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Interdisciplinary collaboration across secondary and primary care to improve medication safety in the elderly (IMMENSE study): Study protocol for a randomised controlled trial
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Hip Fx in the Elderly 2019
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Introduction Drug-related problems (DRPs) are common in the elderly, leading to suboptimal therapy, hospitalisations and increased mortality. The integrated medicines management (IMM) model is a multifactorial interdisciplinary methodology aiming to optimise individual medication therapy throughout the hospital stay. IMM has been shown to reduce readmissions and drug-related hospital readmissions. Using the IMM model as a template, we have designed an intervention aiming both to improve medication safety in hospitals, and communication across the secondary and primary care interface. This paper presents the study protocol to explore the effects of the intervention with regard to healthcare use, health-related quality of life (HRQoL) and medication appropriateness in elderly patients. Methods and analysis A total of 500 patients aged â?¥70 years will be included and randomised to control (standard care) or intervention group (1:1). The intervention comprises five steps mainly performed by pharmacists: (1) medication reconciliation at admission, (2) medication review during hospital stay, (3) patient counselling about the use of medicines, (4) a comprehensible and patient-friendly medication list with explanations in discharge summary and (5) postdischarge phone calls to the primary care level. The primary outcome is the difference between intervention and control patients in the rate of emergency medical visits (acute readmissions and visits to emergency department) 12 months after discharge. Secondary outcomes include length of index hospital stay, time to first readmission, mortality, hip fractures, strokes, medication changes, HRQoL and medication appropriateness. Patient inclusion started in September 2016. Ethics and dissemination The trial was approved by the Norwegian Centre for Research Data and the Norwegian Data Protection Authority. We aim to publish the results in international peer-reviewed open access journals, at national and international conferences, and as part of two PhD theses. Trial registration number NCT02816086.
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Bone disease from monoclonal gammopathy of undetermined significance to multiple myeloma: pathogenesis, interventions, and future opportunities
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MSTS 2018 - Femur Mets and MM
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Manifestations of bone disease-osteopenia, osteolytic lesions, and fractures-are the hallmark of multiple myeloma (MM) and occur clinically in the vast majority of patients. These abnormalities can have devastating clinical effects by increasing both the morbidity and mortality of patients. Bone disease is usually found when patients are diagnosed with active MM; however, recent data suggest that it is present in early myelomagenesis, including patients with myeloma precursor disease, monoclonal gammopathy of undetermined significance (MGUS). The primary mechanisms of abnormal bone remodeling are increased osteoclastic activity, which occurs in close proximity to active myeloma cells, and decreased activity of the surrounding osteoblasts. Better understanding of the pathogenesis of bone disease in MM will allow us to enhance our current therapeutic options in the treatment of bone disease. In patients with active MM and at least one lytic lesion, intravenous bisphosphonates have been shown to decrease skeletal-related events and pain, improve performance status, and maintain quality of life. Emerging evidence suggests that intervention at earlier stages of disease may prevent skeletal-related events at time of progression, but there is no evidence that bisphosphonates in this setting change the natural history of the disease.
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Hip fracture outcomes: does surgeon or hospital volume really matter?
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Management of Hip Fractures in the Elderly
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BACKGROUND: Current data on the association between surgeon and hospital volumes and patient outcomes after hip fracture surgery is inconclusive. We hypothesized that surgeons and hospitals with higher caseloads of hip fracture care have better outcomes as measured by decreased postoperative complications and mortality, shorter length of stay in the hospital, routine disposition of patients on discharge, and decreased cost of care. METHODS: This is a retrospective cohort study using the Nationwide Inpatient Sample database. Data were extracted on 97,894 patients surgically treated for a hip fracture for the years 1988 through 2002. Multiple linear regression models were used to estimate the adjusted association between surgeon and hospital volume and outcomes for femoral neck and pertrochanteric hip fracture care. RESULTS: The in-hospital mortality rate for those patients who had hip fracture fixation by a low-volume surgeon (<7 procedures/yr) was significantly higher than for those whose procedure was performed by a high-volume surgeon (>15 cases/yr) (p = 0.005). The incidence of transfusion, pneumonia, and decubitus ulcer were also higher in those patients managed by a low-volume surgeon (p = <0.05). Conversely, hospital volume was not associated with significant differences in mortality although low-volume hospitals (<57 cases/yr) were associated with higher rates of postoperative infection, pneumonia, transfusion, and nonroutine discharge (p = <0.05). Both low-volume hospitals and surgeons were associated with longer lengths of stay (p = <0.05). CONCLUSIONS: This study provides evidence that surgeon volume, but not hospital volume, is associated with decreased mortality in the treatment of hip fractures. Both surgeon and hospital volume seem to be associated with nonfatal morbidity and length of stay
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Infection rate of intramedullary nailing for treatment of lower limb polyostotic fibrous dysplasia
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DoD SSI (Surgical Site Infections)
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Polyostotic fibrous dysplasia (PFD) generally cause deformities and fractures of femur and tibia and surgery is often required. The current surgical treatment for deformities is based on single or multiple osteotomies followed by stabilization with intramedullary nails, which are commonly used also for fractures. One of the most common surgical complications of intramedullary nailing is represented by surgical site infection with possible extension to the whole skeletal segment. In the present study we evaluated the incidence of surgical site infections in 44 patients affected by PFD in which 91 femurs or tibiae underwent intramedullary nailing to treat deformities or fractures. We never observed any infection of the operated femurs or tibiae until the final follow-up. The only post surgical infection was present in a patient with monomelic involvement at the contralateral non affected limb, which was surgically treated for limb length inequality, by femur shortening osteotomy stabilized by an intramedullary nail. The most likely hypothesis to explain the complete absence of infections in these patients may be related to the high local concentration of prophylactic antibiotic in the highly vascularized fibrodysplastic bone.
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1 |
Effect of Pharmacologic Prophylaxis on Venous Thromboembolism After Radical Prostatectomy: The PREVENTER Randomized Clinical Trial
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MSTS 2022 - Metastatic Disease of the Humerus
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In the Prevention of Venous Thromboembolism Following Radical Prostatectomy (PREVENTER) randomized trial, pharmacologic prophylaxis did not reduce the rate of symptomatic (relative risk [RR] 0.40 [95% confidence interval {CI} 0.08–2.03], p = 0.267) or overall (RR 0.97 [95% CI 0.25–3.81], p = 0.967) venous thromboembolism significantly. There was no increase in adverse events including symptomatic lymphoceles or bleeding.
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0 |
Burden of hip fracture on inpatient care: a before and after population-based study
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HipFx Supplemental Cost Analysis
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SUMMARY: We estimated the excess hospital expenditure attributable to osteoporotic hip fracture (HF) within a population of 6,019 patients. Post-fracture excess of hospital days was 23.1, including 22.7 days in rehabilitation care. HF might result from a patient's pre-fracture poor health status rather than predispose to a worsening of such pre-existing conditions. INTRODUCTION: Hip fracture represents a large burden on hospital services. It is unclear whether the post-fracture expenditure is linked to a worsening of pre-fracture comorbid conditions. We estimated the excess hospital expenditure attributable to osteoporotic HF following the initial hospitalization for acute care (index stay). METHODS: We identified 6,019 patients (> or = 50 years) who experienced HF in 2005 and compared their hospitalizations 1 year before and 1 year after the index stay. Excess expenditure was estimated by subtracting the utilization of hospital days or costs (Euros 2005) before the index stay from those after the index stay. Factors associated with hospitalization during the pre-fracture and post-fracture years were identified using multivariate logistic regressions. RESULTS: Beside the index stay, post-fracture excess of hospital days was 23.1 (95% Confidence Interval (CI) [21.8-24.3]), including 22.7 days (95% CI [21.7-23.7]) in rehabilitation care and 0.3 days (95% CI [0-0.9]) in acute care. Estimated excess cost per patient was <euro>5,986 (95% CI [5,638-6,335]) after the index stay, including <euro>5,673 (95% CI [5,419-5,928]) in rehabilitation care. Male and elderly patients were at higher risk to be hospitalized in acute care during the year preceding and succeeding HF. CONCLUSIONS: Osteoporotic HF represents a pronounced excess expenditure in hospital, which is mostly linked to rehabilitation care. Considering that utilization of inpatient acute care was quite similar before and after the index stay, HF might result from a patient's pre-fracture poor health status, rather than predispose to a worsening of such pre-existing conditions
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0 |
Factors predicting the efficacy of viscosupplementation in knee osteoarthritis
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OAK Recommendation 9 Articles
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a. Purpose: Previous research has demonstrated inconsistent effects of hyaluronic acid supplementation in patients with knee osteoarthritis (OA), and it is not known which patients will have the best clinical response to this therapy. The purpose of the present study is to evaluate some factors that may predict clinical response to a single intra-articular injection of viscosupplementation with Hylan GF-20. b. Methods: This is an observational pilot study of 100 patients at a large urban Veterans Affairs Medical Center (VAMC) with knee osteoarthritis who are scheduled to receive viscosupplementation with Hylan G-F 20 at either the rheumatology or orthopedics clinics. These patients meet the VAMC formulary guidelines for use of viscosupplementation, which entails failure or intolerance of usual methods for managing a symptomatic knee, including corticosteroid injections. Patients with a history of inflammatory arthritis (i.e., rheumatoid arthritis, gout, or pseudogout) are excluded. At baseline, patients complete a series of questionnaires to obtain the Knee Injury and Osteoarthritis Outcome Score (KOOS), Patient Health Questionnaire (PHQ-9) depression score, the New Zealand Joint Priority score (NZ score), as well as further history concerning demographics and previous injury, surgery, or other treatment. The KOOS and PHQ-9 are repeated at 3 and 6 months post-injection. A clinical responder is defined as someone with a change in
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1 |
Why are total knee replacements revised?: analysis of early revision in a community knee implant registry
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Surgical Management of Osteoarthritis of the Knee CPG
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Since 1991, 5760 knee arthroplasty procedures done by 53 surgeons have been registered in a community joint implant registry and were reviewed regarding initial revision done within the healthcare system. The 168 revisions done represented 2.9% of the knee arthroplasties between September 1991 and December 2002. Survival was defined as the absence of revision surgery. Death was considered a censored event. Cumulative survival rates for the different total knee arthroplasty configurations were: cemented total knee arthroplasty with all-polyethylene tibia, 99.2%; cemented total knee arthroplasty with metal-backed tibia, 96.3%; hybrid total knee arthroplasty, 89.3%; and unicondylar knee arthroplasty, 87.2%. Cemented total knee arthroplasty with metal-backed tibia had better survival than hybrid total knee arthroplasty, ingrowth total knee arthroplasty, and unicondylar knee arthroplasty. Cemented total knee arthroplasty with a metal-backed tibia did not have better survival than cemented total knee arthroplasty with an all-polyethylene tibia. Gender was not related to survival. Age was related to survival, with older patients' knees surviving longer. Aseptic loosening or wear was the cause of revision in 40.8% of patients having total knee arthroplasty and 46.6% of patients having unicondylar knee arthroplasty, whereas progression of arthritis necessitated unicondylar knee revision in 51.2% of patients having that procedure. This study presents further evidence of the value of and ongoing need for total joint registries. Cemented total knee arthroplasty with all-polyethylene tibia and with metal-backed tibia showed more than 95% 10-year cumulative survival. Hybrid total knee arthroplasty, ingrowth total knee arthroplasty, and unicondylar knee arthroplasties did not show such good results
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0 |
Smoking is a predictor of worse trabecular mechanical performance in hip fragility fracture patients
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AAHKS (2) Corticosteroids
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Clinical risk factors (CRFs) are established predictors of fracture events. However, the influence of individual CRFs on trabecular mechanical fragility is still a subject of debate. In this study, we aimed to assess differences, adjusted for CRFs, between bone macrostructural parameters measured in ex-vivo specimens from hip fragility fracture patients and osteoarthritis patients, and to determine whether individual CRFs could predict trabecular bone mechanical behavior in hip fragility fractures. Additionally, we also looked for associations between the 10-year risk of major and hip fracture calculated by FRAX and trabecular bone mechanical performance. In this case-control study, a group of fragility fracture patients were compared with a group of osteoarthritis patients, both having undergone hip replacement surgery. A clinical protocol was applied in order to collect CRFs [body mass index (BMI), prior fragility fracture, parental history of hip fracture, long-term use of oral glucocorticoids, rheumatoid arthritis, current smoking, alcohol consumption, age and gender]. The 10-year probability of fracture was calculated. Serum bone turnover markers were determined and dual X-ray absorptiometry performed. Femoral head diameter was evaluated and trabecular bone cylinders were drilled for mechanical testing to determine bone strength, stiffness and toughness. We evaluated 40 hip fragility fracture and 52 osteoarthritis patients. Trabecular bone stiffness was significantly lower (p = 0.042) in hip fragility fracture patients when compared to osteoarthritic individuals, adjusted for age, gender and BMI. No other macrostructural parameter was statistically different between the groups. In hip fragility fracture patients, smoking habits (beta = -0.403; p = 0.018) and female gender (beta = -0.416; p = 0.008) were independently associated with lower stiffness. In addition, smoking was also independently associated with worse trabecular strength (beta = -0.323; p = 0.045), and toughness (beta = -0.403; p = 0.018). In these patients, the 10-year risk of major (r = -0.550; p = 0.012) and hip fracture (r = -0.513; p = 0.021) calculated using only CRFs was strongly correlated with femoral neck bone mineral density but not with mechanical performance. Our data showed that among fragility fracture patients active smoking is a predictor of worse intrinsic trabecular mechanical performance, and female gender is also independently associated with lower stiffness. In this population, the 10-year risk of fracture using CRFs with different weights only reflects bone mass loss but not trabecular mechanical properties.
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Surgical treatment of gynecomastia with severe ptosis: Periareolar incision and dermal double areolar pedicle technique
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Panniculectomy & Abdominoplasty CPG
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Background: Gynecomastia is a morphostructural impairment of the mammary region in men caused by parenchymal hypertrophy or a cutaneous distortion of breast skin covering or both. The clinical classification introduced by Simon et al. in 1973 ranks gynecomastia in three degrees. Each subtype can be treated with a specific technique. This article describes an alternative surgical procedure for treating gynecomastia with severe ptosis (type III and type IIIb of Simon's classification). Methods: Fifty-eight patients were treated for gynecomastia in our Plastic Surgery Unit from 1996 to 2004. The cutaneous excess of periareolar skin is evaluated by a pinching test. A circular periareolar mark is traced corresponding to the cutaneous excess that has to be removed. Initially, liposuction of adipous tissue on the periphery of the mammary region is performed through two cutaneous 3-mm incisions at the 3 o'clock and 9 o'clock positions around the areola. After this, the liposuction incisions are enlarged from 10 o'clock to 8 o'clock and from 2 o'clock to 4 o'clock to create access for the mastectomy. This dissection creates a double dermal areolar pedicle. The new areolar position is fixed with a Benelli round block suture. Results: A resolution of the morphologic deformity without evident scars after hair growth and a correction of the breast deformity has been observed in the 6-month follow-ups conducted for all the patients. Conclusion: We observed that the vascular-nervous net under the areola at 12 o'clock and 6 o'clock is very important, more so than the lateral pedicle, and the conservation of a double vascular-nervous pedicle reduces significantly the risk of areolar necrosis, especially in cases of gynecomastia type III and in cases where there is a high degree of breast malformation such as the tuberous breast. © 2008 Springer Science+Business Media, LLC and International Society of Aesthetic Plastic Surgery.
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A brief history of plastic surgery in Iran
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Panniculectomy & Abdominoplasty CPG
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Although the exact time of performing plastic surgery is not addressed in the medical and historical literature, it can be supposed that these surgical procedures have a long and fascinating history. Recent excavations provided many documents regarding the application of medical instruments, surgical and even reconstructive procedures during the pre-historic and ancient periods. Actually, there is no historical definite time-zone separating general and cosmetic operations in the pre-modern time; however, historically there have been many surgeons who tried to perform reconstructive procedures during their usual medical practice. This article presents a brief look at the history of plastic surgery form the ancient to the contemporary era, with a special focus on Iran.
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Modification of subcutaneous adipose tissue by a methylxanthine formulation: A double-blind controlled study
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Panniculectomy & Abdominoplasty CPG
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BACKGROUND. Excessive subcutaneous adipose tissue is typically treated by physically removing the fat through liposuction, but cost and accessibility have popularized alternative treatments for reducing adipose tissue thickness. OBJECTIVE. The purpose of this study was to test the absolute and relative effectiveness of a liposome-encapsulated caffeine- based cream in modifying subcutaneous adipose tissue. METHODS. Forty-one patients consented and completed the double-blind, single-center, placebo- controlled study. Caliper measurements, tape measurements, and photographs were taken over a 2-month period. RESULTS. Both concentrations of the cream were found to significantly reduce the thickness of the adipose tissue in all areas of the body. In addition, the more concentrated cream was significantly more effective than the less concentrated cream in the areas of the hips and the triceps. CONCLUSION. The caffeine-based liposome-encapsulated cream significantly reduced the thickness of the subcutaneous fat over a 2-month period.
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Lateral patellar tilt and its longitudinal association with patellofemoral osteoarthritis-related structural damage: Analysis of the osteoarthritis initiative data
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AMP (Acute Meniscal Pathology)
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Background: Increase in lateral patellar tilt-(LPT) can cause increased pressure on the lateral facet of the knee and can lead to patellar or femoral cartilage damage and further osseous changes. This study aims to test the hypothesis whether there is an association between increased LPT and MRI-based patellofemoral osteoarthritis-(OA) features at baseline and their worsening over a 2-year follow-up in participants of the Osteoarthritis Initiative-(OAI). Methods: Recorded clinical and imaging data of 600 participants in the FNIH-OA biomarkers consortium was extracted from its database. The LPT-(as the angle between the longest patella diameter and posterior aspect of condyles) was measured using the axial knee MRI. Associations of LPT (every 5° increase) with MRI OA Knee Scoring-(MOAKS) for OA-related features, including cartilage and bone marrow lesions (BMLs) in addition to knee cartilage volume at baseline and their worsening after 2-year follow-up were assessed using regression models adjusted for several possible confounders. Results: The mean LPT angle in this sample was 8.84° ± 5.19. In baseline, higher LPT was associated with lower cartilage volumes and higher cartilage lesions and BMLs MOAKS scores in the lateral trochlear and patellar subregions. Over the follow-ups, subjects with higher LPT measures in the baseline showed higher odds of experiencing BML score worsening in the lateral trochlear subregion-(OR:1.25[1.01–1.56]) over the 2-year follow-ups. Conclusions: Increase in LPT measures may be associated with OA-related features in the trochlear subregion. Therefore, aside from its use as an indicator of patellofemoral instability syndrome, LPT may be associated with longitudinal progression of patellofemoral OA.
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Predictors of not regaining basic mobility after hip fracture surgery
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Hip Fx in the Elderly 2019
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PURPOSE: Regaining basic mobility after hip fracture surgery is a milestone in the in-hospital rehabilitation. The aims were to investigate predictors for not regaining basic mobility at the fifth post-operative day and at discharge after undergoing hip fracture surgery.
METHOD: In a prospective cohort study 274 hip fracture patients were included. Patients with compromised ability to exercise were excluded leaving 167 patients for analysis. Patient demographics, functional level, method of operation, post-operative hemoglobin and the completion of physiotherapy was registered. Basic mobility was assessed by the Cumulated Ambulation Score. Multivariate logistic regression was performed.
RESULTS: Age >80 years (OR = 7.5), low prefracture functional level (OR = 3.0), not completed the physiotherapy on first post-operative day (OR = 4.6) and hemoglobin <6 mmol/L measured on first post-operative day (OR = 5.8) were significant predictors of not regaining basic mobility within the fifth post-operative day (p values: 0.04 - <0.0001). Predictors of not regaining basic mobility at discharge were: Age >80 years (OR = 4.3), prefracture functional level (OR = 7.0) and not completed the physiotherapy on first post-operative day (OR = 3.3) (p values: 0.009-<0.0001).
CONCLUSIONS: This study shows that patients undergoing hip fracture surgery, who are not able to complete physiotherapy on first post-operative day, are at a greater risk of not regaining basic mobility during hospitalization. This highlights the importance of physiotherapy as part of the interdisciplinary treatment.
IMPLICATIONS FOR REHABILITATION: Regaining abilities in basic mobility after hip fracture surgery is a primary goal of rehabilitation during hospitalization in the acute ward. The following factors are indentified to predict patients not regaining their previous level of basic mobility: Age >80 years, low prefracture functional level, patients not being able to complete the physiotherapy on the first post-operative day and hemoglobin value <6 mmol/l on the first post-operative day. In future strategies, the findings regarding both modifiable and unmodifiable factors, can be used to conduct early planning of discharge and to take actions in relation to patients who are at a risk of not regaining basic mobility.
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0 |
Dispensable role of myeloid differentiation primary response gene 88 (MyD88) and MyD88-dependent toll-like receptors (TLRs) in a murine model of osteoarthritis
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OAK 3 - Non-arthroplasty tx of OAK
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Objectives: The aim of our study was to evaluate the role of cell-membrane expressed TLRs and the signaling molecule MyD88 in a murine model of OA induced by knee menisectomy (surgical partial removal of the medial meniscus [MNX]). Methods: OA was induced in 8-10. weeks old C57Bl/6 wild-type (WT) female (n= 7) mice and in knockout (KO) TLR-1 (n= 7), -2 (n= 8), -4 (n= 9) -6 (n= 5), MyD88 (n= 8) mice by medial menisectomy, using the sham-operated contralateral knee as a control. Cartilage destruction and synovial inflammation were evaluated by knee joint histology using the OARSI scoring method. Apoptotic chondrocytes and cartilage metabolism (collagen II synthesis and MMP-mediated aggrecan degradation) were analyzed using immunohistochemistry. Results: Operated knees exhibited OA features at 8. weeks post-surgery compared to sham-operated ones. In menisectomized TLR-1, -2, -4, and -6 deficient mice, cartilage lesions, synovial inflammation and cartilage metabolism were similar to that in operated WT mice. Accordingly, using the same approach, we found no significant protection in MyD88-deficient mice in terms of OA progression as compared to WT littermates. Conclusions: Deficiency of TLRs or their signalling molecule MyD88 did not impact on the severity of experimental OA. Our results demonstrate that MyD88-dependent TLRs are not involved in this murine OA model. Moreover, the dispensable role of MyD88, which is also an adaptor for IL-1 receptor signaling, suggests that IL-1 is not a key mediator in the development of OA. This latter hypothesis is strengthened by the lack of efficiency of IL-1β antagonist in the treatment of OA. © 2014 Société française de rhumatologie.
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1 |
Use and satisfaction with prosthetic devices among persons with trauma-related amputations: a long-term outcome study
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DoD LSA (Limb Salvage vs Amputation)
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OBJECTIVE: To document and examine the use, satisfaction, and problems with prosthetic devices among persons who suffered a trauma-related lower limb amputation. DESIGN: Abstracted medical records and follow-up interview data were collected for a retrospective cohort of persons with a lower limb trauma-related amputation who received their acute care at the University of Maryland R. Adams Cowley Shock Trauma Center, Baltimore, MD, between 1984 and 1994. Patients with spinal cord injury, traumatic brain injury, or only toe amputations were excluded. RESULTS: There were 146 patients identified. Of those, 9% died during the acute admission and 3.5% died after discharge. Seventy-eight amputees were available for interview (68% response rate). The majority of those interviewed were male (87%), and two-thirds had undergone amputation before age 40 yr. Nearly 95% had a prosthesis and wore it an average of 80 hr (SD = 33) per week. Despite high use, only 43% reported being satisfied with the comfort of their prosthesis. About one-quarter of all users reported problems with wounds, skin irritation, or pain. Traumatic amputees used an average of four prostheses since injury, about one new prosthesis every 2 yr. Statistical analyses revealed that males reported higher prosthetic use (P < 0.01). Higher Injury Severity Score negatively impacted on prosthetic use (P < 0.01). Phantom pain negatively influenced reported satisfaction with the prosthesis (P < 0.03) CONCLUSIONS: Although almost all persons living with trauma-related amputations use prosthetic devices, the majority are not satisfied with prosthetic comfort. Phantom pain and residual limb skin problems are also common afflictions in this population.
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0 |
Identification of Discrete Prognostic Groups in Ewing Sarcoma
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MSTS 2022 - Metastatic Disease of the Humerus
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Background: Although multiple prognostic variables have been proposed for Ewing sarcoma (EWS), little work has been done to further categorize these variables into prognostic groups for risk classification. Procedure: We derived initial prognostic groups from 2,124 patients with EWS in the SEER database. We constructed a multivariable recursive partitioning model of overall survival using the following covariates: age; stage; race/ethnicity; sex; axial primary; pelvic primary; and bone or soft tissue primary. Based on this model, we identified risk groups and estimated 5-year overall survival for each group using Kaplan-Meier methods. We then applied these groups to 1,680 patients enrolled on COG clinical trials. Results: A multivariable model identified five prognostic groups with significantly different overall survival: (i) localized, age <18 years, non-pelvic primary; (ii) localized, age <18, pelvic primary or localized, age =18, white, non-Hispanic; (iii) localized, age =18, all races/ethnicities other than white, non-Hispanic; (iv) metastatic, age <18; and (v) metastatic, age =18. These five groups were applied to the COG dataset and showed significantly different overall and event-free survival based upon this classification system (P<0.0001). A sub-analysis of COG patients treated with ifosfamide and etoposide as a component of therapy evaluated these findings in patients receiving contemporary therapy. Conclusions: Recursive partitioning analysis yields discrete prognostic groups in EWS that provide valuable information for patients and clinicians in determining an individual patient's risk of death. These groups may enable future clinical trials to adjust EWS treatment according to individualized risk.
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Bicipital tuberosity bone characteristics in surgical reattachment of the distal biceps: anatomical and radiological study
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Distal Radius Fractures
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PURPOSE: The aim of this study was to measure the cortical thickness and bone density of the different parts of the bicipital tuberosity, to evaluate the importance of these variables on resistance to pulling out of distal biceps tendon reinsertion implants.
METHODS: Sixteen cadaveric arms were used for this study. A multiple detector computed tomography was performed in each proximal radius. Bone thickness and density of anterior, posterior cortex and anterior trabecular bone were measured in proximal, medial and distal parts of the bicipital tuberosity. Statistical and concordance analyses of results were performed.
RESULTS: In our specimens, the medial and distal parts of the anterior cortex and the anterior trabecular bone were thicker, mean 11.3 mm SD 2.72 and 11.17 mm SD 3.05, with a significant difference when compared to the proximal part; mean 10.3 mm SD 2.35, of radial tuberosity. The three posterior segments where all thicker compared to the anterior cortex (proximal 3.15 SD 1.31; medial 3.33 SD 1.5; distal 3.34 SD 1.43 mm), but without statistical differences between them. The measured bone density was equivalent in the three portions of the anterior cortex and trabecular bone [proximal 1924.63 SD 547.22; medial 1848.19 SD 538.59; distal 2100.47 SD 396.32 Hounsfield units (HU)]. The posterior cortex was denser compared to the anterior cortex and the anterior trabecular bone in all the segments (proximal 1962.63 SD 223.57; medial 1907.16 SD 232.08; distal 1987.06 SD 189.12 HU), but without statistical differences between the three parts.
CONCLUSIONS: Based on the results of this anatomic study which have demonstrated that anterior cortex and anterior trabecular bone of the medial and distal regions of the bicipital tuberosity are thicker than proximal part, we postulate that these segments could give better pulling out resistance to monocortical implants. Our findings suggest that the strongest parts of the bicipital tuberosity are the proximal and medial parts of the posterior cortex. We can afford them drilling across the radius using a bicortical implant in the proximal and medial section of the radial tuberosity. Furthermore, we suggest that an increased margin of safety could be achieved to prevent injury to the posterior interosseous nerve, drilling the cortical hole in the proximal part of the radial tuberosity without losing resistance properties.
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Identification of a subgroup of patients at highest risk for complications after surgical cytoreduction and hyperthermic intraperitoneal chemotherapy
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DOD - Acute Comp Syndrome CPG
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OBJECTIVE: To assess the influence of parietal and visceral peritonectomy procedures on moderate/severe morbidity in patients undergoing surgical cytoreducion and hyperthermic intraperitoneal chemotherapy (HIPEC) and to identify subgroups of patients at highest operative risk. BACKGROUND: Cytoreducion with HIPEC is an effective but potentially morbid treatment option for peritoneal surface malignancies. Although complication rates have recently decreased with increasing experience, risk-factors for adverse operative outcome are still poorly understood. METHODS: A prospective database of 426 combined procedures was reviewed. Multivariate analysis tested the correlation between major morbidity and 6 peritonectomies (greater and lesser omentectomy, pelvic, parietal anterior, left and right diaphragmatic peritonectomy), 14 visceral resections, 5 other operative factors, and 12 clinical variables. The extent of peritoneal involvement was quantified by peritoneal cancer index (PCI). RESULTS: Mortality and major morbidity were 2.6% and 28.2%. PCI, number of visceral resections, poor performance status, and cisplatin dose more than 240 mg independently correlated to morbidity. The type and number of parietal peritonectomies and the type of visceral resections did not correlated to complications. Major morbidity rate was 65.7% in 35 (8.2%) patients with at least 2 of the following factors: PCI greater than 30, more than 5 visceral resections, poor performance status. Morbidity was 100% in 9 patients presenting all the risk factors. CONCLUSIONS: Acceptable morbidity and low mortality may be achieved in high-volume centers. Operative outcome is mainly affected by a complex interplay of tumor, patient, and treatment-related factors. Preoperative and early intraoperative assessment of operative risk may identify a subset of patients unlikely to tolerate aggressive management. © 2012 Lippincott Williams & Wilkins, Inc.
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Arthroscopic Partial Trapeziectomy With Soft Tissue Interposition for Symptomatic Trapeziometacarpal Arthritis: 6-Month and 5-Year Minimum Follow-Up
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Glenohumeral Joint OA
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PURPOSE: To determine if arthroscopic partial trapeziectomy (APT) and soft tissue interposition arthroplasty is an effective treatment for symptomatic trapeziometacarpal arthritis.
METHODS: We retrospectively evaluated 30 consecutive patients with symptomatic isolated trapeziometacarpal arthritis, Eaton-Littler stages II and III. Treatment consisted of an APT with soft tissue interposition utilizing an acellular dermal matrix as the interposition material. At a minimum of 6 months and 5 years after surgery, Numeric Pain Rating Scale (NPRS), Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH), grip strength, oppositional and appositional pinch strengths, arthroplasty space, and thumb range of motion (ROM) were evaluated.
RESULTS: At 6-month minimum follow-up, 30 of 30 patients reported a significant reduction in pain; preoperative NPRS averaged 8.2 and decreased to 1.3. Average QuickDASH score was 17.5. Twenty-nine of 30 thumbs could adduct fully in the plane of the palm. Twenty-four patients were available for 5-year minimum follow-up. Average QuickDASH score measured 8.9, whereas pain (mean NPRS, 0.8), grip, and pinch strengths were not significantly different from the 6-month assessment. There was a small reduction in arthroplasty space at 5-year follow-up that did not affect clinical outcome measures. Thumb ROM did not change between the 6-month and the 5-year follow-up. Complications were rare.
CONCLUSIONS: An APT with interposition arthroplasty utilizing an acellular dermal matrix as the interposition material is a safe and reliable procedure with satisfactory outcomes at short- and long-term follow-up. Pain, strength, QuickDASH, and ROM do not significantly change between the 6-month and the 5-year follow-up.
TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.
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0 |
Comparative safety of endovascular aortic aneurysm repair over open repair using patient safety indicators during adoption
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Hip Fx in the Elderly 2019
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IMPORTANCE In 2003, the Agency for Healthcare Research and Quality established Patient Safety Indicators (PSIs) to monitor preventable adverse events during hospitalizations. Copyright 2014 American Medical Association. All rights reserved. OBJECTIVE To evaluate the comparative safety of endovascular aneurysm repair (EVAR) vs open aneurysm repair (OAR) of abdominal aortic aneurysm by measuring PSIs associated with each procedure over time. DESIGN, SETTING, AND PARTICIPANTS Cases of abdominal aortic aneurysm repairwere extracted from the Nationwide Inpatient Sample (2003-2010). Patient Safety Indicators were calculated using Agency for Healthcare Research and Quality software (Win QI, version 4.4). Unadjusted analysis included year, age, sex, race/ethnicity, comorbidities, rupture status, hospital teaching status, and emergency status. Multivariable analysis was stratified by year for any PSI in EVAR vs OAR. Postoperative mortality was analyzed to control for the overall safety. MAIN OUTCOMES AND MEASURES Patient Safety Indicators and mortality. RESULTS In total, 43 385 EVARs and 27 561 OARs were documented, with 1289 (3.0%) and 3094 (11.2%) associated PSIs, respectively. Compared with those receiving OAR, patients receiving EVAR were more likely to be male, older, and of white race/ethnicity; have a lower Charlson Comorbidity Index; and seek care at teaching hospitals (P <.001 for all). Patients were less likely to have a PSI after EVAR than after OAR. Overall, multivariable analysis showed that EVAR was associated with a 42.1% decrease in the risk-adjusted odds of any PSI compared with OAR (odds ratio, 0.58; 95%CI, 0.51-0.65). Stratified by year, the risk-adjusted odds of any PSI after EVAR were comparatively less likely than after OAR every year except for 2007, and the odds of death were comparatively less every year. The annual percentage of PSIs among all aortic repairs decreased from 7.4%in 2003 to 4.4%in 2010, while the proportion of total repairs that were EVARs increased from 41.1%in 2003 to 75.3%in 2010. CONCLUSIONS AND RELEVANCE Patient Safety Indicators can be used to monitor the comparative safety of emerging surgical technologies. Herein, EVAR was safer than OAR. The adoption of minimally invasive technology can improve safety among surgical admissions.
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Do all hip fractures result from a fall?
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Management of Hip Fractures in the Elderly
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Although most fractures of the proximal femur result from a fall and are related to direct loads to the hip, there is evidence that intrinsic factors, such as muscle contraction, can result in a hip fracture and subsequent fall. This paper reviews the current literature on the various mechanisms of femoral neck and intertrochanteric fractures
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The Use of TIGR Matrix in Breast Aesthetic and Reconstructive Surgery: Is a Resorbable Synthetic Mesh a Viable Alternative to Acellular Dermal Matrices?
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Acellular Dermal Matrix
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The authors document their experience in the use of synthetic 100% bioresorbable surgical mesh (TIGR Matrix, Novus Scientific, Uppsala, Sweden) in breast reconstruction as well as in breast aesthetic surgery. They performed a retrospective review on patients who underwent implant-based breast reconstruction as well as patients who underwent breast reduction mammoplasty procedures with the use of TIGR Matrix Surgical Mesh. When compared with other synthetic but nonresorbable meshes, it appears to show a potentially lower seroma and infection rates, but most importantly, a lower rate of revisional and mesh explantation surgeries.
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Long-term results of the ludloff procedure in relation to the intraoperative finding on acetabular labrum
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Developmental Dysplasia of the Hip 2020 Review
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PURPOSE OF THE STUDY Developmental dysplasia of the hip still remains one of the most discussed topics in paediatric orthopaedics. The comprehensive care of paediatric patients with congenital developmental dysplasia of the hip at our department in the period from 1970 to 1985 included, among other things, the open reduction using Ludloff s approach in hip joints where closed reduction was not possible. This technique was supported by some of our own previous observations, such as the original classification of intraoperative findings on acetabular labrum (limbus). This study aims to evaluate the long-term results of treatment of our patients where Ludloff s open reduction was used and seeks to establish a conclusive correlation between the final result and the method of treatment of individual types of limbus, possibly confirming or ruling out that the dependence of later development of the acetabulum is dependent on correct and sparing treatment of this barrier to reduction. MATERIAL AND METHODS In the period from 1970 to 1985, the Ludloff s open reduction was performed in 70 patients. In 8 cases bilateral surgery was carried out. A total of 78 hip joints were operated on. The patients underwent the surgery at the age of 5-23 months. Postoperatively, the Hanausek biomechanical apparatus was applied to complete the treatment. In total, documentation of 21 surgeries performed in 20 patients was successfully tracked down. Two patients were removed from the group for incomplete documentation. The final group of patients included a total of 18 patients, of whom there were 13 women and 5 men. In one female patient the surgery was performed bilaterally. The shape of the femoral head, the center-edge (CE) angle and the degree of osteoarthritic changes were assessed on the pelvic radiograph of each patient. The functional result was evaluated using the Harris Hip Score (HHS). RESULTS For the purpose of assessment, the patients were divided into sub-groups based on the intraoperative finding on acetabular labrum. Type I limbus was found in a total of 5 cases. The mean HHS was 93, the mean CE angle was 22.5°. Aseptic necrosis occurred in one patient. Type II limbus was found in a total of 3 patients. The mean HHS was 84, the mean CE angle was 22°. Aseptic necrosis was observed in one patient. Type III limbus was found in 8 patients. The mean HHS was 79, the mean CE angle was 19.4°. Osteoarthritic changes of degree II-III were identified. Necrosis of the femoral head was recorded in 2 patients. Type IV limbus was found three times. The mean HHS was 73, the mean CE angle was 13.3°. Osteoarthritic changes of type III were present. Necrosis of the femoral head was recorded altogether in 2 patients. DISCUSSION The results of the Ludloff procedure reported in the available literature differ markedly as to the resulting function of the hip joint and the incidence of avascular necrosis. No author gave a description of the actual acetabular labrum deformity or showed a detailed description of individual vessel ligations. The advantage of this method is beyond any doubt its low invasiveness and when correctly performed also the minimal burden to the child. Its disadvantage is a certain degree of difficulty in performing this surgery, a worse visualisation of all barriers to reduction and a more challenging treatment of the posterior portion of the hip joint compared to techniques using the anterior approach. CONCLUSIONS Our outcomes indicate that the resulting Harris Hip Score was best in patients with the intraoperative finding of type I limbus. All the other types (ll-IV) showed worse HHS results. From the current perspective, it is in all likelihood more advantageous to use surgical approaches that enable better visualisation of the anatomical deformities and allow for better options for their treatment.
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Assessment of renal toxicity and osteonecrosis of the jaws in patients receiving zoledronic acid for bone metastasis
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MSTS 2018 - Femur Mets and MM
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BACKGROUND: Bisphosphonates (BP) decrease the incidence of skeletal related events among cancer patients with bone metastases from solid tumors and multiple myeloma. Renal safety and osteonecrosis of the jaws (ONJ) are two major concerns of toxicity. Information about safety of using BP beyond 2 years is scarce.
MATERIALS AND METHODS: Patients receiving zoledronic acid (ZA) at the time of the study were reviewed. Serum creatinine levels (SCL) were collected at three different moments: before the start of BP (baseline), at the time of analysis (final), and the highest SCL during the treatment (highest). Oral examination was carried out in every patient. Separated analysis was made for patients on BP for >2 years. Concomitant risk factors for both renal toxicity and ONJ were evaluated.
RESULTS: Sixty-seven patients were included. Median time of BP was 22 months, with 22 patients receiving BP for >2 years. Median baseline and final values of SCL were 0.71 mg/dl and 0.70 mg/dl, respectively (P = 0.121). Median highest SCL during treatment was 0.82 mg/dl (P <0.0001). A notable increase in the SCL was observed in six of the 67 patients (9%), four of them receiving BP for >2 years (P = 0.085). ONJ was also diagnosed in six patients, four of them in the group of prolonged BP treatment.
CONCLUSION: ZA showed to be safe with a low rate of reversible renal toxicity. Patients receiving BP should be monitored carefully for renal toxicity and ONJ, especially those with exposure to BP beyond 2 years.
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Clinical anatomy in aesthetic gluteal body contouring surgery
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Panniculectomy & Abdominoplasty CPG
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This article describes some of the major anatomical issues that confront plastic surgeons when contouring and augmenting the gluteal region. A better understanding of anatomy can improve the cosmetic results of gluteal augmentation and thereby enhance patient satisfaction. More importantly, this knowledge can reduce the risks of complications, some of which may have long-term adverse effects.
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Reverse shoulder arthroplasty in acute fractures of the proximal humerus: A systematic review
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PJI DX Updated Search
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The indications for surgical intervention in complex fractures of the proximal humerus are disputed. In elderly patients with poor bone stock it may be impossible to obtain satisfactory fixation of the tuberosities to a hemiarthroplasty (HA). In such cases primary insertion of a reverse shoulder arthroplasty (RSA) has been suggested. We aimed to review clinical studies reporting benefits and harms of RSA in acute fractures. A systematic review. We included 18 studies containing 430 RSA in acute fractures. We found no randomized clinical trials. Four studies compared outcome after RSA with a historical control group of HA. The median constant score was 58 (range 44-68) which is comparable to previous reviews of HA in 4-part fractures. Complications included dislocation, infection, hematoma, instability, neurological injury, reflex sympathetic dystrophy, intraoperative fractures, periprosthetic fractures, and baseplate failure. Scapular notching was reported in 11 studies with a median value of 25% (range 0-94). Heterogeneity of study designs and lack of primary data precluded statistical pooling of data. No high quality evidence was identified. Based on the available evidence the use of RSA in acute fractures is questionable. The complication rate was high and the clinical implications of long term scapular notching are worrying. Randomized studies with long term follow up using the latest techniques of tubercular reinsertion in RSA toward HA should be encouraged
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Genome-wide copy-number-variation study identified a susceptibility gene, UGT2B17, for osteoporosis
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Management of Hip Fractures in the Elderly
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Osteoporosis, a highly heritable disease, is characterized mainly by low bone-mineral density (BMD), poor bone geometry, and/or osteoporotic fractures (OF). Copy-number variation (CNV) has been shown to be associated with complex human diseases. The contribution of CNV to osteoporosis has not been determined yet. We conducted case-control genome-wide CNV analyses, using the Affymetrix 500K Array Set, in 700 elderly Chinese individuals comprising 350 cases with homogeneous hip OF and 350 matched controls. We constructed a genomic map containing 727 CNV regions in Chinese individuals. We found that CNV 4q13.2 was strongly associated with OF (p = 2.0 x 10(-4), Bonferroni-corrected p = 0.02, odds ratio = 1.73). Validation experiments using PCR and electrophoresis, as well as real-time PCR, further identified a deletion variant of UGT2B17 in CNV 4q13.2. Importantly, the association between CNV of UGT2B17 and OF was successfully replicated in an independent Chinese sample containing 399 cases with hip OF and 400 controls. We further examined this CNV's relevance to major risk factors for OF (i.e., hip BMD and femoral-neck bone geometry) in both Chinese (689 subjects) and white (1000 subjects) samples and found consistently significant results (p = 5.0 x 10(-4) -0.021). Because UGT2B17 encodes an enzyme catabolizing steroid hormones, we measured the concentrations of serum testosterone and estradiol for 236 young Chinese males and assessed their UGT2B17 copy number. Subjects without UGT2B17 had significantly higher concentrations of testosterone and estradiol. Our findings suggest the important contribution of CNV of UGT2B17 to the pathogenesis of osteoporosis
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Image classification for Die-punch fracture of intermediate column of the distal radius
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Distal Radius Fractures
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OBJECTIVE: The aim of the study was to analyze the imaging findings of Die-punch fracture of intermediate column of the distal radius, and to explore the clinical application value of image classification.
METHODS: The clinical data of 45 patients who were admitted to our hospital from May 2010 to October 2016 were analyzed retrospectively. All patients met the inclusion criteria for Die-punch fracture. X-ray and CT scan were performed to examine the fracture, and the results were assessed by two doctors in a double blind method. Finally, the image classification of Die-punch fracture was formulated.
RESULTS: According to the imaging features of Die-punch fracture, it was divided into four types: type I (dorsal type, 15 cases), type II (volar type, 8 cases), type III (splitting type, 10 cases), type IV (collapsed type, 12 cases). The accuracy rate of CT was 100% (45/45). The misclassification rate of X-ray was 15.6% (7/45) and the missed diagnosis rate was 11.1% (5/45).
CONCLUSIONS: CT examination could accurately diagnose Die-punch fracture and perform preoperative image classification.
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Incidence of Meniscal Entrapment and Associated Knee Injuries in Tibial Spine Avulsions
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AMP (Acute Meniscal Pathology)
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BACKGROUND: Tibial spine avulsions (TSA) have historically been treated as isolated injuries. Data on associated injuries are limited with existing literature reporting wide ranging incidences. The purpose of this multicenter study was to (1) describe the incidence of meniscal entrapment and associated knee injuries in TSA and to (2) compare surgical and magnetic resonance image (MRI) findings for these injuries. Our hypothesis is that tibial spine injuries are not usually isolated injuries, and other meniscal, ligament, and cartilage injuries may be present.
METHODS: MRI and surgical reports for patients with a diagnosis of a tibial spine fracture were retrospectively reviewed. Type of fracture was recorded as noted in the reports along with concomitant meniscal entrapment and osteochondral, ligamentous, and meniscal injury. Images and reports were reviewed by an orthopaedic surgeon at each respective institution.
RESULTS: A total of 163 patients were included in this study. MRI was done for 77 patients and surgery was performed in 144 cases. Meniscal entrapment was found in 39.9% of all patients. MRI diagnosed meniscus, osteochondral, and non-anterior cruciate ligament ligamentous injury was found in 31.2%, 68.8%, and 32.4% of cases, respectively. Surgically diagnosed meniscus, chondral, and non-anterior cruciate ligament ligamentous injury was found in 34.7%, 33.3%, and 5.6% of patients, respectively.
CONCLUSIONS: TSA fractures are associated with significant risk for concomitant knee injuries including meniscal tear, bone contusion, and chondral injury. Incidence of meniscal entrapment found during surgery was high, in spite of low incidence of positive findings by MRI.
LEVEL OF EVIDENCE: Level IV-retrospective case series.
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The accuracy of self-reported fractures in older people
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Management of Hip Fractures in the Elderly
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Self-report is often used in large-scale studies. Therefore, it is important to determine the accuracy of self-report. In the Blue Mountains Eye Study, a population-based study of 3,654 older, community-dwelling Australians, subjects were asked about fracture history at the 5-year follow-up interview. All reported non-rib and vertebral fractures were radiologically confirmed. Hospital radiology records were searched for fracture records of people who reported no fractures in the 5-year period. Of 2,326 subjects who came to the interview, 272 subjects reported 318 fractures sustained since 1990. Overall, 34.6% of fracture reports could not be confirmed, mainly due to no record of treatment. Among self-reported fractures, false positive rates were 10.7% for all fractures and 4.8% for hip, 2.2% for wrist, 19.4% for ankle, and 6.6% for shoulder fractures. Sensitivity and specificity of fracture reports was high, with the lowest sensitivity for shoulder fractures (82.4%). Self-report of major osteoporotic fractures is reasonably accurate but may be improved by obtaining more details about treatment. (copyright) 2002 Elsevier Science Inc. All rights reserved
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Endogenous MMP-9 and not MMP-2 promotes rheumatoid synovial fibroblast survival, inflammation and cartilage degradation
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OAK 3 - Non-arthroplasty tx of OAK
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OBJECTIVE: The aim of this study was to investigate the effect of endogenous matrix metalloproteinases 2 and 9 (MMP-2 and MMP-9) on the invasive characteristics of RA synovial fibroblasts.
METHODS: Synovial fibroblasts isolated from patients with RA or OA were treated with MMP small interfering RNA (siRNA), inhibitors and recombinant proteins or TNF-alpha, with or without cartilage explants. Cell viability and proliferation were measured by 3-[4,5-dimethylthiazol-2-yl]-2,5-diphenyl tetrazolium bromide and 5-bromo-2-deoxyuridine (BrdU) proliferation assays, respectively; apoptosis by an in situ cell death detection kit; migration and invasion by CytoSelect invasion assay, scratch migration and collagen gel assays; cartilage degradation by 1,9-dimethylmethylene blue assay; and inflammatory mediators and MMPs by ELISA, western blot and zymography.
RESULTS: MMP-2 was expressed by both OA and RA synovial fibroblasts, whereas only RA synovial fibroblasts expressed MMP-9. Suppressing MMP-2 or MMP-9 reduced RA synovial fibroblast proliferation equally. However, MMP-9 siRNA had greater effects compared with MMP-2 siRNA on promoting apoptosis and suppressing RA synovial fibroblast viability, migration and invasion. Suppression/inhibition of MMP-9 also decreased the production of IL-1beta, IL-6, IL-8 and TNF-alpha, inactivated nuclear factor kappaB (NF-kappaB), extracellular signal-regulated kinase (ERK) and c-Jun NH2-terminal kinase (JNK) and suppressed RA synovial fibroblast-mediated cartilage degradation. In contrast, suppression/inhibition of MMP-2 stimulated TNF-alpha and IL-17 secretion and activated NF-kappaB, while recombinant MMP-2 (rMMP-2) inactivated NF-kappaB and suppressed RA synovial fibroblast-mediated cartilage degradation. Results using specific inhibitors and rMMPs provided supportive evidence for the siRNA results.
CONCLUSION: Endogenous MMP-2 or MMP-9 contribute to RA synovial fibroblast survival, proliferation, migration and invasion, with MMP-9 having more potent effects. Additionally, MMP-9 stimulates RA synovial fibroblast-mediated inflammation and degradation of cartilage, whereas MMP-2 inhibits these parameters. Overall, our data indicate that MMP-9 derived from RA synovial fibroblasts may directly contribute to joint destruction in RA.
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Obesity, metabolic abnormality, and knee osteoarthritis: a cross-sectional study in Korean women
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OAK 3 - Non-arthroplasty tx of OAK
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BACKGROUND: This study aimed to analyze the association between knee osteoarthritis and four body size phenotypes defined by the presence or absence of metabolic abnormality and obesity.
MEHODS: This was a cross-sectional study using data from 1,549 female participants of the Fifth Korean National Health and Nutrition Examination Survey. Knee osteoarthritis was defined as a Kellgren-Lawrence grade of >= 2. Metabolically abnormal state was defined as presence of more than one abnormality among five metabolic risk factors. Obesity was defined using body mass index. Participants were grouped into one of the four body size phenotypes: metabolically healthy normal weight (MHNW), metabolically abnormal but normal weight (MANW), metabolically healthy obesity (MHO), and metabolically abnormal obesity (MAO).
RESULTS: The distribution of each body size phenotype was as follows: MHNW 54.7%, MANW 30.7%, MHO 4.3%, and MAO 10.3%. Prevalence of symptomatic knee osteoarthritis was higher in MANW than in MHNW, and in MAO than in MHO. In multivariable analysis, the association between symptomatic knee osteoarthritis and the body size phenotypes was as follows (OR [95% CI]): MHNW 1.00 (reference), MANW 1.54 (1.15-2.07), MHO 1.61 (0.83-3.13), and MAO 3.47 (2.35-5.14).
CONCLUSIONS: Obesity showed closest association with knee osteoarthritis when accompanied by metabolic abnormality.
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Supracondylar elbow fractures with impaction of the medial condyle in children
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The Treatment of Pediatric Supracondylar Humerus Fractures AUC
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We reviewed the cases of 13 children with supracondylar elbow fractures with impaction of the medial wall. The displacement was underestimated in two patients and treated as a minimally displaced fracture by simple immobilization without reduction, resulting in a cubitus varus deformity. In one patient, the correct diagnosis was made, but treatment by reduction was refused by the parents. A loss of carrying angle of 10 degrees resulted from this. Two patients referred for treatment of cubitus varus were treated elsewhere for the initial injury: one by reduction and plaster cast immobilization and the other by simple immobilization without reduction. Two children with a supracondylar fracture with buckling of the medial condyle without prominent deformity were not reduced and showed no deformity at follow-up. Six children with collapse of the medial condyle, treated by closed reduction and percutaneous pinning, all had a normal carrying angle at follow-up. We believe that this method is safe to prevent varus angulation
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Large autologous ilium with periosteum for tibiotalar joint reconstruction in Ruedi-Allgower III or AO/OTA type C3 pilon fractures: a pilot study
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DoD SSI (Surgical Site Infections)
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BACKGROUND: Management of Ruedi-Allgower III or AO/OTA type C3 pilon fracture presents numerous challenges to the orthopaedic surgeon. A joint preservation technique using a large autologous ilium with periosteum in combination with internal implant fixation was reported to improve the outcome of reconstruction.
METHODS: Twenty-five patients according to Tscherne/Oestern FxCO-I closed fracture and FxOI open fractures classification after Ruedi-Allgower III or AO/OTA type C3 pilon fracture received a large autologous ilium with periosteum for tibiotalar joint reconstruction and open reduction and internal fixation (ORIF), between March 2015 and September 2018. The visual analog scale (VAS), American Orthopaedic Foot & Ankle Society (AOFAS) score, and Burwell and Charnley criteria were used for outcome analysis.
RESULTS: Twenty patients with an average age of 45.2 years were followed for an average of 18.3 months. The VAS and AOFAS scores, and Burwell and Charnley ratings were recorded at the last follow-up after reconstructive surgery. Two patients developed redness and swelling at the wound site, but recovered after local care and dressing changes. No patient displayed deep surgical site infection, donor site complication, non-union or local complication during the final follow-up. The average bone union time was 18.3 months (range 3-36).
CONCLUSIONS: Large autologous ilium with periosteum in combination with ORIF can be performed for tibiotalar joint reconstruction. This experimental procedure reduces the risk of post-operative complications following articular reconstruction for Ruedi-Allgower III or AO/OTA type C3 pilon fractures in short follow-up.
LEVEL OF EVIDENCE: Level III, retrospective cohort study.
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Migraine and risk of dementia: A nationwide retrospective cohort study
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DoD PRF (Psychosocial RF)
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Objective: Migraines are one of the most common neurological disorders. Dementia is a neurodegenerative disease characterized by slow progressive memory loss and cognitive dysfunction. This retrospective cohort study investigates the association between migraines and dementia using a nationwide population-based database in Taiwan. Methods: We retrieved the data analyzed in this study from the National Health Insurance Research database (NHIRD) in Taiwan. We used multivariate Cox proportion-hazards regression models to assess the effects of migraines on the risk of dementia after adjusting for sociodemographic characteristics and comorbidities. Results: The migraine cohort had a higher prevalence of diabetes, hypertension, coronary artery disease, head injury and depression at baseline (p < 0.0001). After adjusting the covariates, migraine patients had a 1.33-fold higher risk of developing dementia [hazard ratio (HR) 1.33, 95% confidence interval (CI) 1.22-1.46]. The sex-specific incidence rate of dementia was higher in men than in women in both cohorts, with an HR of 1.09 (95% CI 1.00-1.18) for men compared to women. Kaplan-Meier analysis shows that the cumulative incidence of dementia was 1.48% greater in the migraine cohort than in the nonmigraine cohort (log-rank test, p < 0.0001). Conclusions: This study shows that migraines are associated with a future higher risk of dementia after adjusting for comorbidities. Specifically, the association between migraine and dementia is greater in young adults than in older adults. Copyright © 2013 S. Karger AG, Basel.
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Trabecular bone architecture in the distal radius using magnetic resonance imaging in subjects with fractures of the proximal femur. Magnetic Resonance Science Center and Osteoporosis and Arthritis Research Group
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Management of Hip Fractures in the Elderly
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To determine whether magnetic resonance (MR)-derived measures of trabecular bone architecture in the distal radius are predictive for prevalent hip fractures, 20 subjects with hip fractures and 19 age-matched postmenopausal controls were studied. Bone mineral density (BMD) measures at the hip (dual-energy X-ray absorptiometry, DXA) and the distal radius (peripheral quantitative computed tomography, pQCT) were also obtained. We compared the MR-based structural measures derived in the radius with those in the calcaneus of the same patients. In the radius, images were acquired at an in-plane resolution of 156 microm and a slice thickness of 0.5 mm. Stereologic measures such as the apparent trabecular thickness (app. Tb.Th), fractional trabecular bone volume (app. BV/TV), trabecular spacing (app. Tb.Sp) and trabecular number (app. Tb.N) were derived from the images. Measures of app. Tb.Sp and app. Tb.N in the distal radius showed significant (p<0.05) differences between the two groups, as did hip BMD measures. However, radial trabecular BMD measures showed only a marginal difference (p = 0.05). Receiver operating curve analysis was used to determine the diagnostic efficacy of BMD, structural measures and a combination of the two. The area under the curve (AUC) for total hip BMD was 0.73, and for radial trabecular BMD was 0.69. AUC for most of the measures of trabecular bone structure at the distal radius was lower than for hip BMD measures; however, AUC for app. Tb.N at the radius was 0.69, comparable to trabecular BMD using pQCT. The AUC for combined BMD (hip) and structure measures was higher (0.87) when radius and calcaneus structure was included. Measures of trabecular architecture derived from MR images combined with BMD measures improve the discrimination between subjects with hip fractures and normal age-matched controls
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Lack of effect of orally administered human serum immunoglobulin on the normal human oral and intestinal microflora
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Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures
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The aim of this study was to investigate the influence of large doses of orally administered human IgG on the normal gastrointestinal microflora of healthy volunteers since human immunoglobulin has been tried as oral prophylaxis and therapy in gastrointestinal infections. Ten adult healthy volunteers received 10 g of IgG orally, once daily for three consecutive days. Aerobic and anaerobic microorganisms were identified in the saliva and stool specimens, using morphological, biochemical and serological tests and gas-liquid chromatography. Although the immunoglobulin preparation contains antibodies against a variety of microorganisms, there were no significant changes in the numbers of different aerobic and anaerobic microorganisms due to the oral intake of the immunoglobulin. IgG may, therefore, be used against pathogens without disturbing the normal oral and intestinal microflora
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Trochanteric osteotomy versus posterolateral approach: function the first year post surgery. A pilot study
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Management of Hip Fractures in the Elderly
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Although no prospective studies have compared functional results of trochanteric osteotomy and a non-trochanteric approach, most surgeons feel that trochanteric osteotomy is outdated in simple hip arthroplasty. Reasons not to perform an osteotomy include the fear of longer rehabilitation and worse (final) functional outcome. This prospective study examines differences in rehabilitation between posterolateral and trochanteric approach one year post-surgery using questionnaires (WOMAC, SF-36, HHS) and functional tests (walking, climbing stairs, rising from sitting, and strength tests). Of the 109 patients 24 had a trochanteric osteotomy: the selected approach was based on the surgeon's preference. The trochanteric osteotomy group included more patients with developmental dysplasia of the hip. Before the start of the study no power analysis was performed. Data from the questionnaires showed no significant differences between the two groups at 3, 6 and 12-months follow-up. At 3-months follow-up patients in the trochanteric osteotomy group scored lower on the functional tests. This difference had disappeared at 6 and 12-months follow-up, except for abduction force which remained lower in the trochanteric osteotomy group in patients with a non union of the TO. For simple hip arthroplasty an approach without osteotomy seems a logical choice. Although the power of this study is low, in experienced hands trochanteric osteotomy seems to give good functional results at 6-12 months post surgery if trochanteric union is obtained. Therefore, one should not hesitate to perform an osteotomy in difficult cases
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Renal failure in multiple myeloma: reversibility and impact on the prognosis. Nordic Myeloma Study Group
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MSTS 2018 - Femur Mets and MM
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The purpose of the present study was to analyse the importance and prognostic value of renal failure in multiple myeloma patients. The frequency and reversibility of renal failure in 775 multiple myeloma patients diagnosed between 1984-86 and 1990-92 in the Nordic countries were studied. Renal failure, defined as plasma creatinine > 130 micromol/l, was observed in 29% of the cases at the time of diagnosis. During the first year after diagnosis 58% achieved normalisation of p-creatinine, and this was achieved mainly during the first 3 months. Reversibility of renal failure was more frequently observed in patients with moderate renal failure, hypercalcaemia and low Bence-Jones protein excretion. In a multivariate analysis renal failure, high age, stage III disease and hypercalcaemia were independent prognostic factors for survival. Patients who needed dialysis had a poor prognosis, with a median survival of 3.5 months. A 12-months landmark analysis showed that reversibility of renal failure was a more important prognostic factor than response to chemotherapy. It is concluded that renal failure in multiple myeloma is reversible in about half the cases, and reversibility of renal failure improves long-term survival.
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Role of Arthroscopy in the Treatment of Osteoarthritis of Knee
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OAK 3 - Non-arthroplasty tx of OAK
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BACKGROUND: A variety of procedures have been described for treatment of the osteoarthritic knee. Comprehensive Arthroscopic treatment regime has definite role in treating patients with knee Osteoarthritis.
AIM: To evaluate the role of arthroscopy in functional and subjective outcomes of patient with moderate to severe osteoarthritis of knee.
MATERIALS AND METHODS: Between October 2011 to September 2013, 30 patients were treated with an arthroscopic regimen. Patients with primary osteoarthritis who fulfilled clinical and radiographic classification criteria of American College of Rheumatology for osteoarthritis were included. All patients were followed for 18 months. All patients were subjected to comprehensive arthroscopic treatment.
RESULTS: Overall, mean age was 59 years, with 17 females and 13 males. According to Kellgren Lawrence scale, 17 patients had grade 2 osteoarthritis, 10 had grade 3 osteoarthritis and 3 patients had grade 4. The average preoperative Lysholm score was 38.8. According to Outerbridge grading of chondral surface lesions, 14 patients were in grade-1, 5 in grade-2, 8 in grade-3 and 3 patients were in grade-4. The average 18 months postoperative Lysholm score was 83.3 (range 60- 96). 73.33% patients showed good/ excellent outcome. 80% of patients with chondral and meniscal lesions showed excellent/good outcome.
CONCLUSION: This arthroscopic treatment regimen can improve function and activity levels in patients with moderate to severe osteoarthritis. Patients with meniscal and chondral pathology will be benefited more by arthroscopic treatment.
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Roentgen stereophotogrammetric analysis and clinical assessment of unipolar versus bipolar hemiarthroplasty for subcapital femur fracture: a randomized prospective study
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Management of Hip Fractures in the Elderly
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BACKGROUND: Hemiarthroplasty is a well-established treatment for displaced subcapital fracture, but controversy exists about the optimal implant type. Bipolar hemiarthroplasty has proposed advantages over unipolar hemiarthroplasty in terms of better clinical results and decreased wear of acetabular cartilage. METHODS: This study is a randomized prospective study of 51 patients (52 hips) receiving either bipolar or unipolar hemiarthroplasty for displaced subcapital fractures. The outcome measurements were clinical scores and Roentgen stereophotogrammetric analysis (RSA) analysis to determine the rate of acetabular wear. RESULTS: Twenty-three patients completed 2-year follow-up. The RSA data demonstrated that there was slightly less acetabular wear by bipolar prostheses than by unipolar. The combined mean three-dimensional wear of the bipolar prostheses was 0.6 mm compared with 1.5 mm for the unipolar prostheses (P= 0.04). The bipolar group generally achieved higher scores in terms of the Harris Hip Score, Western Ontario and McMaster University Index of Osteoarthritis (WOMAC) questionnaire and 6-min walk test. These results were statistically significant at 3 months but not at 12 and 24 months. CONCLUSION: This study suggests that while the bipolar prosthesis performs slightly better than the unipolar in terms of acetabular cartilage wear and clinical outcomes, it remains debatable whether the benefits are worth the increased cost of the prosthesis
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Titanium Elastic Nailing has Superior Value to Plate Fixation of Midshaft Femur Fractures in Children 5 to 11 Years
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Pediatric Diaphyseal Femur Fractures 2020 Review
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BACKGROUND: American Academy of Orthopaedic Surgeons (AAOS) Clinical Practice Guidelines for pediatric femoral shaft fractures indicate titanium elastic nails (TENs) for children 5 to 11 years old. Growing evidence suggests these fractures may also be treated with open or submuscular plating. The purpose of this study was to compare estimated blood loss (EBL), operative time, fluoroscopy time, cost, and subjective and objective pain scores between TENs and plating techniques used in 5- to 11-year-old children with midshaft femur fractures based on length stability. We hypothesized that EBL, operative time, and fluoroscopy time would be greater and pain would be lower with plate fixation. METHODS: We retrospectively identified all pediatric midshaft femur fractures treated with TENs, submuscular plating, or open plating between 2004 and 2014. Demographic, injury, and surgical data were obtained for analysis. Cost data were obtained from Synthes Inc. Outcomes were determined using the TEN outcome scoring system. Variables were compared between the 3 fixation methods using paired t tests or Fisher exact test as appropriate. Cost data were compared with Mann-Whitney nonparametric test. RESULTS: There were 65 midshaft femur fractures in 63 patients included. TENs accounted for 77% and plating 23%. There were no statistical differences in injury severity score, length of stay, length unstable fractures, open fractures, fluoroscopy time, or pain. However, there was a significantly greater operative time (P=0.007) and a notably greater EBL (P=0.057) for the plating technique compared with TENs. Patient outcomes were found to be equivalent. Implant cost was not significantly different although increased surgical costs were seen in plating (P=0.0007). CONCLUSIONS: This study supports the use of TENs or plating for midshaft femur fractures in children 5 to 11 years old, regardless of length stability. The use of plates resulted in higher EBL, longer operative time, increased cost, and equivalent pain compared with TENs. To our knowledge, this study represents the first direct comparison of the common fixation methods specifically for midshaft femur fractures and favors the use of TENs. LEVEL OF EVIDENCE: Level III.
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Exercise for lower limb osteoarthritis: systematic review incorporating trial sequential analysis and network meta-analysis
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OAK 3 - Non-arthroplasty tx of OAK
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OBJECTIVE: To determine whether there is sufficient evidence to conclude that exercise interventions are more effective than no exercise control and to compare the effectiveness of different exercise interventions in relieving pain and improving function in patients with lower limb osteoarthritis.
DATA SOURCES: Nine electronic databases searched from inception to March 2012.
STUDY SELECTION: Randomised controlled trials comparing exercise interventions with each other or with no exercise control for adults with knee or hip osteoarthritis.
DATA EXTRACTION: Two reviewers evaluated eligibility and methodological quality. Main outcomes extracted were pain intensity and limitation of function. Trial sequential analysis was used to investigate reliability and conclusiveness of available evidence for exercise interventions. Bayesian network meta-analysis was used to combine both direct (within trial) and indirect (between trial) evidence on treatment effectiveness.
RESULTS: 60 trials (44 knee, two hip, 14 mixed) covering 12 exercise interventions and with 8218 patients met inclusion criteria. Sequential analysis showed that as of 2002 sufficient evidence had been accrued to show significant benefit of exercise interventions over no exercise control. For pain relief, strengthening, flexibility plus strengthening, flexibility plus strengthening plus aerobic, aquatic strengthening, and aquatic strengthening plus flexibility, exercises were significantly more effective than no exercise control. A combined intervention of strengthening, flexibility, and aerobic exercise was also significantly more effective than no exercise control for improving limitation in function (standardised mean difference -0.63, 95% credible interval -1.16 to -0.10).
CONCLUSIONS: As of 2002 sufficient evidence had accumulated to show significant benefit of exercise over no exercise in patients with osteoarthritis, and further trials are unlikely to overturn this result. An approach combining exercises to increase strength, flexibility, and aerobic capacity is likely to be most effective in the management of lower limb osteoarthritis. The evidence is largely from trials in patients with knee osteoarthritis.
PROTOCOL REGISTRATION: PROSPERO (www.crd.york.ac.uk/prospero/) No CRD42012002267.
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Self-reported health status of students in-processing into military medical advanced individual training
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DoD PRF (Psychosocial RF)
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It is important to be aware of the health and injury status of students in military training settings in order to adequately plan for their progression through required physical training and provision of health care to meet their needs. This paper describes the self-reported health status of students arriving in two medical training Battalions at Ft. Sam Houston. The results revealed that 43% of arriving soldiers had musculoskeletal symptoms and 35% had symptoms that interfered with their ability to accomplish the normal daily activities required as students. The most common sites of symptoms were knee (17 and 18%), foot/toe (16 and 13%), ankle (9 and 10%), and lower leg (9 and 12%) for the 232nd and 187th Medical Battalions respectively. Risk factors for those with musculoskeletal injury (MSI) symptoms that interfere with their abilities to do their jobs include gender, past history of injury, and self-reported stress and fitness levels. Other risk factors for medical specialties other than combat medic include being older (over 24 yrs of age), active duty status, being overweight, and use of smokeless tobacco. This information can help identify soldiers considered at risk of incurring a MSI during AIT. With this knowledge, physical training can be designed to help soldiers achieve fitness without additional injury and health care facilities can be designed to provide appropriate staffing of the health care professionals needed for evaluation and treatment. (PsycINFO Database Record (c) 2016 APA, all rights reserved)
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Unreconstructable acute distal humeral fractures and their sequelae treated with distal humeral hemiarthroplasty: a two-year to eleven-year follow-up
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The Treatment of Pediatric Supracondylar Humerus Fractures AUC
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BACKGROUND: The aim of this study was to describe for the first time the medium to long-term outcome after distal humeral hemiarthroplasty (DHH). METHODS: Twenty-six patients (mean age, 62; range, 29-92 years) treated with DHH for intra-articular distal humeral fractures and its sequelae were studied retrospectively. RESULTS: Four patients had died and 4 had been revised to total elbow arthroplasty: 2 for periprosthetic fractures and 2 for primary component loosening (all in prostheses without an anterior flange). Six other complications had occurred: ulnar neuritis, 4; stiffness, 1; and wound necrosis, 1. Seventeen patients underwent assessment at a mean of 80 months after surgery. The mean values of the American Shoulder and Elbow Surgeons (ASES) elbow score (pain, 9.93; function, 25; satisfaction, 9.06); Mayo Elbow Performance Score (90); Quick Disabilities of Arm, Shoulder and Hand (19), and EuroQol EQ5D (Index, 0.84; Visual Analog Scale, 80) outcome measures demonstrated good function and satisfaction with little pain. The mean flexion extension arc was 116 degrees . There was no evidence of instability. Radiologic evidence of ulnar wear was seen in 13 patients and may be related to prosthetic design to some extent. Worse wear was associated with a higher ASES pain score, lower satisfaction score, and lower EuroQoL Visual Analog Scale of quality of life. Degree of wear correlates with time after surgery but not with age at the time of surgery. CONCLUSION: DHH offers a treatment option for unreconstructable distal humeral fractures and is associated with a good long-term outcome
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Lower extremity overuse injuries in the skeletally immature athlete
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Osteochondritis Dissecans 2020 Review
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Sport participation is a leading cause of injury in children and adolescents. Although the focus often is on acute injuries, overuse injuries are extremely common and can cause lasting damage when not recognized early and treated appropriately. Overuse injuries result from the combination of repetitive microtrauma and inadequate healing time. Children are especially susceptible for many reasons, including muscle-tendon imbalance, improper technique, and difficulty identifying early signs of injury. In the last decades, not only have more children been participating in sporting activities, but the intensity of their participation has increased, with many participating year-round on multiple teams, often with professional or scholarship aspirations. As a consequence, overuse injuries have become even more prevalent. Bone, cartilage, tendon, physis, or apophysis may be affected, and the diagnosis can be challenging. In an effort to promote prevention, early recognition, and treatment of overuse injuries in children and adolescents, this article provides an overview of these injuries, describes vulnerabilities of the immature skeleton, and provides guidance andtalking points for physicians, parents, and coaches. © 2014 Wolters Kluwer Health.
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Fluconazole prophylaxis in extremely low birth weight neonates reduces invasive candidiasis mortality rates without emergence of fluconazole-resistant candida species
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Patrick’s pharmacoepidemiology project
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Objective. We evaluated the impact of fluconazole prophylaxis for extremely low birth weight infants on invasive candidiasis incidence, invasive candidiasis-related mortality rates, and fluconazole susceptibility of Candida isolates. Methods. Extremely low birth weight infants <5 days of age, except those with liver dysfunction, were eligible for fluconazole prophylaxis. NICU infants (all birth weights) with invasive candidiasis between April 2002 and March 2006 were compared with those with invasive candidiasis before fluconazole prophylaxis (20002001). Results.Twenty-two infants had invasive candidiasis (all candidemia) during fluconazole prophylaxis;before fluconazole prophylaxis, there were 19 cases (candidemia: 17 cases;meningitis: 2 cases). Invasive candidiasis incidence in NICU infants decreased from 0.6% (19 of 3012 infants) before fluconazole prophylaxis to 0.3% (22 of 6393 infants) in 2002-2006 and that in extremely low birth weight infants decreased 3.6-fold. No Candida-attributable deaths occurred during 2002-2006 fluconazole prophylaxis, compared with 4 (21%) before fluconazole prophylaxis. The onset of invasive candidiasis was later during 2002-2006 (23.5 vs 12 days), but risk factors were similar. The invasive candidiasis species distribution remained stable. Of 409 infants who received fluconazole prophylaxis, 119 (29%) received 42 days. Shorter fluconazole prophylaxis duration was related to intravenous access no longer being necessary in 242 cases (59%), noninvasive candidiasis-related death in 29 (7%), hospital transfer in 8 (2%), invasive candidiasis diagnosis in 8 (2%), and transient increase in serum transaminase levels in 4 (1%). One hundred twenty- seven infants (31%) who received fluconazole prophylaxis developed cholestasis during hospitalization, two thirds of whom had other predisposing conditions. On multivariate logistic regression necrotizing enterocolitis and increasing days of total parenteral nutrition, but not increasing number of doses on days of fluconazole, were significantly associated with the development of cholestasis. Coclusion. During 4 years of fluconazole prophylaxis, the incidence of invasive candidiasis and invasive candidiasis- associated mortality rates in extremely low birth weight infants were reduced significantly, without the emergence of fluconazole-resistant Candida species. Copyright �© 2008 by the American Academy of Pediatrics
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Activity-Related Outcomes of Articular Cartilage Surgery: A Systematic Review
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SR for PM on OA of All Extremities
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Objective: The purpose of this systematic review was to compare activity-based outcomes after microfracture, autologous chondrocyte implantation (ACI), and osteochondral autograft (OAT). Design: Multiple databases were searched with specific inclusion and exclusion criteria for level III and higher studies with activity outcomes after microfracture, OAT, osteochondral allograft, and ACI. Activity-based outcomes included the Knee Injury and Osteoarthritis Outcome Score (KOOS), the Tegner Score, the Cincinnati Knee scores, the International Knee Documentation Committee (IKDC) subjective knee score, the Marx activity score, and/or the rate of return-to-sport. Results: Twenty studies were included (1,375 patients). Although results were heterogeneous, significant advantages were seen for ACI and OAT as compared with microfracture in Tegner scores at 1 year (ACI vs. microfracture, P = 0.0016), IKDC scores at 2 years (ACI vs microfracture, P = 0.046), Lysholm scores at 1 year (OAT vs microfracture, P = 0.032), and Marx scores at 2 years (OAT vs microfracture, P < 0.001). The only score or time point to favor microfracture was Lysholm score at 1 year (ACI vs microfracture, P = 0.037). No other standardized outcome measures or time points were significantly different. Several studies demonstrated significantly earlier return to competition with microfracture. Overall reoperation rates were similar, but of reoperations, a higher proportion of those following ACI were unplanned with the majority of performed for graft delamination or hypertrophy. Conclusions: ACI and OAT may have some benefits over microfracture, although return-to-sport is fastest following microfracture. Heterogeneity in technique, outcome measures, and patient populations hampers systematic comparison within the current literature. (copyright) The Author(s) 2013
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Surgery for plasma cell neoplasia patients with spinal instability or neurological impairment caused by spinal lesions as the first clinical manifestation
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MSTS 2018 - Femur Mets and MM
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Purpose: Multiple myeloma (MM) and solitary plasmacytoma of bone (SPB) are two independent subtypes of plasma cell dyscrasias which often occur in spine. However, little is known about the surgical treatment of patients with spinal instability or neurological impairment caused by spinal lesions as the first clinical manifestation. The present study aimed to investigate the surgical outcome of these patients. Methods: We retrospectively reviewed the data of a total of 64 patients receiving spinal surgery in our center, in which 30 were diagnosed as MM and 34 as SPB. Univariate and multivariate analyses were used to identify factors associated with overall survival (OS) and progression-free survival (PFS) of patients. Results: Surgical treatment led to favorable results including pain relief, resumption of ambulatory ability as well as improvement of neurological function and life quality. Univariate analysis suggested that the potential prognostic factors for OS of MM patients were bisphosphonate treatment, post-surgical ambulatory status, Karnofsky Performance Score (KPS) and Frankel scale, and for PFS of MM patients were age at surgery, resection mode, postoperative ambulation status, KPS and Frankel scale, while the PFS of SPB patients was only significantly related to postoperative adjuvant therapies. Multivariate analysis indicated that postoperative ambulation status was the only independent risk factor for both OS and PFS of MM patients. Conclusions: Surgery may be beneficial to patients with spinal instability or neurological impairment caused by spinal lesions as the first clinical manifestation, in which MM patients with postoperative ambulatory ability display better prognosis.
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Temporal in vitro expansion of the luminal lineage of human mammary epithelial cells achieved with the 3T3 feeder layer technique
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Reduction Mammoplasty for Female Breast Hypertrophy
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Human mammary epithelial cells from reduction mammoplasties were serially propagated in vitro from single cells and/or cell clusters using the NIH 3T3 cell feeder layer technique. In seven passages 46 cell population doublings, corrected for plating efficiency were achieved. The plating efficiency of epithelial cells in the primary culture was 0.2%. During subsequent passages it rose to 10-12% and decreased sharply towards the end of the culture life. In the third and fourth passages temporal prevalence of luminal cells was observed. The critical conditions for prevalence of the luminal phenotype were found to be the initial dissociation and optimum seeding density during subculturing. In primary cultures, after optimum dissociation of 0.15 cm3 mammary tissue with 0.05% collagenase A (Boehringher-Mannheim) in Eagle's MEM for 16 h at 37 degrees C, the yield on day 13 was 20 large colonies of 8-10 mm diameter. About 30% of the epithelial cells, which stained positively for the luminal cell marker cytokeratin 19, occupied colony centres. The remaining 70% were actin positive myoepithelial cells at the periphery. In subsequent passages, when using the optimum seeding density of 2 x 10(5) cells per 60 mm culture dish, the proportion of luminal cells gradually increased to 90% on day 35 in the fourth passage. A sudden rise in the proportion of rapidly growing myoepithelial cells to 65% was observed in the fifth passage. In the sixth and seventh passage small colonies were formed, most of which contained at least one keratin-19-positive (luminal) cell. Cells of human breast carcinomas are considered to be of luminal origin. Therefore, the described approach can be useful in studies of cell and molecular biology of mammary carcinomas.
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Postmenopausal women with Colles' fracture have lower values of bone mineral density than controls as measured by quantitative ultrasound and densitometry
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Management of Hip Fractures in the Elderly
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Measurement of ultrasonographic parameters provides information concerning not only bone density but also bone architecture. We investigated the usefulness of ultrasonographic parameters and bone mineral density (BMD) to evaluate the probability of Colles' fracture. Two-hundred eighty-nine postmenopausal women (62.3 (plus or minus) 8.7 yr) with (n = 76) and without (n = 213) Colles' fracture were studied. BMD of lumbar spine and proximal femur was evaluated in all women by dual-energy X-ray absorptiometry (DXA) and speed of sound (SOS), broadband ultrasound attenuation (BUA), and stiffness in the calcaneus were measured by a Sahara ultrasonometer (Hologic). Patients suffering from Colles' fracture had lower values of BMD adjusted by height at the lumbar spine, L2-L4 (0.797 g/cm(2) vs 0.860 g/cm(2)), femoral neck (0.685 g/cm (2) vs 0.712 g/cm(2)), SOS (1518 m/sg vs 1525 m/sg), and stiffness (74.6 vs 77.7) (p < 0.05). Nevertheless, BUA values were similar in both groups. After stepwise logistic regression analysis, the area found under receiver operating characteristic (ROC) curves was 0.60 for L2L4 and 0.63 for a formula combining L2L4 and height. Our data suggest that patients suffering from Colles' fracture have lower values of BMD by DXA, SOS, and stiffness. However, the ability of these techniques to discriminate is low because the values for the area under ROC curve are 0.60 for L2-L4 and 0.63 for a formula derived of the combination of L2-L4 and height. (copyright) Copyright 2005 by Humana Press Inc. All rights of any nature whatsoever reserved
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Localized development of knee osteoarthritis can be predicted from MR imaging findings a decade earlier
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AMP (Acute Meniscal Pathology)
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PURPOSE: To define localized development of knee osteoarthritis (OA) that arises from anterior cruciate ligament (ACL) and meniscal injuries identified at magnetic resonance (MR) imaging performed a decade ago and the subsequent management of those findings in patients with subacute knee symptoms.
MATERIALS AND METHODS: The present study was approved by local medical ethics review boards, and written informed consent was obtained. Three hundred twenty-six patients (mean age, 42 years; 108 female) from a previously reported series of 855 patients were followed up with regard to the effect of MR imaging-guided treatment for subacute knee problems. The mean follow-up period was 10 years. Initial findings and treatment were compared with the follow-up radiograph and 3.0-T MR image findings. Odds ratios (ORs), with corresponding 95% confidence intervals, were used to identify the effects between variables.
RESULTS: Patients with ACL ruptures had an increased risk of developing joint space narrowing (JSN), cartilaginous defects, osteophytes, bone marrow lesions, and subchondral cysts medially or laterally (OR, 2.4-9.8). Patients with medial meniscal tears had an increased risk of developing JSN, cartilaginous defects, osteophytes, and bone marrow lesions medially (OR, 2.0-15.3). Patients with lateral meniscal tears had an increased risk of developing JSN, cartilaginous defects, osteophytes, bone marrow lesions, and subchondral cysts laterally (OR, 2.1-10.5). Meniscectomy had no effect on the risk of developing OA.
CONCLUSION: Localized knee OA developed from risk factors identified from the findings of MR imaging performed a decade ago in patients with subacute knee symptoms and did not depend on the surgical treatment of those findings.
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Physical therapies for improving balance and reducing falls risk in osteoarthritis of the knee: a systematic review
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OAK 3 - Non-arthroplasty tx of OAK
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INTRODUCTION: osteoarthritis (OA) of knee has been reported as a risk factor for falls and reduced balance in the elderly. This systematic review evaluated the effectiveness of physical therapies in improving balance and reducing falls risk among patients with knee OA.
METHODS: a computerised search was performed to identify relevant studies up to November 2013. Two investigators identified eligible studies and extracted data independently. The quality of the included studies was assessed by the PeDro score.
RESULTS: a total of 15 randomised controlled trials involving 1482 patients were identified. The mean PeDro score was 7. The pooled standardised mean difference in balance outcome for strength training = 0.3346 (95% CI: 0.3207-0.60, P = 0.01 < 0.00001, P for heterogeneity = 0.85, I(2) = 0%). Tai Chi = 0.7597 (95% CI: 0.5130-1.2043, P<=0.0014, P for heterogeneity = 0.26, I(2) = 0%) and aerobic exercises = 0.6880 (95% CI: 0.5704-1.302, P < 0.00001, P for heterogeneity = 0.71, I(2) = 0%). While pooled results for falls risk outcomes in, strength training, Tai chi and aerobics also showed a significant reduction in reduced risk of falls significantly with pooled result 0.55 (95% CI: 0.41-0.68, P < 0.00001, P for heterogeneity = 0.39, I(2) = 6%).
CONCLUSION: strength training, Tai Chi and aerobics exercises improved balance and falls risk in older individuals with knee OA, while water-based exercises and light treatment did not significantly improve balance outcomes. Strength training, Tai Chi and aerobics exercises can therefore be recommended as falls prevention strategies for individuals with OA. However, a large randomised controlled study using actual falls outcomes is recommended to determine the appropriate dosage and to measure the potential benefits in falls reduction.
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Stationary potentials after median nerve stimulation: Changes with arm position
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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We previously reported the presence of stationary negative potentials (N3, N6, N9) over the arm ipsilateral to the side of median nerve stimulation. In this study, we examined the effect of different arm positions upon these stationary peaks in 12 normal subjects. When arm position was changed from elbow extended to elbow flexed 90(degrees), we recorded a new negative peak, N4. The peak latency of N4 corresponded to the traveling impulse reaching the distal biceps brachii. With the elbow flexed, N3, N6 and N9 peak latencies significantly shortened compared to those recorded with the arm in the usual elbow extended position. In contrast, with the arm abducted at the shoulder, N6 and N9 latencies were significantly prolonged while N3 remained unchanged. Corresponding latency shifts were also observed in the bipolarly recorded traveling impulse. We consider 2 possible factors for N4 enhancement by elbow flexion. One is the change in conducting volume surrounding the nerve, i.e., increased muscle bulk of biceps brachii. The other is the change in axial orientation of the propagating nerve impulse by 90(degrees). We also propose that the latency shifts of the stationary potential as well as of a traveling wave can be attributed primarily to relaxation or stretching of the nerve trunk with change in arm position
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Hemodialysis-associated carpal tunnel syndrome. A clinical review
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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The clinical features of 88 patients who developed carpal tunnel syndrome (CTS) in association with end stage renal failure and chronic hemodialysis were studied (11 original cases and 77 collected from the literature). Hemodialysis-associated CTS was found to have a 2 to 1 male predominance, to occur more often in angioaccess-bearing (86%) than in unoperated arms (48%) (p = 0.005), and to require surgical release of the median nerve in most of the cases (86%). The analysis of 48 of these patients revealed two patterns of presentation. Patients with the 'early pattern' (41.6%) developed CTS within 1 year of commencing hemodialysis; diabetes mellitus and/or severe polyneuropathy were present in at least 40%. In contrast, patients with the 'late pattern' (58.4%) developed symptoms after at least 1 year on hemodialysis; diabetes mellitus and/or polyneuropathy were present in less than 10%. CTS should be considered in any hemodialysis patient with upper extremity neurological symptoms; early diagnosis and treatment will prevent loss of hand function
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Leptotrichia species in human infections
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Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures
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Leptotrichia species typically colonize the oral cavity and genitourinary tract. These anaerobic bacteria belong to the normal flora of humans and are seldom found in clinically significant specimens. However, on rare occasions, Leptotrichia has been isolated from blood cultures of patients with lesions in the oral mucosa, in particular from patients with neutropenia. These organisms should be considered potential pathogens in neutropenic patients, especially when breaks in the mucosal barriers are present through which they frequently spread to the bloodstream. Leptotrichia has also been recovered from immunocompetent persons, e.g. patients with endocarditis. Although their role in infections remains elusive and not much is known, they have been suggested as emerging pathogens. The present review deals with taxonomy, diagnosis, clinical importance, pathogenesis, host defence, infection control, and spectrum of Leptotrichia infections, and ends with a few typical case reports. Currently, six species have been validly published, but a number of yet uncultivable species exist. Molecular methods recovering uncultivable species should be used to get a real idea of their role as pathogens
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Limited short-term effect of palliative radiation therapy on quantitative computed tomography-derived bone mineral density in femora with metastases
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MSTS 2018 - Femur Mets and MM
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Purpose The aim of this study was to determine the effect of single fraction (SF) and multiple fraction (MF) radiation therapy (RT) on bone mineral density (BMD) in patients with cancer and bone metastases in the proximal femur. We studied this effect in the radiation field and within metastatic lesions, and differentiated between lytic, blastic, and mixed lesions. Methods and materials This prospective cohort study comprised 42 patients with painful bone metastases, including 47 irradiated femora with 52 metastatic lesions in the proximal femur. Patients received either 8 Gy SF or 20 to 24 Gy in 5 to 6 fractions (MF). Quantitative computed tomography scans were obtained before RT and 4 and 10 weeks after the initial scan. Patients who received MF additionally underwent quantitative computed tomography on the final day of their treatment. Automated image registration was performed. Mean BMD was determined at each time point for each proximal femur (region of interest [ROI]-PF) and in greater detail for a region of interest that contained the metastatic lesion (ROI-ML). Statistical analysis was performed using linear mixed models. Results No significant differences in mean BMD were found between SF or MF RT over all time points in both ROI-PF and ROI-ML. Mean BMD did not change in ROI-PF with lytic and mixed lesions, but mean BMD in ROI-PF with blastic lesions increased to 109%. Comparably, when focused on ROI-ML, no differences in mean BMD were observed in lytic ROI-ML but mean BMD in mixed and blastic ROI-ML increased up to 105% and 121%, respectively. Conclusions Ten weeks after palliative radiation therapy in patients with femoral metastatic lesions, a limited increase in BMD was seen with no beneficial effect of MF over SF RT. BMD in lytic lesions was unchanged but slightly increased in mixed and blastic lesions.
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Clinical and arthrographic findings in meniscal cysts
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AMP (Acute Meniscal Pathology)
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Fifty meniscal cysts (36 lateral and 14 medial) were found in a review of 2,522 knee arthrograms. Thirty-eight cysts presented as a palpable bulge. In all cases characteristic horizontal tears extended into the periphery, with pooling of contrast material and club-shaped terminations. The differential diagnosis of a bulge around the knee joint is discussed. Arthrographic evaluation is valuable in determining appropriate treatment.
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Serum cathepsin B and plasma urokinase-type plasminogen activator levels in gastrointestinal tract cancers
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MSTS 2018 - Femur Mets and MM
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Cathepsin B (CATB) and urokinase-type plasminogen activator (UPA) play an important part in cancer invasion and metastasis. The behavior of CATB and UPA has not been evaluated in the same experimental setting in different gastrointestinal tumors and in precancerous lesions. Serum CATB and plasma UPA levels were determined by enzyme-linked immunoadsorbent assay and their sensitivity, specificity, and diagnostic accuracy have been calculated in patients with colorectal (n=72), gastric (n=30), hepatocellular (n=28), and pancreatic cancer (n=15) as well as in gastric epithelial dysplasia (n=25), colorectal adenomas (n=30), and tumor-free control patients (n=44). Serum CATB and plasma UPA antigen concentrations were significantly higher in patients with cancer than in controls. When all tumors were considered, the sensitivity, specificity, and diagnostic accuracy of CATB (89, 86, and 89%) were higher than that of UPA (76, 70, and 74%). CATB demonstrated in all types of tumors a better diagnostic accuracy than UPA. The positive predictive values of CATB (95%) and UPA (89%) may suggest their use in the evaluation of patients with a suspicion of malignancy. CATB and UPA were significantly higher in patients with gastric epithelial dysplasia and colorectal adenomas than in controls. Antigen levels of CATB and UPA were significantly correlated in both cancers and precancerous lesions. At the time of clinical presentation, serum CATB and plasma UPA antigen levels are sensitive indicators of gastrointestinal malignancies. Determination of serum CATB and plasma UPA levels may be useful to identify patients at a higher risk for progression to cancer, who could be subjected to a more strict follow-up protocol.
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Missing data may lead to changes in hip fracture database studies: A study of the American college of surgeons national urgical quality improvement program
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DoD SSI (Surgical Site Infections)
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Aims The aims of this study were to characterize the frequency of missing data in the National Surgical Quality Improvement Program (NSQIP) database and to determine how missing data can influence the results of studies dealing with elderly patients with a fracture of the hip. Patients and Methods Patients who underwent surgery for a fracture of the hip between 2005 and 2013 were identified from the NSQIP database and the percentage of missing data was noted for demographics, comorbidities and laboratory values. These variables were tested for association with 'any adverse event' using multivariate regressions based on common ways of handling missing data. Results A total of 26 066 patients were identified. The rate of missing data was up to 77.9% for many variables. Multivariate regressions comparing three methods of handling missing data found different risk factors for postoperative adverse events. Only seven of 35 identified risk factors (20%) were common to all three analyses. Conclusion Missing data is an important issue in national database studies that researchers must consider when evaluating such investigations.
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The assessment of postural control with stochastic resonance electrical stimulation and a neoprene knee sleeve in the osteoarthritic knee
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OAK 3 - Non-arthroplasty tx of OAK
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OBJECTIVE: To determine whether the combination of stochastic resonance (SR) electrical stimulation and a neoprene knee sleeve could improve center of pressure (COP) measures of postural sway during single-leg stance in those with knee osteoarthritis (OA).
DESIGN: Counterbalanced, repeated-measures intervention study of osteoarthritic adults during 6 different testing conditions: a control condition-control 1 (1); a counterbalance sequence of 4 treatment conditions-no stimulation with sleeve (2), 75% stimulation with sleeve (3), 100% stimulation with sleeve (4), and 150% stimulation with sleeve (5); and a second control condition-control 2 (6).
SETTING: University sports medicine research laboratory.
PARTICIPANTS: Subjects (N=52) with radiographically determined, minimal-to-moderate medial knee OA.
INTERVENTIONS: Neoprene knee sleeve and SR electrical stimulation.
MAIN OUTCOME MEASURES: COP displacement in the medial-lateral and anterior-posterior directions was collected to resolve the mean velocity, SD, range, and total path length.
RESULTS: No significant differences were found in the study measures between the testing conditions. Additionally, no significant differences were found between the 3 stimulation conditions or between the sleeve-alone and stimulation conditions for any of the study measures.
CONCLUSIONS: There were no significant improvements in balance with the use of a neoprene knee sleeve. Additionally, there was no added benefit of the SR stimulation as applied in the current configuration in this population.
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Split gluteal muscle flap for autoprosthesis buttock augmentation
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Panniculectomy & Abdominoplasty CPG
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BACKGROUND: Several flaps have been described to provide autologous augmentation to the gluteal area. Since the authors' original description of a dermal fat flap for buttock augmentation during lower body lift in 2005, the procedure has been refined considerably. Unique to previously described flaps, the technique results in maximum projection of the buttock at its midportion. A decrease in fatty necrosis and greater mobility has been achieved by transitioning to a split gluteal musculocutaneous flap. METHODS: In a retrospective review from January of 2004 to August of 2010, 200 patients, aged 24 to 57 years, underwent autologous buttock augmentation. The last 50 patients of the series underwent an incorporation of a split section of gluteus maximus muscle. Patients were followed for 6 months to 4 years. RESULTS: Of the 200 patients, 30 had the buttock flap as an isolated buttock lift and augmentation; the remainder of the procedures were performed in conjunction with a circumferential body lift. Incorporation of the split gluteus maximus muscle facilitated the rotation of the flap caudally and increased the vascular supply to the flap. Ten percent of the patients had minor complications, which included small areas of delayed wound healing and partial fat necrosis of the dermal flaps. In the group with split musculocutaneous flaps, there was no fatty necrosis. Results were maintained over time. CONCLUSIONS: This is a reliable, versatile, and efficient flap for autologous buttock augmentation. With recent modifications, the incidence of fatty necrosis has been substantially decreased. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.
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Periodontal diagnosis: evaluation of current concepts and future needs
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Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures
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Periodontal diseases are multifactorial pathologies that manifest clinically by destruction of the soft and hard tissues. Bacterial insult has been implicated in the initiation of these diseases, however the degree of destruction is dependent on the host response. The host response varies from individual to individual depending on many factors including the type of the bacterial insult, the duration of the insult, the local and environmental contributing factors, immunological and inflammatory responses, predisposing genetic factors, and association with systemic diseases. The classical methods of periodontal diagnosis have been limited to clinical examination and radiographic evaluation. These methods essentially determine previous destruction, or history of disease. Evaluation of disease activity has been limited to longitudinal evaluation of these parameters, with limited accuracy, and predictors of future disease activity have not been available. The goal of new diagnostic methods is the early diagnosis of disease, before significant destruction has occurred, and measures of successful treatment or disease arrest. To this end, work has begun on genetic predictors of susceptibility which might be used to implement prevention programmes or alter treatment decisions
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Intramuscular corticosteroid injection versus placebo effective in pain reduction in patients with hip osteoarthritis
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PJI DX Updated Search
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Purpose: Several international guidelines recommend intra-articular (IA) corticosteroid injections for patients with hip OA experiencing moderate to severe pain and no responding to oral analgesics. However, injection into the hip joint is challenging and needs ultrasound or fluoroscopic guidance. This makes it almost impossible in general practice. Moreover, an IA injection can lead to septic arthritis. An IA injection in the year preceeding total hip replacement increases the risk of infection leading to early revision surgery. Previous research has shown a systemic effect of an intramuscular (IM) gluteal corticosteroid injection in patients with subacromial impingement shoulder pain. A clinically relevant effect of IM corticosteroid injections would offer a less complex, alternative treatment for patients' episodes of increased pain in hip OA. The trial aim was to assess the efficacy of an IM gluteal corticosteroid injection compared to a placebo injection on patients' reported hip pain severity in patients with hip OA, who were not responding on oral analgesics. Methods: A double blinded randomized controlled trial was performed in primary and secondary care patients with hip OA. Patients were included if they met the clinical ACR and radiographic (KL score >2) criteria for hip OA and scored a severity of hip pain >3 on a scale of 0-10 (0 = no hip pain) despite the use of oral analgesics. Patients were randomized to receive either 40 mg of triamcinolone acetate or saline (placebo) with an IA injection into the ipsilateral gluteus muscle. Primary outcome was severity of hip pain at 2 weeks, measured with numerical rating scale (NRS) in rest and during walking (0-10; 0 = no pain) and with the WOMAC pain subscale (0-100; 0 = no pain). Secondary outcomes included hip pain severity (NRS, WOMAC pain, ICOAP), function (WOMAC function), stiffness (WOMAC stiffness), adverse events, and medical co-interventions (e.g. oral analgesics use and health care visits) at 2, 4, 6, and 12 weeks follow-up. Statistical analyses were performed based on the intention to treat (ITT) principle. Linear mixed models with repeated measurements were used to analyze between group differences. The models were adjusted for variables that changed the effect estimate >10%. Results: 107 of 422 screened patients were randomized. After informed consent, one randomized patient did not show up at the appointment for baseline measurement and subsequent injection and could, because of lack of data, not be included in the ITT analysis. Finally, 52 patients in the corticosteroid injection group, and 54 in the placebo injection received the allocated intervention and were included in the analysis. 68% of the patients were female, and 25% were recruited in secondary care. Mean age was 64 (SD 11) and duration of symptoms was >1 year for 70%. At 2 weeks follow-up (table), the corticosteroid injection was statistically significant and clinically relevant associated with hip pain reduction at rest (coefficient -1.3, 95%CI -2.3 to -0.3) compared to the placebo injection. The corticosteroid injection was also associated with significant hip pain reduction at 4, 6 and 12 weeks. Moreover, at almost all follow-up measurements the estimates showed significant differences in favor of the corticosteroid injection onWOMAC pain, function, stiffness and total score, and ICOAP. No significant differences between groups were found for adverse events and medical co-interventions. Conclusions: An IM gluteal corticosteroid injection was effective in hip pain reduction compared to placebo injection in patients with hip OA at 2 weeks follow-up. Moreover, the effect of the corticosteroid injection prolonged the entire 12 week follow-up period. Based on our results we suggest that IM corticosteroid injection is an effective method to reduce patients' pain in hip OA for a period of at least up to 12 weeks. (Table Presented)
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Spontaneous resolution of soft-tissue interposition after closed reduction of hip endoprosthesis dislocation
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Management of Hip Fractures in the Elderly
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Over a 5-year period at a single institution, 164 endoprostheses were used for the treatment of displaced femoral neck fractures. Soft-tissue restraint preservation and repair (hip capsule and labrum) is recommended to enhance stability after endoprosthesis placement. When dislocation does occur, however, this soft tissue may become interposed after closed reduction. This occurred in 2 of the dislocations reported here. In these 2 dislocations, despite the widened joint space, the range of motion was stable. Neither of these cases had a subsequent dislocation, and after 1 month, both had spontaneously narrowed their joint space back to the immediate postoperative state
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Clinical effects of thai herbal compress: a systematic review and meta-analysis
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OAK 3 - Non-arthroplasty tx of OAK
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Objective . To determine the clinical effects of Thai herbal compress.
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Segmental proximal femoral bone loss and revision total hip replacement in patients with developmental dysplasia of the hip: the role of allograft prosthesis composite
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PJI DX Updated Search
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The treatment of substantial proximal femoral bone loss in young patients with developmental dysplasia of the hip (DDH) is challenging. We retrospectively analysed the outcome of 28 patients (30 hips) with DDH who underwent revision total hip replacement (THR) in the presence of a deficient proximal femur, which was reconstructed with an allograft prosthetic composite. The mean follow-up was 15 years (8.5 to 25.5). The mean number of previous THRs was three (1 to 8). The mean age at primary THR and at the index reconstruction was 41 years (18 to 61) and 58.1 years (32 to 72), respectively. The indication for revision included mechanical loosening in 24 hips, infection in three and peri-prosthetic fracture in three. Six patients required removal and replacement of the allograft prosthetic composite, five for mechanical loosening and one for infection. The survivorship at ten, 15 and 20 years was 93% (95% confidence interval (CI) 91 to 100), 75.5% (95% CI 60 to 95) and 75.5% (95% CI 60 to 95), respectively, with 25, eight, and four patients at risk, respectively. Additionally, two junctional nonunions between the allograft and host femur required bone grafting and plating. An allograft prosthetic composite affords a good long-term outcome in the management of proximal femoral bone loss in revision THR in patients with DDH, while preserving distal host bone
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Noninvasive measurement of distal radius instability
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Distal Radius Fractures
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Except for subjective clinical criteria, there is no formal definition of distal radius fracture instability in the literature. The purposes of this ex vivo biomechanical study were (1) to provide an objective mechanical definition of fracture instability and (2) to demonstrate a noninvasive method that allows for direct measurement of instability. The following 3 questions are addressed: (1) Can the stability of distal radius fractures be measured using computed tomography (CT)? (2) Are the stability measurements reproducible? (3) How does external fixation change stability? A CT technique is described that was used to measure displacement of fracture fragments and measure the compliance of ex vivo distal radius fractures before and after external fixation. Validation studies of the CT technique revealed a mean coefficient of variation of 0.38. There was a linear relationship between measured and known displacements for all 3 orthogonal planes (coefficient of determination 0.99; p < .01). There was significant fracture displacement with loads as small as 20 N. The slope of the load-displacement curve (structural compliance) provided a quantitative measure of fracture instability. Fracture compliance decreased up to 69% after application of an external fixator.
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Developing a strategy to treat established infection in total knee replacement: a review of the latest evidence and clinical practice
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PJI DX Updated Search
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This review summarises the opinions and conclusions reached from a symposium on infected total knee replacement (TKR) held at the British Association of Surgery of the Knee (BASK) annual meeting in 2011. The National Joint Registry for England and Wales reported 5082 revision TKRs in 2010, of which 1157 (23%) were caused by infection. The diagnosis of infection beyond the acute post-operative stage relies on the identification of the causative organism by aspiration and analysis of material obtained at arthroscopy. Ideal treatment then involves a two-stage surgical procedure with extensive debridement and washout, followed by antibiotics. An articulating or non-articulating drug-eluting cement spacer is used prior to implantation of the revision prosthesis, guided by the serum level of inflammatory markers. The use of a single-stage revision is gaining popularity and we would advocate its use in certain patients where the causative organism is known, no sinuses are present, the patient is not immunocompromised, and there is no radiological evidence of component loosening or osteitis. It is our opinion that single-stage revision produces high-quality reproducible results and will soon achieve the same widespread acceptance as it does in infected hip arthroplasty
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Meniscal and chondral loss in the anterior cruciate ligament injured knee
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AMP (Acute Meniscal Pathology)
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Rupture of the anterior cruciate ligament (ACL) of the knee is a commonly occurring injury in the athletic population. Associated meniscal and chondral injury is well recognised. This occurs both at the time of index injury and also secondarily over time in the ACL-deficient knee as a result of several related pathways culminating in osteoarthritis. ACL reconstruction is a well established surgical technique for treatment of symptomatic instability in ACL-deficient knees but the role of ACL reconstruction in the prevention of osteoarthritis remains unclear. This article reviews the contemporary literature on the pathophysiology of chondral and meniscal loss in ACL-injured knees and the role of current treatment techniques, including surgical reconstruction of ligamentous, meniscal and chondral pathology, in altering the natural history of the ACL-deficient knee. [References: 132]
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Effects of risedronate or alfacalcidol on bone mineral density, bone turnover, back pain, and fractures in Japanese men with primary osteoporosis: results of a two-year strict observational study
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Distal Radius Fractures
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Although osteoporosis in men is already a major public health problem, there is still a dearth of data about the effects of risedronate in male osteoporosis, especially in Japanese with primary osteoporosis. Therefore, the objective of our study was to investigate the effects of risedronate on bone mineral density (BMD), bone turnover, back pain, and fractures in these patients prospectively for two years (at baseline, three months, six months, twelve months, and twenty-four months) both longitudinally and compared with those of alfacalcidol. The subjects enrolled for this study were 66 Japanese male patients with untreated primary osteoporosis (mean age 63.52 +/- 8.7 years), who were divided into two groups (44 with risedronate and 22 with alfacalcidol). We measured BMD by dual energy X-ray absorptiometry at three sites-the lumbar spine, femoral neck, and distal radius. Risedronate treatment significantly increased BMD at the lumbar spine and at the femoral neck, reduced bone-specific alkaline phosphatase (BAP) and serum N-terminal telopeptide of type I collagen (NTx), and reduced back pain, both longitudinally and compared with alfacalcidol treatment. We observed a lower rate of incident fracture in risedronate users. However, multiple logistic regression analysis revealed that this trend was not statistically significant, possibly because of the small number of patients enrolled. These potentially beneficial effects of risedronate on bone in male patients with primary osteoporosis suggest the possibility that osteoporosis should be treated with risedronate regardless of gender in order to effectively prevent subsequent osteoporotic fractures.
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Diagnosis of compressive and entrapment neuropathies of the upper extremity: Value of MR imaging
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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Compressive and entrapment neuropathies (CENs) are relatively common clinical syndromes characterized by neurologic manifestations caused by mechanical or dynamic compression of peripheral nerves. Radiologists are often required to evaluate CENs primarily to rule out soft-tissue lesions as a potential cause of the syndrome. MR imaging has become the best technique for accurate delineation of soft-tissue lesions, and it is ideally suited for the assessment of CEN. Although many CENs of the upper extremity have been described in the clinical literature, only a few of them have received attention in radiologic publications. This review focuses on the most common CENs involving the upper extremity, with special emphasis on the MR manifestations
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Glycosaminoglycan distribution in cartilage as determined by delayed gadolinium-enhanced MRI of cartilage (dGEMRIC): potential clinical applications
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AMP (Acute Meniscal Pathology)
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OBJECTIVE: We sought to describe a range of in vivo observations of glycosaminoglycan distribution in knee cartilage using the delayed gadolinium-enhanced MRI of cartilage technique.
CONCLUSION: The index of glycosaminoglycan distribution, T1(Gd), can exceed 500 msec (denoting high glycosaminoglycan) or can be less than 300 msec, with focal areas as low as 240 msec. Compartmental differences, as well as focal defects within the knee, were observed in patients who had sustained injuries to the ligaments and menisci of the knee or who had chronic osteoarthritis. Overall, these results suggest the need for further research into the biochemical changes seen during disease progression and the effects of therapeutic interventions.
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Supracondylar humeral osteotomy in children with severe posttraumatic cubitus varus deformity
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The Treatment of Pediatric Supracondylar Humerus Fractures AUC
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The authors report the results of corrective osteotomy of the humerus in 11 children with severe posttraumatic cubitus varus deformity. The average carrying angle on the affected side was -24.4(degrees), and there was an average internal rotation deformity of the distal humerus of 22(degrees). Flexion and extension of the injured elbow were severely limited. A supracondylar lateral wedge osteotomy of the humerus was performed keeping the medial cortex intact. Two K-wires served as levers to correct the angular and rotational deformity of the elbow and then as fixation material to hold the osteotomy fragments. Postoperatively we immobilized the elbows in 90(degrees)flexion for 3 to 4 weeks. There was no loss of the postoperative osteotomy alignment in most cases. Recurrence of mild varus deformity (-5(degrees)and -7(degrees)) occurred in only two patients. At the end of the follow-up we observed excellent results in 9 patients with an average carrying angle of 7.2(degrees)(range 5-10(degrees))
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Prevention of heterotopic ossification with irradiation after total hip arthroplasty. Radiation therapy with a single dose of eight hundred centigray administered to a limited field
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Management of Hip Fractures in the Elderly
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Sixty-two hips in fifty-five patients who were considered to be at risk for postoperative heterotopic ossification were randomly divided into two groups: one received a single 800-centigray dose of limited-field radiation and the other, 1000 centigray of limited-field radiation in divided doses. The risk for heterotopic-bone formation was identified on the basis of previously described criteria, which included previous heterotopic ossification after an operation about the hip, hypertrophic osteoarthritis or post-traumatic osteoarthrosis characterized by formation of extensive osteophytes, radiographic evidence of diffuse idiopathic skeletal hyperostosis, ankylosing spondylitis, and male sex. The treatment portals excluded prosthetic surfaces that were intended for biological fixation by ingrowth of bone. At a minimum six-month follow-up, progression of heterotopic ossification had occurred in seven (21 per cent) of thirty-four hips in the first group and in six (21 per cent) of twenty-eight hips in the second group. The ossification had advanced more than one grade in only one hip. Extra-field ossification occurred in fifteen (43 per cent) of thirty-five hips that had not had previous heterotopic ossification. Since the time of the study, the treatment portal has been modified to include the lateral aspect of the greater trochanter, so that the risk of bursitis associated with ossification in this area is minimized. Single-dose limited-field radiation is effective for the prevention of heterotopic ossification, without compromise of early fixation of an uncemented implant
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The use of focused ultrasound for non-invasive body contouring in Asians
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Panniculectomy & Abdominoplasty CPG
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Introduction: Previous studies demonstrated that multiple treatments using focused ultrasound can be effective as an non-invasive method for reducing unwanted localized fat deposits. The objective of the study is to investigate the safety and efficacy of this focused ultrasound device in body contouring in Asians. Method: Fifty-three (51 females and 2 males) patients were enrolled into the study. Subjects had up to three treatment sessions with approximately 1-month interval in between treatment. Efficacy was assessed by changes in abdominal circumference, ultrasound fat thickness, and caliper fat thickness. Weight change was monitored to distinguish weight loss induced changes in these measurements. Patient questionnaire was completed after each treatment. The level of pain or discomfort, improvement in body contour and overall satisfaction were graded with a score of 1-5 (1 being the least). Any adverse effects such as erythema, pain during treatment or blistering were recorded. Result: The overall satisfaction amongst subjects was poor. Objective measurements by ultrasound, abdominal circumference, and caliper did not show significant difference after treatment. There is a negative correlation between the abdominal fat thickness and number of shots per treatment session. Conclusion: Focused ultrasound is not effective for noninvasive body contouring among Southern Asians as compared with Caucasian. Such observation is likely due to smaller body figures. Design modifications can overcome this problem and in doing so, improve clinical outcome. © 2009 Wiley-Liss, Inc.
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Knee arthroplasty in Kuwait during 25 years: A national presentation and an international review
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Surgical Management of Osteoarthritis of the Knee CPG
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Since 1984, 577 knee arthroplasty operations were performed in Al Razi Orthopedic hospital in Kuwait. An increase in the number of these operations occurred during the last four years and in 2007 there were almost 100 knee arthroplasty operations performed. Six out of seven operated patients were female. The mean age at operation was 67 years for male and 62 years for female patients. The vast majority were of the total knee arthroplasty type. In Sweden, with a total population of almost 10 million people, 10,544 primary knee prosthesis were implanted during 2006. In Kuwait, there is no certain statistics regarding the actual number of knee arthroplasty operations as Kuwaiti patients are also operated in private hospitals within and outside the country. It is estimated that 200 - 300 knee arthroplasty operations are performed annually on Kuwaitis. In order to get better epidemiological data and in order to improve the quality assurance of Knee and Hip arthroplasty operations in Kuwait, we propose that a national register is organised. National registers are in use in many other countries. The main indication for a knee arthroplasty is to relieve knee pain and to improve knee function. The operation allows for an active life-style. An active lifestyle, with more walking, is an advantage not only for the knee, but also for the general health. It also helps to better control other diseases like diabetes and obesity. The use of knee arthroplasties in Kuwait is increasing and the outcome of the procedure is generally favorable. It is not an overstatement to say that a well functioning knee arthroplasty means an increased quality of the whole life
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High Tibial Osteotomy and Medial Meniscus Transplant
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AMP (Acute Meniscal Pathology)
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Concomitant high tibial osteotomy and meniscal allograft transplant is indicated in patients with medial meniscus deficiency and varus deformity. A synergistic relationship likely exists between knee realignment and restoration of meniscal and chondral tissue. Therefore, it is important to address all sources of pathology, such as meniscal or chondral defects, when addressing axis malalignment. In this article, we review the indications, preoperative considerations, technique, postoperative rehabilitative protocol, and outcomes in patients undergoing high tibial osteotomy with medial meniscal allograft transplant.
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Bone Metastasis in Renal Cell Carcinoma Patients: Risk and Prognostic Factors and Nomograms
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MSTS 2022 - Metastatic Disease of the Humerus
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Background: Bone metastasis (BM) is one of the common sites of renal cell carcinoma (RCC), and patients with BM have a poorer prognosis. We aimed to develop two nomograms to quantify the risk of BM and predict the prognosis of RCC patients with BM.
Methods: We reviewed patients with diagnosed RCC with BM in the Surveillance, Epidemiology, and End Results (SEER) database from 2010 to 2015. Multivariate logistic regression analysis was used to determine independent factors to predict BM in RCC patients. Univariate and multivariate Cox proportional hazards regression analyses were used to determine independent prognostic factors for BM in RCC patients. Two nomograms were established and evaluated by calibration curve, receiver operating characteristic (ROC) curve, and decision curve analysis (DCA).
Results: The study included 37,554 patients diagnosed with RCC in the SEER database, 537 of whom were BM patients. BM's risk factors included sex, tumor size, liver metastasis, lung metastasis, brain metastasis, N stage, T stage, histologic type, and grade in RCC patients. Currently, independent prognostic factors for RCC with BM included grade, histologic type, N stage, surgery, brain metastasis, and lung metastasis. The calibration curve, ROC curve, and DCA showed good performance for diagnostic and prognostic nomograms.
Conclusions: Nomograms were established to predict the risk of BM in RCC and the prognosis of RCC with BM, separately. These nomograms strengthen each patient's prognosis-based decision making, which is critical in improving the prognosis of patients.
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Subcutaneous Direct-to-Implant Breast Reconstruction: Surgical, Functional, and Aesthetic Results after Long-Term Follow-Up
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Acellular Dermal Matrix
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Direct-to-implant breast reconstruction can be achieved more easily by means of soft-tissue replacement devices such as dermal matrices and synthetic meshes. The feasibility of a subcutaneous approach has been recently investigated by some studies with different devices functioning as implant support. Aim of this study is to analyze the long-term results, both objective and subjective, of a previous nonrandomized trial comparing prepectoral (subcutaneous) and retropectoral breast reconstructions. METHODS: Patients enrolled in a nonrandomized prospective trial, comparing the standard retropectoral reconstruction and the prepectoral subcutaneous approach, using a titanium-coated mesh in both techniques, were followed up and evaluated for long-term results. Cases were compared in terms of the causes and rate of reinterventions, of the postoperative BREAST-Q questionnaire results, and of an objective surgical evaluation. RESULTS: The subcutaneous group had a rate of implant failure and removal of 5.1% when compared with 0% in the retropectoral group. Aesthetic outcome was significantly better for the subcutaneous group both at a subjective and at an objective evaluation. Capsular contracture rate was 0% in the subcutaneous group. CONCLUSIONS: A higher rate of implant failure and removal, although not significant, always because of skin flaps and wound problems, should be taken into account for a careful patients selection. The subcutaneous breast reconstruction shows good long-term results. A coherent subjective and objective cosmetic advantage of this approach emerges. Moreover, no capsular contracture is evident, albeit in a relatively limited number of cases.
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Risk of institutionalization following fragility fractures in older people
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Pediatric Supracondylar Humerus Fracture 2020 Review
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Summary: Previously independent living older people suffering fractures of the hip have a high risk of new admission to a nursing home during the subsequent months. This study shows that older people admitted to hospital for fractures of the pelvis and spine have a similar risk of admission to a nursing home. Introduction: Fall-related fractures are a serious threat to the health and well-being of older persons. Long-term consequences of hip fractures such as institutionalization and mortality are well-known. The impact of other fragility fractures is less well-understood. The aim of this study was to estimate risks of institutionalization and death for different fragility fractures and compare them with the corresponding risks after hip fracture. Methods: Data was retrieved from a German health insurance company. Between 2005 and 2008 more than 56,000 community-dwelling people with a hospital admission or discharge diagnosis of a fracture of the femur, spine, pelvis, proximal humerus, distal radius, tibia, or fibula were included. Crude and age-adjusted 6-month incidence rates for institutionalization and death were calculated. To compare the risks of institutionalization or mortality of non-hip fractures with the risk after hip fracture, multivariate regression models were applied. Results: Crude institutionalization rates and mortality were highest in patients with hip fracture. However, after adjustment for age, functional status, and comorbidity, risks of institutionalization after fractures of pelvis (relative risk (RR), 0.94; 95% confidence interval (CI) 0.86; 1.02 in women and 0.89; 95% CI 0.70; 1.12 in men), and spine (RR, 0.95; 95% CI 0.87; 1.03 in women and 0.91; 95% CI 0.76; 1.08 in men) were not statistically different compared to the risk after hip fracture. Conclusions: The risk of institutionalization after fractures of the spine and pelvis was similar to the risk after hip fracture. These fracture sites seem to be associated with a significant decline in physical function.
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Post-operative medical and surgical complications after primary total joint arthroplasty in solid organ transplant recipients: a case series
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OAK 3 - Non-arthroplasty tx of OAK
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Purpose: In a series of solid organ transplant (SOT) recipients who underwent a subsequent primary total joint arthroplasty (TJA) procedure, this study aimed to determine: (1) 90-day morbidity and mortality after primary total knee or hip arthroplasty (TKA and THA), (2) overall post-operative infection rates, and (3) how complication and infection rates compared across primary TJA procedure and type of transplant organ. Methods: The University of Michigan Health System database was retrospectively searched using current procedural terminology codes for any primary TKA or THA performed at the institution in years 2000â??2012 in a patient who previously received a successful SOT at any hospital. Results: The search yielded 44 arthroplasties performed in 29 SOT recipients (average age 54.8 years, average follow-up about 30 months for both groups). No deaths were reported, but 13/27 (48.1%) THA patients and 2/6 (33.3%) TKA patients experienced a total of 29 complications within 90 days of surgery. One patient (3.7%) [1/27 patients, 1/37 joints] underwent revision hip arthroplasty to correct limb length. One THA patient and two TKA patients developed infection requiring revision surgery (3.7% and 33%, respectively). Type of transplant did not affect complication rates (P=0.65), and infection was more common after TKA (P=0.01). Conclusions: A series of SOT recipients demonstrated increased rates of infection and other complications following TJA. Surgical and medical teams should work closely to optimize this population for TJA surgery and minimize peri-operative complications. Level of evidence & study design: Level IV, Prognostic Case-Series.
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Effect of Mode of Femoral Nerve Analgesia on Quadriceps Muscle Strength
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AAHKS (8) Anesthetic Infiltration
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Continuous femoral nerve analgesia technique is relatively safe, can be easily trained, and reduces significantly intravenous opioid consumption. These favorable features make it standard treatment option for postoperative knee pain. However, direct perineural local anesthetic effect is not only confined into pain fiber, but, the other sensory and motor nerve fibers. Therefore, unwanted motor weakness is accompanied. Quadriceps muscle strength, which is important determinant of physical function after knee arthroplasty, can be influenced in continuous femoral nerve block. Various local anesthetic infusion techniques have been suggested to minimize the change of quadriceps muscle strength. Decreasing local anesthetic concentrations affect not only degree of muscle weakness, but also reduces the quality of pain control. Different anatomic location of catheter tip, considering motor fiber in posterior part of femoral nerve, could not reduce motor weakness. In a study with continuous poplitealâ?sciatic nerve blocks after hallux valgus repair, repeated bolus administration seems to be more effective method for pain control without concurrent motor impairment. However, another study with continuous femoral nerve block in healthy volunteers, hourly repeated bolus dose of 5 ml of 0.1% ropivacaine failed to spare motor block. Previously, our institution standard technique is fixed continuous infusion of 0.2% ropivacaine and concomitant intravenous patient controlled fentanyl. Because physical therapy of our institution, usually starts with the 2nd day of operation, so, we assume that continuous fixed infusion may result in more drug accumulation near nerve fiber. So, patient controlled mode of femoral analgesia could be better choice for initiation of physical therapy. At the same time, comparison between patient controlled analgesia and continuous infusion is not fully elucidated until recently. Therefore, in this study, we try to compare quadriceps muscle strength change between continuous infusion and patient controlled femoral analgesia in patients undergoing total knee replacement arthroplasty. Secondary outcomes include sensory effect in femoral nerve distribution, pain scores, iv fentanyl consumption, and other adverse effects.
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Canaletto implant in revision surgery for carpal tunnel syndrome: 21 case series
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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Revision carpal tunnel surgery varies from 0.3% to 19%. It involves a delayed neurolysis and prevention of perineural fibrosis. Despite numerous available procedures, the results remain mediocre. The aim of this study is to evaluate the results of the Canaletto implant in this indication. Our series includes 20 patients (1 bilateral affection) reoperated for carpal tunnel between October 2008 and December 2009. After the first operation, the symptom-free period was 112 weeks, on average. The average incision was 27 mm. After neurolysis, the Canaletto implant was placed in contact with the nerve. Immediate postoperative mobilization was commenced. Sensory (pain, DN4, and hypoesthesia), motor (Jamar, muscle wasting), and functional (disabilities of the arm, should, and hand; DASH) criteria were evaluated. Nerve conduction velocity (NCV) of the median nerve was measured. Average follow up was 12.1 months. All measurements were improved after insertion of the Canaletto implant: pain (6.45-3.68), DN4 (4.29-3.48), Quick DASH (55.30-34.96), Jamar (66.11-84.76), NCV (29.79-39.06 m/s), hypoesthesia (76.2-23.8%), wasting (42.9-23.8%). Nevertheless, four patients did not improve, and pain was the same or worse in six cases. Our results show that in recurrent carpal tunnel syndrome, Canaletto implant insertion gives results at least as good as other techniques, with the added advantage of a smaller access incision, a rapid, less invasive technique, and the eliminated morbidity of raising a flap to cover the median nerve
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Stationary negative potentials near the source vs. positive far-field potentials at a distance
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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We studied the field distribution of referentially recorded negative potentials after stimulation of the median nerve at the wrist in 15 normal subjects. When recorded from multiple sites along the lateral aspect of the arm with the reference electrode at the knee, 3 negative peaks, N3, N6 and N9, appeared at fixed latencies. Of these N3 and N6 were highest in amplitude at the distal insertion of the brachioradialis and the distal end of the deltoid, respectively, and N9, at the acromion. With stimulation of the finger, the negative peaks shifted in latency by about 3 msec, indicating an anatomically fixed generator source for each component. When compared to far-field potentials, N9 was of the same latency as scalp recorded P9, that extended to the arm contralateral to the side of stimulation and to the upper half of the trunk. In contrast, N6 extended to the scalp with P6 spreading to the lower half of the body. When two subjects were connected by the arm, stationary negative or positive peaks were transmissible from the stimulated to the non-stimulated subject. When the stimulated arm of the first subject was in contact with the second subject, N3, N6 and N9 were recorded in the latter. Only P9 was registered when the unstimulated arm was in contact with the second subject. We conclude that N3, N6 and N9 are stationary negative potentials generated at certain points along the nerve pathway, probably representing a negative counterfield for positive far-field peaks, P3, P6 and P9. These stationary potentials can spread widely in a volume conductor and can even be detected in a non-stimulated subject making a close contact to the generator source
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Pneumonectomy in pulmonary metastasis
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MSTS 2022 - Metastatic Disease of the Humerus
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Background: The risk of complication following pneumonectomy is high; therefore, the decision to perform pneumonectomy should be carefully evaluated. A retrospective multicenter study of patients with metastatic lung tumors who underwent pneumonectomy was conducted. Methods: The database from the Metastatic Lung Tumor Study Group of Japan was retrospectively reviewed. Between 1984 and 2013, 4,742 patients underwent pulmonary metastasectomy. Of the 4,742 patients, 55 patients (1.16%) who underwent pneumonectomy were analyzed, and their survival parameters and prognostic factors were evaluated. Results: Of the 55 patients who underwent pneumonectomy, 34 patients were male and 21 patients were female. The primary tumor sites were colorectal in 28 patients, head and neck in 12 patients, bone in three patients, bladder in three patients, and other regions in nine patients (breast, uterus, liver, soft tissues in two patients, respectively, and pancreas in one patient). The overall 5-year survival rate of patients following pneumonectomy was 28.9%. The rate was significantly lower than that of patients who underwent other metastasectomy which had an overall 5-year survival rate of 53.4% (P < 0.001). There were 3 hospital mortalities (3/55, 5.45%). Univariate analysis revealed that patients 55 years old or older (P=0.016) and patients who had lymph node metastasis (P=0.032) were significant predictors of poor prognosis. Multivariate analysis indicated that the age group 55 years old or older was an independent prognostic factor (P=0.040). Conclusions: The indication of pneumonectomy should be carefully reviewed, especially for patients 55 years old or older, however characteristics of each primary organ should also be considered.
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Effect of repeated manipulation on range of motion in patients with stiff total knee arthroplasty
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OAK 3 - Non-arthroplasty tx of OAK
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Although manipulation under anesthesia (MUA) has been considered effective firstline treatment for stiff total knee arthroplasty (TKA), there is no consensus regarding the usefulness of repeated MUA. The purpose of this study was to investigate the usefulness of repeated MUA performed for patients in whom satisfactory range of motion (ROM) was not achieved by MUA. The authors retrospectively reviewed 15 patients who underwent repeated MUA after failure of initial MUA for stiff TKA. Demographic and ROM data were collected. A final ROM of less than 90° was considered a failed manipulation (failure group) and a final ROM of 90° or more was considered a successful manipulation (success group). Average pre-repeated MUA ROM (72.3°±19.5° ) immediately improved to 112.3°±9.7° (P<.001) in the operating room, and final ROM was 89.6°±23.9°, an overall gain of 17.3° (P=.04). However, despite this overall ROM increase, a successful final ROM (90° or more) was achieved in approximately half of patients (7 of 13; 54%). There were no significant differences in demographics between the success and failure groups, except that there was significantly less pre-TKA ROM in the failure group (P=.02). There were no complications related to either the first or the repeated MUA procedures. The findings of this study suggest that repeated MUA can improve overall ROM for stiff TKA. The success rate of repeated MUA was less than that of primary MUA; however, it is a useful treatment modality for stiff TKA. Decreased pre-TKA ROM appeared to be associated with poor outcomes after repeated MUA.
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Compass hinge fixator for acute and chronic instability of the elbow
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Distal Radius Fractures
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OBJECTIVE: To maintain concentric reduction of an unstable elbow and to allow active exercises after the treatment of complex elbow injuries or their sequelae.
INDICATIONS: Recurrent dislocation or subluxation of the elbow after repair or reconstruction of bony, capsuloligamentous, and/or musculotendinous stabilizers. Tenuous fixation of large coronoid fractures due to fragmentation or osteopenia. Stabilization of the joint after fascial arthroplasty or debridement for infection, if the debridement destabilizes the elbow. Relative indication: maintenance of range of motion after release of contractures.
CONTRAINDICATIONS: Absent patient compliance. Lack of familiarity of surgeon with elbow anatomy and function as well as with hinged external fixation techniques.
SURGICAL TECHNIQUE: Preferably posterior longitudinal midline incision. Placement of axis pin in the center of rotation of the distal humerus. Application of the fixator over this wire. Placement of Schanz screws into humerus und ulna taking care to protect the radial and ulnar nerves. Removal of axis pin. Rechecking of entire frame and tightening.
RESULTS: The authors' experience with the Compass Hinge Fixator documents restoration of stability and excellent motion after relocation of a chronic simple elbow dislocation, a useful role in reconstructing acute and chronic elbow instability after fracture-dislocation, and a limited role in restoring mobility after severe contracture release.
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Neuropathic-Like Pain Symptoms in a Community-Dwelling Sample with or at Risk for Knee Osteoarthritis
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OAK 3 - Non-arthroplasty tx of OAK
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OBJECTIVE: To characterize neuropathic-like pain among individuals with or at risk for knee osteoarthritis. SUBJECTS: One hundred eighty-four individuals who self-identified as non-Hispanic black or non-Hispanic white and presented with unilateral or bilateral knee pain. DESIGN: Neuropathic-like pain was assessed using the painDETECT, and those with high vs low neuropathic-like pain were compared on clinical pain, psychological symptoms, physical function, and quantitative sensory testing. Analyses were unadjusted, partially and fully adjusted for relevant covariates. RESULTS: Thirty-two (17.4%) participants reported experiencing neuropathic-like pain features above the painDETECT clinical cut-score. The neuropathic-like pain group reported significantly greater pain severity on all measures of clinical pain and higher levels of psychological symptoms when fully adjusted for covariates, but no differences emerged for disability and lower extremity function. The neuropathic-like pain group also reported greater overall heat pain ratings during the heat pain threshold and increased temporal summation of heat pain in the fully adjusted model. Additionally, those with neuropathic-like pain symptoms reported greater painful after-sensations following heat pain temporal summation in all analyses. No significant group differences in pressure pain threshold emerged at any of the testing sites. In contrast, temporal summation of mechanical pain was significantly greater at both the index knee and the ipsilateral hand for the neuropathic-like pain group in all analyses. CONCLUSIONS: Participants with or at risk for knee osteoarthritis who reported high neuropathic-like pain experienced significantly greater clinical pain and increased heat and mechanical temporal summation at the index knee and other body sites tested, suggesting central sensitization.
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Safe Plastic Surgery of the Breast II: Saving Nipple Sensation
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Reduction Mammoplasty for Female Breast Hypertrophy
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<b>Background:</b> Since its inception, reduction mammoplasty has matured considerably. Primary evolution in clinical research and practice initially focused on developing techniques to preserve tissue viability; breast parenchyma, skin, and nipple tissue that has expanded to include sensation and erectile function play a large role in the physical intimacy of women. Studies regarding primary innervation to the nipple are few and often contradictory. Our past anatomical study demonstrated that primary innervation to the nipple to come from the lateral branch of the fourth intercostal nerve. We propose an unsafe zone in which dissection during reduction mammoplasty ought to be avoided to preserve nipple sensation. <b>Objective:</b> To identify the trajectory of innervation to the nipple and translate these findings to the clinical setting so as to preserve nipple sensation<b>. Methods:</b> Eighty-six patients underwent reduction mammoplasty using the Wise pattern inferior pedicle (n = 72), vertical Hall-Findlay superomedial pedicle (n = 11), and Drape pattern inferior pedicle (n = 3). Aggressive dissection in the most superficial and deep tissue in the inferolateral quadrant of the breast was avoided. <b>Results:</b> All 86 patients reported having the same normal sensation to the breast at postoperative evaluation. <b>Conclusions:</b> The fourth intercostal nerve provides the major innervation to the nipple-areola complex. Avoiding dissection in inferolateral quadrant "unsafe zone" of the breast during reduction mammoplasty can reliably spare nipple sensation and maximize patient outcomes.
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Different ways to treat subtrochanteric fractures with the Medoff sliding plate
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Management of Hip Fractures in the Elderly
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Thirty-two consecutive subtrochanteric fractures in 32 patients were stabilized using the Medoff sliding plate and were followed up prospectively for 1 year. Two patients died during the first postoperative year. Twenty-nine of the remaining 30 (97%) fractures united by 1-year followup. Two types of plate dynamization schema were used: uniaxial (17 patients) and biaxial (15 patients). With uniaxial dynamization, plate sliding averaged 12 mm along the femoral shaft without medialization of the femoral shaft. With biaxial dynamization along the femoral shaft and the neck, plate sliding averaged 11 mm and screw in barrel sliding averaged 9 mm; medialization of the femoral shaft ranged from 0% to 35% of the femoral shaft diameter. Three fractures treated with uniaxial dynamization had migration of the lag screw within the femoral head; all three fractures united without additional screw migration after secondary or staged biaxial plate dynamization
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A Comparison of the Contact Force Distributions on the Acetabular Surface Due to Orthopedic Treatments for Developmental Hip Dysplasia
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Developmental Dysplasia of the Hip 2020 Review
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We used a three-dimensional rigid body spring model (RBSM) to compare the contact force distributions on the acetabular surface of the infant hip joint that are produced by three orthopedic treatments for developmental dysplasia of the hip (DDH). We analyzed treatments using a Pavlik harness, a generic rigid splint, and a spica cast. The joint geometry was modeled from tomography images of a 1-year-old female. The articular cartilage was modeled as linear springs connecting the surfaces of the acetabulum and the femoral head, whereas the femur and the hip bone were considered as rigid bodies. The hip muscles were modeled as tensile-only preloaded springs. The treatments with the Pavlik harness and the generic rigid splint were modeled for an infant in supine position with a hip flexion angle of 90â??deg. Also, since rigid splints are often recommended when children are initiating their gait phase, we modeled the treatment with the infant in standing position. For the spica cast, we only considered the infant in standing position with a flexion angle of 0â??deg, and the fixation bar at two heights: at the ankle and at the knee. In order to analyze the effect of the hip abduction angle over the contact force distribution, different abduction angles were used for all the treatments modeled. We have found that the treatments with the infant in supine position, with a flexion angle of 90â??deg and abduction angles between 60â??deg and 80â??deg, produce a more homogenous contact force distribution compared to those obtained for the treatments with the infant in standing position.
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Galeazzi fracture-dislocation: a new treatment-oriented classification
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Distal Radius Fractures
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Forty patients with Galeazzi fracture-dislocations were treated with open reduction and internal fixation of the radial shaft fracture. Intraoperative distal radioulnar joint (DRUJ) instability after anatomic reduction was managed with supplemental wire transfixion of the DRUJ (10 patients) or open reduction and triangular fibrocartilage complex repair (3 patients). Two patterns of fracture-dislocation were identified based on the location of the radial shaft fracture. Twenty-two type I fractures were in the distal third of the radius within 7.5 cm of the midarticular surface of the distal radius; 12 of these cases were associated with intraoperative DRUJ instability. Eighteen type II fractures were in the middle third of the radial shaft more than 7.5 cm from the midarticular surface of the distal radius. Only one of these fractures had intraoperative DRUJ instability after open reduction and internal fixation of the radial shaft fracture. A high index of suspicion, early recognition, and acute treatment of DRUJ instability will avoid chronic problems in this complex injury.
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Usefulness of meniscal width to transverse diameter ratio on coronal MRI in the diagnosis of incomplete discoid lateral meniscus
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AMP (Acute Meniscal Pathology)
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AIM: To evaluate the clinical utility of the meniscal width to transverse diameter ratio (L/M ratio) of the lateral meniscus in the diagnosis of incomplete discoid lateral meniscus (IDLM) as compared with the arthroscopic diagnosis, meniscal width to tibial diameter ratio (L/T ratio) and conventional lateral meniscus width criteria.
MATERIALS AND METHODS: This retrospective study sample included 41 patients with IDLM who underwent knee magnetic resonance imaging (MRI) and arthroscopy, as well as 50 controls with normal lateral menisci. MRI examinations were interpreted independently by two radiologists, both of whom were blinded to clinical information and radiological reports. Assessment of meniscal width (L), maximal transverse diameter of the lateral meniscus (M), and transverse diameter of the tibia (T) was carried out on central coronal sections that were observed to pass through the medial collateral ligament. L/M and L/T ratios were calculated. These results were correlated with arthroscopic findings and analysed statistically using categorical regression analysis and non-parametric correlation analysis. Using arthroscopic findings as the standard of reference, sensitivity and specificity were calculated for: (1) 12, 13, 14, and 15 mm meniscal width thresholds; (2) 40%, 50%, 60%, and 70% L/M ratio thresholds; and (3) 15%, 18%, 20%, and 25% L/T ratio thresholds.
RESULTS: The mean L/M ratio of the IDLM was approximately 67% and was statistically significantly higher than the control (44%). The best diagnostic discrimination was achieved using a threshold of 50%. The mean L/T ratio of the IDLM was approximately 23% and was statistically significant. The best diagnostic discrimination was achieved using a threshold of 18%. The threshold of 13 mm of meniscal width also showed high sensitivity and high specificity.
CONCLUSION: The use of the L/M ratio or L/T ratio in combination with meniscal width criteria may be a useful method for evaluating IDLM.
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Rest-activity patterns and falls and fractures in older men
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Hip Fx in the Elderly 2019
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Summary: Dysregulated rest-activity rhythm (RAR) patterns have been associated with several health conditions in older adults. This study showed that later acrophase was associated with a modestly greater risk of falls but not fractures in elderly men. Associations between dysregulated RAR patterns and osteoporosis risk warrant further investigation. Purpose: The purpose of this study was to investigate the relationship between rest-activity rhythm (RAR) patterns and risk of falls/fractures in older men. We hypothesized that dysregulated RAR would be associated with incident falls/fractures. Methods: We used wrist-worn actigraphy to measure RAR over 4.8 ± 0.8 24-h periods in men (â?¥67 years) enrolled in the multicenter Outcomes of Sleep Disorders in Men (MrOS Sleep) Study (n = 3001). Men were contacted every 4 months to report occurrence of falls/fractures. RAR parameters included amplitude (difference between peak and nadir activity in counts/minute), mesor (activity counts/minute), acrophase (time of day of peak activity), and pseudo-F statistic (rhythm robustness) and were evaluated as continuous variables with associations reported per SD increase/decrease in models adjusted for confounders. Logistic regression was used to estimate the likelihood (odds ratio, OR) of recurrent falls in the year after the visit. Proportional hazards models were used to estimate the risk (hazard ratio, HR) of fractures. Results: One year after the visit, 417 men (14%) had recurrent (â?¥2) falls. Later acrophase (OR 1.18, 95% CI 1.06â??1.32) was associated with a modestly greater likelihood of falls. In 8.6 years (SD 2.6 years) of >97% complete follow-up, 256 men (8.53%) had a major osteoporotic fracture, 85 (2.8%) had a clinical spine fracture, and 110 (3.7%) had a hip fracture. No consistent, significant associations were observed between RAR patterns and fractures. Conclusions: Later acrophase was associated with a modestly greater risk of falls; this association did not translate into a higher fracture risk in this cohort of elderly men.
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Minimally invasive unicondylar arthroplasty in the post-meniscectomy knee: Repicci knee
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AMP (Acute Meniscal Pathology)
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Loss of the meniscus decreases contact area, resulting in increased stress on the articular cartilage of the knee. Osteoarthritis frequently develops and sclerotic bone is exposed on the articular surfaces of the joint. In the medial compartment, this process is characterized by loss of articular cartilage and anterior cruciate ligament and medial cruciate ligament laxity in the extention gap, with no corresponding laxity in the flexion gap. This focal articular and ligamentous imbalance may persist for a decade or more. Minimally invasive unicondylar arthroplasty is a low-morbidity procedure that resurfaces the medial compartment and rebalances ligaments while preserving bone for future arthroplasty procedures.
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Arthroscopic treatment of acute patellar dislocations
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AMP (Acute Meniscal Pathology)
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Twenty-nine patients treated with arthroscopy alone for acute patellar dislocation were reviewed. All had a significant traumatic episode with hemarthrosis in a previously asymptomatic knee. Clinical follow-up averaged 25 months (range 5-64 months). Fifteen patients had concomitant percutaneous lateral release (LR). Significant-sized osteochondral defects not radiographically visible preoperatively were discovered in 40%. Fragments were excised and corresponding craters debrided or abraded. Additional intraarticular pathology discovered included two meniscal tears and one anterior cruciate tear. Overall excellent (E) and good (G) results were 83%. The recurrence rate was 14%, all of which occurred in the LR group. All recurrent dislocations occurred within 1-year post injury. The LR group had 73% G and E results compared with 93% in those without LR. Arthroscopy followed by immobilization was an efficacious approach to acute traumatic patellar dislocations in this specific group of patients. The addition of LR with early motion, however, detracted from the results.
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Knee osteoarthritis and exercise adherence: a review
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OAK 3 - Non-arthroplasty tx of OAK
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Individuals with knee osteoarthritis, a painful debilitating joint disease affecting many aging adults, are commonly encouraged to pursue a variety of exercise regimens. However, very few studies have specifically focused on barriers and facilitators of exercise adherence as related to knee osteoarthritis. This review focuses on what is known about exercise adherence, as well as those factors that influence exercise adherence, both generally, and in the context of knee osteoarthritis. To this end, a wide array of related studies were retrieved and reviewed. The objective was to better understand the relationship between this disabling health condition and exercise, and factors that might specifically determine long-term exercise participation among this population.
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Psychosocial factors associated with physical activity in ambulatory and manual wheelchair users with spinal cord injury: A mixed-methods study
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DoD PRF (Psychosocial RF)
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Purpose: To identify psychosocial factors which explain lower levels of leisure time physical activity (LTPA) in persons with spinal cord injury (SCI) who are ambulatory relative to those who use manual wheelchairs. Method: For the quantitative study component, 347 adults with SCI (78% male; M age = 47.7) completed baseline measures of LTPA attitudes, subjective norms, perceived behavioural control and intentions. Six months later, LTPA was assessed. The qualitative component involved semi-structured interviews with six ambulant adults with SCI (five male, M age = 52.8) addressing LTPA experiences with an emphasis on barriers and facilitators. Results: Ambulatory individuals had poorer attitudes towards LTPA than chair users (p = 0.004). Their attitudes had significant indirect effects on LTPA, through intentions. Perceived behavioural control was a significant negative predictor of LTPA. Qualitative analysis revealed three themes: an underestimated disability, low wheelchair skill self-efficacy and experiencing chronic pain. Conclusions: Poorer attitudes towards LTPA may partially explain why ambulatory individuals are less active. The qualitative and quantitative data suggest ambulators are an often-overlooked subgroup in need of targeted resources to enhance their attitudes, wheelchair skill self-efficacy and awareness of LTPA opportunities. Implications for Rehabilitation: Rehabilitation practitioners must be sensitive to the unique needs of spinal cord injured individuals who are ambulatory, and tailor physical activity promotional strategies to suit the needs of this distinct group. Lack of wheelchair skills is a participation barrier for ambulators; ambulators should be introduced to activities that do not require wheelchair use, such as swimming, hand-cycling and adapted forms of circuit training. Strategies that encourage wheelchair skill development in non-wheelchair using ambulators, may increase physical activity opportunities for this segment of the spinal injured population. (PsycINFO Database Record (c) 2017 APA, all rights reserved)
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