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Pyoderma gangrenosum following breast reduction: treatment with topical tacrolimus and steroids
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Reduction Mammoplasty for Female Breast Hypertrophy
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UNLABELLED: Pyoderma gangrenosum (PG) is a rare, noninfectious, inflammatory dermatosis usually associated with autoimmune disorders. Wounds may mimic a necrotizing infection, and the diagnosis is usually made after antibiotic therapy fails. Debridement may cause even larger wounds because of pathergy, so PG treatment consists of corticosteroids and local wound care. Pyoderma gangrenosum can be a devastating complication of breast and aesthetic surgery. We describe a case of PG following unilateral breast reduction that resulted in systemic inflammatory response; after treatment with prednisone and topical tacrolimus, the PG was resolved. The application of topical tacrolimus may reduce the need for prolonged corticosteroids. LEVEL OF EVIDENCE: 5.
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Prevalence rate of urinary incontinence in community-dwelling elderly individuals: The Veneto study
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DoD PRF (Psychosocial RF)
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The objectives of the present work were to estimate the prevalence of urinary incontinence (UI) in a community-based population of elderly Italians and to determine the associated physical, social, and psychological factors. A random sample of 867 noninstitutionalized men and 1,531 women, aged 65 yrs and older, from the Veneto region of northeastern Italy, were interviewed at home, using an extensive multidisciplinary questionnaire, to assess their quality of life and social, biological, and psychological correlates. The prevalence rate of UI was of 11.2% among men and of 21.6% among women. Among those reporting the condition, approximately 53% of women and 59% of men reported experiencing incontinence daily or weekly. Association of UI was found for participants older than 70 yrs in both men and women. Three of the medical conditions investigated were associated with increases in the odds in women, namely chronic obstructive pulmonary disease, Parkinsonism, and hip fracture, whereas chronic diarrhea was the only condition associated with UI in men. Participants with a physical disability were 2 times more likely to report incontinence, and the odds were increased by 50% in women who had sleep disturbances. (PsycINFO Database Record (c) 2016 APA, all rights reserved)
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Cosmetic face, neck, and brow lifts with local anesthesia
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Upper Eyelid and Brow Surgery
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The sections on the face, neck, and brow include descriptions of facelift, neck lift, and open brow lift techniques, anesthesia, treatment goals, procedural approaches, complications, management, preoperative and postoperative care, rehabilitation, recovery, and outcomes. The approach to facial rejuvenation the midface and periorbital area is detailed. These operations are often and easily performed entirely with the use of local anesthesia and mild oral sedation. There are very high satisfaction rates. © 2013 Elsevier Inc.
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Core decompression of the osteonecrotic femoral head
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DoD SSI (Surgical Site Infections)
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The results in 114 hips of ninety-two patients who had osteonecrosis of the femoral head were assessed after treatment with core decompression. The average duration of follow-up was three years and four months (range, two years to six years and six months). The average age of the patients was forty-one years (range, fifteen to sixty-seven years). The presumed risk factors were the use of corticosteroids (thirty-seven hips), excessive use of alcohol (thirty-two hips), trauma (seven hips), and various other factors (seven hips). No specific risk factor was identified for thirty-one hips, and the osteonecrosis was considered to be idiopathic. The preoperative evaluation consisted of clinical assessment, magnetic resonance imaging, and radiographic staging according to a modification of the system of Ficat. Thirty-two hips were in stage I; thirty-eight, in stage IIA; twenty-five, in stage IIB (transition stage, with a crescent sign); and nineteen, in stage III. Clinical failure was defined as the performance of a subsequent operation. Over-all, sixty-four hips (56 per cent) failed clinically. Fifty- seven were treated with a hip replacement; four, with a femoral osteotomy; and three, with a vascularized fibular graft. Clinical failure was seen in five (16 per cent) of the thirty-two hips in stage I, twenty (53 per cent) of the thirty-eight hips in stage IIA, twenty (80 per cent) of the twenty-five hips in stage IIB, and in all nineteen of the hips in stage III. The result was a clinical success in fifty hips, but eight (30 per cent) of the twenty- seven hips in stage I, five of the eighteen hips in stage IIA, and four of the five hips in stage lIB exhibited radiographic progression of at least one Ficat stage. When an outcome was considered successful only if the hip had not had a subsequent operation or radiographic progression, only nineteen (59 per cent) of the thirty-two hips in stage I, thirteen (34 per cent) of the thirty-eight hips in stage IIA, one (4 per cent) of the twenty-five hips in stage IIB, and none of the nineteen hips in stage III had a successful result. Ten patients had complications, which included a superficial wound infection (three patients), a stress fracture through the core track (two patients), hematoma (two patients), pulmonary embolism (one patient), deep- vein thrombosis (one patient), and reflex sympathetic dystrophy (one patient). We believe that core decompression is an acceptable treatment for a Ficat stage-I lesion. However, an alternative method of treatment should be used for a stage-IIB or stage-III lesion and should be seriously considered for a stage-IIA lesion.
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No Reduction of Severe Fatigue in Patients with Postpolio Syndrome by Exercise Therapy or Cognitive Behavioral Therapy
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Pediatric Supracondylar Humerus Fracture 2020 Review
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Background. People with postpolio syndrome (PPS) commonly experience severe fatigue that persists over time and negatively affects functioning and health-related quality of life (HRQoL). Objectives. To study the efficacy of exercise therapy (ET) and cognitive behavioral therapy (CBT) on reducing fatigue and improving activities and HRQoL in patients with PPS. Methods. We conducted a multicenter, single-blinded, randomized controlled trial. Over 4 months, severely fatigued patients with PPS received ET, CBT, or usual care (UC). The primary end point (fatigue) was assessed using the subscale fatigue severity of the Checklist Individual Strength (CIS20-F). Secondary end points included activities and HRQoL, which were assessed with the Sickness Impact Profile and the 36-Item Short-Form, respectively. End points were measured at baseline and at 4, 7, and 10 months. Results. A total of 68 patients were randomized. No differences were observed between the intervention groups and UC group for fatigue (mean differences in CIS20-F score = 1.47, 95%CI = '2.84 to 5.79, for ET versus UC; and 1.87, 95%CI = '2.24 to 5.98, for CBT versus UC), activities, or HRQoL. Conclusions. Our results demonstrate that neither ET nor CBT were superior to UC in reducing fatigue in severely fatigued PPS patients. Further research should investigate explanations for the lack of efficacy of these 2 currently advised approaches in clinical practice, which may provide clues to improving treatment aimed at reducing fatigue in PPS.
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Comparison of fracture risk assessment tool score to bone mineral density for estimating fracture risk in patients with advanced prostate cancer on androgen deprivation therapy
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Hip Fx in the Elderly 2019
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Objective To estimate the risk of fracture (Fracture Risk Assessment Tool [FRAX] algorithm) because of the development of osteoporosis in prostate cancer patients undergoing androgen deprivation therapy (ADT) for patients who would otherwise not have been identified for treatment by the T score. Methods This study includes men undergoing ADT for prostate cancer at our urology group. Clinical data were collected via chart review. Subjects were evaluated for fracture risk using country specific (for the United States of America) World Health Organization's FRAX. The FRAX calculations were then compared to fracture risk as determined by T score, for a subset of our cohort that received dual-energy X-ray absorptiometry. Results Our cohort consisted of 613 patients on ADT, 94 of which had a dual-energy X-ray absorptiometry scan. The FRAX algorithm identified 61.6% patients requiring therapy without bone mass density (BMD), 46.8% with BMD, and 19.14% with T score alone. In addition, positive correlation was found between FRAX with and without BMD as well as T score and FRAX with BMD and without BMD. Conclusion Our data indicate that many patients who were not found at significant risk for fracture with T score were in fact found to be at risk with the FRAX calculation. The largest proportion of patients was found to be at risk through the FRAX calculation without BMD, followed by FRAX with BMD, followed by T score alone. The utility of FRAX is beneficial in identifying patients that may benefit from effective bone-tropic treatment modalities. © 2014 Elsevier Inc.
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Intertrochanteric fractures of the femur in rheumatoid arthritis patients
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Management of Hip Fractures in the Elderly
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In a series of 33 intertrochanteric femoral fractures in patients suffering from classic rheumatoid arthritis (RA), the typical patient was about 70 years of age, osteopenic, and severely affected by longstanding polyarticular RA of joints other than the hip. Prefracture involvement of the hip joint (other than osteopenia) was apparent radiographically in only 9.1% of patients. There was a higher rate of avascular necrosis (9.7%) and nonunion (6.5%) than expected in the nonrheumatoid general population. There was also a high rate of secondary displacement. Of three patients with avascular necrosis, two had had corticosteroid treatment
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Expression of CC-chemokine receptor 7 (CCR7) and CXC-chemokine receptor 4 (CXCR4) in head and neck squamous cell carcinoma
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MSTS 2018 - Femur Mets and MM
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OBJECTIVES: We tried to clarify the correlation of the expression of CCR7 and CXCR4 with lymph node and distant metastasis.
MATERIALS AND METHODS: We examined expression of CCR7 and CXCR4 in 9 HNSCC cell lines and 25 HNSCC tissues by semi-quantitative RT-PCR and immunohistochemistry study. We examined the expression levels of CCR7 and CXCR4 in undifferentiated and differentiated human normal keratinocyte.
RESULTS: All cell lines expressed CCR7 mRNA, and three expressed CXCR4 mRNA. CCR7 and CXCR4 mRNAs were significantly higher in HNSCC tissues than in non-neoplastic tissues (p<0.05, respectively) and correlated with lymph node metastasis (p<0.05, respectively). The level of CXCR4 mRNA also correlated with distant metastasis (p<0.05). Immunohistochemistry demonstrated localization of CCR7 and CXCR4 to carcinoma cells and lymphocytes and immunohistochemical staining scores of CCR7 and CXCR4 also showed similar correlation to lymph node and distant metastasis with CCR7 and CXCR4 mRNA levels. The level of CCR7 mRNA was significantly higher in poorly and moderately differentiated than in well-differentiated HNSCC (p<0.05). The level of CCR7 mRNA in undifferentiated keratinocyte was significantly higher than that in differentiated keratinocyte.
CONCLUSION: The expression of CCR7 in HNSCC increases by dedifferentiation and plays an important role in lymph node metastasis of HNSCC and CXCR4 plays an important role in lymph node metastasis as well as distant metastasis.
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Musculoskeletal complaints, functional capacity, personality and psychosocial factors
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DoD PRF (Psychosocial RF)
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Objectives: The aim of the research was to study the association between psychosocial and personality factors, and neck and wrist-hand musculoskeletal complaints, taking account of the occupational factors of force, posture and repetitiveness, and non-occupational risk factors such as sport, hobbies, medical history. Methods: During personal interviews 133 women from seven different companies, working at constraining workplaces (very repetitive work), answered several questionnaires. These concerned: personal characteristics and history; work characteristics; psychosocial factors (perception and appreciation of the work situation, satisfaction at work, stress symptoms, Karasek questionnaire) and personality factors (neuroticism, conscientiousness, type-A behavior). They also undertook functional and psychomotor tests (wrist angles, grip strength and a dexterity test). Logistic regression models were calculated. Results: Wrist-hand complaints appear to be associated with some personal characteristics (smoking habits, fewer hobbies), work constraints (fewer breaks, heavy lifting efforts) and some personality (introversion) and psychosocial factors (worse appreciation of work). Neck complaints are also associated with some personal characteristics (young people, small, bad health, hormonal problems, fewer hobbies), some personality (urgency of time) and psychosocial factors (constraints as seen by the supervisor). Conclusion: The study confirms the multifactorial character of the musculoskeletal disorders and underlines the need for a global ergonomic approach to work situations, taking into account all their physical, psychological and social components.
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Intra-articular platelet-rich plasma injections versus intra-articular corticosteroid injections for symptomatic management of knee osteoarthritis: systematic review and meta-analysis
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PRP (Platelet-Rich Plasma)
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BACKGROUND: Intra-articular (IA) corticosteroid (CS) injections are the mainstay of treatment for symptomatic management in knee osteoarthritis (OA), particularly in the UK. IA platelet-rich plasma (PRP) injections are a promising alternative, but no systematic reviews to date have compared them to the current standard of care, IA CS injections. We aim to investigate the effect of IA PRP injections versus IA corticosteroid injections for the symptomatic management of knee OA.
METHODS: All published trials comparing IA PRP and CS injections for knee OA were included. MEDLINE, EMBASE, Scopus and Web of Science were searched through June 2020. Risk of bias was assessed using the Cochrane Risk of Bias tool. A random effects model was used to calculate standardized mean difference with 95% confidence interval in WOMAC/VAS score (or subscores), comparing IA PRP to CS injections across studies.
RESULTS: Included were eight studies and 648 patients, 443 (68%) were female, mean age 59 years, with a mean BMI of 28.4. Overall, the studies were considered at low risk of bias. Compared with CS injections, PRP was significantly better in reducing OA symptoms (pain, stiffness, functionality) at 3, 6 and 9 months post-intervention (P < 0.01). The greatest effect was observed at 6 and 9 months (- 0.78 (- 1.34 to - 0.23) standard mean deviations (SMD) and - 1.63 (- 2.14 to - 1.12) SMD respectively). At 6 months, this equates to an additional reduction of 9.51 in WOMAC or 0.97 on the VAS pain scales. At 6 months PRP allowed greater return to sporting activities than CS, measured by the KOOS subscale for sporting activity, of magnitude 9.7 (- 0.45 to 19.85) (P = 0.06). Triple injections of PRP, generally separated by a week, were superior to single injections over 12 months follow-up (P < 0.01).
CONCLUSIONS: IA-PRP injections produce superior outcomes when compared with CS injections for symptomatic management of knee OA, including improved pain management, less joint stiffness and better participation in exercise/sporting activity at 12 months follow-up. Giving three IA-PRP, with injections separated by a week, appears more effective than 1 IA-PRP injection.
Prospero trial registration number: Crd42020181928 .
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ALK+ lymphoma: clinico-pathological findings and outcome
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MSTS 2022 - Metastatic Disease of the Humerus
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A distinct pathologic entity (ALK+ lymphoma) that is characterized by expression of the anaplastic lymphoma kinase (ALK) protein has recently emerged within the heterogeneous group of CD30(+) anaplastic large-cell lymphomas. Information on clinical findings and treatment outcome of ALK+ lymphoma is still limited, and no data are available concerning the value of the International Prognostic Index when applied to this homogeneous disease entity. To clarify these issues, a recently developed monoclonal antibody ALKc (directed against the cytoplasmic portion of ALK) was used to detect expression of the ALK protein in paraffin-embedded biopsies from 96 primary, systemic T/null anaplastic large-cell lymphomas, and the ALK staining pattern was correlated with morphological features, clinical findings, risk factors (as defined by the International Prognostic Index), and outcome in 78 patients (53 ALK+ and 25 ALK-). Strong cytoplasmic and/or nuclear ALK positivity was detected in 58 of 96 ALCL cases (60.4%), and it was associated with a morphological spectrum (common type, 82.7%; giant cell, 3.5%; lymphohistiocytic, 8. 6%; and small cell, 5.2%) that reflected the ratio of large anaplastic elements (usually showing cytoplasmic and nuclear ALK positivity) to small neoplastic cells (usually characterized by nucleus-restricted ALK expression). Clinically, ALK+ lymphoma mostly occurred in children and young adults (mean age, 22.01 +/- 10.87 years) with a male predominance (male/female [M/F] ratio, 3.0) that was particularly striking in the second-third decades of life (M/F ratio, 6.5) and usually presented as an aggressive, stage III-IV disease, frequently associated with systemic symptoms (75%) and extranodal involvement (60%), especially skin (21%), bone (17%), and soft tissues (17%). As compared with ALK+ lymphoma, ALK- cases occurred in older individuals (mean age, 43.33 +/- 16.15 years) and showed a lower M/F ratio (0.9) as well as lower incidence of stage III-IV disease and extranodal involvement at presentation. Overall survival of ALK+ lymphoma was far better than that of ALK- anaplastic large-cell lymphoma (71% +/- 6% v 15% +/- 11%, respectively). However, within the good prognostic category of ALK+ lymphoma, survival was 94% +/- 5% for the low/low intermediate risk group (age-adjusted International Prognostic Index, 0 to 1) and 41% +/- 12% for the high/high intermediate risk group (age-adjusted International Prognostic Index, >/=2). Multivariate analysis identified ALK expression and the International Prognostic Index as independent variables that were able to predict survival among T/null primary, systemic anaplastic large-cell lymphoma. Thus, we suggest that such parameters should be taken into consideration for the design of future clinical trials.
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Psychosocial responses associated with perceived risk of cancer in an African-American community
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DoD PRF (Psychosocial RF)
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This epidemiologic health survey study examined the association between health risk perceptions and psychosocial factors in 145 African Americans in East Montgomery, Alabama. The survey gathered information on demographics, population dynamics, health risk perceptions, and coping behaviors. Psychosocial variables measured were worries, concern, stress, and trauma associated with perceived risk of cancer. Results indicated that women were more concerned about the environmental health risks in their community than men. Compared to men, women were highly concerned about the economic effect of perceived environmental health risk. The findings indicate that an individual's health status and educational level were significant predictors of psychosocial responses.
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Incorporating self-management in prosthetic rehabilitation: case report of an integrated knowledge-to-action process
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DoD LSA (Limb Salvage vs Amputation)
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BACKGROUND: In improvement of clinical practice, unidirectional approaches of translating evidence into clinical practice have been pinpointed as main obstacles. The concept of engaged scholarship has been introduced to guide knowledge-to-action (KTA) processes, in which research knowledge and practical knowledge derived from therapists, patients, and organizational structures mutually inform each other. Accordingly, KTA experts should engage end-users earlier in knowledge translation and work in concert with them on both knowledge creation and knowledge implementation. PURPOSE: The purposes of this case report are: (1) to provide an illustrative example of an evidence-informed improvement process in prosthetic rehabilitation in a local setting and (2) to articulate the bidirectional translation work incorporated into an integrated KTA process. CASE DESCRIPTION: A KTA expert translated research knowledge on self-management and task- and context-specific training into a functional prosthetic training program for patients with a lower limb amputation. Therapists contributed as co-creators to the translation process with practical knowledge of the specificities of the target group and local organizational context. The KTA expert moved the co-created knowledge into action in iterative and interactive steps with local therapists, patients, and managers. OUTCOME: This bidirectional KTA translation process led to shared ownership of the functional prosthetic training program, in which self-management and task- and context-specific training principles and practices were integrated. DISCUSSION: Bidirectional knowledge translation builds on explicating and integrating the different knowledge practices of researchers, therapists, and their patients. Knowledge-to-action experts and end-users have their own roles and activities in such knowledge translation processes. Appreciating these different roles in genuine partnerships and acknowledging the distinct but equally valued knowledge practices can help in effectively translating evidence into action.
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1 |
Blepharoplasty with ancillary procedures
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Upper Eyelid and Brow Surgery
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Treatment of the aging eye has made significant advances over the past 30 years. Evaluation of the aging periorbital areas with the concepts of rehabilitation and a review of the many modalities and combinations of surgical correction are discussed. Careful preoperative evaluation of the problem with the choice of single or multiple procedures is stressed.
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Improving the quality of occupational health care in Washington State: new approaches to designing community-based health care systems
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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The need for concerted action to improve quality was stressed in the recent Institute of Medicine report, Crossing the Quality Chasm: A New Health Care System for the 21st Century. This article describes an innovative community-based delivery system initiative designed to improve quality and health outcomes for occupational health conditions. Known as the Occupational Health Services (OHS) project, this Washington State initiative focuses on three targeted conditions: low back sprain, carpal tunnel syndrome, and fractures. To fulfill its purpose, which is to provide clinical resources and training opportunities and foster quality improvement activities on a community-wide basis, the OHS incorporates several key delivery system components, including systems to track patient and employer satisfaction and health outcomes; formal physician agreements that will provide incentives for using best-practices; and community-based Centers of Occupational Health and Education (COHEs) that will function as a resource for providers, patients, and employers. Our experience in developing the OHS quality improvement initiative should have relevance for health care clinicians, administrators, policy makers, and researchers engaged in similar pursuits outside the field of occupational health
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Patient factors associated with delayed diagnosis of developmental dysplasia of the hip
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Developmental Dysplasia of the Hip 2020 Review
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PURPOSE: Early detection and intervention for developmental dysplasia of the hip (DDH) is important for normal hip development. Previous studies have shown disparities in access to paediatric specialty care among different racial and socioeconomic backgrounds. This study aims to identify whether these factors are related to timely referral for infants with DDH. METHODS: A retrospective cohort study of patients seen and treated for DDH between July 2006 and June 2011 at a single institution were reviewed. The patients were divided into early-presenting (seen before six months of age) and late-presenting patients (seen at six months of age or later). RESULTS: A total of 457 patients met the eligibility criteria. There were 378 early and 79 late presentations. Late presentations were significantly more likely to be vertex at birth (85% vs 41%, p < 0.001). Bivariate analysis also demonstrated that late presentations were more likely to be non-white (65% vs 45%, p = 0.004), non-English speaking (20% vs 8%, p = 0.003), from lower income areas ($70 769 vs $61 591, p < 0.001) and hold public insurance (25%, p = 0.001). However, a logistic multiple regression analysis showed that only vertex birth presentation (p = 0.000), absent family history of DDH (p = 0.047) and affected right side (p = 0.001) were significantly associated with late presentation. CONCLUSION: Despite screening algorithms to facilitate early diagnosis of infants with DDH, better research is needed to understand how different demographic and socioeconomic factors play into the delayed access to paediatric orthopaedic care for DDH so that we may ultimately improve rates of early treatment.
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Hand ischemia associated with elbow trauma in children
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Pediatric Supracondylar Humerus Fracture 2020 Review
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Objectives: Previous observational studies suggest that children with hand ischemia following elbow trauma can be safely observed if Doppler signals are present in the wrist arteries (pink pulseless hand, PPH). Nonoperative management of PPH is predicated on the assumption that PPH results from local arterial spasm, but the mechanism of arterial compromise has not been investigated. We hypothesized that PPH signifies a brachial artery injury that requires surgical repair. Methods: Retrospective review of operations performed on children with hand ischemia following elbow trauma at a level I trauma center pediatric hospital. Results: Between 2003 and 2010, 12 children (seven males, mean age 7.4 years) underwent brachial artery exploration for hand ischemia following elbow trauma (11 supracondylar fractures, one elbow dislocation) due to falls (n = 10) or motor vehicle crashes (n = 2). At presentation, three subjects had normal radial pulses, eight subjects had Doppler signals but no palpable pulses, and one had weak Doppler flow with advanced hand ischemia. Six of the nine subjects without palpable pulses also had neurosensory changes. All 12 subjects underwent brachial artery exploration either initially (n = 2) or following orthopedic fixation (n = 10) due to persistent pulselessness. At operation, eight of 12 patients (67%) had focal brachial artery thrombosis due to intimal flaps, and four had brachial artery and median nerve entrapment within the pinned fracture site. At discharge, all 12 subjects had palpable radial pulses, but three with entrapment had dense median nerve deficits. One of the three subjects with dense neurologic deficit had complete recovery of neurologic function at ten months. The other two subjects had residual median nerve deficits with partial recovery at 5 and 6 months follow-up, respectively. No patient developed Volkman's contracture. Conclusions: Brachial artery injuries should be anticipated in children with hand ischemia associated with elbow trauma. Neurovascular entrapment at the fracture site is a possible complication of orthopedic fixation. Absence of palpable wrist pulses after orthopedic fixation should prompt immediate brachial artery exploration. PPH should not be considered a consequence of arterial spasm in these patients. © 2011 Society for Vascular Surgery.
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Functioning Without Cartilage: Older People With Radiographic Knee Osteoarthritis Who Self-Report No Functional Limitations Do Score Lower on a Performance Battery
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OAK 3 - Non-arthroplasty tx of OAK
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The majority of the older population shows signs of radiographic knee osteoarthritis. However, many remain without functional complaints for a long period. This study aims to find early functional changes associated with stages of radiographic knee osteoarthritis. A group of older people without self-reported complaints was divided in two groups: knee osteoarthritis (K&L = 2-4, N = 29) and control (K&L = 0-1, N = 31). Muscle function was assessed with voluntary and electrically-stimulated isometric knee contractions, including a fatigue test. Physical functioning was assessed with a 6-min walk test (6MWT), a stair climb test (SCT), and a short performance battery. There were no differences in muscle function parameters, 6MWT, and SCT between groups. A clinically relevant lower score on the performance battery was found in participants with knee osteoarthritis. In conclusion, even when older people indicate to have no functional limitations, a decline in functional outcome can be measured with a physical performance battery.
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An Orthopedic-Hospitalist Comanaged Hip Fracture Service Reduces Inpatient Length of Stay
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Hip Fx in the Elderly 2019
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INTRODUCTION: Hip fractures are common in the elderly patients with an incidence of 320 000 fractures/year in the United States, representing a health-care cost of US$9 to 20 billion. Hip fracture incidence is projected to increase dramatically. Hospitals must modify clinical models to accommodate this growing burden. Comanagement strategies are reported in the literature, but few have addressed orthopedic-hospitalist models. An orthopedic-hospitalist comanagement (OHC) service was established at our hospital to manage hip fracture patients. We sought to determine whether the OHC (1) improves the efficiency of hip fracture management as measured by inpatient length of stay (LOS) and time to surgery (TTS) and (2) whether our results are comparable to those reported in hip fracture comanagement literature.
METHODS: A comparative retrospective-prospective cohort study of patients older than 60 years with an admitting diagnosis of hip fracture was conducted to compare inpatient LOS and TTS for hip fracture patients admitted 10 months before (n = 45) and 10 months after implementation (n = 54) of the OHC at a single academic hospital. Secondary outcome measures included percentage of patients taken to surgery within 24 or 48 hours, 30-day readmission rates, and mortality. Outcomes were compared to comanagement study results published in MEDLINE-indexed journals.
RESULTS: Patient cohort demographics and comorbidities were similar. Inpatient LOS was reduced by 1.6 days after implementation of the OHC (P = .01) without an increase in 30-day readmission rates or mortality. Time to surgery was insignificantly reduced from 27.4 to 21.9 hours (P = .27) and surgery within 48 hours increased from 86% to 96% (P = .15).
DISCUSSION: The OHC has improved efficiency of hip fracture management as judged by significant reductions in LOS with a trend toward reduced TTS at our institution.
CONCLUSION: Orthopedic-hospitalist comanagement may represent an effective strategy to improve hip fracture management in the setting of a rapidly expanding patient population.
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Nightshift work and fracture risk: the Nurses' Health Study
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Hip Fx Time to Surgery
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SUMMARY: Nightshift work suppresses melatonin production and has been associated with an increased risk of major diseases including hormonally related tumors. Experimental evidence suggests that light at night acts through endocrine disruption likely mediated by melatonin. To date, no observational study has addressed the effect of night work on osteoporotic fractures, another condition highly sensitive to sex steroid exposure. Our study, to our knowledge, the first to address this question, supports the hypothesis that nightshift work may negatively affect bone health, adding to the growing list of ailments that have been associated with shift work. INTRODUCTION: We evaluated the association between nightshift work and fractures at the hip and wrist in postmenopausal nurses. METHODS: The study population was drawn from Nurses' Health Study participants who were working full or part time in nursing in 1988 and had reported their total number of years of rotating nightshift work. Through 2000, 1,223 incident wrist and hip fractures involving low or moderate trauma were identified among 38,062 postmenopausal women. We calculated multivariate relative risks (RR) of fracture over varying lengths of follow-up in relation to years of nightshift work. RESULTS: Compared with women who never worked night shifts, 20+ years of nightshift work was associated with a significantly increased risk of wrist and hip fractures over 8 years of follow-up [RR = 1.37, 95% confidence interval (CI), 1.04-1.80]. This risk was strongest among women with a lower body mass index (<24) who never used hormone replacement therapy (RR = 2.36; 95% CI, 1.33-4.20). The elevated risk was no longer apparent with 12 years of follow-up after the baseline single assessment of nightshift work. CONCLUSIONS: Long durations of rotating nightshift work may contribute to risk of hip and wrist fractures, although the potential for unexplained confounding cannot be ruled out.
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Medial thigh lift and DE.C.LI.VE
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Panniculectomy & Abdominoplasty CPG
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Vertical dermocrurolipectomy is a technique that in Italy has been named "DECLIVE," (which in Latin means something that moves downward). The first medial thigh lift with the DECLIVE technique was done in 1993. Since then, based on its excellent results 50 patients have been operated on, following DECLIVE. Therefore, DECLIVE should be considered just a variant in the medial thigh lift, because resecting a triangular portion from the perivulvar skin, it stops the displacement of the scar downward. Special acknowledgment goes to Ted Lockwood's studies for his role in the development of this technique.
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Use of adjunctive palmaris longus abductorplasty (Camitz) tendon transfer in pediatric median nerve injury
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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A number of tendon transfers have been described for opponensplasty. Transfer of the palmaris longus (PL) tendon with a palmar fascial extension was initially described by Camitz. This technique has mostly been combined with carpal tunnel release in patients with long standing median neuropathy with atrophy of the thenar muscles. However, the Camitz transfer has not been previously described in the setting of pediatric median nerve injury. We report 4 cases of Camitz transfer in pediatric patients with median nerve injuries. Four children (all female; age range 3-15 yrs) underwent PL tendon transfer following median nerve injury. The causes of injury included trauma, iatrogenic injury, and neuritis of the brachial plexus. The Camitz procedure was performed at the time of median nerve decompression and/or reconstruction. All patients had excellent early return of function. Transfer of the palmaris longus tendon reliably restores palmar abduction, with minimal to no additional morbidity, in carefully selected pediatric patients with median nerve injury undergoing release of the carpal tunnel
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Effects of dehydroepiandrosterone replacement therapy on bone mineral density in older adults: a randomized, controlled trial
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Management of Hip Fractures in the Elderly
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CONTEXT: Dehydroepiandrosterone (DHEA) and its sulfate (DHEAS) decrease with aging and are important androgen and estrogen precursors in older adults. Declines in DHEAS with aging may contribute to physiological changes that are sex hormone dependent.OBJECTIVE: The aim was to determine whether DHEA replacement increases bone mineral density (BMD) and fat-free mass.DESIGN, SETTING, AND PARTICIPANTS: A randomized, double-blinded, controlled trial was conducted at an academic research institution. Participants were 70 women and 70 men, aged 60-88 yr, with low serum DHEAS levels.INTERVENTION: The intervention was oral DHEA 50 mg/d or placebo for 12 months.MEASUREMENTS: BMD, fat mass, and fat-free mass were measured before and after intervention.RESULTS: Intent-to-treat analyses revealed trends for DHEA to increase BMD more than placebo at the total hip (1.0%, P = 0.05), trochanter (1.2%, P = 0.06), and shaft (1.2%, P = 0.05). In women only, DHEA increased lumbar spine BMD (2.2%, P = 0.04; sex-by-treatment interaction, P = 0.05). In secondary compliance analyses, BMD increases in hip regions were significant (1.2-1.6%; all P < 0.02) in the DHEA group. There were no significant effects of DHEA on fat or fat-free mass in intent-to-treat or compliance analyses.CONCLUSIONS: DHEA replacement therapy for 1 yr improved hip BMD in older adults and spine BMD in older women. Because there have been few randomized, controlled trials of the effects of DHEA therapy, these findings support the need for further investigations of the benefits and risks of DHEA replacement and the mechanisms for its actions
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Is minimally invasive surgery-total knee arthroplasty truly less invasive than standard total knee arthroplasty? A quantitative evaluation
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PJI DX Updated Search
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With recent technical advancements, the number of operative manipulations in the knee joint by minimally invasive surgery-total knee arthroplasty (MIS-TKA) is now considered to be the same as that using standard TKA (S-TKA). The question still remains, however, if MIS-TKA improves recovery compared to S-TKA. We compared MIS-TKA and S-TKA patients' physical activity as measured by an accelerometer. Physical activity expressed as cumulative acceleration was significantly higher in the MIS-TKA than in the S-TKA group on postoperative days (POD1, 2, 3, 4, 5, 10, 11) (P < .05). The recovery time, defined as the number of days required to achieve cumulative acceleration of 80% of the preoperative level, was significantly shorter (P < .05) in the MIS-TKA (3.0 ñ 3.3 days) group than in the S-TKA (7.0 ñ 3.5 days) group. Minimally invasive surgery-total knee arthroplasty appears to allow an earlier recovery after the operation than S-TKA. Less invasion to muscle during the surgery appears to contribute to shorter convalescence. é 2010 Elsevier Inc
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Popliteal vessel trauma: Surgical approaches and the vessel-first strategy
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DoD LSA (Limb Salvage vs Amputation)
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BACKGROUND: In this study, we analyzed long-term outcomes following treatment of traumatic popliteal vascular injuries in an urban level I trauma center, using a vessel-first approach in the case of combined vascular and bony/ligamentous injuries and discussing the relative merits of the medial and posterior approach to popliteal vessels. METHODS: Data including patient demographics, mechanism and type of injury, severity of limb ischemia, Injury Severity Score (ISS), limb ischemia time, time to revascularization from admission, treatment strategy, type of vascular reconstruction, limb salvage and mortality were retrospectively collected in patients treated for traumatic popliteal vessel lesions. All patients in this study were operatively treated using medial and posterior approaches. A vessel-first approach was used where possible. RESULTS: Twenty-four patients (13 male) with a median age of 45years (range 21-88) and popliteal vessel injury after traumatic knee dislocation (n=10, 42%), proximal tibia fracture (n=5, 21%), distal femur fracture (n=4, 17%), blunt popliteal injury (n=3, 12%) and penetrating trauma (n=2, 8%) were identified. Twelve (50%) patients were treated via a medial approach and 12 (50%) via a posterior approach. All had injury of the popliteal artery (15 complete transection, eight local intimal disruption and one pseudoaneurysm) with seven having additional popliteal vein and five with nerve injury. Nineteen patients (88%) presented with limb ischemia Rutherford category >/=II. Vessel reconstruction (four direct sutures, four patch plasties, 16 venous interposition/bypasses) was performed prior to bone/joint stabilization in 22 patients (92%). Thirty-day mortality was zero. Two above-knee amputations were performed within 30days due to severe infection. During a median follow-up of 59 (range 12-143) months, there were no deaths and no amputations. At the end of follow-up, all patients denied claudication. CONCLUSIONS: The vessel-first strategy promises an excellent outcome, independent of the surgical approach needed to repair traumatic popliteal vessel injuries.
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Anterior cruciate ligament tears: MR imaging-based diagnosis in a pediatric population
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Anterior Cruciate Ligament Injuries CPG
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PURPOSE: To evaluate the diagnostic accuracy of primary and secondary magnetic resonance (MR) imaging findings of anterior cruciate ligament (ACL) tears in young patients with immature skeletal systems. MATERIALS AND METHODS: MR images obtained in 43 patients aged 5-16 years who underwent arthroscopy were retrospectively reviewed. Two reviewers evaluated primary findings (abnormal signal intensity, abnormal course as defined by Blumensaat angle, and discontinuity), secondary findings (bone bruise in lateral compartment, anterior tibial displacement, uncovering of posterior horn of lateral meniscus, posterior cruciate ligament line, and posterior cruciate angle), and meniscal and other ligamentous injuries. RESULTS: There were 19 ACL tears and 24 intact ACLs. Overall sensitivity and specificity of MR imaging in detecting ACL tears were 95% and 88%, respectively. Sensitivities of the primary findings were 94% for abnormal Blumensaat angle; 79%, abnormal signal intensity; and 21% discontinuity. The specificity of all primary findings was 88% or greater. The sensitivity and specificity of the secondary findings, respectively, were 68% and 88% for bone bruise; 63% and 92%, anterior tibial displacement; 42% and 96%, uncovered posterior horn of lateral meniscus; 68% and 92%, positive posterior cruciate line; and 74% and 71%, abnormal posterior cruciate angle. Fifteen (79%) patients had meniscal tears, and five (26%) had collateral ligament injuries. CONCLUSION: Primary and secondary findings of ACL tears in young patients have high specificity and are useful for diagnosis
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Avoiding and treating perioperative complications of distal radius fractures
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DOD - Acute Comp Syndrome CPG
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Numerous methods of treatment are available for the management of distal radius fractures, with modern trends favoring volar fixed-angle distal radius plates. Whatever the method of fixation, recognition, management, and prevention of the known associated complications are essential to achieve a good outcome. This article reviews the common preventable complications that are associated with operative treatment of distal radius fractures, including tendon injuries, inadequate reduction, subsidence or collapse, intra-articular placement of pegs or screws, nerve injuries, complex regional pain syndrome, carpal tunnel syndrome, and compartment syndrome.
Copyright © 2012 Elsevier Inc. All rights reserved.
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Arthroscopic rotator cuff debridement
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The Treatment of Pediatric Supracondylar Humerus Fractures AUC
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Recent evidence has shown that rotator cuff pathology, in most patients, is due to primary intrinsic tendon degeneration. This degeneration leads to a build up of tendinosis at the insertion of the rotator cuff. Arthroscopic debridement of this tendinosis tissue without acromioplasty has been shown to have long-term efficacy in the treatment of "impingement syndrome" (rotator cuff symptoms in the absence of a full-thickness tear). The details of this technique are described. (copyright) 2006 Lippincott Williams & Wilkins
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Predictors and outcomes of lateral release in total knee arthroplasty: a cohort study of 1859 knees
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PJI DX Updated Search
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The use of lateral retinacular release (LR) to improve patellar tracking during total knee arthroplasty (TKR) remains contentious. This cohort study explored which pre-operative factors predicted LR, and analysed the effect of LR on short term complications and long term outcomes. One thousand eight hundred fifty-nine TKR patients were followed up for a mean of 5.49 years. One hundred fifty-four (8.3%) underwent LR. After regression analysis only, valgus deformity, year of surgery, maximal flexion and the operative surgeon predicted LR. LR patients stayed longer in hospital (10.8 vs 8.6 days) and had higher transfusion rates (20.3% vs 10.1%) than non-LR patients, but patellar fracture and infection rates were the same. Range of motion was poorer in the LR patients, but AKS Knee and functional scores were unaffected long term
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Comparison of static and mobile antibiotic-impregnated cement spacers for the treatment of infected total knee arthroplasty
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Dental Implant Infection
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Infection after total knee arthroplasty (TKA) is a devastating complication, and two-stage reimplantation has evolved as an effective treatment option. This study was undertaken to compare the clinical results and radiological changes associated with static or mobile cement spacer placement for the treatment of infected TKA. Between July 2000 and February 2007, 36 consecutive patients were treated by two-stage reimplantation using antibiotic-impregnated cement spacers (AICS) for infected TKAs. Static spacers were used in 20 knees and mobile spacers in 16 knees. Clinical outcomes included success rates of TKR revisions, ranges of motion (ROM), and Hospital for Special Surgery knee scores (HSS), pain and function scores of the Knee Society (KS), joint exposure methods, and bone loss. In this study, mobile spacers provided better ranges of motion and functional knee scores without concomitant increases in infection rate and bone loss in the initial and mid-term periods.
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Comparison between exercise therapy and non-hydrolyzed collagen (UC-II) in functionality and quality of life in women with knee osteoarthritis : A randomized controlled clinical trial
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AMP (Acute Meniscal Pathology)
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BACKGROUND: Knee osteoarthritis (OA) is characterized by a progressive degeneration of cartilage and menisci, leading to pain and locomotor disability. Here, we aimed to assess the effect of an exercise protocol and the oral use of non-hydrolyzed collagen (UC-II) on the functionality and quality of life of women with knee OA.
MATERIAL AND METHODS: Individuals were divided into three groups (CG [control group]; MG [medication group]; EG [exercise group]). In the CG there was no intervention, while MG received an oral dose (1 capsule/day) of UC-II and the EG held 12 sessions of an exercise protocol.
RESULTS: In the functionality tests (6-min walk test, 6MWT and timed up and go test [TUG]) the EG (p< 0.001/p= 0.020) and MG (p= 0.010/p= 0.010) revealed a significant improvement when compared to the CG. In the analysis of quality of life by WOMAC, a significant improvement was found only in the EG (p= 0.030) when compared to the CG; the same happened in the stiffness domain (EG, p= 0.010), despite in the pain domain, both the EG (p< 0.001) and the MG (p= 0.060) were better than the CG.
CONCLUSION: Data obtained here reveal that an exercise protocol and UC-II have similar effects for functionality, despite exercise being superior in promoting the quality of life score.
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Painful neuroma requiring surgical excision after lower limb amputation caused by landmine explosions
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DoD LSA (Limb Salvage vs Amputation)
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This article reports an analysis of 75 consecutive lower limb amputees who developed painful neuroma requiring surgical excision after lower limb amputation following landmine explosions. This retrospective study analyses the results of 75 patients who were treated for painful neuroma after lower limb amputation following landmine explosions between the years 2000 and 2006. The average time period from use of prosthesis to start of symptoms suggesting neuroma was 9.6 months. The average time period from start of pain symptoms to neuroma surgery was 7.8 months. All clinically proven neuromas were surgically resected. In the mean follow-up of 2.8 years, all patients were satisfied with the end results and all were free of any pain symptoms. Painful stump with clinical diagnostic findings of neuroma described above may be regarded as neuroma without requiring any further imaging modalities and is an indication for surgery if conservative measures fail.
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Myositis ossificans following total knee replacement. A report on two cases
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Surgical Management of Osteoarthritis of the Knee CPG
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Two cases of myositis ossificans involving the quadriceps femoris muscle are described following total knee replacement arthroplasty. This condition appears to be a very rare complication of this operation. One case was helped by ultrasound therapy
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Fatigue Failure of the GAP Ring
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Management of Hip Fractures in the Elderly
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This study reports the results and early failures using the Graft Augmentation Prosthesis ring in the reconstruction of acetabular defects encountered during total hip arthroplasty. Seventeen consecutive Graft Augmentation Prosthesis rings were used during 7 complex primary and 10 revision hip arthroplasties. Five patients died during the follow-up period. Of the remaining 12 patients, 7 had been revised at an average of 5 years follow-up. Five cases were revised because of fatigue failure of the implant associated with allograft resorption. Two cases were revised for recurrent dislocations. Because of this high mechanical failure rate (5 of 12 cases at only 5 years follow-up), we have abandoned this device in favor of implants with more mechanical strength. (copyright) 2007
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Association between change in BMD and fragility fracture in women and men
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Management of Hip Fractures in the Elderly
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Our objective was to estimate the relationship between longitudinal change in BMD and fragility fractures. We studied 3635 women and 1417 men 50-85 yr of age in the Canadian Multicentre Osteoporosis Study who had at least two BMD measurements (lumbar spine, femoral neck, total hip, and trochanter) within the first 5 yr of the study and fragility fractures (any, main, forearm/wrist, ribs, hip) within the first 7 yr. Multiple logistic regression was used to model the relationship between baseline BMD, BMD change, and fragility fractures. We found that, among nonusers of antiresorptives, independent of baseline BMD, a decrease of 0.01 g/cm(2)/yr in total hip BMD was associated with an increased risk of fragility fracture with ORs of 1.15 (95% CI: 1.01; 1.32) in women and 1.34 (95% CI: 1.02; 1.78) in men. The risk of fragility fractures in subgroups such as fast losers and those with osteopenia was better estimated by models that included BMD change than by models that included baseline BMD but excluded BMD change. Although the association between baseline BMD and fragility fractures was similar in users and nonusers of antiresorptives, the association was stronger in nonusers compared with users. These results show that BMD change in both men and women is an independent risk factor for fragility fractures and also predicts fracture risk in those with osteopenia. The results suggest that BMD change should be included with other variables in a comprehensive fracture prediction model to capture its contribution to osteoporotic fracture risk. (copyright) 2009 American Society for Bone and Mineral Research
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Comparison of mid-term results between conversion total knee arthroplasties following closed wedge high tibial osteotomy and primary total knee arthroplasties: A matched pair study including patellar symptom and position
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OAK 3 - Non-arthroplasty tx of OAK
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BACKGROUND: The purpose of this study was to compare mid-term clinical and radiographic results of conversion total knee arthroplasties (TKA) following a closed-wedge high tibial osteotomy (HTO) and primary TKAs.
METHODS: A total of 32 conversion TKAs (29 patients) were compared with a matched control group of patients who had undergone primary TKA. The clinical results were evaluated using the Knee Society Knee and Function score, the Western Ontario and McMaster Universities score, patella score, and range of motion (ROM). The radiographic results were evaluated using femorotibial angle, mechanical axis (MA), the method employed by the American Knee Society, joint line height (JLH), the amount of tibial bone resection, and the Insall-Salvati ratio. The clinical and radiographic results of conversion TKAs were compared with primary TKAs. The thickness of the polyethylene insert was also compared.
RESULTS: No significant differences were observed in the clinical scores or ROM between two groups. No significant differences were detected in femorotibial angle, MA, and position of the components between two groups. The amount of tibial bone resection and pre-operative JLH both were significantly lower in the conversion group than those in the control group, although postoperative JLH and pre and postoperative Insall-Salvati ratio did not differ between two groups. No significant difference in the thickness of the polyethylene insert was identified between two groups.
CONCLUSIONS: The previous closed-wedge HTO itself had no detrimental effect on the mid-term outcome of the subsequent TKA, including patellar symptom and position. No significant differences in the postoperative joint line and patella height were detected between the conversion and primary TKA groups.
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Cephalomedullary Nail Fixation of Intertrochanteric Femur Fractures: Are Two Proximal Screws Better Than One?
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Hip Fx in the Elderly 2019
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OBJECTIVES: To analyze radiographic changes in intertrochanteric (IT) fracture alignment after treatment with either a single sliding lag screw or an integrated compressed and locked, dual screw, cephalomedullary nail construct.
DESIGN: Retrospective comparative study.
SETTING: Level 1 regional trauma center.
PATIENTS: 1004 OTA/AO 31A, 31B2.1 fractures treated with either a single screw cephalomedullary nail (Gamma 3) or an integrated dual screw cephalomedullary nail (InterTAN) between February 1, 2005, and June 30, 2013. Four hundred thirteen remained after exclusion criteria; 130 were treated with a single screw device (79 stable and 51 unstable), and 283 with an integrated dual screw device (155 stable and 128 unstable).
INTERVENTION: Cephalomedullary nail insertion.
OUTCOME MEASURES: Radiographic analysis included fracture pattern, fracture reduction, neck-shaft angle (NSA), and femoral neck shortening (FNS) differences at 3, 6, and 12 months. Measurements were normalized using known lag screw dimensions, digitally corrected for magnification. Rotation between x-rays was controlled using a ratio of known to measured dimensions. The Mann-Whitney U test was used for statistical analysis.
RESULTS: The single screw device resulted in 2.5 times more varus collapse (NSA) and 2 times more FNS over 1 year, as compared to the locked, integrated dual screw device, regardless of stability (P < 0.001). NSA and FNS changes were greater for both devices in unstable fracture patterns, but significantly less movement occurred with the dual screw device (P < 0.001).
CONCLUSIONS: A cephalomedullary nail with 2 integrated proximal screws that can be compressed and then locked seems to maintain initial IT fracture reduction and subsequent position over time, with less varus collapse and less shortening than a single screw device.
LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Prepectoral versus Subpectoral Tissue Expander Breast Reconstruction: A Historically Controlled, Propensity Score-Matched Comparison of Perioperative Outcomes
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Acellular Dermal Matrix
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BACKGROUND: The rising popularity of prepectoral tissue expander placement with acellular dermal matrices in immediate breast reconstruction has prompted many studies on the safety of this technique. However, a comprehensive propensity-matched, historically controlled trial comparing perioperative outcomes following prepectoral versus partial subpectoral (dual-plane) placement of tissue expanders is lacking. METHODS: Retrospective propensity-matched cohort analysis was performed on all patients of two senior reconstructive surgeons who underwent bilateral tissue expander placement following a mastectomy with one of three breast surgeons at a single academic institution from 2012 onward (n = 260). Two matched groups (prepectoral and partial subpectoral) each consisted of 102 patients. Univariate and multivariable analyses were also performed to contextualize the risks associated with prepectoral reconstruction relative to demographic characteristics and other clinical factors. RESULTS: Compared to dual-plane subpectoral placement, prepectoral placement resulted in similar rates of overall perioperative complications (32 percent versus 31 percent; p = 1.00) and perioperative complications that required operative treatment (21 percent versus 21 percent; p = 1.00). There were no significant differences between the groups in complication rates for hematomas, seromas, impaired wound healing, and infection. Although prepectoral placement was associated with prolonged time to drain removal, those patients completed the expansion process twice as fast, were expanded further in the operating room, and were more than twice as likely to forgo clinic-based expansion. Prepectoral reconstruction was not associated with increased risk for any complications in univariate or multivariable analysis. CONCLUSIONS: Prepectoral tissue expander placement permitted greater intraoperative filling of expanders and a reduced likelihood of clinic-based expansion, with no increase in adverse outcomes compared to partial subpectoral placement. Adoption of this technique may reduce unnecessary clinic visits; shorten the delay before adjuvant therapy; and minimize patient apprehension, pain, and discomfort related to clinic-based expansion. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.
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The Upper Paleolithic triple burial of Dolni Vestonice: pathology and funerary behavior
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The Treatment of Pediatric Supracondylar Humerus Fractures AUC
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This work focuses on paleopathological analysis of one of the skeletons from the Gravettian triple burial of Dolni Vestonice (Moravia) and addresses issues of Upper Paleolithic funerary behavior. The burial includes the well-preserved skeletons of three young individuals. The skeleton in the middle (DV 15) is pathological and very problematic to sex; the other two (DV 13 and DV 14) are males and lie in an unusual position. The young age, the possibility of a simultaneous interment, and the position of the three specimens have given rise to speculations about the symbolic significance of this spectacular and intriguing funerary pattern. The pathological condition of the skeleton in the middle further emphasizes its peculiarity. Main pathological changes of the DV 15 skeleton include: asymmetric shortening of the right femur and of left forearm bones, bowing of the right femur, right humerus, and left radius, elongation of fibulae, dysplasias of the vertebral column, and very marked enamel hypoplasias. Scrutiny of the medical literature suggests that the most likely etiology is chondrodysplasia calcificans punctata (CCP) complicated by trauma and early fractures of the upper limbs. CCP is a rare inherited disorder characterized by stippled ossification of the epiphyses. The cartilaginous stippling is a transient phenomenon that disappears during infancy, leaving permanent deformities on affected bones. Among the different forms of CCP, the X-linked dominant form is that resulting in asymmetric shortening and is lethal during early infancy in males. Thus, survival of DV 15 until young adult age would require the specimen to be a female. Clinical findings often associated with the disease (erythemas, ichthyosis, alopecia, cataracts, and joint contractures, among others) would emphasize the singular aspect of this individual, pointing to a condition that should be carefully taken into account when speculating on the significance of that peculiar burial
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Younger patients report greater improvement in self-reported function after knee joint replacement
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OAK 3 - Non-arthroplasty tx of OAK
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STUDY DESIGN: Retrospective chart review.OBJECTIVES: To evaluate and compare the relationship between patients' age and the change in Oxford Knee Score from preoperative to postoperative assessments, and to investigate whether there is a relationship between preoperative Oxford Knee Score results and the indication for total knee replacement surgery, and if age affects this relationship.BACKGROUND: An increasing number of younger patients receive knee joint replacements, yet it is unknown how this cohort functions after surgery. This warrants investigation into the potential age-related differences in joint function following surgery. The Oxford Knee Score has been validated as a clinical tool but has yet to be accepted in the decision-making process regarding the need for, or appropriateness of, total knee replacement.METHODS: In a retrospective chart review, 240 patients completed the Oxford Knee Score questionnaire to evaluate chronic pain and/or dysfunction associated with the knee.RESULTS: The largest improvement with joint replacement was observed to occur in the youngest patient group (50-59 years old). Moreover, the Oxford Knee Score was shown to be the strongest predictor (odds ratio = 0.61) for the indicated intervention when compared to other predictors. The youngest patient group reported a significantly (P<.03) higher Oxford Knee Score result when indicated for surgery, compared to the oldest patient group (80-89 years old).CONCLUSION: The results provide insight into how age influences self-perceived joint function before and after joint replacement surgery, and into the clinical decision to provide the surgical option to younger patients. Moreover, the observed relationship between the Oxford Knee Score and the indicated treatment supports the use of the questionnaire as a preoperative tool in considering treatment options for patients with knee osteoarthritis.LEVEL OF EVIDENCE: Prognosis, level 2b. Copyright © 2013 Journal of Orthopaedic & Sports Physical Therapy.
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Development of an Ex Vivo Murine Osteochondral Repair Model
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Osteochondritis Dissecans 2020 Review
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OBJECTIVE: Mouse models are commonly used in research applications due to the relatively low cost, highly characterized strains, as well as the availability of many genetically modified phenotypes. In this study, we characterized an ex vivo murine osteochondral repair model using human infrapatellar fat pad (IPFP) progenitor cells. DESIGN: Femurs from euthanized mice were removed and clamped in a custom multidirectional vise to create cylindrical osteochondral defects 0.5 mm in diameter and 0.5 mm deep in both condyles. The IPFP contains progenitors that are a promising cell source for the repair of osteochondral defects. For proof of concept, human IPFP-derived progenitor cells, from osteoarthritic (OA) patients, cultured as pellets, were implanted into the defects and cultured in serum-free medium with TGFβ3 for 3 weeks and then processed for histology and immunostaining. RESULTS: The custom multidirectional vise enabled reproducible creation of osteochondral defects in murine femoral condyles. Implantation of IPFP-derived progenitor cells led to development of cartilaginous tissue with Safranin O staining and deposition of collagen type II in the extracellular matrix. CONCLUSIONS: We showed feasibility in creating ex vivo osteochondral defects and demonstrated the regenerative potential of OA human IPFP-derived progenitors in mouse femurs. The murine model can be used to study the effects of aging and OA on tissue regeneration and to explore molecular mechanisms of cartilage repair using genetically modified mice.
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Clinical evaluation of fluproquazone in post-operative pain. A report of double-blind comparative trials in patients after surgical interventions
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AMP (Acute Meniscal Pathology)
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A collaborative double-blind randomized trial was carried out involving 123 hospitalized patients with moderate or severe pain following surgical interventions such as episiotomy, vaginal uterus extirpation or meniscectomy. The analgesic effect of multiple oral doses of 4-(p-fluorophenyl)-1-isopropyl-7-2(1H)-quinazolinone (fluproquazone) (100 mg) was compared with that of paracetamol (500 mg). Self-assessments were made of pain relief by the patients over a 3-day period. The results showed that fluproquazone produced at least comparable relief to paracetamol after the first dose and at the end of the overall treatment period. Furthermore, the analgesic effect of fluproquazone was significantly superior to paracetamol after a 6-h period. Over-all tolerance to multiple doses was assessed as excellent or good by all the patients receiving fluproquazone. The commonest side-effects in both treatment groups were gastrointestinal symptoms. However, the overall incidence of side-effects was lower in the fluproquazone group and those that were reported were mostly mild as compared with the paracetamol group.
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Management of traumatic wounds and a novel approach to delivering wound care in children
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DoD SSI (Surgical Site Infections)
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Significance: The costs and morbidity of pediatric traumatic wounds are not well known. The literature lacks a comprehensive review of the volume, management, and outcomes of children sustaining soft tissue injury. We briefly review the existing literature for traumatic wounds such as open fractures and burns. Such injuries require dedicated wound care and we propose a novel approach for more efficient and more effective delivery of dedicated pediatric wound care. Recent Advances: New pediatric literature is emerging regarding the long-term effects of wound care pain in traumatic injuries - especially burns. A variety of wound dressings and alternative management techniques exist and are geared toward reducing wound care pain. Our institution utilizes a unique model to provide adequate sedation and pain control through a dedicated pediatric wound care unit. We believe that this model reduces the cost of wound care by decreasing emergency department and operating room visits as well as hospital length of stay. Critical Issues: First, medical costs related to pediatric traumatic wound care are not insignificant. The need for adequate pain control and sedation in children with complex wounds is traditionally managed with operating room intervention. Afterward, added costs can be from a hospital stay for ongoing acute wound management. Second, morbidities of complex traumatic wounds are shown to be related to the acute wound care received. Future Directions: Further guidelines are needed to determine the most effective and efficient care of complex traumatic soft tissue injuries in the pediatric population. Copyright © 2014 by Mary Ann Liebert, Inc.
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Creatinine-Based Renal Function Estimates and Dosage of Postoperative Pain Management for Elderly Acute Hip Fracture Patients
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Hip Fx in the Elderly 2019
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Many analgesics and their metabolites are renally excreted. The widely used Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI)-estimated glomerular filtration rate (eGFR) equations are not developed for use in the elderly, while the recent Berlin Initiative Study (BIS), Full Age Spectrum (FAS), and Lund-Malmo revised (LMR) equations are. This observational study investigated differences between creatinine-based eGFR equations and how the choice of equation influences dosage of analgesics in elderly (>=70 years) patients admitted with acute hip fracture. eGFR was calculated by the CKD-EPI, BIS, Cockcroft-Gault (CG), FAS, LMR, and Modification of Diet in Renal Disease (MDRD) equations. Standard daily dose for postoperative pain medications ibuprofen, morphine and gabapentin was simulated for each equation according to dosage recommendations in Renbase<sup> R</sup>. For 118 patients, mean eGFR from the CKD-EPI, BIS, CG, FAS, LMR, and MDRD equations was 67.3 mL/min/1.73 m2, 59.1 mL/min/1.73 m2, 56.9 mL/min/1.73 m2, 60.3 mL/min/1.73 m2, 58.9 mL/min/1.73 m2, and 79.1 mL/min/1.73 m2, respectively (p < 0.0001). Mean difference to CKD-EPI was -10.4 mL/min/1.73 m2 to 11.8 mL/min/1.73 m2. Choice of eGFR equation significantly influenced the recommended dose (p < 0.0001). Shifting to BIS, FAS, or LMR equations led to a lower recommended dose in 20% to 31% of patients. Choice of eGFR equation significantly influenced dosing of ibuprofen, morphine, and gabapentin.
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Tibial plateau leveling osteotomy in small breed dogs with high tibial plateau angles using a 4-hole 1.9/2.5 mm locking T-plate
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PJI DX Updated Search
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OBJECTIVES: To report clinical experiences with tibial plateau leveling osteotomy (TPLO) to address cranial cruciate ligament (CCL) disease in small breed dogs with high tibial plateau angles (TPA) using a specific 4-hole locking T-plate. STUDY DESIGN: Retrospective case series. ANIMALS: Small breed dogs (<15 kg) with high TPA (>30 degrees ): n = 19 (29 CCL ruptures). METHODS: TPLO was performed by standard technique using a 1.9/2.5 mm 4-hole locking T-plate. Preoperative, immediate postoperative, and 6-8 weeks postoperative TPA were measured from radiographs. Lameness was scored subjectively preoperatively and 6-8 weeks postoperatively. Mid to long term follow-up was by client telephone questionnaire (mean, 12.1 months after surgery). RESULTS: Mean +/- SD preoperative TPA was 37.0 +/- 4.9 degrees , immediate postoperative TPA, 6.4 +/- 2.8 degrees and 6-8 weeks postoperative TPA, 8.0 +/- 4.9 degrees . Postoperative complications occurred in 4 dogs (13.8%) all of which had been operated as single-session bilateral procedures. Three stifles had failure of a single screw and postoperative increase in TPA. Periprosthetic infection necessitated plate removal in 1 dog. Lameness scores by veterinary assessment reduced from mean 3.4/5 preoperatively to 0.4/5 at 6-8 weeks postoperatively. Mid to long-term follow-up revealed no lameness by owner assessment. CONCLUSION: A 4-hole 1.9/2.5 mm locking T-plate may be used in the stabilization of unilateral TPLO in small breed dogs with high TPA
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Neurological findings in Hunter disease: pathology and possible therapeutic effects reviewed
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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Hunter disease (mucopolysaccharidosis type II, MPS II) is an X-linked lysosomal storage disease caused by deficiency of iduronate-2-sulfatase. Accumulation of chondroitin sulfate B and heparan sulfate in various tissues is the biochemical consequence of MPS II. Children with Hunter disease are normal at birth, and symptoms occur between 2 and 10 years of age. Typical symptoms include coarse facies with enlarged tongue and prominent forehead as well as a short, stocky built stature with short neck. The cardiovascular, respiratory and gastrointestinal systems may be affected, and oral, dermatological and psychiatric as well as neurological complications are described. Life expectancy is markedly reduced and may be limited to 12 years for severely affected patients. The most common causes of death are airway obstruction and cardiac failure. The most severe symptoms may result from neurological symptoms or complications including hydrocephalus, spinal cord compression, cervical myelopathy, optic nerve compression, and hearing impairment. Patients may also develop carpal tunnel syndrome, sleep apnoea, seizures or mental retardation. This review describes characteristic neurological manifestations in MPS II and its underlying pathophysiology. In addition, an appraisal is given whether or not enzyme replacement therapy may be able to improve in particular the neurological symptoms of Hunter disease
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Improved comfort and function of arm prosthesis after implantation of a Humerus-T-Prosthesis in trans-humeral amputees
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The Treatment of Pediatric Supracondylar Humerus Fractures AUC
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The use of arm prosthesis in trans-humeral amputees is limited; due to the cone form of the amputation stump. A Humerus-T-Prosthesis was implanted in three patients to create artificial humerus condyles. Two of the patients were successfully rehabilitated with the application of a new type trans-humeral arm prosthesis. This arm prosthesis had a socket which is suspended and stabilized by the humerus and implant only. Traction and rotational stability were secured by adjustable pressure adaptation around the artificial condyles. The third patient developed a pressure wound over the lateral part of the artificial condyle that later healed. He also was subject to a new trauma with a fracture of the ipsilateral scapula and until now has had limited the use of his new arm prosthesis. It was concluded that this new concept for prosthesis fitting of trans-humeral amputees looks promising, but alternative designs of the implant should be tested
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Forearm BMD as measured by peripheral quantitative computed tomography (pQCT) in a German reference population
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Distal Radius Fractures
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Low bone mass as estimated by decreased bone mineral density (BMD) is an established predictor of osteoporotic fractures. One of the latest developments in bone densitometry is peripheral quantitative computed tomography (pQCT) of the forearm. In Germany, the CT bone scanner XCT 900 has already been widely used; however, interpretation of measurements with respect to osteoporosis risk assessment can be improved by better defined and validated reference data. In the present study, this device was used to measure BMD at the distal radius in a well-defined healthy population of 179 German adults (91 men, 88 women) aged 20-79 years. In vivo precision was 1.67% for trabecular and 0.81% for total BMD measurements. Peak values of trabecular and total BMD were observed at the ages 40-50 years in women and 30-40 years in men. Beyond these ages, both trabecular and total BMD showed a linear decline with age, decreasing by 0.85% and 1.08% per year in women and by 0.59% and 0.54% in men, respectively. Measures of BMD were not influenced by weight, height or body mass index (BMI). In both sexes, trabecular and total radial BMD showed a positive and significant correlation with femoral BMD measures obtained by dual X-ray absorptiometry (DXA). Weaker correlations were observed with DXA measures of the lumbar spine. Compared with the 95% reference range provided by the manufacturer, the distribution of age- and sex-specific values of trabecular BMD of the distal radius was shifted to lower values by up to 1 standard deviation.(ABSTRACT TRUNCATED AT 250 WORDS)
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Comparison of hook plate with versus without double-tunnel coracoclavicular ligament reconstruction for repair of acute acromioclavicular joint dislocations: A prospective randomized controlled clinical trial
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Trial Systematic Review Project
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Purpose: This study was designed to compare the surgical outcomes of a hook plate with double-tunnel coracoclavicular (CC) ligament reconstruction by conjoined tendon transfer versus single hook plate surgery for the repair of acute type of Rockwood type III and V acromioclavicular (AC) joint dislocations. Methods: The study cohort included 62 patients with acute (within 6 weeks after trauma) Rockwood type III and V AC joint dislocations who underwent surgery from February 2012 to September 2015. The patients were randomly allocated to the ligament reconstruction group (LR group, n = 31) or the single hook plate group (HP group, n = 31). In both groups, reduction of the AC joint by hook plate and repair of the ruptured AC ligament with absorbable Vicryl sutures were performed homoplastically. The lateral half of the short tendon of the biceps brachii muscle and the lateral half of the flexor tendon were used to reconstruct the trapezoid and conoid ligaments, respectively. Differences in surgical duration, intraoperative blood loss, incision length, and total cost were compared between the two groups. Furthermore, the preoperative and postoperative visual analogue score (VAS), postoperative American Shoulder and Elbow Surgeons (ASES) score, Constant–Murley score (CMS), Karlsson score, complication rates, and patient satisfaction at the last follow-up were compared to evaluate the curative effects of the surgical treatments. Magnetic resonance imaging (MRI) after hook plate removal was used to evaluate the reconstructed ligaments and tendon-bone interface. Results: In total, 25 patients in the LR group and 26 in the HP group completed the follow-up. There were no statistically significant differences in age, sex, Rockwood type, placing time, total cost, and follow-up duration between the LR and HP groups (p > 0.05). However, as compared with the HP group, the surgical duration and incision length were longer in the LR group (92.08 ± 19.25 vs. 56.54 ± 21.29 min and 13.64 ± 0.90 vs. 6.65 ± 1.01 cm, respectively, p < 0.05). In addition, there was no significant difference in preoperative VAS scores, but the postoperative VAS score was lower in LR group than in the HP group (2.52 ± 1.19 vs. 4.12 ± 1.45, respectively, p < 0.05). Moreover, patients in LR group had a remarkable higher CMS and ASES score (89.56 ± 2.80 vs. 79.31 ± 4.97 and 92.60 ± 2.79 vs. 82.35 ± 3.44, respectively, p < 0.05). The overall excellent or good result rate, as evaluated by the Karlsson score, was 92.00% (23/25) and 50.00% (13/26), respectively (p < 0.05). MRI findings revealed good condition of the reconstructed ligaments and tendon-bone interface. The incidence of complications was lower and the satisfaction rate was higher in the LR group than in the HP group (1/25 vs. 16/26 and 23/25 vs. 14/26, respectively, p < 0.05). Conclusions: The overall surgical effect of the use of a hook plate combined with double-tunnel CC ligament reconstruction is superior to single hook plate surgery for the repair of acute Rockwood type III and V AC joint dislocations.
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Free composite medial femoral trochlea osteochondral cutaneous flap for wrist scaphoid and lunate cartilage lesions: Advantages of a skin paddle
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Osteochondritis Dissecans 2020 Review
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The medial femoral trochlea flap is a chondrocorticoperiosteal flap. It has recently been described in the context of cartilage lesions. It is mainly used for reconstruction in non-union of the scaphoid's proximal pole and Kienböck disease. The medial femoral trochlea flap may be harvested with a skin island flap to monitor its vascularization. The surgical technique has been extensively described for its primary osteochondral form. However, the corticoperiosteal form has not been thoroughly studied and described. Here, we describe and report the early results of three cases of the composite medial femoral trochlea flap, with a skin paddle for postoperative monitoring, being used to reconstruct the injured proximal scaphoid and lunate.
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Profiles of biomarkers of excess alcohol consumption in patients undergoing total hip replacement: Correlation with function
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DoD SSI (Surgical Site Infections)
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Aims. Patients who misuse alcohol may be at increased risk of surgical complications and poorer function following hip replacement. Identification and intervention may lead to harm reduction and improve the outcomes of surgery. The aim of this study was to determine the prevalence of biomarker elevation in patients undergoing hip replacement and to investigate any correlation with functional scores and complications. Methods. We performed a retrospective study that examined the profile of biomarkers of alcohol misuse in 1049 patients undergoing hip replacement. Results. Gamma-glutamyltransferase was elevated in 150 (17.6), and mean corpuscular volume was elevated in 23 (4). At one year general physical health was poorer where there was elevation of GT, and the mental health and hip function was poorer with elevation of MCV. There were no differences in complications. Discussion. Raised biomarkers can alert clinicians to potential problems. They also provide an opportunity to perform further investigation and offer intervention. Future research should focus on the use in orthopaedic practice of validated screening questionnaires and more sensitive biomarkers of alcohol misuse. Conclusion. This study demonstrates a potential substantial proportion of unrecognised alcohol misuse that is associated with poorer functional scores in patients after total hip replacement. Copyright © 2011 Paul J. Jenkins et al.
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Epidemiology of periprosthetic femoral fractures in 5417 revision total hip arthroplasties: a 40-year experience
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Hip Fx in the Elderly 2019
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AIMS: The goals of this study were to define the risk factors, characteristics, and chronology of fractures in 5417 revision total hip arthroplasties (THAs).
PATIENTS AND METHODS: From our hospital's prospectively collected database we identified all patients who had undergone a revision THA between 1969 and 2011 which involved the femoral stem. The patients' medical records and radiographs were examined and the relevant data extracted. Post-operative periprosthetic fractures were classified using the Vancouver system. A total of 5417 revision THAs were identified.
RESULTS: There were 668 intra-operative fractures, giving an incidence of 12%. Fractures were three times more common with uncemented stems (19%) than with cemented stems (6%) (p < 0.001). The incidence of intra-operative femoral fracture varied by uncemented stem type: fully-coated (20%); proximally-coated (19%); modular fluted tapered (16%) (p < 0.05). Most fractures occurred during the insertion of the femoral component (35%). One-third involved the diaphysis and 26% were of the calcar: 69% were undisplaced. There were 281 post-operative fractures of the femur (20-year probability = 11%). There was no difference in risk for cemented and uncemented stems. Post-operative fractures were more common in men < 70 years (p = 0.02). Periprosthetic fractures occurred earlier after uncemented revision of the femoral component, but later after a cemented revision. The most common fracture type was a Vancouver B1 (31%). Of all post-operative fractures, 24% underwent open reduction and internal fixation and 15% revision arthroplasty.
CONCLUSION: In revision THA, intra-operative fractures occurred three times more often with an uncemented stem. Many were undisplaced diaphyseal fractures treated with cerclage fixation. While the risk of post-operative fracture is similar between uncemented and cemented components, they occur at notably different times depending on the type of stem fixation.
TAKE HOME MESSAGE: In revision THA, intra-operative periprosthetic femoral fractures occur three times more often with uncemented stems. Many are non-displaced diaphyseal fractures treated with cerclage fixation. While postoperative fracture risks are equivalent between uncemented and cemented components, they occur at notably different time periods based on stem fixation type.
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Predictive factors for developing osteochondritis dissecans after surgery for discoid lateral meniscus are younger age and shorter meniscal width
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Osteochondritis Dissecans 2020 Review
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PURPOSE: This study aimed to identify the predictive factors for postoperative osteochondritis dissecans (OCD) in juvenile and adolescent knees with discoid lateral meniscus (DLM). METHODS: In total, 242 patients with symptomatic DLM who underwent surgery were identified. Inclusion criteria were set as follows: (1) ageâ??â?¤â??17 years with an open growth plate, (2) follow-up magnetic resonance imaging, and (3) absence of preoperative OCD. Consequently, 52 patients were retrospectively investigated. Average age during surgery, body mass index (BMI), and follow-up duration were 12 years [95% confidence interval (CI) 11-13], 19.2 kg/m(2) (95% CI 18.4-20.1), and 27.3 months (95% CI 20.9-33.7), respectively. Age, sex, sports activities, BMI, symptomatic OCD in other joints, postoperative rehabilitation, preoperative shift of DLM by Ahn's classification, surgical procedures (saucerization alone or with stabilization, and subtotal meniscectomy), and postoperative meniscal width were analyzed as possible predictive factors. RESULTS: Postoperatively, 42 patients without OCD and 10 with OCD were observed. In univariate analysis, younger age [odds ratio (OR) 1.5; pâ??=â??0.003], subtotal meniscectomy (OR 6.3; pâ??=â??0.027), and shorter meniscal width (OR 2.7; pâ??=â??0.005) were predictive factors for postoperative OCD. Multivariate analysis demonstrated that younger age (OR 1.6; pâ??=â??0.009) and shorter meniscal width (OR 1.5; pâ??=â??0.003) were predictive factors. CONCLUSIONS: To prevent postoperative OCD after DLM surgeries, achieving stabilization with adequate meniscal width is necessary for juvenile knees. LEVEL OF EVIDENCE: III.
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Metastatic pulmonary adenocarcinoma in a llama (Lama glama)
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MSTS 2018 - Femur Mets and MM
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An adult female llama with a comminuted fracture of the left femoral head was necropsied. A firm multinodular mass infiltrated skeletal muscle adjacent to the fracture. Multiple, firm, white nodules were in the pulmonary parenchyma and pleura. A single nodule was in the liver. Microscopically, transition from nonneoplastic bronchiolar epithelium to neoplastic epithelium that formed acinar structures was evident at bronchioloalveolar junctions. A diagnosis of pulmonary adenocarcinoma was made. Similar neoplastic tissue was in the liver and in the perifemoral mass. Immunohistochemically, neoplastic cells were positive for pan-cytokeratin, cytokeratin 7, and cytokeratin 5/6 antibodies and negative for vimentin and cytokeratins 8/18 and 20.
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Investigation of Postoperative Complications of Intrabony Cystic Lesions in the Oral and Maxillofacial Region
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MSTS 2022 - Metastatic Disease of the Humerus
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PURPOSE: The purpose of this study was to identify factors that can complicate the surgical removal of intrabony cysts and any relevant correlations between them.
PATIENTS AND METHODS: The medical records of 249 patients who underwent surgical removal of intrabony cysts were retrospectively reviewed. Outcome variables were postoperative complications, infection, and recurrence. Predictor variables were patient age, gender, comorbidities, anatomic location, pathologic diagnosis, preoperative infection, previous marsupialization, and bone graft methods. Logistic regression analysis was performed to identify risk factors of postoperative infection and recurrence.
RESULTS: The cystic lesion was smallest in patients who did not receive a bone graft and increased steadily in those who received a xenogeneic bone graft and an autogenous bone graft, in that order. Paresthesia occurred after enucleation of the cystic lesion in 38 cases. Pathologic fractures were observed in 4 cases. There were 59 postoperative infections. The postoperative infection rate was as high as 63.6% in patients who underwent autogenous bone grafting. In contrast, infection rates were as low as 26.8 and 19.5% in those who underwent xenogeneic bone grafting and no bone grafting, respectively. Location of the cystic lesion in the maxilla or mandible affected the infection rate. When cysts were located in the anterior mandible, no postoperative infection occurred. In contrast, the infection rate was highest for cysts in the mandibular ramus, followed by those in the posterior mandible. Cystic lesion recurrence was observed in 7 cases: 5 cases of odontogenic keratocysts, 1 case of periapical cyst, and 1 case of dentigerous cyst. These findings suggest that cyst pathologic identity affects the recurrence rate. Cyst size was meaningfully correlated with recurrence rate.
CONCLUSIONS: These results suggest that autogenous bone grafts increase the risk of postoperative infection compared with absence of a bone graft.
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Impact of length of red blood cells transfusion on postoperative delirium in elderly patients undergoing hip fracture surgery: A cohort study
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Hip Fx Time to Surgery
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PURPOSE: The purpose of the present study was to test whether older red blood cells (RBCs) transfusion results in an increased risk of postoperative delirium (POD) and various in-hospital postoperative complications in elderly patients undergoing hip fracture surgery. MATERIALS AND METHODS: Patients (>/=65 years) who underwent hip fracture surgery were enrolled, 179 patients were divided into two groups according to the storage time of the RBCs. The shorter storage time of RBCs transfusion group comprised patients who received RBCs </=14 days old and the longer storage time of RBCs transfusion group comprised patients who received RBCs >14 days old. The blood samples were collected before anaesthesia induction, 4 and 24 h after RBCs transfusion for the determination of proinflammatory mediators, malondialdehyde, and superoxide dismutase activity. RESULTS: There was no difference in the baseline characteristics, the incidence of POD, and the in-hospital postoperative complications between the shorter storage time of RBCs transfusion group and the longer storage time of RBCs transfusion groups (P>0.05). Compared with the shorter storage time of RBCs transfusion group, the longer storage time of RBCs transfusion caused significantly longer duration of POD (P<0.05). There were significantly increased plasma levels of IL-8 and malondialdehyde at 24 h and IL-1beta at 4 h after RBCs transfusion in the POD group compared with the non-POD group (P<0.05). CONCLUSION: Transfusion of the longer storage RBCs is not associated with a higher incidence of POD or in-hospital postoperative complications, but with longer duration of POD in elderly patients undergoing hip fracture surgery.
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Prevention of deep venous thrombosis: The Hospital for Special Surgery approach
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Surgical Management of Osteoarthritis of the Knee CPG
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Deep vein thrombosis is the most common complication after total knee and total hip arthroplasty. At the Hospital for Special Surgery we have tried to develop a multimodal approach for deep vein thrombosis prophylaxis. For patients undergoing total hip arthroplasty this approach involves multiple intraoperative and postoperative modalities. These include hypotensive epidural anesthesia, intraoperative heparin, and minimization of venous kinking during the surgery as well as postoperative pneumatic compression devices, early weight bearing, and pharmacologic prophylaxis with either aspirin or warfarin. Intraoperative measures are less important in patients undergoing total knee arthroplasty considering that the intraoperative tourniquet limits the benefits of hypotensive anesthesia and intraoperative heparin. We therefore advocate postoperative combination protocols involving pneumatic compression and either aspirin or warfarin. For institutions that do not use multimodal treatment options, low molecular weight heparin, warfarin, or modern oral thrombin inhibitors such as ximelagran (FDA approval pending) are the treatment of choice. (copyright) 2005 Elsevier Inc. All rights reserved
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Changes in articular cartilage mechanics with meniscectomy: A novel image-based modeling approach and comparison to patterns of OA
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AMP (Acute Meniscal Pathology)
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Meniscectomy is a significant risk factor for osteoarthritis, involving altered cell synthesis, central fibrillation, and peripheral osteophyte formation. Though changes in articular cartilage contact pressure are known, changes in tissue-level mechanical parameters within articular cartilage are not well understood. Recent imaging research has revealed the effects of meniscectomy on the time-dependent deformation of physiologically loaded articular cartilage. To determine tissue-level cartilage mechanics that underlie observed deformation, a novel finite element modeling approach using imaging data and a contacting indenter boundary condition was developed. The indenter method reproduces observed articular surface deformation and avoids assumptions about tangential stretching. Comparison of results from an indenter model with a traditional femur-tibia model verified the method, giving errors in displacement, solid and fluid stress, and strain below 1% (RMS) and 7% (max.) of the absolute maximum of the parameters of interest. Indenter finite element models using real joint image data showed increased fluid pressure, fluid exudation, loss of fluid load support, and increased tensile strains centrally on the tibial condyle after meniscectomy-patterns corresponding to clinical observations of cartilage matrix damage and fibrillation. Peripherally there was decreased consolidation, which corresponds to reduced contact and fluid pressure in this analysis. Clinically, these areas have exhibited advance of the subchondral growth front, biological destruction of the cartilage matrix, cartilage thinning, and eventual replacement of the cartilage via endochondral ossification. Characterizing the changes in cartilage mechanics with meniscectomy and correspondence with observed tissue-level effects may help elucidate the etiology of joint-level degradation seen in osteoarthritis.
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Reduced time to surgery improves mortality and length of stay following hip fracture: results from an intervention study in a Canadian health authority
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Hip Fx in the Elderly 2019
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BACKGROUND: Existing literature demonstrating the negative impact of delayed hip fracture surgery on mortality consists largely of observational studies prone to selection bias and may overestimate the negative effects of delay. We conducted an intervention study to assess initiatives aimed at meeting a 48-hour benchmark for hip fracture surgery to determine if the intervention achieved a reduction in time to surgery, and if a general reduction in time to surgery improved mortality and length of stay.
METHODS: We compared time to surgery, length of stay and mortality between pre- and postintervention patients with a hip fracture using the Kaplan-Meier estimator and Cox proportional hazards model adjusting for age, sex, comorbidities, type of surgery and year.
RESULTS: We included 3525 pre- and 3007 postintervention patients aged 50 years or older. The proportion of patients receiving surgery within the benchmark increased from 66.8% to 84.6%, median length of stay decreased from 13.5 to 9.7 days, and crude in-hospital mortality decreased from 9.6% to 6.8% (all p < 0.001). Adjusted analyses revealed reduced mortality in hospital (hazard ratio [HR] 0.68, 95% confidence interval [CI] 0.57-0.81) and at 1 year (HR 0.87, 95%CI 0.79-0.96). Independent of the intervention period, having surgery within 48 hours demonstrated decreased adjusted risk of death in hospital (HR 0.51, 95%CI 0.41-0.63) and at 1 year postsurgery (HR 0.72, 95% CI 0.64-0.80).
CONCLUSION: Coordinated, region-wide efforts to improve timeliness of hip fracture surgery can successfully reduce time to surgery and appears to reduce length of stay and adjusted mortality in hospital and at 1 year.
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All-arthroscopic meniscus repair of avascular and biologically at-risk meniscal tears
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AMP (Acute Meniscal Pathology)
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Meniscal repair strategies have evolved over time from a more invasive open method to less invasive, all-arthroscopic approaches. Novel devices and surgical techniques currently enable the successful arthroscopic placement of biomechanically optimal sutures that provide compression across the tear site with less potential surgical morbidity. Current techniques do not require accessory posteromedial or posterolateral incisions and significantly reduce the incidence of complications and pain associated with more invasive surgery. Along with these improved methods, the indications for meniscal repair are expanding to include tear patterns previously considered biologically at risk for poor healing. More recently, with the addition of biologic augmentation methods, such as the introduction of platelet- rich plasma as well as reported tissue engineering advances, it may be possible to continue to broaden the indications and success of meniscal preservation through repair and replacement.
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Systemic Lupus Erythematosus Does Not Increase Risk of Adverse Events in the First 6 Months after Total Knee Arthroplasty
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AAHKS (2) Corticosteroids
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Background Increasing numbers of patients with systemic lupus erythematosus (SLE) are undergoing total knee arthroplasty (TKA). Whether postsurgical adverse events (AEs) are higher in patients with SLE than patients with osteoarthritis (OA) is unknown. Objectives This study aims to compare AEs within 6 months of TKA. Methods Patients in a single institution's arthroplasty and SLE registries who underwent TKA from 2007 to 2014 were eligible. SLE cases were matched 1:2 to OA on age, sex, year of TKA, and procedure type. AEs were collected through chart review and registry responses. Baseline characteristics were compared and regression analysis performed to determine predictors of AEs. Results Fifty-two SLE TKA were matched to 104 OA TKA. There was no difference in follow-up between groups. SLE patients had more comorbidities (â?¥1 Charlson-Deyo comorbidity: SLE 38.4% vs. OA 17.3%; P-value < 0.001) and steroid use (preoperative [SLE 28.8% vs. OA 1.9%, P-value < 0.001] and perioperative "stress-dose" [30.8% vs. 2.9%, P-value = 0.01]). SLE patients did not experience more major (SLE 25.0% vs. OA 19.2%; P-value = 0.41), minor (15.4% vs. 10.6%; P-value = 0.39), or total (38.5% vs. 27.9%; P-value = 0.18) AEs. AEs were not increased among patients on stress-dose steroids. In a multiple logistic regression analysis controlling for comorbidities and diagnosis, neither SLE (OR 1.61, 95% CI 0.74-3.50) nor >1 comorbidity (OR 1.05, 95% CI 0.46-2.39) was an independent risk factor for AEs. Conclusion SLE is not an independent risk factor for increased AEs 6 months after TKA. Stress-dose steroid use does not heighten AE risk. These findings should inform recommendations for SLE patients considering TKA.
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To derotate or not? The impact of a permanent derotation screw on the revision rate of dynamic hip screw fixation for intracapsular neck of femur fractures
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Hip Fx in the Elderly 2019
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Background: In this retrospective study, we examine the impact that employing a permanent derotation screw (DRS) has on the rate of revision for 2-hole dynamic hip screws (DHS, a.k.a. sliding hip screws), used for internal fixation of intracapsular neck of femur (NOF) fractures. To the best of our knowledge, we are the first to examine the impact of using a derotation screw on DHS revision rate. Methods: We obtained a list of 64 patients suffering intracapsular NOF fracture treated with 2-hole DHS over a 5-year period, 28 of these were also treated with a DRS, forming our DRS group, 36 were not (non-DRS group). Fracture severity and patient demographics between the groups were compared to ensure homogeneity. The rate of revision to arthroplasty (total or hemi) of the two groups were compared. Results: The mean age in the DRS group was 70.79 years, 1.77 years lower than the non-DRS group (p=0.570). The DRS group had a rate of revision of 14%, in comparison with 39% in the non-DRS group (p=0.0299), corresponding with a number needed to treat of 4.06 derotation screws to prevent a single failure. Conclusions: In this study, employing a permanent derotation screw alongside a 2-hole DHS was associated with a significantly lower rate of revision to arthroplasty than using a 2-hole DHS alone. We would recommend this be further investigated with prospective randomized trials, to provide robust evidence and make clinical recommendations.
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Effect of an unrepaired fracture of the ulnar styloid base on outcome after plate-and-screw fixation of a distal radial fracture
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Distal Radius Fractures
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BACKGROUND: The impact of an unrepaired fracture of the ulnar styloid base on recovery after internal fixation of a fracture of the distal part of the radius is uncertain. We evaluated a series of patients with an internally fixed fracture of the distal part of the radius to test the hypothesis that there is no difference in wrist motion or function scores between those with an untreated fracture of the ulnar styloid base and those with no ulnar fracture.
METHODS: Two cohorts of seventy-six matched patients, one with a fracture of the ulnar styloid base and the other with no ulnar fracture, were retrospectively analyzed by examining data gathered in a prospective study of plate-and-screw fixation of distal radial fractures. Patients were matched for age, sex, AO fracture type, and injury mechanism. The two cohorts were analyzed for differences in motion, grip strength, pain, the Gartland and Werley score, the DASH (Disabilities of the Arm, Shoulder and Hand) score, and the SF-36 (Short Form-36) score at six, twelve, and twenty-four months postoperatively. In a second analysis, sixty-four patients with <2 mm of displacement of a fracture of the ulnar styloid base were compared with forty-nine patients with greater displacement. Differences between cohorts and within cohorts over time were determined with use of regression analysis and the likelihood ratio test.
RESULTS: No significant differences were found between patients with an unrepaired fracture of the ulnar styloid base and those with no ulnar fracture at any of the follow-up intervals. However, a trend was observed toward less grip strength at six months (71% [of that on the contralateral side] compared with 79%; mean difference, -8% [95% confidence interval=-15.3% to -0.6%]; p=0.03) and less flexion (54 degrees compared with 59 degrees ; mean difference, -5 degrees [95% confidence interval=-11.7 degrees to -0.8 degrees ]; p=0.02) and ulnar deviation (32 degrees compared with 36 degrees ; mean difference, -4 degrees [95% confidence interval=-7 degrees to -0.1 degrees ]; p=0.05) at twenty-four months after surgery in patients with an untreated fracture of the ulnar styloid base. There were no significant differences with regard to any tested outcome measure between the patients with >or=2 mm of displacement of an unrepaired fracture of the ulnar styloid base and those with less displacement.
CONCLUSIONS: An unrepaired fracture of the base of the ulnar styloid does not appear to influence function or outcome after treatment of a distal radial fracture with plate-and-screw fixation, even when the ulnar fracture was initially displaced >or=2 mm.
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Management of hip involvement in ankylosing spondylitis
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DoD SSI (Surgical Site Infections)
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Ankylosing spondylitis (AS) is an inflammatory rheumatologic disease characterized by inflammation and progressive structural damage of the affected joints. Hip involvement often results in severe deformities and significant impairment on function. Although, tremendous progress has been made in conservative management for AS, effective prevention strategies for hip involvement and long-term need for total hip arthroplasty (THA) remain indefinite. When hip involvement has progressed to intractable pain and disability, THA is still the most effective treatment strategy to relieve pain and restore function. However, certain AS-specific problems regarding "preoperative preparation," "intraoperative difficulties," "perioperative pharmacological management," "postoperative physiotherapy," "operation benefits," and "operation complications" need more concern and further discussion. © 2013 Clinical Rheumatology.
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Variation of skeletal degenerative joint disease features in an identified Italian modern skeletal collection
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OAK 3 - Non-arthroplasty tx of OAK
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OBJECTIVES: The objective of this study was to investigate the relationship of degenerative joint disease (DJD) features (marginal lipping, porosity, surface osteophytes, eburnation, and loss of joint morphology) with sex, age, and occupation.
MATERIALS AND METHODS: We devised a recording method for scoring the single features in the shoulder, elbow, wrist, hip, knee, and ankle of an Italian skeletal sample of 332 individuals (males = 161, females = 171) of known sex, age, and occupation from the Frassetto collection (Sassari, Sardinia, 19th-20th century).
RESULTS: Our data revealed that: (1) the frequency of all features increases with age; (2) porosity is the first feature to appear, being in general the most frequent feature in young adults; (3) sex differences are especially found in the upper limbs of mature and elderly adults; (4) marginal lipping and surface osteophytes show a lesser age correlation and, in general, higher frequencies in the left lower limb; (5) no differences were found among different occupations.
DISCUSSION: We explain these results in light of different metabolic and adaptive processes in relation to age and sex. Static (weight-bearing) rather than dynamic mechanical stress could play a pivotal role in the distribution of the features observed in the lower limbs. The considerable increase in marginal lipping and surface osteophytes in elderly adults may be an adaptation for sustaining mechanical loading, balancing the loss of bone tissue which is characteristic of ageing processes (osteopenia, osteoporosis). Am J Phys Anthropol, 2016. © 2016 Wiley Periodicals, Inc. Am J Phys Anthropol 160:683-693, 2016. © 2016 Wiley Periodicals, Inc.
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Prognostic relevance of increased angiogenesis in osteosarcoma
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MSTS 2022 - Metastatic Disease of the Humerus
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PURPOSE: The purpose of this work was to evaluate the prognostic relevance of microvessel density (MVD) for response to chemotherapy and long-term outcome in osteosarcoma.
EXPERIMENTAL DESIGN: Pretherapeutic tumor biopsies of 60 patients with high-grade central osteosarcoma, who were treated according to multimodal neoadjuvant protocols of the German-Austrian-Swiss Cooperative Osteosarcoma Study Group, were evaluated for intratumoral MVD. MVD was correlated with demographic and tumor-related variables, response, and survival.
RESULTS: The median intratumoral MVD was 52 microvessels per 0.26-mm2 field area (interquartile range, 31-77 microvessels per 0.26-mm2 field area). At a median follow-up period of 3.5 years, patients with a high (>median) MVD had significantly higher 5- and 10-year overall survival rates (84%) than patients with low (< or =median) MVD (49%; P = 0.0029). Furthermore, increased relapse-free survival for patients with high MVD (P = 0.0064) was observed. In a subgroup analysis of 44 patients with primary high-grade central osteosarcoma of the extremities without primary metastases and good surgical remission, high MVD was associated with 5- and 10-year overall survival rates of 91% compared with 58% for low MVD (P = 0.034). Cox regression analysis revealed that MVD was an independent prognostic factor for survival. A good response to chemotherapy (histologic grading scale of Salzer-Kuntschik) correlated significantly with a high MVD (P = 0.006).
CONCLUSIONS: Increased angiogenesis is a prognostic indicator for higher survival and response rates to chemotherapy in patients with osteosarcoma. Thus, measurement of MVD might be useful in decisions selecting patients for future neoadjuvant treatment.
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Patellar resurfacing complications in total knee arthroplasty
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PJI DX Updated Search
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Purpose: The ideal management of the patella during total knee arthroplasty (TKA) is still controversial. Patellar retention is generally associated with an increased rate of anterior knee pain; however, patient satisfaction is similar in cases of replacement or retention. When the patella is replaced, potential severe complications can occur. Aim of this study was to retrospectively review results of a continuous series of patients having been treated with TKA and patella resurfacing. Methods: The charts of 1,600 consecutive total knee prostheses were analysed to evaluate the rate of patellar resurfacing. All implants were posterior stabilized; 310 patients having received a patellar replacement were reviewed at follow-up (FU) examination. Complete physical examination as well as administration of the Hospital for Special Surgery (HSS) score was performed. X-rays analysis included weightbearing anteroposterior (AP) and lateral views of the injured knee and bilateral skyline views at 30 flexion. Results: Two hundred and eighty patients were available for clinical and imaging investigation at an average FU of 96 (58-144) months. Mean age at the time of surgery was 70 (62-80) years. Mean HSS score was 85.9 ñ 7.6. The overall rate of patellofemoral complications was 7 % (19 cases); 13 patients claimed anterior knee pain, five had symptomatic patellar maltracking and one had patellar component loosening. Conclusion: Our data are in accordance with those available in the literature. Recent meta-analyses demonstrated lower risk of re-operation after patellar resurfacing. However, when complications of the resurfaced patella occur, they can be potentially catastrophic events. é 2013 Springer-Verlag Berlin Heidelberg
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Vascular injuries of the extremities are a major challenge in a third world country
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DoD LSA (Limb Salvage vs Amputation)
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BACKGROUND: Traumatic vascular injuries of the extremities are a major challenge especially in the third world countries. These injuries are mostly due to poor traffic laws, street crimes, firearms and blast associated injuries. We therefore would like to share our 10 years of experience in dealing with vascular injuries in Pakistan. METHODS: This was a retrospective observational study conducted in the department of vascular surgery of Liaquat National Hospital, Karachi, Pakistan. Patients' records were retrieved from the department and were reviewed. Cases with vascular injuries of upper and lower limb that presented with signs of salvageable limb and presented within 12 hours of injury were included in the study. Patients with more than 12 hours of presentation and in whom primary amputation was done, were excluded from the study. RESULTS: There were 328 patients who presented with vascular injuries of the extremities that fell in the inclusion criteria. Limb salvage rate was 41 %, whereas 30-days perioperative mortality was 5.48 %. The major cause of limb loss was delay in presentation of more than 8 h of injury. Major vessels involved were popliteal artery (41.76 %), followed by femoral artery (27.43 %). CONCLUSION: Vascular injuries are becoming a major contributor of limb loss in third world countries due to violence, terrorism and unavailability of vascular facilities. This morbidity can be reduced by improving law and order situation, evolving an effective emergency ambulatory system and with better training and provision of vascular services in remote areas so that the delay factor can be reduced.
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0 |
Cementless total hip replacement with subtrochanteric femoral shortening for severe developmental dysplasia of the hip
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Management of Hip Fractures in the Elderly
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Total hip replacement for high dislocation of the hip joint remains technically difficult in terms of preparation of the true acetabulum and restoration of leg length. We describe our experience of cementless total hip replacement combined with a subtrochanteric femoral shortening osteotomy in 20 hips with Crowe grade IV dislocation with a mean follow-up of 8.1 years (4 to 11.5). There was one man and 17 women with a mean age of 55 years (44 to 69) at the time of the operation. After placment of the acetabular component at the site of the natural acetabulum, a cementless porous-coated cylindrical femoral component was implanted following a subtrochanteric femoral shortening osteotomy. The mean Japanese Orthopedic Association hip score improved from a mean of 38 (22 to 62) to a mean of 83 points (55 to 98) at the final follow-up. The mean lengthening of the leg was 14.8 mm (-9 to 34) in patients with iliofemoral osteoarthritis and 35.3 mm (15 to 51) in patients with no arthritic changes. No nerve palsy was observed. Total hip replacement combined with subtrochanteric shortening femoral osteotomy in this situation is beneficial in avoiding nerve injury and still permits valuable improvement in inequality of leg length. (copyright)2009 British Editorial Society of Bone and Joint Surgery
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1 |
Therapeutic efficacy of zoledronic acid combined with calcitriol in elderly patients receiving total hip arthroplasty or hemiarthroplasty for osteoporotic femoral neck fracture
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Hip Fx in the Elderly 2019
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Zoledronic acid could improve the clinical outcome in elderly patients receiving total hip arthroplasty or hemiarthroplasty for osteoporotic femoral neck fracture in the 1-year prospective study.
INTRODUCTION: To validate the therapeutic efficacy of zoledronic acid (ZOL) in elderly patients with femoral neck fracture who received total hip arthroplasty (THA) or hemiarthroplasty (HA).
METHODS: Included in this study were 95 elderly patients with femoral neck fractures who received THA/HA between August 2015 and June 2018. They were randomized into a ZOL group and a control group. Patients in ZOL group received a yearly single dose of 5 mg ZOL intravenous injection plus 0.5 mug/day calcitriol and 1000 mg/day calcium carbonate 2 days before THA or HA. Patients in the control group were treated with the same dose of calcitriol and calcium carbonate only without ZOL. Bone mineral density (BMD) was measured by dual-energy X-ray absorptiometry. Bone metabolism markers including the total extension of the peptide type I collagen amino end (P1NP) and beta collagen degradation product (beta-CTX) were obtained by serum examination. The postoperative functional outcome was assessed using Harris Hip Score (HHS).
RESULTS: During the follow-up period, BMD in the ZOL group was improved and significantly higher than that in the control group at 6 and 12 months post-operation. Bone metabolism markers P1NP and beta-CTX in ZOL group remained at a relatively low level as compared with that in the control group at 6 months after treatment. No significant difference in the mean HHS and the excellent/good rate of joint function was observed during the follow-up period between the two groups. The occurrence of adverse events in the ZOL group was significantly higher than that in the control group.
CONCLUSIONS: A single infusion of ZOL shows promise in improving BMD of the healthy side of the femoral neck, lumbar spine, and total hip and decreasing the level of bone markers, which may improve the clinical outcome of patients with osteoporotic femoral neck fractures receiving THA/HA.
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0 |
Delirium in patients with cancer at the end of life
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MSTS 2022 - Metastatic Disease of the Humerus
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PURPOSE: Delirium is a common and distressing syndrome seen in patients with advanced cancer. Behavioral manifestations of delirium, such as agitation, may result in medical intervention, stress to family caregivers, and inpatient hospice admission. The purpose of this study was to examine the frequency, characteristics, and presumed causes of delirium in patients with advanced cancer.
DESCRIPTION OF STUDY: Records of all patients with cancer who were admitted to an inpatient hospice facility in 1995 were reviewed retrospectively (N = 210). Patients were classified as delirious based on the clinical judgment of the admitting physician.
RESULTS: Delirium was the third most common reason for admission (20%). Male gender (P = .04) and the presence of a primary or metastatic brain tumor (P = .03) were significant risk factors for delirium, while advanced age and primary or metastatic liver, lung, or bone cancer were not. Resolution of the agitation, the most disruptive symptom of delirium, occurred in 69% of patients before death or discharge.
CLINICAL IMPLICATIONS: Delirium is common in hospice patients with cancer and is an important cause of family distress and increased cost of care. The recognition of early clinical signs and predisposing factors should facilitate prompt diagnosis. Appropriate intervention is usually successful in alleviating the most distressing symptoms of delirium.
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0 |
Prevalence of osteoarthritis in former elite athletes: a systematic overview of the recent literature
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SR for PM on OA of All Extremities
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The aim of this study was to systematically review the recent scientific literature to explore the prevalence of osteoarthritis (OA) in former elite athletes from team and individual sports. A systematic review of observational studies was conducted. Based on three categories of keywords (and synonyms), a sensitive search strategy was built in order to search
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How High-Risk Comorbidities Co-Occur in Readmitted Patients With Hip Fracture: Big Data Visual Analytical Approach
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Hip Fx in the Elderly 2019
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BACKGROUND: When older adult patients with hip fracture (HFx) have unplanned hospital readmissions within 30 days of discharge, it doubles their 1-year mortality, resulting in substantial personal and financial burdens. Although such unplanned readmissions are predominantly caused by reasons not related to HFx surgery, few studies have focused on how pre-existing high-risk comorbidities co-occur within and across subgroups of patients with HFx.
OBJECTIVE: This study aims to use a combination of supervised and unsupervised visual analytical methods to (1) obtain an integrated understanding of comorbidity risk, comorbidity co-occurrence, and patient subgroups, and (2) enable a team of clinical and methodological stakeholders to infer the processes that precipitate unplanned hospital readmission, with the goal of designing targeted interventions.
METHODS: We extracted a training data set consisting of 16,886 patients (8443 readmitted patients with HFx and 8443 matched controls) and a replication data set consisting of 16,222 patients (8111 readmitted patients with HFx and 8111 matched controls) from the 2010 and 2009 Medicare database, respectively. The analyses consisted of a supervised combinatorial analysis to identify and replicate combinations of comorbidities that conferred significant risk for readmission, an unsupervised bipartite network analysis to identify and replicate how high-risk comorbidity combinations co-occur across readmitted patients with HFx, and an integrated visualization and analysis of comorbidity risk, comorbidity co-occurrence, and patient subgroups to enable clinician stakeholders to infer the processes that precipitate readmission in patient subgroups and to propose targeted interventions.
RESULTS: The analyses helped to identify (1) 11 comorbidity combinations that conferred significantly higher risk (ranging from P<.001 to P=.01) for a 30-day readmission, (2) 7 biclusters of patients and comorbidities with a significant bicluster modularity (P<.001; Medicare=0.440; random mean 0.383 [0.002]), indicating strong heterogeneity in the comorbidity profiles of readmitted patients, and (3) inter- and intracluster risk associations, which enabled clinician stakeholders to infer the processes involved in the exacerbation of specific combinations of comorbidities leading to readmission in patient subgroups.
CONCLUSIONS: The integrated analysis of risk, co-occurrence, and patient subgroups enabled the inference of processes that precipitate readmission, leading to a comorbidity exacerbation risk model for readmission after HFx. These results have direct implications for (1) the management of comorbidities targeted at high-risk subgroups of patients with the goal of pre-emptively reducing their risk of readmission and (2) the development of more accurate risk prediction models that incorporate information about patient subgroups.
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0 |
Stiffness after TKR: how to avoid repeat surgery
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PJI DX Updated Search
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Stiffness after total knee replacement (TKR) is a frustrating complication that has many possible causes. Although the definition of stiffness has changed over the years, most would agree that flexion <75 degrees and a 15 degrees lack of extension constitutes stiffness. The management of this potentially unsatisfying situation begins preoperatively with guidance of the patient's expectations; it is well-known that preoperative stiffness is strongly correlated with postoperative lack of motion. At the time of surgery, osteophytes must be removed and the components properly sized and aligned and rotated. Soft tissue balancing must be attained in both the flexion/extension and varus/valgus planes. One must avoid overstuffing the tibiofemoral and/or patellofemoral compartments with an inadequate bone resection. Despite these surgical measures and adequate pain control and rehabilitation, certain patients will continue to frustrate our best efforts. These patients likely have a biological predisposition for formation of scar tissue. Other potential causes for the stiff TKR include complex regional pain syndrome or joint infection. Close follow-up of a patient's progress is crucial for the success in return of range of motion. Should motion plateau early in the recovery phase, the patient should be evaluated for manipulation under anesthesia. The results of reoperations for a stiff TKR are variable due to the multiple etiologies. A clear cause of stiffness such as component malposition, malrotation, or overstuffing of the joint has a greater chance of regaining motion than arthrofibrosis without a clear cause. Although surgical treatment with open arthrolysis, isolated component, or complete revision can be used to improve TKR motion, results have been variable and additional procedures are often necessary
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0 |
Clinical results of trochanteric fractures treated with the
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Management of Hip Fractures in the Elderly
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The aim of this study was to investigate the outcome of 352 (71 males) patients with trochanteric fractures that were treated with the
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0 |
A Systematic Review and Meta-analysis of the Association Between Vitamin K Antagonist Use and Fracture
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Hip Fx in the Elderly 2019
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Background: Vitamin K antagonist (VKA) anticoagulant use is suspected to increase the risk of bone fracture through inhibition of vitamin Kâ??dependent cofactors of bone formation, an effect not seen with non-vitamin K antagonist oral anticoagulants (NOACs). The purpose of our systematic review and meta-analysis is to investigate the association between VKA use and fracture. Methods: We searched PubMed, EMBASE, and Cochrane Library for studies analyzing fracture in adults using VKAs versus controls. Two authors independently reviewed articles. We assessed for risk of bias using the Newcastle-Ottawa Quality Assessment Scale and the Cochrane Risk of Bias Tool and calculated pooled effects using random effects models. Results: We included 23 articles (22 observational studies and 1 randomized controlled trial), studying 1,121,582 subjects. There was no increased odds of fracture in VKA users versus controls (pooled OR 1.01, 95% CI 0.89, 1.14) or in VKA users versus NOAC users (pooled OR 0.95, 95% CI 0.78, 1.15). Subjects using a VKA for 1Â year or longer did not have increased odds of fracture (pooled OR 1.07, 95% CI 0.90, 1.27). Compared to controls, there was increased odds of fracture in women (pooled OR 1.11, 95% CI 1.02, 1.21) and older VKA users (â?¥ 65) (pooled OR 1.07, 95% CI 1.01, 1.14). Discussion: We found no increase in odds of fracture in VKA users versus controls or NOAC users. There was a small increase in odds of fracture among female and elderly VKA users, which may not be clinically important when accounting for other considerations in choosing an anticoagulant. Our findings suggest that, when anticoagulation is necessary, fracture risk should not be a major consideration in choice of an agent. Future studies directly comparing VKA to NOAC users and studies with longer duration of VKA use may be needed.
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0 |
Level of undercarboxylated osteocalcin in reproductive Thai females
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Management of Hip Fractures in the Elderly
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Osteocalcin is a vitamin K dependent protein requiring vitamin K as a cofactor for the enzyme gamma glutamyl carboxylase which converts the glutamate residues at 17, 21, 24 position of the molecule into gamma carboxyglutamate or Gla residues. The carboxylation makes immature osteocalcin or undercarboxylated osteocalcin (ucOC) into mature osteocalcin which enhances calcium binding in bone. The level of undercarboxylated osteocalcin is recognized as a marker of vitamin K2 bone. The level of undercarboxylated osteocalcin is recognized as a marker of vitamin K2 in blood necessary for this process. Mature osteocalcin has a higher affinity for hydroxyapatite than undercarboxylated osteocalcin. Foreign studies have shown that ucOC level is increased in elderly women and postmenopausal women in comparison with young, healthy, reproductive women and level of ucOC is also the marker to predict the risk of hip fracture. The standard value of undercarboxylated osteocalcin in Thai women is not available. The aim of the present study was to find the level of ucOC in reproductive Thai females. 357 healthy female volunteers who had regular menstruation, 20-50 years of age, average age 38.5 years old. The volunteers had no intake of any kind of medicine affecting bone metabolism before blood examination. The mean value of undercarboxylated osteocalcin is 2.69 ng/ml, median is 2.10_ng/ml standard deviation = 2.02,_standard error = 0.107 with 95% confident interval = 2.485 to 2.906 ng/ml. In the authors previous pilot study in elderly and postmenopausal women, the authors found that the mean of ucOC in Thai elderly and postmenopausal women was higher than that of reproductive women
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1 |
Abdominal Panniculectomy Can Simplify Kidney Transplantation in Obese Patients
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Panniculectomy & Abdominoplasty CPG
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BACKGROUND: Obesity is frequently present in patients suffering from end-stage renal disease (ESRD). However, overweight kidney transplant candidates are a challenge for the transplant surgeon. Obese patients tend to develop a large abdominal panniculus after weight loss creating an area predisposed to wound-healing disorders. Due to concerns about graft survival and postoperative complications after kidney transplantation, obese patients are often refused in this selective patient cohort. The study aimed to analyze the effect of panniculectomies on postoperative complications and transplant candidacy in an interdisciplinary setting. METHODS: A retrospective database review of 10 cases of abdominal panniculectomies performed in patients with ESRD prior to kidney transplantation was conducted. RESULTS: The median body mass index was 35.2 kg/m2 (range 28.5-53.0 kg/m2) at first transplant-assessment versus 31.0 kg/m2 (range 28.0-34.4 kg/m2) at panniculectomy, and 31.6 kg/m2 (range 30.3-32.4 kg/m2) at kidney transplantation. We observed no major postoperative complications following panniculectomy and minor wound-healing complications in 2 patients. All aside from 1 patient became active transplant candidates 6 weeks after panniculectomy. No posttransplant wound complications occurred in the transplanted patients. CONCLUSION: Abdominal panniculectomy is feasible in patients suffering ESRD with no major postoperative complications, thus converting previously ineligible patients into kidney transplant candidates. An interdisciplinary approach is advisable in this selective patient cohort.
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0 |
Soft drink intake and progression of radiographic knee osteoarthritis: Data from the osteoarthritis initiative
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OAK 3 - Non-arthroplasty tx of OAK
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Objectives: We examine the prospective association of soft drink consumption with radiographic progression of knee osteoarthritis (OA). Design: Prospective cohort study. Setting: This study used data from the osteoarthritis initiative (OAI). Participants: In OAI, 2149 participants with radiographic knee OA and having dietary data at baseline were followed up to 12, 24, 36 and 48 months. Measures: The soft drink consumption was assessed with a Block Brief Food Frequency Questionnaire completed at baseline. To evaluate knee OA progression, we used quantitative medial tibiofemoral joint space width (JSW) based on plain radiographs. The multivariate linear models for repeated measures were used to test the independent association between soft drink intake and the change in JSW over time, while adjusting for body mass index and other potential confounding factors. Results: In stratified analyses by gender, we observed a significant dose-response relationship between baseline soft drink intake and adjusted mean change of JSW in men. With increasing levels of soft drink intake (none, â?¤1, 2-4 and â?¥5 times/week), the mean decreases of JSW were 0.31, 0.39, 0.34 and 0.60 mm, respectively. When we further stratified by obesity, a stronger dose-response relationship was found in nonobese men. In obese men, only the highest soft drink level (â?¥5 times/week) was associated with increased change in JSW compared with no use. In women, no significant association was observed. Conclusions: Our results suggest that frequent consumption of soft drinks may be associated with increased OA progression in men. Replication of these novel findings in other studies demonstrating the reduction in soft drink consumption leads to delay in OA progression is needed.
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Attachment style, relationship quality, and psychological distress in patients with psychogenic non-epileptic seizures versus epilepsy
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DoD PRF (Psychosocial RF)
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OBJECTIVES: Psychopathology levels are elevated in patients with psychogenic non-epileptic seizures (PNES) and those with epilepsy. However, patients with PNES report higher rates of trauma and neglect, poorer health-related quality of life (HRQoL), and an increased prevalence of insecure attachment. We examined to what extent attachment style and relationship quality with their main informal carer impact on levels of HRQoL, depression, and anxiety in patients with PNES versus those with epilepsy.
METHOD: Consecutive patients with PNES (N=23) and epilepsy (N=72) completed questionnaires about attachment style, quality of their relationship with their main informal carer, seizure severity, HRQoL, depression, and anxiety.
RESULTS: Patients with PNES reported higher levels of anxiety and depression and lower HRQoL than those with epilepsy. PNES: No significant correlations were found with HRQoL but depression correlated positively with attachment avoidance, attachment anxiety, and relationship conflict. Anxiety correlated positively with attachment avoidance, attachment anxiety, and relationship conflict, and negatively with relationship depth and support. Epilepsy: HRQoL correlated negatively with seizure severity, depression, anxiety, attachment avoidance, and attachment anxiety. Depression correlated positively with attachment avoidance, attachment anxiety, and relationship conflict. Anxiety correlated positively with seizure severity, attachment avoidance, and attachment anxiety. Correlations between measures of relationship quality and anxiety were stronger in patients with PNES versus those with epilepsy (zs=2.66 to 2.97, ps<0.004). Attachment style and relationship quality explained larger amounts of variance in depression (45%) and anxiety (60%) in the patients with PNES than those with epilepsy (16% and 13%).
SIGNIFICANCE: Levels of anxiety and depression were higher in patients with PNES than those with epilepsy. Interpersonal problems were much more closely associated with anxiety and depression in patients with PNES than those with epilepsy. The findings support the use of therapeutic interventions for PNES focusing on attachment and relationship issues.
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0 |
Predictors of functional outcome after revision total knee arthroplasty following aseptic failure
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OAK 3 - Non-arthroplasty tx of OAK
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BACKGROUND: There are a limited number of studies related to quality of life and functional outcome after revision total knee arthroplasty (TKA). The present study aimed to identify predictors of functional outcome after revision TKA for aseptic failure.
METHODS: One hundred seventy-five patients with mean age of 66.6 years (range, 35-88) who underwent revision TKA for aseptic failure at our institute from 2003 to 2007 were identified. Short-form 36 (SF-36), Western Ontario and McMaster Osteoarthritis Index (WOMAC) and Knee Society Scores (KSS) collected preoperatively and at 2 years follow up were evaluated. Univariate and multivariate analyses were performed to determine predictors of functional outcome in studied patients.
RESULTS: Both physical and mental dimensions of SF-36, pain, functional, and stiffness subscales of WOMAC and both functional and clinical scores of KSS improved significantly after revision TKA (p<0.001). In the multivariate analysis, male gender, a lower Charlson comorbidity index, and higher preoperative functional KSS were predictors of higher functional KSS at 2 years after revision. Lower preoperative pain and higher clinical KSS were predictors of better outcome as measured by pain scale of WOMAC. Body mass index (BMI) and preoperative clinical KSS were significant predictors of function and stiffness as measured by WOMAC.
CONCLUSIONS: BMI is a modifiable predictor of functional outcome after revision TKA. Moreover, patients with higher preoperative functional scores appear to have better postoperative function.
LEVEL OF EVIDENCE: Level II.
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1 |
The value of a new ultrasound stress test in assessment and treatment of clinically detected hip instability
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Developmental Dysplasia of the Hip CPG
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Fifty patients with clinical suspicion of hip dislocation were investigated prospectively with a dynamic ultrasound stress test. A posterior force was applied to hips in flexion and any movement between the femoral head and the acetabulum was measured. The results of this test showed that posterior movement ranged from 0 to 13.0 mm. Hips that were clinically normal had a mean movement of 1.4 mm, hips with minor clinical instability had a mean movement of 0.6 mm, hips with moderate instability had a mean movement of 4.5 mm, and those with major instability had a mean movement of 5.1 mm. This was statistically significant to a 1% confidence interval. We propose two groups of ultrasound-detected movement: group A less than 5.0 mm representing physiologic laxity, and group B greater than or equal to 5.0 mm being pathological and requiring treatment
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Patients' and practitioners' views of knee osteoarthritis and its management: A qualitative interview study
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AAHKS (2) Corticosteroids
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Purpose: To identify the views of patients and care providers regarding the management of knee osteoarthritis (OA) and to reveal potential obstacles to improving health care strategies. Methods: We performed a qualitative study based on semi-structured interviews of a stratified sample of 81 patients (59 women) and 29 practitioners (8 women, 11 general practitioners [GPs], 6 rheumatologists, 4 orthopedic surgeons, and 8 [4 GPs] delivering alternative medicine). Results: Two main domains of patient views were identified: one about the patient-physician relationship and the other about treatments. Patients feel that their complaints are not taken seriously. They also feel that practitioners act as technicians, paying more attention to the knee than to the individual, and they consider that not enough time is spent on information and counseling. They have negative perceptions of drugs and a feeling of medical uncertainty about OA, which leads to less compliance with treatment and a switch to alternative medicine. Patients believe that knee OA is an inevitable illness associated with age, that not much can be done to modify its evolution, that treatments are of little help, and that practitioners have not much to propose. They express unrealistic fears about the impact of knee OA on daily and social life. Practitioners' views differ from those of patients. Physicians emphasize the difficulty in elaborating treatment strategies and the need for a tool to help in treatment choice. Conclusions: This qualitative study suggests several ways to improve the patient-practitioner relationship and the efficacy of treatment strategies, by increasing their acceptability and compliance. Providing adapted and formalized information to patients, adopting more global assessment and therapeutic approaches, and dealing more accurately with patients' paradoxal representation of drug therapy are main factors of improvement that should be addressed. © 2011 Alami et al.
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Design, Preparation, and Bioactivity Study of New Fusion Protein HB-NC4 in the Treatment of Osteoarthritis
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AMP (Acute Meniscal Pathology)
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Osteoarthritis (OA) is now becoming the main disease that affects public health. There is no specific medicine used for OA in clinical application until now. Recently, several studies demonstrated that OA is closely related to the complement system, and some complement regulators such as N-terminal non-collagenous domain 4 (NC4) aimed at alleviating OA have shown a promising therapeutic effect. However, targeting ability is the main limitation for NC4. In this study, a fusion protein named heparin-binding domain-N-terminal non-collagenous domain 4 (HB-NC4) was proposed to solve this problem, which could provide a better way for OA treatment. First, HB-NC4 plasmid was constructed using ClonExpress II one-step ligation kit method. And Escherichia coli BL21 was utilized to express the fusion protein, Ni<sup>2+</sup>-sepharose, and a desalting gravity column were introduced to purify HB-NC4. The results showed that 0.84 mg HB-NC4 could be obtained from a 1 L culture medium with a purity higher than 92.6%. Then, the hemolytic assay was introduced to validate the anti-complement activity of HB-NC4; these results demonstrated that both HB-NC4 and NC4 had a similar anti-complement activity, which indicated that heparin-binding (HB) did not affect the NC4 structure. Targeting ability was investigated in vivo. HB-NC4 showed a higher affinity to cartilage tissue than NC4, which could prolong the retention time in cartilage. Finally, the destabilization of the medial meniscus (DMM) model was applied to investigate HB-NC4 pharmacodynamics in vivo. The results indicated that HB-NC4 significantly slowed cartilage degradation during the OA process. In summary, compared with NC4, HB-NC4 had better-targeting ability which could improve its therapeutic effect and prolonged its action time. It could be used as a new complement regulator for the treatment of OA in the future.
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0 |
Colles' fracture: end results in relation to radiologic parameters
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Distal Radius Fractures
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Thirty-seven patients with unilateral Colles' fractures were examined clinically and roentgenographically at least 1 year after fracture. Statistical analysis of the data, comparing roentgenographic parameters with clinical results, showed that loss of volar tilt directly affected the final results by decreasing grip and pinch strength. But regardless of radiologic appearance, all patients had similar levels of activity, pain and range of motion.
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0 |
A Prospective Evaluation of Complications after Use of Exposed Pins in the Hand and Wrist
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DoD SSI (Surgical Site Infections)
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BACKGROUND: Kirschner wires are commonly used during hand surgical procedures. These pins are often left exposed (protruding from the skin) for ease of removal. Complications such as loosening, migration, or infection are not uncommon (ranging from 7 to 18 percent in current retrospective studies) and can compromise surgical outcome. This study evaluated the frequency of Kirschner wire-related complications.
METHODS: All patients who had Kirschner wires placed as part of their surgical procedure in the hand or wrist by one of 12 attending hand surgeons over a 6-month period were enrolled prospectively. Complications were recorded by the attending surgeon at follow-up visits. Demographics and patient comorbidities including diabetes mellitus and smoking history were recorded.
RESULTS: There were 141 patients enrolled and 230 pins used, including 65 women and 76 men. The mean age was 40.7 years. Thirteen patients were smokers, and eight had a history of diabetes. There were 35 soft-tissue procedures and 106 fractures. There were 35 complications (25 percent). There was a 12 percent rate of infection (n = 17), including two cases of osteomyelitis. There were 18 other complications, nine of which were major complications (6.4 percent). Smoking, age, and location (hand/fingers versus wrist) were significantly associated with infection.
CONCLUSIONS: In this study, one in four patients treated with Kirschner wires developed a minor or major complication, a rate that is substantially higher than reported in existing retrospective studies. Although Kirschner wires are often needed during hand surgery, surgeons should be aware that adverse events are frequent. Patients and surgeons should be vigilant in the perioperative period.
CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.
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0 |
Frequency doubling technology and confocal scanning ophthalmoscopic optic disc analysis in open-angle glaucoma with hemifield defects
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Upper Eyelid and Brow Surgery
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PURPOSE: To evaluate the potential of frequency doubling technology for detecting early glaucomatous damage. PATIENTS AND METHODS: Forty-nine eyes of 49 patients with open-angle glaucoma with visual field defects only in one hemifield according to the Humphrey Field Analyzer 30-2 program were included. Forty-five healthy patients were also included as control subjects. In each patient, frequency doubling technology with the threshold N-30 program and optic disc analysis using the Heidelberg Retina Tomograph was performed. Frequency doubling technology test results and the Humphrey Field Analyzer test results were compared. Optic disc parameters corresponding to the hemifield designated intact by the Humphrey Field Analyzer were compared between the eyes in which the hemifield was normal by frequency doubling technology and those in which the hemifield was abnormal. RESULTS: Forty-one percent of the 49 hemifields designated intact by the Humphrey Field Analyzer were abnormal based on frequency doubling technology, whereas 98% of the 49 hemifields designated defective by the Humphrey Field Analyzer were abnormal and 12% of the 90 hemifields designated intact by the Humphrey Field Analyzer were abnormal in healthy patients. The percentage of the hemifields designated abnormal by frequency doubling technology was significantly higher than that in healthy patients (P < 0.001). The rim volume was significantly smaller in eyes with abnormal results based on frequency doubling technology than in eyes with normal results (P < 0.05, paired t test, with Bonferroni correction for multiple comparison). CONCLUSION: Frequency doubling technology can detect glaucomatous damage earlier than conventional static perimetry can.
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1 |
Comparative assessment of early versus delayed surgery to treat proximal femoral fractures in elderly patients: A systematic review and meta-analysis
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Hip Fx in the Elderly 2019
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BACKGROUND: Recently, many studies have suggested that timely surgery to treat proximal femoral fractures can benefit patients in many respects. However, both the short- and long-term outcomes, and the perioperative complications, of early surgery remain controversial. In addition, the optimal cut-off time for early surgery remains unclear. Thus, we performed a meta-analysis to compare and evaluate the benefits of early versus delayed surgery in terms of the clinical outcomes of patients with proximal femoral fractures.
METHODS: We searched the Cochrane Library, PubMed, EMBASE, and Web of Science databases to February 1, 2018 and retrieved original studies comparing the efficacy of early versus delayed surgery for proximal femoral fractures. We calculated risk ratios (RRs) and odds ratios (ORs) with 95% confidence intervals (CIs) and compared the outcomes of early and delayed surgery. We performed subgroup analyses to explore mortality and perioperative complications associated with different cut-off times for surgery, for various periods. Two reviewers assessed the quality of the included studies and independently extracted the data. We followed the suggestions of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement. All statistical analyses were performed using the standard statistical procedures of Review Manager 5.2.
RESULTS: A total of 27 studies (N=33,727 participants) were included in the present analysis. Compared to delayed surgery, early surgery significantly reduced mortality and complications. The mortality rates of patients who underwent surgery within 48 and 24h of fracture were 28 and 23% less than those of patients operated upon after 48h (RR=0.72; 95% CI: 0.71-0.73) and 24h (RR=0.77; 95% CI: 0.65-0.93). In addition, early surgery was associated with fewer perioperative complications than delayed surgery (OR=0.52; 95% CI: 0.35-0.76), especially in terms of postoperative pressure ulcers (OR=0.55; 95% CI: 0.45-0.68), urinary tract infections (OR=0.57; 95% CI: 0.49-0.67), and thromboembolic events (OR=0.61; 95% CI: 0.39-0.96).
CONCLUSIONS: Early surgery reduces mortality associated with proximal femoral fractures and the frequency of serious perioperative complications when comparing with delayed surgery.
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0 |
Superiority of age and weight as variables in predicting osteoporosis in postmenopausal white women
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Management of Hip Fractures in the Elderly
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Identification of women at risk for osteoporosis is of great importance for the prevention of osteoporotic fractures. Routine BMD measurement of all women is not feasible for most populations, hence identification of a high-risk subset of women is an important element of effective preventive strategies. METHODS: We identified 959 postmenopausal non-Hispanic women aged 51 years and above from the NHANES III study to assess the relative contribution of risk predictors for low BMD at the whole proximal femur and the femoral neck regions. Based on recognized risk factors for osteoporosis identified by a systematic literature search, we ran several multiple linear regression models based on the results of preceding bivariate analyses. We show several models based on their explanatory ability assessed by adjusted r(2), ROC, and C-value analyses rather than on the coefficients and P values. We furthermore examined the sensitivity, specificity, and predictive values of our preferred models for various cutoff T-scores-the choice of which will vary depending on different study goals and population characteristics. RESULTS: Age and weight were by far the most informative predictors for low bone mineral density out of a list of 20 candidate risk predictors. Our preferred prediction models for the two regions hence contained only two variables: i.e., age and measured weight. The resulting parsimonious model to predict BMD at whole proximal femur had an adjusted r(2) of 0.43, an area under the ROC curve of 0.85, and a C-value of 0.70. Similarly, prediction for BMD at the femoral neck had adjusted r(2), area under the curve, and C-value of 0.39, 0.83, and 0.66, respectively. CONCLUSIONS: The model equations, predicted T-score = -1.332-0.0404 x (age) + 0.0386 x (measured weight) and predicted T-score = -1.318-0.0360 x (age) + 0.0314 x (measured weight) for whole proximal femur and femoral neck, respectively, can be used in field conditions for screening purposes. More complex prediction equations add little explanatory power. Based on the study goals and the population characteristics, specific cutoff T-scores have to be decided before using these equations
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Ultrasound diagnosis of juvenile forearm fractures
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Distal Radius Fractures
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PURPOSE: Metaphyseal forearm fractures are a common pathology in any emergency department. The standard diagnostic procedure is an X-ray of the forearm and wrist. Former studies have shown that these fractures can be visualized by ultrasound. The intention of this study was to evaluate the safety and reliability of the ultrasound diagnostic procedure in comparison with X-ray diagnosis.
METHODS: Patients aged 0-12 years with tentative diagnosis of forearm fracture in a physical examination were then examined, from six positions, with a 7.5-MHz linear array transducer. The diagnosis and the recommended treatment were noted, after which standard X-rays were taken. Finally, differences between diagnoses, the extent and direction of the deformity, and the treatment recommended after both diagnostic procedures were analysed.
RESULTS: From January 2007 to May 2008, 93 patients were examined. We found 77 fractures in 64 patients (48 radius, 2 physeal fractures of the radius, 1 ulna, and 13 radius and ulna). The sensitivity of ultrasound in diagnosing forearm fractures was 94%, and the specificity was 99%. Difference between the means of the deformities were 1.6degree (radius anterior-posterior direction), 1.6degree (radius medial-lateral direction), 0.2degree (ulna anterior-posterior direction), and 0.2degree (ulna medial-lateral direction).
CONCLUSION: Ultrasound seems to be a valuable and safe alternative to X-ray diagnosis.
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Above-knee amputations in psychiatric inpatients
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Surgical Management of Osteoarthritis of the Knee CPG
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Data on 121 primary above-knee amputations and 12 stump revisions performed on a population of nonambulatory elderly psychiatric inpatients showed that the overall morbidity and mortality rates compared favorably with those in previously published reports on other groups of patients who received the same type of amputations, despite the precarious health of the psychiatric patients. By use of spinal anesthesia; meticulous attention to the prevention, early detection, and prompt treatment of wound complications; and identification of patients at high risk, this often desperately needed operation can be performed with good results
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Minimally invasive surgery of distal radius fractures: a series of 20 cases using a 15mm anterior approach and arthroscopy
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Distal Radius Fractures
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UNLABELLED: This study reports the results of minimally invasive surgical treatment of distal radius fractures using a 15mm incision with arthroscopic assistance. This was a retrospective series of 20 distal radius fractures in young or middle-aged patients caused by high-energy trauma and/or with articular involvement. The surgical procedure included two stages: fixation using a locking plate and then arthroscopy. The incision for plating was always 15mm long. Arthroscopy was used to reduce osteochondral fragments in two cases and to suture and pin six scapholunate lesions. After a mean follow-up of 4.3 months, the mean pain score was 1.9, QuickDASH was 24.6 and the mobility and grip strength were at least 75% of the contralateral side. The mean palmar tilt was 8.8degree and the mean radial inclination 20.7degree. The radio-ulnar index was -1mm with no DISI and the scapholunate gap was 1.5mm. There were three cases of CRPS type I. Our results show that arthroscopy-assisted, minimally invasive surgery for distal radius fractures using a 15mm incision results in a scar with good cosmetics and allows for easy reduction and fixation, and management of articular and ligament lesions. Its indications must take into account the functional demands placed on the wrist by the patient, energy of the trauma and fracture type.
Level of evidence: Iv.
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(untitled)
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OAK 3 - Non-arthroplasty tx of OAK
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The purpose of this report is to retrieve and review the existing clinical effectiveness evidence on the treatment of knee osteoarthritis (OA) patients with exercise as compared to no intervention, placebo, or opioids.
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Expression of C-X-C chemokine receptor type 7 in otorhinolaryngologic neoplasms
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MSTS 2018 - Femur Mets and MM
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INTRODUCTION: C-X-C chemokine receptor type 7 (CXCR7) has recently been characterised as a novel receptor for the C-X-C motif chemokine 12 (CXCL12)/stromal cell-derived factor 1-alpha. CXCR7 has been thought to play an important role in the pathogenesis of chronic rhinosinusitis, angiogenesis and tumour metastasis. The present study aimed to examine the expression of CXCR7 in tissue samples of laryngeal cancer and maxillary sinus carcinoma to determine its role in the development of otorhinolaryngologic neoplasms.
METHODS: Samples of otorhinolaryngologic neoplasms were obtained from 17 patients with either nasal polyps (n = 7), laryngeal cancer (n = 5) or maxillary sinus carcinoma (n = 5), and who underwent surgical resection at West China Hospital of Sichuan University. Total RNA was isolated and CXCR7 mRNA expression was examined and quantified by relative real-time reverse transcription polymerase chain reaction. A one-way analysis of variance was performed using SPSS Statistics version 11.0 (SPSS Inc, Chicago, IL, USA) to compare the CXCR7 mRNA levels among the three groups of patients.
RESULTS: All samples tested positive for CXCR7 mRNA. The quantitative results showed that the CXCR7 mRNA levels were highest in laryngeal cancer and lowest in maxillary sinus carcinoma neoplasms, although there was no significant difference among the three samples.
CONCLUSION: CXCL12 and its receptor CXCR7 may contribute to eosinophilic inflammation in patients with chronic sinusitis and nasal polyps. Our results also suggest that CXCR7 may play a role in the progression, metastasis and angiogenesis of otorhinolaryngologic tumours.
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Mortality after the hospitalization of a spouse
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Management of Hip Fractures in the Elderly
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BACKGROUND: The illness of a spouse can affect the health of a caregiving partner. We examined the association between the hospitalization of a spouse and a partner's risk of death among elderly people. METHODS: We studied 518,240 couples who were enrolled in Medicare in 1993. We used Cox regression analysis and fixed-effects (case-time-control) methods to assess hospitalizations and deaths during nine years of follow-up. RESULTS: Overall, 383,480 husbands (74 percent) and 347,269 wives (67 percent) were hospitalized at least once, and 252,557 husbands (49 percent) and 156,004 wives (30 percent) died. Mortality after the hospitalization of a spouse varied according to the spouse's diagnosis. Among men, 6.4 percent died within a year after a spouse's hospitalization for colon cancer, 6.9 percent after a spouse's hospitalization for stroke, 7.5 percent after a spouse's hospitalization for psychiatric disease, and 8.6 percent after a spouse's hospitalization for dementia. Among women, 3.0 percent died within a year after a spouse's hospitalization for colon cancer, 3.7 percent after a spouse's hospitalization for stroke, 5.7 percent after a spouse's hospitalization for psychiatric disease, and 5.0 percent after a spouse's hospitalization for dementia. After adjustment for measured covariates, the risk of death for men was not significantly higher after a spouse's hospitalization for colon cancer (hazard ratio, 1.02; 95 percent confidence interval, 0.95 to 1.09) but was higher after hospitalization for stroke (hazard ratio, 1.06; 95 percent confidence interval, 1.03 to 1.09), congestive heart failure (hazard ratio, 1.12; 95 percent confidence interval, 1.07 to 1.16), hip fracture (hazard ratio, 1.15; 95 percent confidence interval, 1.11 to 1.18), psychiatric disease (hazard ratio, 1.19; 95 percent confidence interval, 1.12 to 1.26), or dementia (hazard ratio, 1.22; 95 percent confidence interval, 1.12 to 1.32). For women, the various risks of death after a spouse's hospitalization were similar. Overall, for men, the risk of death associated with a spouse's hospitalization was 22 percent of that associated with a spouse's death (95 percent confidence interval, 17 to 27 percent); for women, the risk was 16 percent of that associated with death (95 percent confidence interval, 8 to 24 percent). CONCLUSIONS: Among elderly people hospitalization of a spouse is associated with an increased risk of death, and the effect of the illness of a spouse varies among diagnoses. Such interpersonal health effects have clinical and policy implications for the care of patients and their families
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Causes of pain and loss of function in rotator cuff disease: analysis of 1383 cases
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Trial Systematic Review Project
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BACKGROUND: The New Zealand Rotator Cuff Registry is a multicentre, nationwide prospective study of rotator cuff repairs established in March 2009.
METHODS: A total of 1383 rotator cuff repairs were included in this study, all with completed baseline Flex-SF scores, pain scores and standardized operative forms.
RESULTS: Increasing tear size and tear retraction, over 4cm, were associated with decreasing Flex-SF scores but not pain. Tear area (a composite of tear size and retraction) is increased with advancing age, male gender and a traumatic history but not with smoking. Increased pain scores were associated with supraspinatus (SS) single tears, compared to subscapularis tears, and with labral tears. SS/infraspinatus tears had lower Flex-SF scores compared to subscapularis/SS.
CONCLUSION: This study presents the relationship between baseline function, pain and tear characteristics in symptomatic rotator cuff tears. Increasing tear size and retraction are related to a loss of function but have minimal effect upon pain. Pain generators included labral pathology, and the involvement of SS. The intraoperative appearance of the long head of biceps pathology did not predict baseline pain and function.
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Carpal tunnel decompression: open vs endoscopic
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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Carpal tunnel decompression is a common operation. While most patients report satisfaction there are recognized complications. New endoscopic techniques are claimed to reduce the incidence of these. However, the new techniques are not without complications of their own
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Reducing costly falls after total knee arthroplasty
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OAK 3 - Non-arthroplasty tx of OAK
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AIM: To investigate whether adductor canal nerve block (ACB) reduces patient falls when compared to femoral nerve block (FNB) after total knee arthroplasty (TKA).
METHODS: We conducted an institutional review of all-cause falls after TKA from January 2013 to August 2016 using a quality improvement database. Our inclusion criteria were patients with diagnosis of primary knee osteoarthritis who underwent primary unilateral TKA with either a FNB or an ACB and sustained a fall during their hospitalization. We excluded patients who had revision TKA and extensor mechanism reconstruction. We also excluded patients with a history of post-traumatic arthritis, prior history of lower extremity fracture, history of neurological disease, or cerebrovascular disease.
RESULTS: A total of 834 patients had TKA with femoral nerve block and knee immobilizer (FNB + KI). Of those patients, 11 (1.3%) experienced a fall during their hospital stay. In contrast, 791 patients had TKA with ACB. Of those patients, only one (0.13%) patient fall was recorded within this group. We used the Fisher's exact test to compare the differences between the two groups. The difference between the two groups achieves statistical significance (P = 0.006). We also found that 11 out of the 12 patients that fell had a right TKA procedure while one patient had a left TKA procedure. Nine out of twelve patients that fell were female, while only three patients were male.
CONCLUSION: Given the reduction in the number of falls with ACB, it is recommended that ACB be considered the preferred analgesia for patients undergoing a TKA procedure.
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The anatomy, symptoms, and signs of carpal tunnel syndrome
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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The described anatomy and signs of CTS have remained consistent throughout the years, although there has been a considerable discrepancy in the medical literature regarding the sensitivity and specificity of signs related to CTS. The following conclusions are supported by the body of medical literature available on CTS: 1. Night pain that is relieved by shaking out the wrist and hand is the most specific symptom for CTS. 2. The Hoffmann-Tinel sign was not developed for the detection of CTS and is not a sensitive test for CTS. It therefore is not recommended as a part of the examination for CTS. 3. The Phalen sign or modified Phalen sign has approximately a 55%, to 60% sensitivity and 80% specificity for CTS. Its absence does not exclude CTS. It is recommended as a part of the physical examination for CTS. 4. The LaBan sign has a high sensitivity and specificity and is helpful for cases of chronic CTS with median motor nerve fiber involvement. 5. The square wrist (A-P to M-L) ratio of 0.7 or greater has approximately a 70%, sensitivity and specificity for CTS in symptomatic subjects. It is recommended as a part of the physical examination for CTS. 6. Hypesthesia in the median nerve distribution of the hand has a sensitivity of about 50%, and a specificity of over 80%, in cases of CTS. Light touch and pinwheel sensibility are recommended as a part of the physical examination for CTS. 7. Thenar weakness has approximately a 66%, sensitivity and specificity for CTS. Evaluation of thenar strength is recommended as a part of the physical examination for CTS. 8. Two-point discrimination and the tourniquet test are not very sensitive for CTS and the tourniquet test can have a high false-positive rate. 9. The gold standard for the diagnosis of CTS remains nerve conduction studies of the motor and sensory fibers of the median nerve. Sensory nerve-to-nerve comparisons have reported sensitivities of about 90%. That percentage would be even higher if the principle of examining the median nerve proximal and distal to the site of entrapment was followed. Thenar atrophy is usually only present in advanced cases of CTS. Sensory complaints noted by history often cannot be confirmed by examination in early cases of CTS. Physical signs are frequently absent in early CTS. No sign is reliable more than about 66% of the time and they include a square- shaped wrist and thenar weakness - not the commonly documented Tinel and Phalen signs. The diagnosis of CTS should be suspected on the basis of presenting symptoms and risk factors and confirmed by electrodiagnostic evaluation of the median nerve. Nerve conduction studies objectively document median nerve dysfunction with a high sensitivity and remain the gold standard for the diagnosis of CTS
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The prevention of early-onset neonatal group B streptococcus infection: technical report from the New Zealand GBS Consensus Working Party
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Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures
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AIMS: Early-onset neonatal group B streptococcus (GBS) is the leading infectious cause of disease in newborn babies. Since intrapartum antibiotics interrupt vertical GBS transmission, this is now a largely preventable public health problem. An important first step is to develop (then implement) nationally, agreed prevention policies. METHODS: Representatives from the New Zealand College of Midwives, the Paediatric Society of New Zealand, the New Zealand Committee of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists, the Royal New Zealand College of General Practitioners, and the Homebirth Association met to review evidence that will assist in the formulation of GBS prevention policies that are most suitable for New Zealand. RESULTS: The Technical Working Group noted that (i) no strategy will prevent all cases of early-onset GBS infection, (ii) intrapartum antibiotics are associated with rare, but serious, adverse effects, (iii) concerns remain over developing antibiotic resistance, (iv) an economic analysis is required to help inform policy, (iv) reliable bedside diagnostic tests for GBS in early labour are not yet available and (iv) the most important determinant of effectiveness will be compliance with a single national prevention policy. CONCLUSIONS: As an interim measure a GBS risk-based prevention strategy is recommended. This exposes the least numbers of women and their babies to antibiotics, while virtually preventing all deaths from GBS sepsis. Continuing education of health professionals and pregnant women, auditing protocol compliance, tracking adverse events amongst pregnant women, and national surveillance of neonatal sepsis and mortality rates and antibiotic resistance are necessary for the strategy's success
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