiological severity between women and men in either group, except for distal motor latency of the median nerve that was more delayed and duration of symptoms that was shorter in men than women in non-surgical sample. Men had a higher BMI than women. Women had higher BQ scores in the surgical and non-surgical samples. These differences remained when the results were analysed matching the men with an identical number of women of the same age, education and BMI. In the surgical population, the results of surgical decompression did not modify the gender-related differences in severity. As in many other syndromes and diseases, for a given clinical severity, women with CTS were more sensitive than men in reporting their symptoms. Risk factors of CTS, such as age, education and BMI, were not responsible for these differences. The results of surgical decompression were similar in men and women
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0 |
Rehabilitation of the elbow in the throwing athlete
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The Treatment of Pediatric Supracondylar Humerus Fractures AUC
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Rehabilitation following an injury to the elbow joint complex is common in physical therapy practice. The unique anatomical considerations of the elbow joint provide a significant challenge to the therapist in rehabilitating elbow injuries. The purpose of this paper is to describe the rehabilitation process for various elbow pathologies and provide a rationale for their treatment. The rehabilitation process for the injured elbow presented in this paper will emphasize phases that are progressive, sequential, and based on clinical and scientific research
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0 |
Sesamin inhibits IL-1beta-stimulated inflammatory response in human osteoarthritis chondrocytes by activating Nrf2 signaling pathway
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OAK 3 - Non-arthroplasty tx of OAK
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Sesamin, a bioactive component extracted from sesame, has been reported to exert anti-inflammatory and anti-oxidant effects. In this study, we evaluated the anti-inflammatory effects of sesamin on IL-1beta-stimulated human osteoarthritis chondrocytes and investigated the possible mechanism.
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0 |
The American Society for Aesthetic Plastic Surgery (ASAPS) survey: current trends in liposuction
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Panniculectomy & Abdominoplasty CPG
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BACKGROUND: The emergence of new technologies necessitates a study of current trends in liposuction and other methods for fat removal. OBJECTIVE: The American Society for Aesthetic Plastic Surgery (ASAPS) conducted a survey of its members to gain valuable information from Board-certified plastic surgeons about their experience with new technologies for fat removal and managing complications after liposuction. METHODS: The ASAPS Current Trends in Liposuction Survey was emailed to 1713 ASAPS members. Data were tabulated and examined to determine current trends in liposuction and other fat removal techniques performed by ASAPS members. RESULTS: The response rate for the survey was 28.7% (n = 492). Most ASAPS respondents reported performing between 50 and 100 liposuction procedures annually. Most plastic surgeons currently employ or have previous experience with suction-assisted lipectomy/liposuction (SAL), ultrasound-assisted liposuction (UAL), and power-assisted liposuction, but fewer reported experience with laser-assisted liposuction (LAL), mesotherapy, or external, noninvasive devices. SAL was the preferred method of fat removal for 51.4%. UAL, LAL, and SAL were most commonly associated with complications. Only 10.5% of ASAPS members employ LAL; 38% have treated a patient with complications secondary to LAL. CONCLUSIONS: Valuable information about current trends in liposuction and other fat removal techniques has been gained from this survey. Although many studies have been published that review issues related to safety, morbidity, aesthetics, and recovery after different methods of fat removal, more prospective studies with standardized objective outcome measures comparing these techniques, particularly newer modalities, are needed to continue improving safety-related standards of care.
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0 |
Post-operative imaging of soft tissue sarcomas
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MSTS AUC - Based on ACR Lit Review
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Soft tissue sarcomas are uncommon malignancies that have a high risk of local recurrence despite adequate initial surgery. The aim of follow-up imaging with any malignancy is to detect recurrence promptly so that treatment can be instigated at the earliest possible opportunity. In this review article, we discuss the imaging modalities that can be employed to detect local recurrence following surgery for an extremity soft tissue sarcoma. The role of radiographs, computed tomography, magnetic resonance imaging and positron emission tomography is reviewed followed by a discussion on the imaging modalities useful in the detection of metastatic disease. Finally, we present a robust pathway that is suggested for the follow-up of patients with an extremity soft tissue sarcoma
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0 |
Interleukin-1beta-mediated suppression of microRNA-27a-3p activity in human cartilage via MAPK and NF-kappaB pathways: A potential mechanism of osteoarthritis pathogenesis
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OAK 3 - Non-arthroplasty tx of OAK
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The aim of the present study was to investigate the role of microRNA (miR)-27a-3p in osteoarthritis (OA). Reverse transcription-quantitative polymerase chain reaction and western blotting were performed to determine the expression of miR-27a-3p and aggrecanase-2 (ADAMTS5) in cartilage tissues from patients with OA and healthy controls, and also in interleukin (IL)-1beta-treated primary human chondrocytes. Primary human chondrocytes were transfected with miR-27a-3p. A luciferase reporter assay was used to validate the direct contact between miR-27a-3p and its putative binding site in the 3'-untranslated region ADAMTS5 mRNA. Furthermore, the effects of IL-1beta-induced activation of mitogen-activated protein kinase (MAPK) and nuclear factor (NF)-kappaB on miR-27a-3p were evaluated using specific inhibitors. The results revealed that the level of miR-27a-3p was reduced in OA cartilage tissues compared with those of normal controls. In addition, decreased miR-27a-3p and increased ADAMTS5 expression was observed in a time- and dose-dependent manner in chondrocytes treated with IL-1beta. Furthermore, overexpression of miR-27a-3p suppressed the expression of ADAMTS5 in human chondrocytes induced by IL-1beta. miR-27a-3p overexpression also decreased the luciferase activity of the wild-type ADAMTS5 reporter plasmid. Mutation of the miR-27a-3p binding site in the 3'-untranslated region of ADAMTS5 mRNA abolished the miR-27a-3p-mediated repression of reporter activity. Furthermore, the use of specific inhibitors demonstrated that IL-1beta may regulate miR-27a-3p expression via NF-kappaB and MAPK signaling pathways in chondrocytes. The present study concluded that miR-27a-3p was downregulated in human OA and was suppressed by IL-1beta, and functions as a crucial regulator of ADAMTS5 in OA chondrocytes. In addition, IL-1beta-mediated suppression of miR-27a-3p activity may occur via the MAPK and NF-kappaB pathways. The present study may provide a novel strategy for clinical treatment of OA caused by upregulation of miR-27a-3p.
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0 |
Safety of bilateral total knee arthroplasty in morbidly obese patients
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PJI DX Updated Search
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There has been an increase in the prevalence of morbid obesity and the demand for total knee arthroplasty (TKA). Physicians must help patients with bilateral knee arthritis to make informed decisions regarding whether to undergo staged, sequential, or simultaneous TKA. The purpose of this study was to evaluate the perioperative complications of 2-team simultaneous bilateral TKA in the morbidly obese. The authors performed a retrospective review of the records at a single tertiary hospital from 1997 to 2007 and identified 35 morbidly obese (body mass index [BMI] greater than 40 kg/m(2)) patients who had undergone unilateral TKA, as well as 42 morbidly obese and 79 nonobese (BMI less than 30 kg/m(2)) patients who underwent simultaneous bilateral TKA. Clinical, operative, and postoperative variables and complication rates were recorded. Clinical variables were similar between the morbidly obese TKA patients. The bilateral group had significantly increased operative times (132.4 vs 115.5 minutes; P<.01), intravenous fluids (2556.1 vs 2114.7 mL; P=.03), percentage transfused (64.2% vs 11.4%; P<.01), days in the hospital (3.6 vs 3.2 days; P=.03), and discharge rates to rehabilitation facility (72.7% vs 48.6%; P=.01). Major and minor complications were few and comparable, with the need for manipulation under anesthesia in unilateral TKA (11.4%; P=.04) as the only significant difference between groups, including when comparing bilateral nonobese TKAs with bilateral morbidly obese TKAs. The authors feel that morbidly obese patients may undergo 2-team simultaneous bilateral TKA after careful discussion regarding some of the differences in short-term outcomes
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1 |
Relationship between stressfulness of claiming for injury compensation and long-term recovery: a prospective cohort study
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DoD PRF (Psychosocial RF)
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IMPORTANCE: Each year, millions of persons worldwide seek compensation for transport accident and workplace injuries. Previous research suggests that these claimants have worse long-term health outcomes than persons whose injuries fall outside compensation schemes. However, existing studies have substantial methodological weaknesses and have not identified which aspects of the claiming experience may drive these effects.
OBJECTIVE: To determine aspects of claims processes that claimants to transport accident and workers' compensation schemes find stressful and whether such stressful experiences are associated with poorer long-term recovery.
DESIGN, SETTING, AND PARTICIPANTS: Prospective cohort study of a random sample of 1010 patients hospitalized in 3 Australian states for injuries from 2004 through 2006. At 6-year follow-up, we interviewed 332 participants who had claimed compensation from transport accident and workers' compensation schemes ("claimants") to determine which aspects of the claiming experience they found stressful. We used multivariable regression analysis to test for associations between compensation-related stress and health status at 6 years, adjusting for baseline determinants of long-term health status and predisposition to stressful experiences (via propensity scores).
MAIN OUTCOMES AND MEASURES: Disability, quality of life, anxiety, and depression.
RESULTS: Among claimants, 33.9% reported high levels of stress associated with understanding what they needed to do for their claim; 30.4%, with claim delays; 26.9%, with the number of medical assessments; and 26.1%, with the amount of compensation they received. Six years after their injury, claimants who reported high levels of stress had significantly higher levels of disability (+6.94 points, World Health Organization Disability Assessment Schedule sum score), anxiety and depression (+1.89 points and +2.61 points, respectively, Hospital Anxiety and Depression Scale), and lower quality of life (-0.73 points, World Health Organization Quality of Life instrument, overall item), compared with other claimants. Adjusting for claimants' vulnerability to stress attenuated the strength of these associations, but most remained strong and statistically significant.
CONCLUSIONS AND RELEVANCE: Many claimants experience high levels of stress from engaging with injury compensation schemes, and this experience is positively correlated with poor long-term recovery. Intervening early to boost resilience among those at risk of stressful claims experiences and redesigning compensation processes to reduce their stressfulness may improve recovery and save money.
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0 |
Quality of life implications of bisphosphonate-associated osteonecrosis of the jaw
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MSTS 2018 - Femur Mets and MM
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Purpose. Potentially debilitating, osteonecrosis of the jaw (ONJ) is an emerging complication of bisphosphonates. However, its effect on quality of life (QoL) is unknown. We determined the ONJ-related QoL decline in a cancer patient cohort. Patients and Methods. Thirty-four cancer patients with bisphosphonate-associated ONJ completed a telephone survey (October 2007 through May 2008). The Oral Health Impact Profile 14 (OHIP) retrospectively assessed participant oral health-related QoL before and after ONJ. Standardized ONJ descriptions were developed in a multidisciplinary, iterative process and were evaluated with three frequently used preference based QoL measurement methods on a 0 (death) to 1 (perfect health) scale: Visual Analogue Scale (VAS), Time Trade-Off (TTO), and EQ-5D. Results. ONJ significantly (p <.001) increased OHIP scores (worse QoL) for additive (3.56-16.53) and weighted (7.0-17.5) methods. Seven individual OHIP items significantly increased (Bonferroni correction p <.0035): pain, eating discomfort, self-consciousness, unsatisfactory diet, interrupted meals, irritability, and decreased life satisfaction. Mean preference-based QoL values significantly decreased (p <.001) with worsening ONJ stage (VAS, TTO, and EQ-5D): no ONJ (0.76, 0.86, 0.82), ONJ stage 1 (0.69, 0.82, 0.78), ONJ stage 2 (0.51, 0.67, 0.55), and ONJ stage 3 (0.37, 0.61, 0.32). As ONJ worsened, EQ-5D domain scores significantly increased (p <.001). Pain/discomfort and anxiety/depression contributed most to declining QoL. Conclusions. ONJ significantly affects QoL, a detriment that increases with worsening ONJ. QoL impairments for ONJ stages 2 and 3 are similar to other treatment side effects that influence decision-making. Bisphosphonate-associated ONJ QoL is an important consideration for patients, clinicians, and policy makers. © Alpha Med Press.
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0 |
Body mass index change after knee replacement in the multicenter osteoarthritis study cohort
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Surgical Management of Osteoarthritis of the Knee CPG
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Purpose: Individuals with painful knee OA who undergo knee replacement (KR) are reported to have reduced pain and increased physical activity that might allow for subsequent weight reduction. However, a recent report of subjects who underwent a KR demonstrated a significant increase in body mass index (BMI) of approximately 1 kg/m(2) over 2 years following KR compared to a control group without knee pain, knee OA or change in BMI over the same period. To further explore this question, we conducted a matched longitudinal cohort study to examine the relation of KR to subsequent change in BMI comparing with persons with knee OA but who did not undergo a KR. Methods: We studied subjects enrolled in the NIH-funded Multicenter Osteoarthritis Study (MOST), an observational study of persons aged 50 to 79 years with either symptomatic knee OA or at high risk of disease at baseline. Participants were evaluated at baseline, 30 months and 60 months. For this analysis, we identified those persons who had a KR during the first 30 months of the MOST study but who did not have a subsequent contralateral TKR at any time up to 60 months. Subjects with unilateral KR at baseline and no new KR in the second knee were excluded. We also eliminated subjects who were missing BMI information at 30 months or 60 months. We matched cases to controls on age (as 5 year age categories), sex, study center, race, the worst K/L grade at baseline (Kellgren/Lawrence 0-1, 2, >=3; K/L), and the maximum of five Western Ontario McMaster (WOMAC) knee pain questions at baseline (none, mild, moderate, severe/ extreme). We followed these two groups for BMI change from the 30 month to the 60 month visit of MOST. To determine if KR is associated with BMI change we performed multiple linear regression adjusting for physical activity level (measured by Physical Activity Scale for the Elderly; PASE) and pain medication use at baseline. Results: Seventy-four subjects met the criteria for cases and were matched to controls on a one to one basis. At baseline, in both groups, mean agewas 64.2, 13.5% were African American, 90.5% had K/L>=3, 47.3% had maximal
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0 |
Functioning free-muscle transplantation for the upper extremity
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DoD - ACS - Interrater Reliability
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Functioning free-muscle transplantation (FFMT) is an advanced microneurovascular technique indicated in patients who have an injury with major functional muscle or muscle group loss or denervation and no locally available or ideal musculotendinous donor units. Over the 9-year period, from 1986 to 1994, 47 FFMTs were applied in patients who had severe hand and upper-extremity injuries (not including brachial plexus injury). Thirteen patients had 15 FFMTs to reconstruct muscle loss caused by severe Volkmann's ischemia. Seventeen patients had 21 FFMTs for reconstruction after severe crushing and traction injuries of the forearm or arm, with major muscle loss or major nerve injury. Nine patients, with 11 FFMTs, sustained major limb avulsion amputation for which replantation without nerve repair was done initially. FFMT was the only technique available to resolve the motor deficit and consequent deformity. Most patients achieved significant functional improvement. [References: 22]
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1 |
Global Prevalence and Preferences of Progressive Tension Suture Usage in Abdominoplasties
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Panniculectomy & Abdominoplasty CPG
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BACKGROUND: Abdominoplasty is one of the most popular esthetic procedures. Seroma is the most frequent postoperative complication. Two decades of literature have described benefits of quilting sutures/progressive tension sutures (PTS) in reducing seroma rates and other complications in abdominoplasties. Despite this, PTS have not been universally adopted by plastic surgeons (ISAPS international survey on aesthetic/cosmetic procedures performed in 2020, 2021) Furthermore, PTS techniques and preferences vary widely. OBJECTIVE: The aim of this study is to determine the prevalence of PTS use, reasons for reluctance to utilize them, and variety of techniques utilized by plastic surgeons performing abdominoplasties internationally. METHODS: A 13-question survey was emailed via ISAPS to 3842 plastic surgeons internationally. Responses were collected and analyzed. RESULTS: Of the 272 respondents, the majority, 58%, currently use PTS. 46% were introduced to PTS during training. Only PTS training exposure was found to significantly correlate with current usage. Only 22% of North American trainees were exposed to PTS compared to 40-62% of trainees from other geographies. Of respondents who utilize PTS, most, 74%, combine them with drains. The majority use interrupted sutures, 65%, while 19% utilize a running suture, and the remaining 16% combine interrupted and running sutures. Of respondents who do not currently utilize PTS, the most common reason stated is that the surgeon's technique works well without them, 73%, which was significantly correlated with years in practice. CONCLUSION: Globally, most plastic surgeons currently utilize PTS (typically with drains) with training exposure being a significant predictor. There are still areas to address reluctance to implement them and use them without drains. 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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Perioperative creatine phosphokinase trends in elderly patients with hip fracture
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Management of Hip Fractures in the Elderly
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A prospective study of the serum levels of unfractionated creatine phosphokinase (CPK) in 69 consecutive elderly patients undergoing surgery for hip fracture is reported. Serum unfractionated CPK levels were measured on admission, on the evening following surgery and daily for the first five days post-operatively. All of the CPK levels measured on admission were within the normal range for this laboratory. A gradual rise in CPK levels followed surgery. On the evening following surgery 75% of values were greater than the upper limit of the normal reference range. The peak values were seen on day 1 post-operatively but 25% of values were still less than the reference maximum. A gradual decline was seen after this and at day 5 post operatively 50% of values were within the normal reference range. A single unfractionated CPK determination is not of diagnostic benefit in the post-operative period in elderly patients with hip fracture. However, patients with intracapsular and intertrochanteric fractures do not show elevation of unfractionated CPK levels prior to surgery
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Risk factors for superficial wound complications in hip and knee arthroplasty
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AAHKS (2) Corticosteroids
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Superficial wound complications have been consistently implicated in the development of prosthetic joint infection. This cohort study aimed to determine perioperative risk factors associated with superficial wound complications. The study was performed over an 18-month period (January 2011 to June 2012) and included 964 patients undergoing prosthetic hip or knee replacement surgery. The factors associated with superficial wound complication differed according to arthroplasty site. In the combined cohort the following factors were associated with superficial wound complications: the use of 0.5% chlorhexidine in 70% alcohol for surgical skin preparation compared with 1% iodine in 70% alcohol (odds ratio (OR) 4.75; 95% confidence interval (CI) 1.42, 15.92; p = 0.012); increasing age (OR, 1.13; 95% CI, 1.06,1.19; p 0.18); increasing body mass index (BMI) (OR, 1.08; 95% CI, 1.05,1.12; p < 0.001); rheumatoid arthritis (OR, 2.56; 95% CI, 1.17, 5.58; p 0.018); and increasing blood transfusions (OR, 1.26; 95% CI, 1.06,1.49; p 0.008). In the hip arthroplasty cohort, the use of 0.5% chlorhexidine in 70% alcohol for surgical skin preparation (OR, 13.35; 95% CI, 2.11, 84.29; p 0.006), increasing BMI (OR, 1.13; 95% CI, 1.06, 1.19; p < 0.001) and increasing blood transfusions (OR, 1.26; 95% CI, 1.06, 1.49; p 0.008) were associated with superficial wound complications. In the knee arthroplasty cohort rheumatoid arthritis (OR, 2.75; 95% CI, 1.03, 7.33; p 0.043) and increasing tourniquet time (OR, 1.01; 95% CI, 1.00, 1.02; p = 0.029) were independent predictors of superficial wound complications. Further research is warranted to assess the impact of modification of these factors on the subsequent development of wound complications and prosthetic joint infection. © 2013 European Society of Clinical Microbiology and Infectious Diseases.
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Does the Angle of the Nail Matter for Pertrochanteric Fracture Reduction? Matching Nail Angle and Native Neck-Shaft Angle
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Hip Fx in the Elderly 2019
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OBJECTIVES: To determine whether fixation of pertrochanteric hip fractures with cephalomedullary nails (CMNs) with a neck-shaft angle (NSA) less than the native NSA affects reduction and lag screw cutout.
DESIGN: Retrospective comparative study.
SETTING: Level I trauma center.
PATIENTS/PARTICIPANTS: Patients treated with a CMN for unstable pertrochanteric femur fractures (OTA/AO 31-A2.2 and 31-A2.3) between 2005 and 2014.
INTERVENTION: CMN fixation.
MAIN OUTCOME MEASUREMENT: NSA reduction and lag screw cutout.
RESULTS: Patients fixed with a nail angle less than their native NSA were less likely to have good reductions [17% vs. 60%, 95% confidence interval (CI), -63% to -18%; P = 0.0005], secondary to more varus reductions (41% vs. 10%, 95% CI, 9%-46%; P = 0.01) and more fractures with >=4 mm of displacement (63% vs. 35%, 95% CI, 3%-49%; P = 0.03). The cutout was not associated with the use of a nail angle less than the native NSA (60% vs. 76%, 95% CI, -56% to 18%; P = 0.5), varus reductions (60% vs. 32%, 95% CI, -13% to 62%; P = 0.3), or poor reductions (20% vs. 17%, 95% CI, -24% to 44%; P = 1.0).
CONCLUSIONS: The fixation of unstable pertrochanteric hip fractures with a nail angle less than the native NSA was associated with more varus reductions and fracture displacement but did not affect the lag screw cutout.
LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Mini-Open Posterior Compartment Release for Chronic Exertional Compartment Syndrome of the Leg
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DOD - Acute Comp Syndrome CPG
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Chronic exertional compartment syndrome (CECS) is a well-recognized cause of leg pain in endurance athletes. Surgical fasciotomy for posterior leg CECS historically has inferior clinical results compared with anterior and lateral compartment release. Poor surgical technique with inadequate release may contribute to less reliable outcomes. In this Technical Note with accompanying video, we describe a mini-open approach for posterior CECS of the leg.
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Adverse effects of bisphosphonates
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MSTS 2018 - Femur Mets and MM
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Use of bisphosphonates has been growing steadily in the last decade. This follows the introduction of simpler dosing regimes, the availability of lower-priced generics, and concerns about the safety of hormone-replacement therapy. Bisphosphonates have a relatively good safety record and are tolerated by the majority of patients, but serious adverse events have been recorded in some cases. Only the most common of adverse effects are robustly observable in clinical trials. In general, studies were not powered to detect effects that were lower in incidence than fractures. This review of adverse events in bisphosphonate-treated patients was based on published information from case reports, case series, claims databases, national databases, surveys, adverse event reporting databases, and single or pooled clinical trials. The most common acute adverse events with bisphosphonates for osteoporosis are gastrointestinal discomfort and acute influenza-like illness. Renal complications are very rare with oral bisphosphonates and rare with i.v. bisphosphonates when used appropriately. Based on our current knowledge, skeletal events in the form of osteonecrosis of the jaw and atypical fragility fractures are rare compared with the risk of osteoporotic fractures, at least in patients with the same risk of fractures as those in the phase III trials. It is biologically plausible that atypical fragility fractures could follow from suppression of bone remodeling, but high-quality studies proving causality are lacking. Physicians are advised to critically reassess BMD and risk profile after 3-5 years of therapy to avoid treatment in patients at low risk. © 2010 Springer Science+Business Media, LLC.
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Dry arthroscopy and its applications
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Distal Radius Fractures
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Wrist arthroscopy can be performed without infusing fluid, as simple traction suffices to maintain the working space. The lack of tissue infiltration by fluid keeps soft tissues in pristine condition if open surgery is needed after the arthroscopic exploration. The dry technique makes fluid distension irrelevant, thus opening new possibilities by combining arthroscopy with moderate-sized incisions. Although any modification of a technique with which one is familiar can be regarded with major reticence, the advantages of the dry technique merit its use. Accomplished wrist arthroscopists will have minimal problems swapping from the wet to the dry and vice versa.
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Subchondral insufficiency fracture of the femoral head in a patient with alkaptonuria
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PJI DX Updated Search
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We report a patient with alkaptonuria accompanied by bilateral rapidly destructive arthrosis of the hip. The destruction of the left hip joint with its severe functional impairment necessitated total hip arthroplasty (THA). The outcome was satisfactory. Both magnetic resonance imaging (MRI) and pathologic findings were compatible with a subchondral insufficiency fracture. A year and half later, during a follow-up visit, the patient complained of right coxalgia. Radiography showed that the right femoral head had already disappeared, requiring THA of the right hip. Although there have been a few reports of rapid destructive hip osteoarthritis associated with ochronotic arthropathy, the pathogenesis of the destructive change is not clear. Subchondral insufficiency fracture was diagnosed on MR imaging and pathologically confirmed in our patient with alkaptonuria, suggesting that subchondral insufficiency fracture is one of the causes of ochronotic hip destruction. é ISS 2013
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The occipitofrontalis muscle is composed of two physiologically and anatomically different muscles separately affecting the positions of the eyebrow and hairline
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Upper Eyelid and Brow Surgery
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After the surgical correction of aponeurotic blepharoptosis or blepharoplasty, the positions of the eyebrow and hairline change as if the frontal belly is independent from the occipital belly of the occipitofrontalis muscle. Therefore, the occipitofrontalis muscle was studied physiologically with electromyographic evaluation in healthy subjects and anatomically with cadaver dissections. Along with contraction of the levator muscle to maintain an adequate visual field, at a less upward gaze position, contraction of only the frontal belly was induced, and at a more upward gaze position, contraction of both the frontal and the occipital bellies was always induced to lift the eyebrow with the upper eyelid skin. The superficial fascia overlying the occipital belly becomes the temporoparietal fascia and ends at the superior end of the frontal belly, thus creating a superficial musculoaponeurotic system that lifts the eyebrow and pulls the scalp forwards. Beneath the superficial musculoaponeurotic system, the occipital belly of the occipitofrontalis muscle becomes the galea aponeurotica and inserts into the underside of the frontal belly, thus creating a deep musculoaponeurotic system that pulls the superficial musculoaponeurotic system with the scalp backwards. Thus, the occipitofrontalis muscle appears to be composed of two physiologically and anatomically different muscles.
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1 |
The outcome of operatively treated anterior cruciate ligament disruptions in the skeletally immature child
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Anterior Cruciate Ligament Injuries CPG
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The purpose of this study was to evaluate the outcome of transphyseal ligament reconstruction in skeletally immature children with midsubstance anterior cruciate ligament (ACL) disruption. Five consecutive patients (mean age, 12.9 years; range, 8 to 14 years) with radiographically documented "wide" open growth plates and a minimum of 5 cm of expected remaining growth, underwent intra-articular reconstruction of the ACL. Operative treatment included three ACL reconstructions using hamstring tendons and two with quadriceps patellar tendon. All involved a centrally placed 6-mm or smaller tibial drill hole through an open physis and graft placement in an over-the-top position on the femur. At an average follow-up of 7.4 years (range, 4.5 to 9.9 years), no patient had a positive anterior drawer, Lachman, or pivot shift test. On KT-1000 arthrometer testing, all patients had 3 mm or less of increased anterior-posterior displacement (mean +/- SD = 1.0 +/- 1.6 mm). Magnetic resonance imaging showed that four tibial physes had fused in a symmetric fashion and one was still open. Orthoroentgenograms showed that no patient had a significant leg length discrepancy (-0.8 mm +/- 3.4 mm). The mean increase in height postoperatively was 17.7 cm (range, 7.6 to 31.0 cm). Overall, using the International Knee Documentation Committee (IKDC) evaluation form, there were four patients with grade A and one with grade C. The one patient with a poor IKDC grade had sustained a subsequent patellar dislocation with osteochondral fracture. In conclusion, ACL reconstruction using small drill holes placed through open tibial physes does not seem to adversely affect outcome or future growth
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Clinical observation of 35 cases of pediatric Gartland ¢ó fractures of distal humerus treated with oral Cassia Twig decoction and manipulative reduction plus Kirschner wire fixation
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Pediatric Supracondylar Humerus Fracture 2020 Review
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Objective To observe the effect of oral Cassia Twig decoction and manipulative reduction with Kirschner wire fixation in the treatment of children with distal humeral Gartland III fracture. Methods 70 cases of children with distal humeral Gartland ¢ó fractures were randomly divided into treatment group and control group, 35 cases in each group. 2 groups of patients were treated with emergency manual reduction, Kirschner wire fixation. and tube plaster fixation. Treatment group was additionally given oral Cassia Twig decoction 7 days after operation and after plaster was removed. Circumference at fixed position and elbow joint flexion and extension activities were observed. Results 7 days after operation£¬there was difference between the 2 groups in swelling upper limb circumference ( t=1.15, P<0.05) ; 7 days after plaster removal£¬there was difference between the 2 groups in swelling upper limb circumference ( t= 2.74, P <0.05) . 48 hours after plaster removal, limbs of 2 groups were stiff, and elbow joint activities had no difference ( P<0.05) ; 1 week after plaster was removed, elbow activities between the 2 groups had difference ( t=4.18, P<0.05) . All the patients were successfully recovered after treatment, with no serious complications or sequelae, no elbow deformity. After the operation; in the control group, there were 4 cases of tensive blisters, 3 cases of mild impairment of circulation at limbs end, all naturally recovered, with no special treatment; in the treatment group, there was no tensive blister and peripheral circulation patient. Conclusion Oral Cassia Twig decoction and manipulative reduction plus Kirschner wire fixation has good effect in treating pediatric distal humeral Gartland III fractures.
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Analysis for apoptosis and necrosis on adipocytes, stromal vascular fraction, and adipose-derived stem cells in human lipoaspirates after liposuction
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Panniculectomy & Abdominoplasty CPG
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BACKGROUND: Adipose-derived stem cells have become the most studied adult stem cells. The authors examined the apoptosis and necrosis rates for adipocyte, stromal vascular fraction, and adipose-derived stem cells in fresh human lipoaspirates. METHODS: Human lipoaspirate (n = 8) was harvested using a standard liposuction technique. Stromal vascular fraction cells were separated from adipocytes and cultured to obtain purified adipose-derived stem cells. A panel of stem cell markers was used to identify the surface phenotypes of cultured adipose-derived stem cells. Three distinct stem cell subpopulations (CD90/CD45, CD105/CD45, and CD34/CD31) were selected from the stromal vascular fraction. Apoptosis and necrosis were determined by annexin V/propidium iodide assay and analyzed by flow cytometry. RESULTS: The cultured adipose-derived stem cells demonstrated long-term proliferation and differentiation evidenced by cell doubling time and positive staining with oil red O and alkaline phosphatase. Isolated from lipoaspirates, adipocytes exhibited 19.7 +/- 3.7 percent apoptosis and 1.1 +/- 0.3 percent necrosis; stromal vascular fraction cells revealed 22.0 +/- 6.3 percent of apoptosis and 11.2 +/- 1.9 percent of necrosis; stromal vascular fraction cells had a higher rate of necrosis than adipocytes (p < 0.05). Among the stromal vascular fraction cells, 51.1 +/- 3.7 percent expressed CD90/CD45, 7.5 +/- 1.0 percent expressed CD105/CD45, and 26.4 +/- 3.8 percent expressed CD34/CD31. CD34/CD31 adipose-derived stem cells had lower rates of apoptosis and necrosis compared with CD105/CD45 adipose-derived stem cells (p < 0.05). CONCLUSIONS: Adipose-derived stem cells had a higher rate of apoptosis and necrosis than adipocytes. However, the extent of apoptosis and necrosis was significantly different among adipose-derived stem cell subpopulations.
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1 |
Total shoulder arthroplasty
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Glenohumeral Joint OA
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Shoulder arthroplasty has been the subject of marked advances over the last few years. Modern implants provide a wide range of options, including resurfacing of the humeral head, anatomic hemiarthroplasty, total shoulder arthroplasty, reverse shoulder arthroplasty and trauma-specific implants for fractures and nonunions. Most humeral components achieve successful long-term fixation without bone cement. Cemented all-polyethylene glenoid components remain the standard for anatomic total shoulder arthroplasty. The results of shoulder arthroplasty vary depending on the underlying diagnosis, the condition of the soft-tissues, and the type of reconstruction. Total shoulder arthroplasty seems to provide the best outcome for patients with osteoarthritis and inflammatory arthropathy. The outcome of hemiarthroplasty for proximal humerus fractures is somewhat unpredictable, though it seems to have improved with the use of fracture-specific designs, more attention to tuberosity repair, and the selective use of reverse arthroplasty, as well as a shift in indications towards internal fixation. Reverse shoulder arthroplasty has become extremely popular for patients with cuff-tear arthropathy, and its indications have been expanded to the field of revision surgery. Overall, shoulder arthroplasty is a very successful procedure with predictable pain relief and substantial improvements in motion and function.
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Early initiation of home-based sensori-motor training improves muscle strength, activation and size in patients after knee replacement: A secondary analysis of a controlled clinical trial
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OAK 3 - Non-arthroplasty tx of OAK
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Background: There is accumulating evidence for the advantages of rehabilitation involving sensori-motor training (SMT) following total knee replacement (TKR). However, the best way in which to deliver SMT remains elusive because of potential interference effects amongst concurrent exercise stimuli for optimal neuromuscular and morphological adaptations. The aim of this study was to use additional outcomes (i.e. muscle strength, activation and size) from a published parent study to compare the effects of early-initiated home-based rehabilitative SMT with functional exercise training (usual care) in patients undergoing TKR. Methods: A controlled clinical trial was conducted at the Orthopedic University Hospital of Rion, Greece involving allocation concealment to patients. Fifty-two patients electing to undergo TKR were randomised to either early-initiated SMT [experimental] or functional exercise training [control] in a home-based environment. Groups were prescribed equivalent duration of exercise during 12-weeks, 3-5 sessions of ~ 40 min per week of home-based programmes. Muscle strength and activation (peak force [PF]; peak amplitude [Peak Amp.] and root mean square of integrated electromyography [RMS iEMG]), muscular size (including rectus femoris muscle cross-sectional area [CSARF]), and knee ROM were assessed on three separate occasions (pre-surgery [0 weeks]; 8 weeks post-surgery; 14 weeks post-surgery). Results: Patients undertaking SMT rehabilitation showed significantly greater improvements over the 14 weeks compared to control in outcomes including quadriceps PF (25.1 ± 18.5 N vs 12.4 ± 20.8 N); iPeak Amp. (188 ± 109.5% vs 25 ± 105.8%); CSARF (252.0 ± 101.0 mm2 vs 156.7 ± 76.2 mm2), respectively (p < 0.005); Knee ROM did not offer clinically relevant changes (p: Ns) between groups over time. At 14 weeks post-surgery, the SMT group's and control group's performances differed by relative effect sizes (Cohen's d) ranging between 0.64 and 1.06. Conclusion: A prescribed equivalent time spent in SMT compared to usual practice, delivered within a home-based environment, elicited superior restoration of muscle strength, activation and size in patients following TKR.
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Deprivation influences the functional outcome from total hip arthroplasty
|
PJI DX Updated Search
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Socioeconomic inequality through deprivation and access to healthcare is an aetiological factor in many disease processes. It is associated with the development of osteoarthritis, the need for joint arthroplasty and poorer access to secondary healthcare. Few studies have investigated the influence of deprivation on the function of patients undergoing total hip arthroplasty. The aim of this study was to investigate the association between deprivation and function in these patients before their operation and at 18 months. The secondary aim was to investigate if deprivation was associated with comorbidity or adverse outcomes. A prospectively database of functional scores of 1865 patients undergoing total hip arthroplasty over seven years was used. Deprivation was categorized using the Scottish Index of Multiple Deprivation (SIMD) government rating. The most deprived quintiles had lower absolute functional scores at time of operation. At 18 months the least deprived quintile had a greater SF36 physical function score and relative improvement. Deprivation was not linked with length of stay or BMI. There was a higher proportion of ASA (American Society of Anesthesiologists) category 1 patients in the least deprived group signifying less comorbidity. Smoking was more prevalent in patients from areas of greater deprivation. There was no observed difference in mortality, infection, dislocation or thromboembolism. This study demonstrates a socioeconomic gradient in the function of patients undergoing total hip arthroplasty. Further investigation is required to elucidate the biological and social mechanisms driving these outcomes, and to determine whether these gradients persist at longer term follow-up. LEVEL OF EVIDENCE: II (Prognostic Studies--Investigating the effect of a patient characteristic on the outcome of disease)
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Safety and efficacy of methylprednisolone infiltration in anserine syndrome treatment
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Surgical Management of Osteoarthritis of the Knee CPG
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OBJECTIVE: The anserine syndrome is a common cause of knee pain. Infiltration with glucocorticoids has been evaluated in studies with low level of evidence and there are no published clinical trials to determine its usefulness. The objective of this study was to determine the efficacy and safety of the infiltration of methylprednisolone in the treatment of Anserin Syndrome. METHODS: We conducted a clinical trial in 58 adult patients with anserin syndrome, which presented intra-articular pathology ruled that reflected pain in the medial aspect of the knee. The WOMAC scale was assessed at baseline and patients were randomized to receive an infiltration of lidocaine plus 40 mg methylprednisolone acetate (group 1) versus xylocaine plus distilled water (group 2). Both groups received 100mg of diclofenac sodium for 10 days. The WOMAC scale was applied at 4 weeks and adverse events were recorded. RESULTS: Equivalence was demonstrated in both groups for demographic variables and initial clinical evaluation. There was no statistical difference in the three domains of assessment of the baseline WOMAC score. The median baseline WOMAC in group 1 was 32 and in group 2 was 25.5 points. At 4 weeks it was 8 and 6.5 points, which corresponded to an improvement of 61.6 and 62.8% respectively. CONCLUSION: The infiltration with methylprednisolone in anserin syndrome is not superior to placebo in patients taking diclofenac measured by the WOMAC scale at 4 weeks. The incidence of adverse events did not show any differences either
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Focal knee resurfacing and effects of surgical precision on opposing cartilage. A pilot study on 12 sheep
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OAK 3 - Non-arthroplasty tx of OAK
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Background: Full thickness cartilage lesions (ICRS grade 3-4) and focal lesions of degenerative origin may progress to osteoarthritis (OA). Such focal lesions can be treated by metallic implants. We hypothesized that such treatment results in opposing surface cartilage damage that correlates with implant position (height) relative to the adjacent cartilage surface. This relationship was investigated using a sheep animal model. Methods: Both medial femoral condyles of 12 sheep were operated. The implants, were inserted in the weight-bearing surface at different heights relative to the surrounding cartilage. Euthanasia was performed at 6 or 12 weeks. After retrieval, implant height was analyzed using laser scanning. Damage to the opposing tibial cartilage was evaluated macroscopically and microscopically according to the modified Mankin score. Results: Twenty-two knees were available for evaluation and showed cartilage lesions ranging from severe damage (Mankin stage 11) to almost pristine conditions (Mankin stage 1). There was a strong correlation between implant height and cartilage damage. Standard deviation from the aimed implant height was 0.47 mm. Conclusions: Our results showed significant surgical imprecision and protruding implants imposed severe cartilage damage. We therefore suggest implants should be placed recessed (approx. 0.5 mm) below the surrounding cartilage in this animal model. These results encourage further studies of metallic implants yet the utmost precision regarding position is required. © 2013 Osteoarthritis Research Society International.
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Articular cartilage surface roughness as an imaging-based morphological indicator of osteoarthritis: A preliminary investigation of osteoarthritis initiative subjects
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AMP (Acute Meniscal Pathology)
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Current imaging-based morphometric indicators of osteoarthritis (OA) using whole-compartment mean cartilage thickness (MCT) and volume changes can be insensitive to mild degenerative changes of articular cartilage (AC) due to areas of adjacent thickening and thinning. The purpose of this preliminary study was to evaluate cartilage thickness-based surface roughness as a morphometric indicator of OA. 3D magnetic resonance imaging (MRI) datasets were collected from osteoarthritis initiative (OAI) subjects with Kellgren-Lawrence (KL) OA grades of 0, 2, and 4 (n = 10/group). Femoral and tibial AC volumes were converted to two-dimensional thickness maps, and MCT, arithmetic surface roughness (S<sub>a</sub> ), and anatomically normalized S<sub>a</sub> (normS<sub>a</sub> ) were calculated. Thickness maps enabled visualization of degenerative changes with increasing KL grade, including adjacent thinning and thickening on the femoral condyles. No significant differences were observed in MCT between KL grades. S<sub>a</sub> was significantly higher in KL4 compared to KL0 and KL2 in the whole femur (KL0: 0.55 +/- 0.10 mm, KL2: 0.53 +/- 0.09 mm, KL4: 0.79 +/- 0.18 mm), medial femoral condyle (KL0: 0.42 +/- 0.07 mm, KL2: 0.48 +/- 0.07 mm, KL4: 0.76 +/- 0.22 mm), and medial tibial plateau (KL0: 0.42 +/- 0.07 mm, KL2: 0.43 +/- 0.09 mm, KL4: 0.68 +/- 0.27 mm). normS<sub>a</sub> was significantly higher in KL4 compared to KL0 and KL2 in the whole femur (KL0: 0.22 +/- 0.02, KL2: 0.22 +/- 0.02, KL4: 0.30 +/- 0.03), medial condyle (KL0: 0.17 +/- 0.02, KL2: 0.20 +/- 0.03, KL4: 0.29 +/- 0.06), whole tibia (KL0: 0.34 +/- 0.04, KL2: 0.33 +/- 0.05, KL4: 0.48 +/- 0.11) and medial plateau (KL0: 0.23 +/- 0.03, KL2: 0.24 +/- 0.04, KL4: 0.40 +/- 0.10), and significantly higher in KL2 compared to KL0 in the medial femoral condyle. Surface roughness metrics were sensitive to degenerative morphologic changes, and may be useful in OA characterization and early diagnosis. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:2755-2764, 2017.
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Multiple Low-Dose Dexamethasone Further Improves Clinical Outcomes Following Total Hip Arthroplasty
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AAHKS (8) Anesthetic Infiltration
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Background: The recommended dose regimen of dexamethasone in total hip arthroplasty (THA) has not been determined. This study was performed to assess the effects of multiple low-dose dexamethasone on clinical outcomes after THA. Methods: Two hundred ten patients undergoing THA received 3 doses of normal saline (Group A), 2 doses of intravenous dexamethasone and 1 dose of normal saline (Group B), or 3 doses of intravenous dexamethasone (Group C). The primary outcome was the visual analog scale (VAS) score for pain and nausea. The incidence of postoperative nausea and vomiting, use of analgesic and antiemetic rescue, C-reactive protein (CRP) level, range of motion, length of stay (LOS), and complications were also compared. Results: The VAS score (dynamic pain and nausea) on postoperative day 1 was significantly lower in Groups C and B than Group A. On postoperative day 2, the VAS score (dynamic pain and nausea) was lower in Group C than Groups A and B. In Group C, patients had a lower incidence of postoperative nausea and vomiting and reduced use of analgesic and antiemetic rescue. The CRP level was lower in Group B than Group A. Group C had the lowest CRP level among all 3 groups. LOS was shorter in Group B than Group A, while Group C had an even shorter LOS than Group B. Range of motion was greater in Group C. No complications occurred in any group. Conclusion: The 3-dose dexamethasone regimen can further relieve postoperative pain, ameliorate postoperative nausea, provide additional inflammatory control, enhance mobility, and shorten LOS following THA.
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