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Measurement of meniscofemoral contact pressure after repair of bucket-handle tears with biodegradable implants
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AMP (Acute Meniscal Pathology)
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Introduction: Biodegradable implants are frequently used for meniscus repair. Articular cartilage damage has been reported recently after meniscus repair with biodegradable implants. The aim of the study was to investigate the meniscofemoral contact pressure at the posterior horn of the medial and lateral meniscus after repair of bucket-handle lacerations. Materials and methods: Specimens were mounted in a materials testing machine (Bionix 858, MTS) which was equipped with a load cell. The quadriceps tendon was attached to a hydraulic cylinder, and knee motion was controlled via tension of the quadriceps tendon. A piezo-resistive system (Tekscan, Boston, MA, USA) measured the meniscofemoral contact pressure. Five different types of biodegradable implants (Arrow, Dart, Fastener, Stinger and Meniscal Screw) and horizontal suture (no. 2 Ethibond) were tested. The knee was extended from 90° of flexion to 0° under a constant load of 350 N due to adjustment of the tension force of the quadriceps tendon. The femorotibial pressure and contact area were recorded at 0°, 30°, 60° and 90° of flexion. Results: The meniscofemoral pressure did not increase after meniscus repair with biodegradable implants or sutures. The meniscofemoral peak pressure at the posterior horn was 1.46±1.54 MPa in the medial compartment and 1.08±1.17 MPa in the lateral compartment at full knee extension. The meniscofemoral pressure increased significantly in both compartments with knee flexion from 0° to 90°. Conclusion: Biodegradable implants for meniscus repair do not affect the meniscofemoral pressure. However, there remains a risk of damage to the cartilage when barbed implants are used. If the implant is not entirely advanced into the meniscus, the sharp head or some of the barbs at the column of the implant may come into direct contact with the articular cartilage of the femoral condyle or tibial plateau. The authors presume that incorrect positioning of the implant seems to be the major reason for cartilage damage. © Springer-Verlag 2004.
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Critical shoulder angle in an East Asian population: correlation to the incidence of rotator cuff tear and glenohumeral osteoarthritis
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Glenohumeral Joint OA
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BACKGROUND: Focus has recently been on the critical shoulder angle (CSA) as a factor related to rotator cuff tear and osteoarthritis (OA) in the European population. However, whether this relationship is observed in the Asian population is unclear.
METHODS: The correlation between the CSAs measured on anteroposterior radiographs and the presence or absence of rotator cuff tears or OA changes was assessed in 295 patients. Rotator cuff tears were diagnosed with magnetic resonance imaging or ultrasonography. OA findings were classified using the Samilson-Prieto classification. The CSAs among the patients with rotator cuff tears, OA changes, and those without pathologies were compared. Multivariable analyses were used to clarify the potential risks for these pathologies.
RESULTS: The mean CSA with rotator cuff tear (33.9degree +/- 4.1degree) was significantly greater than that without a rotator cuff tear (32.3degree +/- 4.5degree; P = .002). Multivariable analysis also showed that a greater CSA had a significantly increased risk of rotator cuff tears, with the odds ratio of 1.08 per degree. OA findings showed no significant correlation to the CSAs.
CONCLUSIONS: Our study demonstrates that the CSA is greater in those with a rotator cuff tear than in those without a tear or OA changes, which may be an independent risk factor for the incidence of rotator cuff tears in the Japanese population.
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Bone mineral density and walking ability of elderly patients with hip fracture: a strategy for prevention of hip fracture
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Management of Hip Fractures in the Elderly
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The main risk factors for proximal femoral fracture include the hazard of falling and osteoporosis. The change in walking ability of patients before injury was evaluated over the last 10 years in a rapidly advancing aging society in Tokyo, Japan. The bone quality of patients was clarified in order to develop a strategy for prevention of hip fractures. The subjects were 157 women with proximal femoral fractures treated between 1989 and 1993 (group A) and 216 women treated between 1999 and 2003 (group B). Bone mineral density (BMD) of the radius of the patients showed slightly lower values than those of the elderly general population, but no statistically significant difference was observed in each age group except for the 75-79-year-old age group (p<0.05). Many patients had problems in walking, and 27% of patients in group A and 44% in group B could not walk outdoors or go shopping alone before the injury, and their bone mineral density was reduced. For the prevention of hip fractures, it is important to improve the physical function to avoid falls, which directly cause hip fracture. Patients who have difficulty performing effective physical exercise because of reduced walking ability require medication for osteoporosis
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Comparison of quasi-static and dynamic squats: a three-dimensional kinematic, kinetic and electromyographic study of the lower limbs
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OAK 3 - Non-arthroplasty tx of OAK
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Numerous studies have described 3D kinematics, 3D kinetics and electromyography (EMG) of the lower limbs during quasi-static or dynamic squatting activities. One study compared these two squatting conditions but only at low speed on healthy subjects, and provided no information on kinetics and EMG of the lower limbs. The purpose of the present study was to contrast simultaneous recordings of 3D kinematics, 3D kinetics and EMG of the lower limbs during quasi-stat ic and fast-dynamic squats in healthy and pathological subjects. Ten subjects were recruited: five healthy and five osteoarthritis subjects. A motion-capture system, force plate, and surface electrodes respectively recorded 3D kinematics, 3D kinetics and EMG of the lower limbs. Each subject performed a quasi-static squat and several fast-dynamic squats from 0degree to 70degree of knee flexion. The two squatting conditions were compared for positions where quasi-static and fast-dynamic knee flexion-extension angles were similar. Mean differences between quasi-static and fast-dynamic squats were 1.5degree for rotations, 1.9 mm for translations, 2.1% of subjects' body weight for ground reaction forces, 6.6 Nm for torques, 11.2 mm for center of pressure, and 6.3% of maximum fast-dynamic electromyographic activities for EMG. Some significant differences (p<0.05) were found in internal rotation, anterior translation, vertical force and EMG. All differences between quasi-static and fast-dynamic squats were small. 69.5% of compared data were equivalent. In conclusion, this study showed that quasi-static and fast-dynamic squatting activities are comparable in terms of 3D kinematics, 3D kinetics and EMG, although some reservations still remain.
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Recurrent lateral patella dislocation affects knee function as much as ACL deficiency - However patients wait five times longer for treatment
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OAK 3 - Non-arthroplasty tx of OAK
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Background: Surgical treatment of young patients with recurrent lateral patella dislocation (RLDP) is often recommended because of loss of knee function that compromises their level of activity or even their daily life functioning. This situation is comparable to young patients with an anterior cruciate ligament (ACL) rupture. The purpose of this study was therefore to explore the time from injury to surgery and the pre-operative symptoms and knee function of young RLPD patients scheduled for stabilizing surgery and compare this group to age and sex-matched ACL-deficient patients. Method: Forty-seven patients with unilateral RLPD listed for isolated medial patellofemoral ligament reconstruction were included in the study (RLPD-group). This group was compared to an age, sex and BMI matched ACL patient group obtained from the Norwegian knee ligament registry (ACL-group) for the following outcome measures: the knee injury and osteoarthritis outcome score (KOOS) assessed on the day of surgery and time from injury to surgery. Results: The RLPD-group scored significantly lower than the ACL-group for the three KOOS subscales "Pain" (73.6 vs. 79.8, p < 0.05), "Symptoms" (71.7 vs. 79.3, p < 0.05) and "ADL" (84.7 vs 89.5, p < 0.05). The lowest KOOS values were found for Sports/Recreation (53.5 vs. 51.3, p = 0.65) and Quality of life (37.6 vs. 36.7, p = 0.81). The average time from primary injury to surgery was 6 months for the ACL group and 31 months for the RLPD group. Conclusion: RLPD affected knee function as much as ACL deficiency, and was associated with more pain. Still the RLDP patients waited on average 5 times longer for surgery. Trial registration: The patients with RLPD consisted of patients who were examined for possible recruitment for a concurrent prospective randomized controlled trial comparing conservative treatment and isolated surgical medial patellofemoral ligament (MPFL) reconstruction (Clinical trials no: NCT02263807, October 2014).
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Treatment and outcomes of Vancouver type B periprosthetic femoral fractures
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Hip Fx in the Elderly 2019
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AIMS: Vancouver type B periprosthetic femoral fractures (PFF) are challenging complications after total hip arthroplasty (THA), and some treatment controversies remain. The objectives of this study were: to evaluate the short-to-mid-term clinical outcomes after treatment of Vancouver type B PFF and to compare postoperative outcome in subgroups according to classifications and treatments; to report the clinical outcomes after conservative treatment; and to identify risk factors for postoperative complications in Vancouver type B PFF.
METHODS: A total of 97 consecutive PPFs (49 males and 48 females) were included with a mean age of 66 years (standard deviation (SD) 14.9). Of these, 86 patients were treated with surgery and 11 were treated conservatively. All living patients had a minimum two-year follow-up. Patient demographics details, fracture healing, functional scores, and complications were assessed. Clinical outcomes between internal fixation and revisions in patients with or without a stable femoral component were compared. Conservatively treated PPFs were evaluated in terms of mortality and healing status. A logistic regression analysis was performed to identify risk factors for complications.
RESULTS: In surgically treated patients, all fractures united and nine complications were identified. The mean postoperative Visual Analogue Scale (VAS) for pain was 1.5 (SD 1.3), mean Parker Mobility Score (PMS) was 6.5 (SD 2.4), and mean Harris Hip Score (HHS) was 79.4 (SD 16.2). Among type B2 and type B3 fractures, patients treated with internal fixation had significantly lower PMS (p = 0.032) and required a longer time to heal (p = 0.012). In conservatively treated patients, one-year mortality rate was 36.4% (4/11), and two patients ultimately progressed to surgery. Young age (p = 0.039) was found to be the only risk factor for complications.
CONCLUSION: The overall clinical outcome among Vancouver type B PFF was satisfactory. However, treatment with internal fixation in type B2 and B3 fractures had a significantly longer time to heal and lower mobility than revision cases. Conservative treatment was associated with high rates of early mortality and, in survivors, nonunion. This probably reflects our selection bias in undertaking surgical intervention. In our whole cohort, younger patient age was a risk factor for postoperative complications in Vancouver type B PFF. Cite this article: Bone Joint J 2020;102-B(3):293-300.
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How confident are general dental practitioners in their decision to administer antibiotic prophylaxis? A questionnaire study
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Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures
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BACKGROUND: Common dental procedures induce bacteremia. To prevent infectious complications from bacteremia in patients with specific medical conditions, antibiotic prophylaxis is considered. Recommendations are often unclear and ambiguous. In a previous study we reported wide variations in general dental practitioners' (GDPs') administrations of antibiotic prophylaxis. We hypothesized that within such a conflicting clinical area, decisions are made with a high level of personal uncertainty. This study examined GDPs' confidence in their decisions and analyzed the extent to which case-related factors might explain individual variations in confidence. METHODS: Postal questionnaires in combination with telephone interviews were used. The response rate was 51% (101/200). There were no significant differences between respondents and non-respondents regarding sex, age, or place of work. The GDPs were presented to patient cases of different medical conditions, where some should receive antibiotic prophylaxis according to recommendations when performing dental procedures that could cause gingival bleeding. The GDPs assessed on visual analogue scales how confident they were in their decisions. The extent to which case-related factors, medical condition and dental procedure, could explain individual variation in confidence was analyzed. RESULTS: Overall the GDPs exhibited high confidence in their decisions regardless of whether they administered antibiotic prophylaxis or not, or whether their decisions were in accordance with recommendations or not. The case-related factors could explain between 30-100% of the individual variation in GDPs' confidence. For 46%, the medical condition significantly explained the individual variation in confidence. However, for most of these GDPs, lower confidence was not presented for conditions where recommendations are unclear and higher confidence was not presented for conditions where recommendations are more clear. For 8% the dental procedure significantly explained the variation, although all procedures could cause bacteremia. For 46% neither the medical condition nor the dental procedure could significantly explain the individual variation in confidence. CONCLUSION: The GDPs presented high confidence in their decisions, and the majority of GDPs did not present what could be considered a justified varied level of confidence according to the clarity of recommendations. Clinicians who are overconfident in their decisions may be less susceptible to modifications of their behavior to more evidence-based strategies
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Early predictors of acetabular growth after closed reduction in late detected developmental dysplasia of the hip
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Developmental Dysplasia of the Hip 2020 Review
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This study evaluates improvement of the acetabular index (AI) in patients with developmental dysplasia of the hip at 4 years after closed reduction, and determines the association between the final AI and a set of factors. Sixty-two patients (74 hips) treated with closed reduction were categorized into three groups according to age: group A (0-12 months, 18 hips), group B (13-18 months, 24 hips), and group C (>18 months, 32 hips). There was no difference in AI among the three groups before reduction (P=0.293). In groups A and C, the AI decreased significantly over time until 3 years after reduction and no differences were observed between the time points of 3 and 4 years. At 4 years after reduction, the AI of group C was significantly higher than that of groups A (P<0.001) and B (P=0.012). The overall AI improvement rate was 28.63%. The AI improvement rate of group A was significantly higher than that of group C (P=0.005). Pearson correlation analysis indicated no correlation between center-head distance discrepancy and the final AI (P=0.811). Linear regression suggested that age and initial AI correlated significantly with the final AI (R=0.617, F=15.031, P<0.001). Other factors, such as sex, center-edge angle of Wiberg, bilaterally involved, and avascular necrosis of the femoral head, showed no correlations with the final AI (P>0.05). According to the coefficients, initial AI (β1=0.432, P<0.001) had greater effect than age (β2=0.197, P=0.023) on the final AI. In conclusion, the AI decreases in all patients after reduction and stabilizes at 3 years after reduction. The AI improvement rate is correlated negatively with age. Age and initial AI are early predictors of the progress of AI after closed reduction in developmental dysplasia of the hip patients.
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Streptococcus dysgalactiae subspecies dysgalactiae infection after total knee arthroplasty: a case report
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PJI DX Updated Search
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Streptococcus dysgalactiae subspecies dysgalactiae (SDSD), Lancefield group C streptococcus, is an animal pathogen which often causes pyogenic infection in domestic animals. Human infection by SDSD has been reported as a cellulitis on the upper arm, but a prosthetic joint infection caused by SDSD after total knee arthroplasty (TKA) has not yet been reported in the literature demonstrating that its clinical manifestation and management have not been well established. In this case report, we aimed to present a case of SDSD prosthetic joint infection after TKA, which was successfully treated by two-stage re-implantation with an application of antibiotic-impregnated cement spacer
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Atypical diaphyseal femoral fractures-new aspects
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DoD SSI (Surgical Site Infections)
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Post menopausal osteoporotic fractures are a major public health concern worldwide with oral bisphosphonates favored for their prevention and treatment. Recent interest has centered on clinically observed, unusually sited femoral diaphyseal fractures, particularly attributed to alendronate. Their imaging presentations on routine radiographs, alternate imaging modalities, and associated pitfalls in nine fractures in six patients are selectively illustrated by seven fractures in four patients that serve to emphasize the following: (1) Bisphosphonates other than alendronate have been used for treating various bone diseases in children and men as well as osteoporotic women. (2) Effects may differ with each bisphosphonate's route of administration and prolongation of activity, despite discontinuation. Prior investigations and theoretical mechanisms of bisphosphonates as a class rather than with a specific alendronate association are reviewed to provide a broader basis for evaluating their recently observed clinical and radiographic complications. © ISS 2011.
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Educational e-learning tool to improve fascia iliac block uptake for neck of femur fracture patients: A multi-disciplinary approach
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Hip Fx in the Elderly 2019
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Background: There are 75,000 neck of femur (NOF) fractures that occur each year in England and Wales. Prompt, adequate analgesia is a major priority in hip fracture management to reduce the risk of delirium and facilitate earlier return to mobility and independence. NICE guidelines recommend the use of fascia iliaca block (FIB) for NOF fracture patients. Current literature suggests that FIB significantly improves pre-operative pain scores; however despite this, the uptake of FIB still varies between centers. Objective: The study aimed to review pre-operative analgesia management of NOF patients in our center. The primary endpoint was to improve uptake of regional fascia iliaca block (FIB) in NOF patients by means of an educational e-learning tool. Study Design and Methods: We performed a prospective review of all patients with NOF fractures admitted via the emergency department from September to October 2018 in a single district general hospital in the UK. We recorded patient demographics, time of admission, grade of physician performing block and pain scores and total FIB uptake. A multidisciplinary-led, short interventional training program of FIB administration was then developed and delivered to all relevant staff. Pain management and pain scores were recorded in a second prospective cycle along with uptake of FIB. Results: There was a 53.2% reduction in pain score in the group that received FIB compared to 26.7% in patients who received oral analgesia only, consistent with current literature (p value = 0.0046). There was a significant increase (2.66x) in FIB administration by orthopedic doctors (27.3% in cycle 1 to 100% in cycle 2) after the educational session intervention. Conclusion: This study shows that with the use of an educational training tool, all members of the multidisciplinary team can successfully administer FIB without any complications. Our educational tool has enabled a significant increase in delivery of FIB.
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Broken necks of the femur in a psychogeriatric hospital
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Management of Hip Fractures in the Elderly
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We report a prospective study of the results of treatment of fractures of the neck of the femur in 102 patients in a psychogeriatric hospital. The results show that early operation may reduce complications but the aftercare should be in the familiar surroundings of the mental hospital. The costs of this policy are also considered
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Arthroscopic management of elbow trauma
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The Treatment of Pediatric Supracondylar Humerus Fractures AUC
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The arthroscope can assist in effectively treating traumatic injuries about the elbow, including some intra-articular fractures. Proper selection of patients is important to ensure effective treatment, but when used judiciously, arthroscopic-assisted debridement and fracture fixation is effective. The arthroscope is a valuable tool in the diagnosis and management of acute intra-articular fractures and in dealing with the sequelae that sometimes cause problems after healing has occurred. It allows for effective fracture treatment without the extensive soft tissue disruption that would be otherwise necessary for exposure. The authors certainly cannot advocate arthroscopic treatment of all intra-articular elbow fractures, but in specific circumstances, the arthroscope cannot only assist but also improve treatment of these sometimes difficult and often challenging injuries. The arthroscope is also useful in the identification of varus, valgus, and posterolateral rotatory instability, particularly when these instabilities are less obvious on clinical examination
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Comparison of early surgical alternatives in the management of open abdomen: a randomized controlled study
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DOD - Acute Comp Syndrome CPG
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BACKGROUND: Abdominal compartment syndrome (ACS) is a clinical syndrome characterized by progressive intraabdominal organ dysfunction resulting from an acute increase in intra-abdominal pressure (IAP). In the absence of prompt treatment, ACS can lead to lethal organ failure. Treatment of ACS is achieved by immediate decompression of the abdominal cavity. As to how and when decompression laparotomy should be performed depends on the clinical condition of the patients. There is limited data regarding outcomes of abdominal closure techiques. The present study aimed to investigate two different temporary closure methods, the vacuum assisted closure (VAC) and Bogota bag techniques, in 40 patients who underwent decompressive laparotomy as part of the management of ACS.
METHODS: The study included 40 patients who developed ACS during follow-up or following trauma and abdominal surgery. As part of the treatment for ACS, these patients underwent decompressive laparotomy at the Cukurova University Medical Faculty, General Surgery Department and followed up in the Intensive Care Unit of the same hospital. VAC and Bogota bag procedures were performed as temporary closure methods for the treatment of ACS. Patients were randomly assigned to each of the two groups according to the temporary closure method performed. Clinical, laboratory, mortality and morbidity results of the patients in both groups were compared.
RESULTS: Demographic features of the patients (age, sex, body mass index, co-morbidities) were similar between the two groups. The most common reason of ACS was gastrointestinal perforation in 12 (30%) patients. Decrease in incision width was significantly faster in the VAC group than in the Bogota group. Primary closure of fascia was considered appropriate in 16.9 days in the VAC group and 20.5 days in the Bogota bag group. The decrease in abdominal pressure was similar between the two groups on days 1, 4 and 7 but appeared to be significantly lower on day 14 in the VAC group. 12 patients (30%) died during the study. Among the deceased patients, 5 (12%) were in the VAC group, whereas, 7 (17.5%) belonged to the Bogota bag group.
CONCLUSION: Based on these results, it is suggested that VAC has advantages when compared to the Bogota bag as a temporary closure method in the management of abdominal compartment syndrome.
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Meniscal root tears occur frequently in multi-ligament knee injury and can be predicted by associated MRI injury patterns
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AMP (Acute Meniscal Pathology)
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PURPOSE: The frequency of meniscal root tears in association with multi-ligament knee injury has not been established but adds to the complexity of surgical reconstruction and may have long-term consequences. Therefore, identifying root tears, on preoperative imaging, is important. The aim of this study was to identify the frequency of meniscal root tears, on preoperative magnetic resonance imaging, following multi-ligament injury and distinguish associated injury patterns that may aid detection.
METHODS: Cases were identified from a prospectively collected institutional database. The magnetic resonance imaging of 188 multi-ligament injuries [median age 31 years (range 16-64)] was retrospectively reviewed by three musculoskeletal radiologists with the presence of meniscal injuries recorded alongside the ligament injury pattern and intra-articular fractures. Assessment of injury pattern was solely made on this imaging.
RESULTS: 38 meniscal root injuries were identified in 37 knees (overall frequency = 20.2%; medial = 10.6%; lateral = 9.6%). The frequency of meniscal root tears was not increased in higher grade injuries (21.5% vs. 17.0%, n.s.). Valgus injury patterns were associated with lateral root tears (p < 0.05) and varus patterns were associated with medial root tears (p < 0.05). Further, fractures in the same compartment were associated with both medial and lateral root tears (p < 0.05).
CONCLUSIONS: Meniscal root tears occur more frequently in multi-ligament knee injury than previously reported with isolated anterior cruciate rupture. Root tears can be predicted by ligament injury patterns and fractures sustained (suggestive of a compressive force). In multi-ligament cases, the preoperative magnetic resonance imaging can be used to detect these tears and associated patterns of injury.
Level of evidence: Iv.
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Unsatisfactory accuracy as determined by computer navigation of VISIONAIRE patient-specific instrumentation for total knee arthroplasty
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Surgical Management of Osteoarthritis of the Knee CPG
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This investigation evaluated the Smith and Nephew VISIONAIRE patient-specific cutting block (PSCB) system for total knee arthroplasty. A consecutive series of 60 patients was recruited. Intraoperative computer navigation was used to evaluate the accuracy of the cutting blocks in the coronal and sagittal planes for the tibia, as well as rotational plane for the femur. The PSCB would have placed 79.3% of the sample within +/-3 degrees of the preoperative plan in the coronal plane, while the rotational and sagittal alignment results within +/-3 degrees were 77.2% and 54.5% respectively. The VISIONAIRE PSCB system achieved unacceptable accuracy when assessed by computer navigation. There might be many sources of error, but caution is recommended before using this system routinely without objective verification of alignment
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Carpal tunnel syndrome: Study of the relation between psychiatric symptoms and clinical signs and the result of treatment
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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Purpose: Carpal tunnel syndrome (CTS) is considered the most common chronic compressive neuropathies manifests by signs and symptoms of median nerve irritation in carpal tunnel at the wrist. The main etiologies are structural, genetic and biological with environmental and occupational factors playing a role. There are many studies about psychological effects on clinical symptoms and treatment outcome in CTS. The objective of this study is to find factors contributing to CTS, the relation between symptoms of CTS and psychological distress, the relation between treatment outcome and psychological distress. The psychological distress in this study was assessed by the hospital anxiety and depression scale. Methods: The study was performed by retrospective chart review of out patient diagnosed as CTS in Somdet Chaopraya Institute of Psychiatry during October 2006-September 2007 in view of demographic distributions, severity of the disease and psychological illness. All data were collected and analysed by SPSS 10th edition. Results: There were 42 complete data out of total 68 patient diagnosed as CTS with complete psychological assessment. Demographic study showed most patients were female age between 41-59 years old and the occupations related to CTS were typist, messenger, and house wife. Psychological study showed one-third of the patients had no psychological symptoms, 5% had anxiety, 28.6% had depression and 26.2% had both anxiety and depressive symptoms. Conclusion: No statistically significant was found for the relationship between psychological symptoms and severity of the disease (CTS). Neither was found for the relationship between psychological symptoms and treatment outcomes. This study had many limitations due to retrospective study and small sample size that controlled prospective study was recommended for further study
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Prediction of hip osteoporotic fractures from composite indices of femoral neck strength
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Management of Hip Fractures in the Elderly
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Objective: To clarify whether composite hip strength indices improve predictive ability for hip osteoporotic fractures independent of conventional bone mineral density (BMD). Subjects and methods: Three hundred and eighty-two health controls and 43 women with hip fractures (aged 28.2-87.7 years, mean age 59.5(plus or minus)9.2 years) were measured by dual energy X-ray absorptiometry for femoral neck bone mineral density (FN-BMD) and proximal femur geometry parameters of hip, and composite hip strength indices (Compression strength index, Bending strength index, and Impact strength index). The association between the studied parameters and the fractures was modelled using multiple logistic regression, including age, height, weight, and menopausal status. Fracture-predicted probability was calculated for each predictor tested. ROC curve areas (AUCs) were calculated for the fracture status, having the calculated fracture-predicted probability as a test variable. AUCs were compared by the Hanley-McNeil test. Results: Women with hip fractures had lower FN-BMD, composite hip strength indices, and longer hip axis length than controls, and no significant difference in femoral neck width. Logistic regression showed composite hip strength indices could predict hip fractures risk. To the same extent as FN BMD, Compression Strength Index (CSI) best predicted the risk for each fracture (AUC = 0.787 (plus or minus) 0.028). When CSI was added to FN-BMD, there was a small but not statistically significant increase in AUC to 0.796 (plus or minus) 0.027 (P = 0.9018). Conclusion: Composite indices of femoral neck strength may be valuable in the assessment of the biomechanics of bone fragility; however, they do not appear to add diagnostic value to the simple measurement of BMD. (copyright) 2012 ISS
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Increased renal retention of 99mTc-methylene diphosphonate after nephron-sparing surgery
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MSTS 2018 - Femur Mets and MM
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UNLABELLED: Nephron-sparing surgery has become established as an effective treatment for localized renal cell carcinoma when preservation of renal function is necessary. The surgery usually requires temporary renal artery occlusion and may induce ischemic renal damage. In this study, we retrospectively evaluated renal activity on bone scintigraphy after nephron-sparing surgery.
METHODS: Eleven patients who underwent nephron-sparing surgery for renal cell carcinoma and had a normal contralateral kidney were studied. A total of 12 bone scintigraphy images with 99mTc-labeled methylene diphosphonate were obtained within 1 y after surgery in these patients to assess skeletal metastasis. Activity in the spared renal parenchyma was compared visually with that in the contralateral normal kidney.
RESULTS: The tumor was successfully resected in every patient, and no clinically significant complications occurred. Activity in the spared renal parenchyma was elevated in six of seven examinations performed within 21 d after surgery. In three examinations, the increase in renal activity was heterogeneous, being relatively prominent near the surgical margin. Increased renal activity was not observed on five examinations performed 3 mo or more after surgery.
CONCLUSION: Renal retention of bone-seeking agents is elevated in the early period after nephron-sparing surgery, probably as a result of ischemic insult during the surgical procedure. Bone scintigraphy may aid in evaluating the presence and degree of ischemic damage of the spared renal parenchyma.
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Arthrographic, clinical, and surgical analysis of 100 problem knees
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AMP (Acute Meniscal Pathology)
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Knee arthrography by the double contrast fluoroscopic technique is a safe and accurate preoperative outpatient diagnostic modality. It is recommened as an extension of the clinical evaluation of the knee before arthroscopy or arthrotomy. It can decrease procrastination, provide the final level of confidence in the decision to operate, and influence the site of the surgical incision. In addition, almost all arthrographic findings can be confirmed by arthroscopy and arthrotomy. The removal of a normal meniscus should therefore be an extremely rare event. Arthrography should not be considered in competition with arthroscopy, because it can safely provide detailed and reliable information before arthroscopy or arthrotomy.
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The relationship between prosthesis use, phantom pain and psychiatric symptoms in male traumatic limb amputees
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DoD LSA (Limb Salvage vs Amputation)
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OBJECTIVES: The purpose of this study was to identify psychiatric symptoms by comparing male patients with traumatic leg amputations (LAs) with healthy controls and to determine the association between these psychiatric symptoms and phantom pain and prosthesis use characteristics. METHODS: One hundred four volunteers, 51 LA patients (group 1) and 53 healthy controls (group 2) were included. Demographic data including age, height, weight, time since amputation, duration of prosthesis use, and Satisfaction with Prosthesis Questionnaire scores were recorded. Phantom pain was measured a visual analog scale (VAS). Psychiatric symptoms were measured using the Symptom Checklist-90-R, Beck Depression Inventory, Pittsburgh Sleep Quality Index, Rosenberg Self-Esteem Scale, and State-Trait Anxiety Inventory. Correlations were determined between time since amputation, duration of prosthesis use and satisfaction with prosthesis questionnaire scores and psychiatric scale scores. RESULTS: Amputee patients had higher phobic anxiety, state anxiety, trait anxiety and sleep disturbance scores (p<0.05) than the controls. No difference was determined in terms of psychiatric symptoms between the phantom pain and no phantom pain groups (p>0.05). There were significant negative correlations between time since amputation, duration of prosthesis use, duration of daily prosthesis use, and satisfaction with prosthesis questionnaire scores and psychiatric symptoms. CONCLUSIONS: Apart from anxiety (state, trait or phobic) and disturbed sleep, other psychiatric symptoms in amputee patients undergoing lengthy prosthetic rehabilitation may not differ from those of healthy controls. The presence and severity of phantom pain appear to be unrelated to general psychiatric symptomatology. Length of time since amputation, length of prosthesis use, daily length of prosthesis use and prosthesis satisfaction are negatively correlated with general psychiatric symptoms. These characteristics must be borne in mind in psychiatric and prosthetic rehabilitation.
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Geriatric vision loss due to cataracts, macular degeneration, and glaucoma
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HipFx Supplemental Cost Analysis
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The major causes of impaired vision in the elderly population of the United States are cataracts, macular degeneration, and open-angle glaucoma. Cataracts and macular degeneration usually reduce central vision, especially reading and near activities, whereas chronic glaucoma characteristically attacks peripheral vision in a silent way, impacting balance, walking, and driving. Untreated, these visual problems lead to issues with regard to taking medications, keeping track of finances and personal information, walking, watching television, and attending the theater, and often create social isolation. Thus, visually impaired individuals enter nursing homes 3 years earlier, have twice the risk of falling, and have 4x the risk of hip fracture. Consequently, many elderly with low vision exercise greater demands on community services. With the prospect of little improvement and sustained visual loss, in the face of poor tolerance of low-vision services and not accepting magnification as the only way to read, clinical depression is common. In many instances, however, early and accurate diagnosis can result in timely treatment and can preserve quality of life. This review will look at current diagnostic and therapeutic considerations. Currently, about 20.5 million people in the United States have cataracts. The number will reach 30 million by 2020. About 1.75 million Americans currently have some form of macular degeneration, and the number is estimated to increase to 2.95 million in 2020. Approximately 2.2 million Americans have glaucoma, and by 2020 that number is estimated to be close to 3.4 million people. It is projectedthat by 2030 there will be 72.1 million seniors. With some overlap of the above 3 groups conservatively estimated (if you add the 2030 cataract group to the macular degeneration and glaucoma groups), then about 1 in 2 senior individuals by 2030 may have some significant ocular disease, which could account for about 50% of the healthcare budget for the elderly. (copyright) 2012 Mount Sinai School of Medicine
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Anti-platelet agents and surgical delay in elderly patients with hip fractures
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Management of Hip Fractures in the Elderly
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PURPOSE: To assess the risk of surgical delay in elderly hip fracture patients on anti-platelet agents. METHODS: Records of 180 patients aged over 65 years with either an intertrochanteric or femoral neck fracture were reviewed. The clopidogrel group included 10 patients on clopidogrel alone and 11 others on clopidogrel and aspirin, whereas the control group included 69 on aspirin alone and the remaining 90 not on any anti-coagulants. The 2 groups were compared with regard to time to surgery, preoperative American Society of Anesthesiologists (ASA) score, pre- and post-operative haemoglobin levels, in-patient complication rates, duration of hospital stay, and 30-day mortality. RESULTS: In the clopidogrel and control groups respectively, the mean times to surgery were 7.2 and 2.1 days (p=0.03, t-test), the mean preoperative ASA scores were 3.35 and 2.8 (p=0.29, t-test), the mean preoperative haemoglobin levels were 119 and 115 g/l (p=0.5, t-test), the mean postoperative haemoglobin levels were 98 and 96 g/l (p=0.68, t-test), the mean durations of hospital stay were 7.4 and 3.1 days (p=0.02, t-test). The 30-day mortalities were 6/21 (29%) and 6/159 (4%) [p=0.0003, Fisher's exact test]. CONCLUSION: Surgical delay in elderly patients on anti-platelet agents with hip fracture was associated with higher mortality. Despite the risk of increased blood loss, we suggest early surgery be carried out by an experienced surgeon to expedite the operating time. Pooled platelets should be given intravenously one to 2 hours preoperatively
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Decreased extension gap and valgus alignment after implantation of total knee prosthesis in primary varus knees
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OAK 3 - Non-arthroplasty tx of OAK
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PURPOSE: It was hypothesised that implantation of a total knee prosthesis may change the size and shape of the joint gap. To test this hypothesis, a tensor device was used which was specifically designed to reproduce the conditions before and after implantation, including attachment of the polyethylene insert trial. This study aimed to compare the joint gaps before and after implantation of a total knee prosthesis using this new tensor device. METHODS: A total of 259 primary varus knees were included in this study. Knees were exposed using a medial parapatellar approach, and the anterior and posterior cruciate ligaments were resected. After the trial reduction, the intraoperative joint gap kinematics was measured using the tensor device. RESULTS: Implantation of a total knee prosthesis decreased the size of the extension joint gap and made it valgus, but did not influence the size or shape of the flexion joint gap. CONCLUSIONS: The present findings suggest that the classical gap technique, which creates equal and rectangular extension and flexion joint gaps in the bone cutting surface, results in an imbalance between the extension and flexion joint gaps after implantation. To achieve equal and rectangular extension and flexion joint gaps after implantation, the prepared extension joint gap should be about 2Â mm larger than the flexion joint gap and slightly varus before implantation in primary varus knees. LEVEL OF EVIDENCE: Therapeutic study, Level II.
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Current progress in γδ T-cell biology
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MSTS 2018 - Femur Mets and MM
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T lymphocytes bearing γ-and δ-chain T-cell receptor heterodimers are named γδ T cells. Interestingly, γδ and αβ T cells share the same progenitors, and they undergo a fate decision in the thymus. Functional differentiation of γδ T cells occurs both inside and outside the thymus. Antigen recognition of γδ T-cell receptors is very unique, and the responses frequently exhibit innate characteristics. Nevertheless, peripheral γδ T cells exert a number of effector and regulatory functions. γδ T cells rapidly produce cytokines like interferon (IFN)-γ and IL-17 and promote inflammation, partly due to the inherent epigenetic and transcriptional programs, which facilitates a quick and extensive response. Moreover, γδ T cells lyse target cells directly, and this is necessary for pathogen or tumor clearance. γδ T cells can even serve as regulatory cells, and may contribute to immune suppression. Orchestration of γδ T-cell and other immune cell interactions may be critical for host defense and immune regulation. Recently, γδ T cells have been used for immunotherapy for infectious diseases and malignancy. In this review, we summarize the abstracts presented at the recent γδ T cell Conference held from 19 to 21 May 2010, in Kiel, Germany (please see the website for details: http://www.gammadelta-conference.uni-kiel.de/index.html). © 2010 CSI and USTC. All rights reserved.
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Inter- and intra-rater reliability of patellofemoral kinematic and contact area quantification by fast spin echo MRI and correlation with cartilage health by quantitative T1? MRI
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AMP (Acute Meniscal Pathology)
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Background: Patellar maltracking is a leading cause of patellofemoral pain syndrome (PFPS). The aim of this study was to determine the inter- and intra-rater reliability of a semi-automated program for magnetic resonance imaging (MRI) based patellofemoral kinematics. Methods: Sixteen subjects (10 with PFPS [mean age 32.3; SD 5.2; eight females] and six controls without PFPS 19 [mean age 28.6; SD 2.8; three females]) participated in the study. One set of T2-weighted, fat-saturated fast spin-echo (FSE) MRIs were acquired from each subject in full extension and 30° of knee flexion. MRI including axial T1? relaxation time mapping sequences was also performed on each knee. Following image acquisitions, regions of interest for kinematic MRI, and patellar and trochlear cartilage were segmented and quantified with in-house designed spline- based MATLAB semi-automated software. Results: Intraclass Correlations Coefficients (ICC) of calculated kinematic parameters were good to excellent, ICC > 0.8 in patellar flexion, rotation, tilt, and translation (anterior -posterior, medial -lateral, and superior -inferior), and contact area translation. Only patellar tilt in the flexed position and motion from extended to flexed state was significantly different between PFPS and control patients (= 0.002 and p = 0.006, respectively). No significant correlations were identified between patellofemoral kinematics and contact area with T1? relaxation times. Conclusions: A semi-automated, spline-based kinematic MRI technique for patellofemoral kinematic and contact area quantification is highly reproducible with the potential to help better understand the role of patellofemoral maltracking in PFPS and other knee disorders. Level of Evidence: Level IV.
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Do rheumatoid arthritis patients expect less from total knee arthroplasty?
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Surgical Management of Osteoarthritis of the Knee CPG
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Background/Purpose: RA patients undergoing TKA often do not achieve the same functional results as osteoarthritis (OA) patients, yet are surprisingly satisfied. Satisfaction is determined not just by absolute improvements in pain and function, but also by fulfillment of pre-operative expectations. It is unknown if RA patients have different expectations compared to similar OA patients. Methods: RA patients undergoing TKA were compared to OA patients matched for age, gender, and lower extremity activity (LEAS) score. All were drawn from a prospective institutional registry, patients with previous arthroplasties were excluded. Expectations were assessed using the validated Hospital for Special Surgery Expectations Survey (see Table 1). A composite score is calculated; range: 0-100; 100=highest expectations. Preoperative data collection also included level of education, living situation, WOMAC, VAS for pain, ED-5Q, SF-36. Wilcoxon Signed Ranks test with Bonferroni correction was used to compare individual expectation items and T-test for mean expectations score. (Table Presented) Results: 62 RA patients were identified and matched to 124 OA controls. 87.1% were women, average age was 64.7(plus or minus)9.7 years, and average
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1 |
Nonoperative Treatments for Knee Osteoarthritis: An Evaluation of Treatment Characteristics and the Intra-Articular Placebo Effect: A Systematic Review
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OAK 3 - Non-arthroplasty tx of OAK
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BACKGROUND: Guidelines recommending various nonoperative treatments for patients with knee osteoarthritis remain inconsistent. Much of this controversy relates to what constitutes a clinically important effect. The purposes of the present study were to compare treatment effect sizes from recent meta-analyses evaluating pharmacological or medical device interventions for the treatment of knee osteoarthritis and to further assess the clinical impact that the intra-articular placebo effect may have on intra-articular injection therapies.
METHODS: A search of PubMed, MEDLINE, and Embase from the inception date of each database through May 30, 2017 was conducted for all articles involving meta-analyses of pharmacological or medical device knee osteoarthritis treatments compared with controls. Two reviewers independently screened articles for eligibility and extracted data for analysis. We present effect estimates on a standardized mean difference (SMD) scale and compare them all against a threshold for clinical importance of 0.50 standard deviation (SD) unit.
RESULTS: Ten meta-analyses (sample size range, 110 to 39,814) providing a total of 19 different effect sizes for pain were included in this review. SMD estimates ranged from 0.08 to 0.79 for various electrical modalities, orthotic devices, topical and oral nonsteroidal anti-inflammatory drugs (NSAIDs), dietary supplements, and intra-articular injection therapies. Seventeen treatments demonstrated significant improvements in terms of pain when patients who had received treatment were compared with controls. After accounting for the intra-articular placebo effect, the greatest effect estimates were those of intra-articular platelet-rich plasma and high molecular weight hyaluronic acid. When these were judged according to our threshold for clinical importance, high molecular weight intra-articular hyaluronic acid was found to have the most precise effect estimate that surpassed this threshold. Platelet-rich plasma was found to provide the greatest point estimate of the treatment effect, but the precision around this estimate had the largest amount of uncertainty across all treatments.
CONCLUSIONS: While many nonoperative treatments demonstrated significant improvements in pain, we found the greatest effect estimates for intra-articular treatments. While platelet-rich plasma provided the greatest point estimate of the treatment effect, variability among studies suggests that future research into optimal formulations is required. The strongest current evidence supports clinically important and significant treatment effects with intra-articular hyaluronic acid formulations between 1,500 and >6,000 kDa.
LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.
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Unremitting fever and right-sided abdominal distension in a 7-week-old
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Patrick’s pharmacoepidemiology project
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⢠The clinical presentation of unremitting fever in a neonate warrants further investigation. ⢠In cases of abdominal distension and fever, rare abdominal lesions, such as alimentary tract duplications, should be considered when more common causes have been ruled out. ⢠Alimentary tract duplications are rare abdominal masses that often result in complications when left untreated. ⢠The best diagnostic modality for intraabdominal cysts is ultrasonography. ⢠Computed tomography or magnetic resonance imaging can further characterize suspicious abdominal lesions. ⢠Surgical excision with histologic review is necessary to confirm the diagnosis of an alimentary tract duplication. ⢠On histologic review, alimentary duplication cysts have a well-developed smooth muscle wall with mucosal lining. ⢠Complete surgical resection of an uncomplicated alimentary tract duplication can result in an excellent prognosis
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Evaluation of the accuracy of a patient-specific instrumentation by navigation
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OAK 3 - Non-arthroplasty tx of OAK
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Purpose: The aim of this study is to evaluate the accuracy of a patient-specific instrumentation (PSI) as assessed by the intraoperative use of knee navigation software during the surgical procedure. Methods: Fifteen patients with primary gonarthrosis were selected for unilateral total knee arthroplasty. The first three patients were excluded from this study, as they were considered to be a warm up to set-up the procedure. All patients were operated on with a cemented posterior-stabilised prosthesis cruciate ligament-sacrificing by the same surgeon using the patient matched cutting jigs. The size of the implant, level of resection, and alignment in the coronal and sagittal planes were evaluated. An unsatisfactory result was considered an error �2° in both planes for each component as a possible error of 4° could result in aggravation. Results: On the coronal plane the mean deviation of the tibial guide from the ideal alignment was 1.2 ± 1.5 (range 0-5°) and in the sagittal plane was 3.8 ± 2.4 (range 0-7.5°). On the coronal plane the mean deviation of the femoral guide from the ideal alignment was 1.2 ± 0.6 and in the sagittal was 3.7 ± 2. Conclusion: On the basis of this preliminary experience the PSI system based only on data acquisition with A-P radiograms and RMN cannot be defined as accurate. In cases of the use of the custom made cutting jigs it is recommended to perform an accurate control of the alignment before making the cuts, for any step of the procedure. Level of evidence: II. © 2012 Springer-Verlag.
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Distal musculoskeletal manifestations in polymyalgia rheumatica: a prospective followup study
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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OBJECTIVE: To determine the frequency and the characteristics of distal musculoskeletal manifestations in polymyalgia rheumatica (PMR). METHODS: Prospective followup study of 177 consecutive patients meeting clinical criteria for PMR, diagnosed over a 5-year period in 2 rheumatology secondary referral centers in Italy. RESULTS: Seventy-nine of the 177 patients (45%) had distal musculoskeletal manifestations. Peripheral arthritis occurred in 45 patients (25%), carpal tunnel syndrome in 24 (14%), distal extremity swelling with pitting edema in 21 (12%), and distal tenosynovitis in 5 (3%). These manifestations were usually associated with PMR proximal symptoms (69%); however, 31% of the episodes represented isolated relapse/recurrence at distal sites. Distal symptoms responded promptly to corticosteroids. No evidence of joint deformities, erosions, or development of rheumatoid arthritis was observed during the followup. The group of patients with peripheral arthritis included a higher proportion of females, had a longer duration of therapy, and had more relapses/ recurrences. Patients who had distal extremity swelling with pitting edema had a higher age at disease onset, a shorter duration of therapy, and lower initial and cumulative prednisone doses. CONCLUSION: Inflammatory involvement of distal articular and/or tenosynovial structures occurs in approximately half of the cases of PMR. Peripheral arthritis is associated with more severe disease, while distal extremity swelling with pitting edema appears to identify a more benign disease subset
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Concurrent little leaguer's elbow and shoulder in a 15-year-old baseball pitcher and football quarterback
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The Treatment of Pediatric Supracondylar Humerus Fractures AUC
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Little leaguer's elbow and Little leaguer's shoulder are overuse pathologies seen in overhead-throwing athletes. No instance of simultaneously occurring pathologies has been published. A 15-year-old baseball pitcher and football quarterback developed pain in his throwing shoulder and elbow during spring baseball, which partially resolved with several months of rest. During fall football practice, he felt a pop and pain over his medial throwing elbow. Five days after the initial injury, medial elbow tenderness, mild swelling, and decreased range of motion were noted. Radiographs revealed a Salter I avulsion fracture of the medial humeral epicondyle (Little leaguer's elbow) and a periosteal reaction along the lateral aspect of the humeral metadiaphysis with slight widening (Little leaguer's shoulder). Surgical fixation of the medial epicondyle fracture and nonoperative treatment of the shoulder pathology were performed. Two-year follow-up radiographs showed a healed medial epicondylar fracture and resolution of the periosteal reaction of the humeral metadiaphysis. The patient returned to full activity and was starting quarterback for his football team. Biomechanical forces specific to overhead-throwing activities are associated with the development of Little leaguer's elbow and shoulder. Treatments of both pathologies remain controversial, with either initial operative vs nonoperative care. In this patient, a good outcome was achieved with surgical fixation of the elbow fracture and conservative management of the shoulder pathology. Educating coaches and parents on proper throwing technique and pitching limits should be the first step in reducing the occurrence of either pathology in this population
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Best evidence topic report. Fasting before prilocaine Biers' block
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Distal Radius Fractures
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A short cut review was carried out to establish whether a period of fasting increases the safety of Biers' block (intravenous regional anaesthesia). A total of 50 papers were found using the reported search, of which four presented the best evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses of these best papers are tabulated. A clinical bottom line is stated.
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1 |
Orthogeriatric services associated with lower 30-day mortality for older patients who undergo surgery for hip fracture
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Hip Fx in the Elderly 2019
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OBJECTIVE: To examine the impact of orthogeriatric services on 30-day mortality and length of stay (LOS) for hip fracture patients undergoing surgery in public hospitals in New South Wales.
DESIGN, SETTING AND PATIENTS: A retrospective analysis of patients aged 65 years and older who had a fractured hip and received surgical intervention between 1 July 2009 and 30 June 2011 at one of the 37 NSW public hospitals operating on hip fracture patients.
MAIN OUTCOME MEASURES: 30-day mortality and LOS.
RESULTS: During the study period, there were 9601 hip fracture cases for which surgery was done. Mean age, sex and comorbidity distribution were similar for hip fracture patients treated in hospitals with an orthogeriatric service compared with those treated in hospitals without an orthogeriatric service. There were 706 deaths within 30 days of hip fracture surgery, and the overall unadjusted 30-day mortality rate was 7.4%. The median adjusted 30-day mortality rate for hospitals with an orthogeriatric service was significantly lower than that for hospitals without an orthogeriatric service (6.2% v 8.4%; P < 0.002). Median total LOS was longer at hospitals with an orthogeriatric service compared with hospitals that did not have an orthogeriatric service (26 days v 22 days; P < 0.001).
CONCLUSIONS: The presence of an orthogeriatric service was associated with a reduction in 30-day mortality but a longer LOS. More research is required to understand the key aspects of care that determine health outcomes. The recently launched Australian and New Zealand Hip Fracture Registry will provide data that will enable improvements in care.
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1 |
Does Dexamethasone Reduce Hospital Readiness for Discharge, Pain, Nausea, and Early Patient Satisfaction in Hip and Knee Arthroplasty? A Randomized, Controlled Trial
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AAHKS (2) Corticosteroids
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BACKGROUND: Reduction in postoperative pain, nausea, and vomiting in patients undergoing total joint arthroplasty may facilitate earlier discharge from hospital and reduce healthcare costs. This study was performed to primarily assess whether perioperative dexamethasone reduced hospital length of stay and to assess the effect on pain, nausea and vomiting, and patient satisfaction.
METHODS: One hundred sixty-four patients undergoing total hip arthroplasty or total knee arthroplasty were randomized to receive either 8 mg intravenous dexamethasone (n = 86) or placebo (n = 78) at induction and at 24 hours postsurgery. The primary outcome was length of stay and secondary outcomes were pain and nausea visual analog scale scores, analgesic and antiemetic usage, blood glucose level, and patient satisfaction.
RESULTS: Participants in the study group achieved earlier readiness for discharge. There was a 20% reduction in pain scores and morphine usage was 27% lower in the study group. Nausea scores were similar in the 2 groups but there was lower antiemetic usage in the study group. Satisfaction scores at 6 weeks postsurgery in the dexamethasone group were significantly higher than the placebo group. There was no difference in complication rates between the 2 groups.
CONCLUSION: The administration of intravenous dexamethasone could lead to earlier readiness for discharge especially in patients undergoing elective total hip arthroplasty, primarily by a reduction in postoperative pain scores and/or morphine requirements.
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Impact of late post-traumatic seizures on physical health and functioning for individuals with brain injury within the community
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DoD PRF (Psychosocial RF)
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PRIMARY OBJECTIVE: To better characterize, describe and highlight issues that individuals with TBI and active LPTS may face in their daily lives.
DESIGN: Prospective multi-centre mixed method qualitative and quantitative interview.
PARTICIPANTS: Twenty-five individuals, 5-13 years post-injury, who had reported having LPTS and TBI.
MEASURES: Disability Rating Scale (DRS); Supervision Rating Scale (SRS); Glasgow Outcome Scale-Extended (GOS-E); Perceived Stress Scale (PSS); Craig Handicap Assessment Reporting Technique-Short Form (CHART-SF) sub-scales: Physical Independence, Cognitive Independence, Mobility, Occupation, Social Integration; and Craig Hospital Inventory of Environmental Factors (CHIEF); and qualitative interview questions pertaining to management of the seizure disorder and its effect on the individual's health, function, community integration and participation.
RESULTS: Data are presented regarding seizure activity and management; return to driving post-seizure; coping and participation; and standardized outcome measures.
CONCLUSIONS: Individuals with TBI and LPTS are at a double-barrelled disadvantage regarding ongoing physical, cognitive, psychosocial and reintegration issues following brain injury and epilepsy. Clearer clinical guidelines and treatment strategies need to be developed to help ameliorate these ongoing issues. Additional research is needed to identify what the rehabilitation community can do to continue to facilitate people living safely and independently.
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Cost-effectiveness of transfusion of platelet components prepared with pathogen inactivation treatment in the United States
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Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures
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BACKGROUND: The Intercept Blood System (IBS) for platelets has been developed to reduce pathogen transmission risks during transfusions. OBJECTIVE: This study was a comprehensive economic analysis of the cost-effectiveness of using the IBS for single-donor apheresis platelets (AP) and random-donor pooled platelet concentrates (PC) versus AP and PC without the IBS in the United States in patient populations in which platelets are commonly transfused. METHODS: All data used in this analysis were summarized from existing published sources (primarily indexed in MEDLINE) and data on file at Baxter Healthcare Corporation (Chicago, Illinois) and Cerus Corporation (Concord, California). A literature-based decision-analytic model was developed to assess the economic costs and clinical outcomes associated with the use of AP and PC treated with the IBS for several conditions and procedures that account for a considerable proportion of the platelet usage in the United States: acute lymphocytic leukemia, non-Hodgkin's lymphoma, coronary artery bypass graft, and hip arthroplasty Risks of infection with HIV, hepatitis C virus (HCV), hepatitis B virus, human T-cell lymphotropic virus type 1, or bacterial agents were incorporated into the model. Possible benefits of reduction of the risk of emerging HCV like pathogens and elimination of the need for gamma irradiation were explored in sensitivity analyses. RESULTS: The incremental cost per quality-adjusted life-year gained by using AP + IBS versus untreated AP ranged from 1,308,833 dollars to 4,451,650 dollars (without bacterial testing) and 4,759,401 dollars to 22,968,066 dollars (with bacterial testing). Corresponding figures for PC + IBS versus untreated PC ranged from 457,586 dollars to 1,816,060 dollars. Inclusion of emerging HCV like virus and the elimination of the need for gamma irradiation improved the cost-effectiveness to a range of 177,695 dollars to 1,058,127 dollars for AP without bacterial testing, 176,572 dollars to 1,330,703 dollars for AP with bacterial testing, and 22,888 dollars to 153,564 dollars for PC. The model was most likely to be affected by mortality from bacterial contamination, IBS effect on platelet utilization, and the inclusion of potential benefits (ie, gamma irradiation and/or emergent HCV-like virus). The model was relatively insensitive to changes in the IBS price and viral transmission risks. CONCLUSIONS: The cost-effectiveness of pathogen inactivation via the IBS for platelets is comparable to that of other accepted blood safety interventions (eg, nucleic acid amplification technology). The IBS for platelets may be considered a desirable strategy to increase the safety of platelet transfusions and a potential insurance against the threat of emerging pathogens
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Contribution of the collagen I alpha1 and vitamin D receptor genes to the risk of hip fracture in elderly women
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Management of Hip Fractures in the Elderly
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CONTEXT AND OBJECTIVE: Hip fracture is partially genetically determined. The present study was designed to examine the contributions of vitamin D receptor (VDR) and collagen I alpha1 (COLIA1) genotypes to the liability to hip fracture in postmenopausal women. DESIGN: The study was designed as a prospective population-based cohort investigation. SUBJECTS: Six hundred seventy-seven postmenopausal women of Caucasian background, aged 70 +/- 7 yr (mean +/- SD), have been followed for up to 14 yr. Sixty-nine women had sustained a hip fracture during the period. MAIN OUTCOME: Atraumatic hip fractures were prospectively identified through radiologists' reports. Bone mineral density (BMD) at the hip and lumbar spine was measured by dual-energy x-ray absorptiometry. GENOTYPES: The TaqI and SpI COLIA1 polymorphisms of the VDR and COLIA1 genes were determined. Using the Single Nucleotide Polymorphism database, VDR TT, Tt, and tt genotypes were coded as TT, TC, and CC, whereas COLIA1 SS, Ss, and ss were coded as GG, GT, and TT. RESULTS: Women with VDR CC genotype (16% prevalence) and COLIA1 TT genotype (5% prevalence) had an increased risk of hip fracture [odds ratio (OR) associated with CC, 2.6; 95% confidence interval (CI), 1.2-5.3; OR associated with TT, 3.8; 95% CI, 1.3-10.8] after adjustment for femoral neck BMD (OR, 3.4 per SD; 95% CI, 2.3-5.0) and age (OR, 1.4 per 5 yr; 95% CI, 1.1-1.7). Approximately 20 and 12% of the liability to hip fracture was attributable to the presence of the CC genotype and TT genotype, respectively. CONCLUSION: The VDR CC genotype and COLIA1 TT genotype were associated with increased hip fracture risk in Caucasian women, and this association was independent of BMD and age
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Massive bone loss from fungal infection after anterior cruciate ligament arthroscopic reconstruction
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Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures
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Although there are numerous reports of septic pyogenic arthritis after arthroscopic anterior cruciate ligament (ACL) reconstruction, there is limited information regarding the outcomes of fungal infection. We determined the outcomes of six patients with mycotic infection after regular ACL reconstruction. There were four males and two females with a mean age of 33 years. We determined the number of procedures performed, bone loss originating to control infection, and final reconstruction in these patients. An average of five arthroscopic lavage procedures had been performed at the referring centers. Fungal infection was diagnosed based on pathologic samples; five infections were the result of mucormycosis and one was Candida. After final debridement, the mean segmental bone loss was 12.8 cm. All patients were treated with intravenous antifungal coverage and cement spacers before final reconstruction. At final followup, all patients were free of clinical infection. Three had reconstruction with an allograft-prosthesis composite, two with hemicylindrical allografts, and one with an intercalary allograft arthrodesis. Despite the extremely unusual presentation of this complication, surgeons should be aware of potential and catastrophic consequences of this severe complication after ACL reconstruction. Level of Evidence: Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence. (copyright) 2009 The Association of Bone and Joint Surgeons
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Incidence of hip fracture over a 10-year period (1991-2000): reversal of a secular trend
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HipFx Supplemental Cost Analysis
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INTRODUCTION: Hip fractures are a major cause of burden associated with osteoporosis in terms of mortality, disability, and costs. With the ageing of the population, a marked increase in the number of fractures is expected. Furthermore, many studies reveal an increase of the age-adjusted hip fracture incidence. We specifically examined secular changes in the incidence of hip fracture in women and men aged 50 years and over in the well-defined area of Geneva, Switzerland. MATERIALS AND METHODS: All hip fractured patients were retrospectively identified from the computer medical records of the main hospital, which is receiving 95% of hip fractures occurring in a well-defined area. RESULTS: From 1991 to 2000, 4115 hip fractures were recorded in 2981 women and 822 men with a mean age (+/-S.D.) of 83.1+/-8.9 and 78.3+/-11.6 years, respectively. A second hip fracture occurred in 276 women (9.3%) and 36 men (4.4%), on average 2.1+/-1.9 (median 1.44) years after the first event without gender difference. The overall incidence of hip fractures was 455 (95% CI: 439-471) per 100,000 person-years in women and 153 (95% CI: 143-163) in men. The number of hip fractures remained constant (412 (95% CI: 397-426)), but the mean age of these patients increased each year by 0.13 year in women (p=0.019) and by 0.04 year in men (NS). Furthermore, the age-adjusted incidence of hip fractures, standardized to the 2000 Geneva population, decreased significantly by 1.4% (95% CI: -2.6 to -0.1) per year in women (p=0.021), but remained stable in men (0.5% (95% CI: -1.7 to +2.8) per year, p=0.66). The overall female/male ratio of hip fracture incidence was 2.99 (95% CI: 2.80-3.18, p<0.001) and significantly decreased by 0.07 (95% CI: -0.13 to -0.01) per year (p=0.024). CONCLUSION: Despite an increase in the population at risk and in the mean age of hip fractured women, there was a significant decrease in age-adjusted incidence in women but not in men. These results may suggest a reversal of the previously observed secular trend
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0 |
Cutaneous surgery and the pregnant patient
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Reconstruction After Skin Cancer
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Cutaneous surgery in 34 pregnant women is described. The main indication for surgery was the diagnosis and/or treatment of malignancy. Surgery during the period of organogenesis (15 to 56 days) should be avoided when possible. Patients should be positioned on the left side during the procedure to avoid the supine hypotensive syndrome. Monitoring of the fetal heartbeat is desirable. Local anesthetics, penicillin, and erythromycin are safe if used carefully. Acetaminophen is the analgesic of choice. Exposure to the sun should be avoided during the perioperative period.
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0 |
Bisphosphonates in patients with renal cell carcinoma and bone metastases: a sunitinib global expanded-access trial subanalysis
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MSTS 2018 - Femur Mets and MM
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AIM: To investigate retrospectively the effects of bone metastases and bisphosphonates in sunitinib-treated metastatic renal cell carcinoma patients.
PATIENTS & METHODS: Patients in Groups (Gp) 1 and 2, but not Gp3, had bone metastases. Gp2 received bisphosphonates following standard practice.
RESULTS: Gp2 had less favorable prognosis than Gp1. Gp3 had fewer metastases and the best prognosis. More serious adverse events occurred in Gp2 versus Gp1. The difference in overall survival between Gp1 and Gp2 was not significant after adjusting for covariates. Significantly shorter overall survival in Gp1 versus Gp3 persisted after adjusting for covariates.
CONCLUSION: Bone metastases may have a negative prognostic impact in metastatic renal cell carcinoma. Bisphosphonates may have delayed early disease progression for prognostically worse sunitinib/bisphosphonate-treated patients.
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To compare and research the clinical effect of treating the comminute distal radius fractures by refining splintage
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Distal Radius Fractures
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OBJECTIVE: To treat the comminute distal radius fractures by improved splint, and obersve the curative effect and compare the radiology with the traditional splint. METHODS: Ninetyâ?two patients with distal radius comminute fracture were randomly divided into two groups. There were 38 males and 54 females. The average age was 63 years old ranging from 23 to 82. Acording to AO classification on the distal fracture of the radius, there were 15 cases of A3, 40 cases of C1, 26 cases of C2 and 11 cases of C3. After all patients were treated by manipulative reduction, 46 cases of the treatment group were fixed supraâ?carpometacarpal joints by improved splint and trapezoid pad, the other 46 cases of control group were treated with the traditional spilint. Both groups were regularly taken Xâ?ray recheck and changed dressings to obtain the clinical cicatrization. Patients were guided to do functional exercise after splints were taken off. Six weeks later all patients were evaluated the curative and radiologic effect according to Gartlandâ?Werlley wrist score and Lidstrom grade respectively. RESULTS: According to wrist score,there were 13 cases on excellent, 34 cases on fine and 9 cases on normal in treatment group, which average score was (4.0 +/â? 2.6) and the percent of wrist functional fitness was 80.6%. There were 9 cases on excellen, 19 cases on fine and 18 cases on normal in control group, which average score was (6.0 +/â? 4.2) and the percent of wrist grad and 4 cases on the third grade in treatment group. There were 22 cases on the first grade, 16 cases on the second grad and 8 cases on the third grade in control group. CONCLUSION: The outcome of improved splint was better than that of traditional splint on the function and radiology for treating the comminute distal radius fracture.
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Long-term outcome of nonsurgically treated distal radius fractures
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Distal Radius Fractures
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PURPOSE: To study the long-term outcome after nonsurgically treated distal radius fractures including recovery of grip strength, mobility, and radiographic parameters.
METHODS: Eighty-seven patients, mean age 55 (range 19-78) years, treated with closed reduction and casts, were evaluated radiographically and clinically during the first 6 months and finally after 9-13 years. Fifty patients had extra-articular fractures (AO Class A), 4 had simple intra-articular fractures (AO Class B) and 33 had complete intra-articular fractures (AO Class C).
RESULTS: Fifty-two of 66 patients with unilateral fractures were, after 9-13 years, rated as excellent/good according to the Green and O'Brien score as modified by Cooney et al (GOBC score). Fracture class according to AO did not correlate to outcome. Considerable fracture displacements remained: dorsal angulation (mean 13 degrees in <60 y, 18 degrees in >/=60 y), greater radial shortening than initially (mean 2 mm in <60 y, 3 mm in >/=60 y). Five patients had remaining joint step-off (1-2 mm) after reduction, but only one developed mild osteoarthritis. Patients with an unsatisfactory outcome had sustained more displaced fractures that also healed with greater displacement. The remaining subjective complaints were pain or reduced function during heavier tasks. Outcome was not correlated to age. Wrist mobility returned notably faster than grip strength. Patients over 60 years of age recovered slower in both mobility and strength. Closed reduction and plaster improved dorsal angulation but not radial shortening.
CONCLUSIONS: Our data indicate that a number of patients with nonsurgically treated distal radius fractures still experience some hand/wrist impairment a decade after the trauma. The severity of fracture displacement seems to influence the clinical outcome in contrast to patients' age. Recovery of grip strength is slower than that of range of motion. Elderly patients recover more slowly than young patients. Dorsal angulation was improved but remained considerable (13 degrees -18 degrees ), while final radial shortening (2-3 mm) increased from the injury status.
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Positive effects of exercise on falls and fracture risk in osteopenic women
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Management of Hip Fractures in the Elderly
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Copyright release for this abstract has not been granted
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1 |
Evaluation of the use of anti-platelet therapy throughout the peri-operative period in patients with femoral neck fracture surgery. A retrospective cohort study
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Hip Fx in the Elderly 2019
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INTRODUCTION: Fracture neck of femur (hip fracture) is a very common problem among old age group. Such elderly patients usually have some comorbidities for which they may use anti-platelet therapy (such as clopidogrel, aspirin, or others) for long duration (chronic use). These anti-platelet medications might make the blood thin and increase bleeding tendency. So, if these elderly people present with fracture neck of femur requiring surgical intervention, they might be at increased risk of bleeding and other complications if the use of these anti-platelet agents was continued throughout the peri-operative period.
OBJECTIVES: This current study aims to find out whether it is safe or not to continue the use of anti-platelet drugs during the peri-operative period in patients with hip fracture surgery. If it is safe and there are no complications, then there is no harm to continue the use of these drugs peri-operatively without any surgical delay. But if it is unsafe and there is increased risk of bleeding or blood transfusion or other complications, then such medications must be stopped peri-operatively. Thus, the medical practice and care will be improved to achieve patient safety.
METHODS: It was a retrospective study which reviewed files and notes of patients who had hip fracture surgery. These patients were divided into 2 groups. First group was on long-term anti-platelet treatment (APTG), and the use of these medicines continued during the peri-operative phase. The second group was not on anti-platelet treatment at all (NAPTG). Then, a comparison was done between both groups in terms of the following parameters during the peri-operative (pre- and post-operative) period: (i) intra-operative blood loss, (ii) operative time in minutes (length of surgery), (iii) pre-operative haemoglobin level, (iv) the need for blood transfusion, (v) haematoma formation, (vi) re-operation for any reason, (vii) post-operative wound infection, and (viii) duration in days to achieve complete wound healing post-operatively. So these measures are good parameters to assess bleeding tendency and bleeding risk. Data was collected, and statistical analysis was done using Pearson's chi-squared test and independent sample t test as appropriate.
RESULTS: 325 participants were enrolled in the study. There were 163 patients in the APTG (Anti-Platelet Treatment Group) and 162 patients in the NAPTG (Non-Anti-Platelet Treatment Group). It has been found that there was no statistically significant difference between the APTG and NAPTG in terms of these peri-operative parameters: (i) intra-operative blood loss, (ii) operative time in minutes (length of surgery), (iii) pre-operative haemoglobin level, (iv) the need for blood transfusion, (v) haematoma formation, (vi) re-operation for any reason, (vii) post-operative wound infection, and (viii) duration in days to achieve complete wound healing post-operatively (P > 0.650).
CONCLUSION: It is safe to continue the use of anti-platelet therapy throughout the peri-operative phase in patients with hip fracture surgery. The continuation of such therapy is not associated with increased risk of bleeding or blood transfusion or other complications in patients who had surgical treatment for femoral neck fracture.
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Barriers to Adherence with Post-Operative Hand Therapy Following Surgery for Fracture of the Distal Radius
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Distal Radius Fractures
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The success of hand surgery relies heavily on post-operative therapy. The ability to identify barriers to patient adherence with therapy may therefore allow for improvement in therapeutic and surgical decisions and results. The purpose of this study was to identify significant barriers to adherence with hand therapy following surgery for distal radius fracture. A questionnaire addressing demographic, social, psychological, occupational and medical factors was administered to 20 subjects undergoing surgery for distal radius fracture. Adherence was evaluated by the therapist and by the number of missed sessions. There were 9 males and 11 females. Average age was 46.2 (19-88). The therapists' evaluation of adherence and number of missed appointments were significantly correlated (R2 = 0.86, p < 0.0001, Spearman's test). Gender, distance from therapy, and driving status were significantly related to adherence. Difficulty in reaching the therapy sessions was negatively related to adherence with hand therapy in our population. Other parameters such as smoking, were borderline significant. Further study is needed to investigate the effect of additional parameters, in a larger population in order to better define barriers to patient postsurgical adherence.
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0 |
Diagnostic Performance of Artificial Intelligence for Detection of Anterior Cruciate Ligament and Meniscus Tears: A Systematic Review
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AMP (Acute Meniscal Pathology)
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PURPOSE: To (1) determine the diagnostic efficacy of artificial intelligence (AI) methods for detecting anterior cruciate ligament (ACL) and meniscus tears and to (2) compare the efficacy to human clinical experts.
METHODS: PubMed, OVID/Medline, and Cochrane libraries were queried in November 2019 for research articles pertaining to AI use for detection of ACL and meniscus tears. Information regarding AI model, prediction accuracy/area under the curve (AUC), sample sizes of testing/training sets, and imaging modalities were recorded.
RESULTS: A total of 11 AI studies were identified: 5 investigated ACL tears, 5 investigated meniscal tears, and 1 investigated both. The AUC of AI models for detecting ACL tears ranged from 0.895 to 0.980, and the prediction accuracy ranged from 86.7% to 100%. Of these studies, 3 compared AI models to clinical experts. Two found no significant differences in diagnostic capability, whereas one found that radiologists had a significantly greater sensitivity for detecting ACL tears (P = .002) and statistically similar specificity and accuracy. Of the 5 studies investigating the meniscus, the AUC for AI models ranged from 0.847 to 0.910 and prediction accuracy ranged from 75.0% to 90.0%. Of these studies, 2 compared AI models with clinical experts. One found no significant differences in diagnostic accuracy, whereas one found that the AI model had a significantly lower specificity (P = .003) and accuracy (P = .015) than radiologists. Two studies reported that the addition of AI models significantly increased the diagnostic performance of clinicians compared to their efforts without these models.
CONCLUSIONS: AI prediction capabilities were excellent and may enhance the diagnosis of ACL and meniscal pathology; however, AI did not outperform clinical experts.
CLINICAL RELEVANCE: AI models promise to improve diagnosing certain pathologies as well as or better than human experts, are excellent for detecting ACL and meniscus tears, and may enhance the diagnostic capabilities of human experts; however, when compared with these experts, they may not offer any significant advantage.
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Effect of vitamin D supplementation on knee osteoarthritis: A systematic review and meta-analysis of randomized clinical trials
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AMP (Acute Meniscal Pathology)
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Objective. To provide evidence regarding the effect of vitamin D supplementation on symptomatic knee osteoarthritis (OA). Methods A systematic review and meta-analysis was performed to quantitatively pool the results from randomized clinical trials. Studies were identified from a search of the Embase, MEDLINE and Web of Science databases up to January 22, 2017, and also from conference abstracts, ClinicalTrials.gov and the reference lists of identified studies. A standardized mean difference (SMD) was used to assess effect sizes, as outcomes were reported on different scales. Depending on the degree of heterogeneity, random-effects or fixed-effects models were used to pool outcomes. Results Up to January 22, 2017, four clinical trials containing 570 subjects in the vitamin D supplementation group and 560 subjects in the placebo group were identified. All of the included studies were of high quality and had a low risk of bias for each domain. The results indicated that vitamin D supplementation had a statistically significant but small-to-moderate effect on pain control in patients with knee OA (SMD = - 0.32, 95% CI: -0.63 to - 0.02). However, no effects were observed for the change in tibial cartilage volume (SMD = 0.12, 95% CI: -0.05 to 0.29) or joint space width (SMD = 0.07, 95% CI: -0.08 to 0.23). The subgroup analysis indicated that vitamin D supplementation had no significant effect regardless of whether patients had sufficient or insufficient serum 25(OH)D levels at baseline. Conclusions The results of this study indicate that vitamin D supplementation may not have a clinically significant effect on pain control or structure progression among patients with knee OA. Longer-term clinical trials with rigorous measurement of symptom and radiologic changes are required to further clarify the effect of vitamin D supplementation in patients with symptomatic knee OA and low serum 25(OH)D levels.
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Prolonged hypophosphatemia following parathyroidectomy in chronic hemodialysis patients
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Management of Hip Fractures in the Elderly
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Background and objectives: Hypoparathyroidism in patients with functioning kidneys leads to hyperphosphatemia. This paper reviews data suggesting that hypoparathyroidism in patients on maintenance dialysis leads to hypophosphatemia. Design: Clinical data in 2 patients on dialysis with hypoparathyroidism following parathyroid surgery; literature review of dialysis patients with hypoparathyroidism following parathyroid surgery. Results: In the patients presented both here and in the literature, hypoparathyroidism in dialysis patients is associated with persistent hypophosphatemia or decrease in serum phosphorus from its pre-surgery level. Conclusion: In patients on maintenance dialysis, persistent hypoparathyroidism post-parathyroidectomy may lead to chronic hypophosphatemia, in contrast to the hyperphosphatemia usually associated with hypoparathyroidism. Proposed mechanisms for this paradoxical phenomenon include ongoing phosphorus deposition into bone (Hungry Bone Syndrome), phosphorus deposition into soft tissue and/or diminished intestinal phosphorus absorption or increased intestinal phosphorus loss. (copyright) 2012 Dustri-Verlag Dr. K. Feistle
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Ultrasound-guided interventional procedures around the shoulder
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PRPs for Lateral Epicondylitis/Elbow Tendinopathies
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Ultrasound is an established modality for shoulder evaluation, being accurate, low cost and radiation free. Different pathological conditions can be diagnosed using ultrasound and can be treated using ultrasound guidance, such as degenerative, traumatic or inflammatory diseases. Subacromial-subdeltoid bursitis is the most common finding on ultrasound evaluation for painful shoulder. Therapeutic injections of corticosteroids are helpful to reduce inflammation and pain. Calcific tendinopathy of rotator cuff affects up to 20% of painful shoulders. Ultrasound-guided treatment may be performed with both single- and double-needle approach. Calcific enthesopathy, a peculiar form of degenerative tendinopathy, is a common and mostly asymptomatic ultrasound finding; dry needling has been proposed in symptomatic patients. An alternative is represented by autologous platelet-rich plasma injections. Intra-articular injections of the shoulder can be performed in the treatment of a variety of inflammatory and degenerative diseases with corticosteroids or hyaluronic acid respectively. Steroid injections around the long head of the biceps brachii tendon are indicated in patients with biceps tendinopathy, reducing pain and humeral tenderness. The most common indication for acromion-clavicular joint injection is degenerative osteoarthritis, with ultrasound representing a useful tool in localizing the joint space and properly injecting various types of drugs (steroids, lidocaine or hyaluronic acid). Suprascapular nerve block is an approved treatment for chronic shoulder pain non-responsive to conventional treatments as well as candidate patients for shoulder arthroscopy. This review provides an overview of these different ultrasonography-guided procedures that can be performed around the shoulder.
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Finite element analysis of mobile-bearing unicompartmental knee arthroplasty: The influence of tibial component coronal alignment
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PJI DX Updated Search
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Background: Controversies about the rational positioning of the tibial component in unicompartmental knee arthroplasty (UKA) still exist. Previous finite element (FE) studies were rare, and the results varied. This FE study aimed to analyze the influence of the tibial component coronal alignment on knee biomechanics in mobile-bearing UKA and find a ration range of inclination angles. Methods: A three-dimensional FE model of the intact knee was constructed from image data of one normal subject. A 1000 N compressive load was applied to the intact knee model for validating. Then a set of eleven UKA FE models was developed with the coronal inclination angles of the tibial tray ranging from 10ð valgus to 10ð varus. Tibial bone stresses and strains, contact pressures and load distribution in all UKA models were calculated and analyzed under the unified loading and boundary conditions. Results: Load distribution, contact pressures, and contact areas in intact knee model were validated. In UKA models, von Mises stress and compressive strain at proximal medial cortical bone increased significantly as the tibial tray was in valgus inclination >4ð, which may increase the risk of residual pain. Compressive strains at tibial keel slot were above the high threshold with varus inclination >4ð, which may result in greater risk of component migration. Tibial bone resection corner acted as a strain-raiser regardless of the inclination angles. Compressive strains at the resected surface slightly changed with the varying inclinations and were not supposed to induce bone resorption and component loosening. Contact pressures and load percentage in lateral compartment increased with the more varus inclination, which may lead to osteoarthritis progression. Conclusions: Static knee biomechanics after UKA can be greatly affected by tibial component coronal alignment. A range from 4ð valgus to 4ð varus inclination of tibial component can be recommended in mobile-bearing UKA
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Differentiation of patented crystalline glucosamine sulfate from other glucosamine preparations will optimize osteoarthritis treatment
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AAHKS (4) Acetaminophen
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Symptomatic slow-acting drugs for osteoarthritis (SYSADOAs) are recommended for the medium- to long-term management of knee osteoarthritis (OA) due to their abilities to control pain, improve function and delay joint structural changes. Among SYSADOAs, evidence is greatest for the patented crystalline glucosamine sulfate (pCGS) formulation (Mylan). Glucosamine is widely available as glucosamine sulfate (GS) and glucosamine hydrochloride (GH) preparations that vary substantially in molecular form, pharmaceutical formulation and dose regimen. Only pCGS is given as a highly bioavailable once-daily dose (1500 mg), which consistently delivers the plasma levels of around 10 μmol/L required to inhibit interleukin-1-induced expression of genes involved in the pathophysiology of joint inflammation and tissue destruction. Careful consideration of the evidence base reveals that only pCGS reliably provides a moderate effect size on pain that is higher than paracetamol and equivalent to non-steroidal anti-inflammatory drugs (NSAIDs), while non-crystalline GS and GH fail to reach statistical significance for pain reduction. Chronic administration of pCGS has disease-modifying effects, with a reduction in need for total joint replacement lasting for 5 years after treatment cessation. Pharmacoeconomic studies of pCGS demonstrate long-term reduction in additional pain analgesia and NSAIDs, with a 50% reduction in costs of other OA medication and healthcare consultations. Consequently, pCGS is the logical choice, with demonstrated medium-term control of pain and lasting impact on disease progression. Physician and patient education on the differentiation of pCGS from other glucosamine formulations will help to improve treatment selection, increase treatment adherence, and optimize clinical benefit in OA.
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0 |
The epidemiology of sports-related fractures in adolescents
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Pediatric Supracondylar Humerus Fracture 2020 Review
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Objective: To examine the epidemiology of sports-related fractures in adolescents aged 10-19 years. Methods: All fractures in adolescents presenting to the Royal Hospital for Sick Children and the Royal Infirmary of Edinburgh in a one-year period were prospectively documented and all sports-related fractures retrospectively examined. These two hospitals have a defined population facilitating epidemiological studies. Results: There were 408 adolescent sports-related fractures giving an overall incidence of 5.63/1000/year. The gender ratio was 87/13% male/female and 84% were upper limb fractures. Thirty sports produced 22 different fracture types. Football, rugby and skiing accounted for 66.2% of the fractures. The commonest fractures were in the finger phalanges (28.7%), distal radius and ulna (23.0%) and metacarpus (12.7%). Conclusions: Sport-related fractures are common in adolescents, particularly in males. They tend to be low-energy injuries affecting the upper limb in particular. Few require operative treatment although their frequency means that they impose significant demands on orthopaedic surgeons and health systems. © 2010 Elsevier Ltd. All rights reserved.
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Complications of forefoot and midfoot fractures
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DOD - Acute Comp Syndrome CPG
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Complications of the forefoot and midfoot are not as common as injuries to the hindfoot. The problem areas that the author will focus on with these injuries will be open injuries, unstable fractures, slow or poor healing fractures, and neurovascular injuries. The author also will discuss the toes, metatarsals, tarsometatarsal, cuneiforms, and talonavicular areas. Because the forefoot and midfoot must support as much as four times the body weight, alterations caused by injury to the weightbearing surface can have significant consequences. Treatment rationale to maintain a sound weightbearing plantar surface will be discussed. Each region will be highlighted with respect to the complications that can occur. Anatomic alignment with stable fixation and good soft tissue coverage in an appropriate rehabilitation program are the principles that should be followed and discussed. [References: 25]
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1 |
A prospective randomized controlled study of fixation of long oblique and spiral shaft fractures of the proximal phalanx: Closed reduction and percutaneous Kirschner wiring versus open reduction and lag screw fixation
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DoD SSI (Surgical Site Infections)
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Patients with an isolated spiral or long oblique fracture of the proximal phalanx were randomized into two groups. One was treated by closed reduction and Kirschner wire fixation and the second treated by open reduction and lag screw fixation. An independent observer assessed function, pain, movement, grip strength and intrinsic muscle function. X-rays were assessed for malunion. Thirty-two patients were entered the study and 15 in the Kirschner wire and 13 in the lag screw group were reviewed at a mean follow-up of 40 months. There was no significant difference in the functional recovery rates or in the pain scores for the two groups. X-rays showed similar rates of malunion and there were no statistically significant differences in range of movement or grip strength.
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Teriparatide for acceleration of fracture repair in humans: a prospective, randomized, double-blind study of 102 postmenopausal women with distal radial fractures
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Distal Radius Fractures
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Animal experiments show a dramatic improvement in skeletal repair by teriparatide. We tested the hypothesis that recombinant teriparatide, at the 20 microg dose normally used for osteoporosis treatment or higher, would accelerate fracture repair in humans. Postmenopausal women (45 to 85 years of age) who had sustained a dorsally angulated distal radial fracture in need of closed reduction but no surgery were randomly assigned to 8 weeks of once-daily injections of placebo (n = 34) or teriparatide 20 microg (n = 34) or teriparatide 40 microg (n = 34) within 10 days of fracture. Hypotheses were tested sequentially, beginning with the teriparatide 40 microg versus placebo comparison, using a gatekeeping strategy. The estimated median time from fracture to first radiographic evidence of complete cortical bridging in three of four cortices was 9.1, 7.4, and 8.8 weeks for placebo and teriparatide 20 microg and 40 microg, respectively (overall p = .015). There was no significant difference between the teriparatide 40 microg versus placebo groups (p = .523). In post hoc analyses, there was no significant difference between teriparatide 40 microg versus 20 microg (p = .053); however, the time to healing was shorter in teriparatide 20 microg than placebo (p = .006). The primary hypothesis that teriparatide 40 microg would shorten the time to cortical bridging was not supported. The shortened time to healing for teriparatide 20 microg compared with placebo still may suggest that fracture repair can be accelerated by teriparatide, but this result should be interpreted with caution and warrants further study.
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Wound healing process in post-bariatric patients: an experimental evaluation
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Panniculectomy & Abdominoplasty CPG
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Bariatric surgery is the most effective treatment for morbid obesity. Despite this, side effects are recorded. One of them is redundant skin hanging from the patients' body causing both aesthetical and functional deformities. They can only be corrected with body contouring surgery, whose wound complication rate is very high in previously obese population. Despite several hypotheses, an adequate explanation is still awaited. The aim of our study was to evaluate the wound healing process in post-bariatric patients. Seven patients, six women and one man, were enrolled. They all were nonsmokers and nondiabetic. They all underwent biliopancreatic diversion (BPD). After 36 months, abdominoplasty was performed. Biochemical parameters before and after bariatric surgery were evaluated. The content of total protein and hydroxyproline was assessed in multiple scar biopsies before and after BPD. Abdominoplasty horizontal scar skin samples were subjected to histological evaluation with Weigert-Van Gieson stain for elastic fibers and connectivum. All biochemical parameters analyzed were reduced post-BPD compared to the preoperative period. Tissue proteins were significantly reduced after BPD both in their totality and as hydroxyproline and hydroxyproline/total tissue protein. Histological evaluation revealed abnormal dermal elastic and collagen fibers. The cause of aberrant healing in massive weight loss body contouring is likely multifactorial. A relationship between nutritional state, wound collagen accumulation, and elastic fiber content seems to be only partially involved. The high mechanical stress of tissues before BPD probably influences the wound healing process after BPD.
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Ethnicity and reported pain scores among children with long-bone fractures requiring emergency care
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Pediatric Supracondylar Humerus Fracture 2020 Review
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OBJECTIVES: Previous studies have shown that regular pain measurement improves pain management. As the diversity of patients seeking emergency care continues to grow, a better understanding of the potential differences in pain perception and analgesic needs among various cultural groups will be required. The purpose of this study was to describe the differences in pain scores reported among ethnic groups treated for a long-bone fracture. METHODS: A retrospective review of patients with a long-bone fracture treated in an urban pediatric emergency department during a 12-month period was performed. Pain scores were assessed using previously validated pain scales. RESULTS: Eight hundred eighty patients met our inclusion criteria. Wrist fracture was the most common type of fracture in our study. There were significant differences noted in reported pain scores. Patients identified as Hmong had the highest pain scores, and patients identified as Somali had the lowest pain scores reported. Patients with wrist fractures had the highest average pain score when compared with other types of fractures. Children with fractures requiring reduction in the emergency department had higher pain scores than those who had a fracture that did not require reduction. CONCLUSIONS: To our knowledge, this is the first study to investigate the relationships between ethnicity and pain scores reported in children treated emergently for a long-bone fracture. Copyright © 2012 by Lippincott Williams & Wilkins.
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Midpalmar approach to the carpal tunnel: an alternative to endoscopic release
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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The midpalmar approach involves making a 2.5-cm incision in the palm, sparing the skin directly overlying the carpal tunnel. Through this incision, a small fiber-optically illuminated retractor is introduced, which allows direct inspection of the transverse carpal ligament and any anatomic variations of the median nerve. The transverse carpal ligament can then be safely and completely divided under direct visualization. This approach also allows inspection of the carpal tunnel for any space-occupying masses or neurolysis, if deemed necessary. By avoiding a skin incision directly over the carpal tunnel, the postoperative course is very gentle and very similar to that of an endoscopic release. Unlike the endoscopic release, this approach is versatile, easy to learn, allows complete visualization of the anatomy, and does not require expensive instrumentation
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Comparison of low field (0.2T) and high field (1.5T) MR imaging in the differentiation of torned from intact menisci
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AMP (Acute Meniscal Pathology)
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PURPOSE: To evaluate the usefulness of a low field MRI system (0.2T; Esaote, Biomedica) for the evaluation of meniscal tears with regard to anatomic site, and to compare the results with findings from a high field unit (1.5T; Siemens, Erlangen).
MATERIAL AND METHODS: MRI was performed in 25 patients in a low field (0.2T; Esaote, Biomedica), and a high field (1.5T; Siemens, Erlangen) MRI unit. The images were analyzed for the presence or absence of meniscal tears and the confidence of decision making. Results were further analyzed for the number of identical and unidentical findings on both imaging modalities. In seven patients, arthroscopy was performed and the findings compared with the results from MR imaging. Statistical analysis was performed by chi 2-test, Wilcoxon test and Friedman analysis.
RESULTS: Qualitative evaluation of the level of confidence in decision making was significantly superior on high field strength images. When comparing the evaluations from both image modalities in 21 of 25 patients (84%), the diagnosis concerning the presence or absence of meniscal tears was identical.
CONCLUSION: Although low field MR imaging might offer diagnostic potential concerning the presence or absence of meniscal tears, the level of confidence in decision making is significantly superior with high field strength imaging, probably reflecting the higher conspicuity of lesions from high field strength units.
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Nerve ultrasound depicts peripheral nerve enlargement in patients with genetically distinct Charcot-Marie-Tooth disease
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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Objective To elucidate the ultrasound (US) features of peripheral nerves including nerve roots in patients with different types of Charcot-Marie-Tooth disease (CMT), and the association between US findings, clinical features and parameters of nerve conduction studies (NCS) in CMT1A. Methods US of median, sural and great auricular nerves and the C6 nerve root was performed in patients with CMT1A (n=20), MPZ-associated CMT (n=3), NEFL-associated CMT (n=4), EGR2-associated CMT (n=1),
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An excellent 5-year survival rate despite a high incidence of distal femoral cortical hypertrophy in a short hip stem
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DoD SSI (Surgical Site Infections)
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Background: Although reported results on short stems sound very promising, the occurrence of distal femoral cortical hypertrophy is often observed. The aim of the present study was to report 5-year survival data of a commercially available trochanter sparing short stem and investigate the clinical impact of distal femoral cortical hypertrophy on the outcome. Methods: 123 total hip arthroplasties were performed on 120 patients from April 2008 to May 2010 (mean age 62, range 29–89 years; 71 hips from male patients, 58%). Clinical and radiological data were collected preoperative, at 6 weeks, 1, 2, 3, and 5 years postoperative to assess the outcome. Radiographs taken immediately postoperative as well as 1 and 5 years postoperative were used to identify and assess cortical hypertrophy. Results: 1 stem had to be revised due to aseptic loosening, resulting in a Kaplan-Meier survival analysis with endpoint for stem revision of 99.2% (95% Confidence Interval 94.1–99.9) at 5 years. 96 radiological and 95 clinical follow-ups were analysed 5 years postoperative. 68 (71%) hips showed distal femoral cortical hypertrophy after 5 years. The average Harris Hip Score and Oxford Hip Score improved 33 (standard deviation (SD) 15.1, range 2–70), 18 (SD 12.1, range -10–43) points, respectively. Overall 16% of the patients reported thigh pain, unrelated to the presence of cortical hypertrophy. Discussion: This short stem shows an excellent 5-year survival rate and good clinical outcome despite a high incidence of cortical hypertrophy. However, the question of the mechanism of load transfer arises.
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0 |
Changes in bone mineral density in patients with recent onset, active rheumatoid arthritis
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Management of Hip Fractures in the Elderly
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OBJECTIVES: We examined the effects of four different treatment strategies on bone mineral density (BMD) in patients with recently diagnosed, active rheumatoid arthritis (RA) and the influence of disease-related and demographic factors on BMD loss after 1 year of follow-up in the BeSt trial.METHODS: BMD measurements of the lumbar spine and total hip were performed in 342 patients with recent onset RA at baseline and after 1 year. Multivariable regression analyses were performed to determine independent associations between disease and demographic parameters and BMD loss after 1 year.RESULTS: Median BMD loss after 1 year was 0.8% and 1.0% of baseline in the spine and the hip, respectively. No significant differences between the treatment groups, including corticosteroids and the anti-tumour necrosis factor-alpha infliximab, were observed with regard to BMD loss after 1 year of treatment. Joint damage at baseline and joint damage progression according to the Sharp-van der Heijde score were independently associated with more BMD loss after 1 year. The use of bisphosphonates independently protected against BMD loss.CONCLUSIONS: After 1 year of follow-up in the BeSt study, we did not find differences in BMD loss between the four treatment strategies, including high doses of corticosteroids and anti-tumour necrosis factor-alpha. Joint damage and joint damage progression are associated with high BMD loss, which emphasises that BMD loss and erosive RA have common pathways in their pathogenesis
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0 |
Short-term outcome after posterior versus lateral surgical approach for total hip arthroplasty - A randomized clinical trial
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Management of Hip Fractures in the Elderly
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PURPOSE: Currently, total hip replacement (THR) is most commonly performed via a posterior or a direct lateral approach, but the impact of the latter on the invention's outcome has yet not been quantified.METHODS: We compared the short-term outcome of cementless THR using the both approaches in a prospective, randomized controlled trial. 60 patients with unilateral osteoarthritis were included. Outcome assessment was performed one day before surgery and one week, four weeks, six weeks and 12 weeks after surgery, respectively, using the Harris Hip score as primary objective.RESULTS: We found no significant difference in the intraindividual Harris Hip Score improvement at the pre- and three months post-operative assessments between both treatment groups (p = 0.115). However, Harris Hip scores and most functional and psychometric secondary endpoints showed a consistent tendency of a slightly better three months result in patients implanted via the posterior approach. In contrast a significant shorter operating time of the direct lateral approach was recorded (67 minutes versus 76 minutes, p<0.001).CONCLUSION: In our opinion this slightly better short-term functional outcome after posterior approach is not clinical relevant. However, to make definitive conclusions all clinical relevant factors (i.e. mid- to long-term function, satisfaction, complication rates and long-term survival) have to be taken into account.LEVEL OF EVIDENCE: I - therapeutic
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0 |
Hip resurfacing: Mid-term results of the last-generation metal-on-metal devices
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Hip Fx in the Elderly 2019
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Total hip resurfacing has long been conceptually attractive to both surgeons and patients. However, historically it has been plagued by limited durability and marked acetabular bone loss. The recent development of wear-resistant bearings such as metal-on-metal has led to renewed interest in hip resurfacing in the orthopaedic community. We report the clinical and radiological results of 350 consecutive surface arthroplasties performed in 325 patients (mean follow-up 20 months). Harris Hip Score increased over time from 57 pre-operatively to 98 at 2 years follow-up. Complication's rate was low. Four patients required revision surgery. The overall survival rate was 98.8%. Considering the positive results of more than 350 implants of our series, we now believe that there is evidence showing that this surgical concept deserves consideration, particularly when treating young patients with hip diseases. © Springer-Verlag Italia 2007.
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Magnetic resonance imaging signal changes in denervated muscles after peripheral nerve injury
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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The evaluation of peripheral nerve disorders has traditionally relied on a clinical history, physical examination, and electrodiagnostic studies. Recent studies have used magnetic resonance imaging (MRI) to evaluate a variety of both nerve and muscle disorders. In this article, we describe the use of MRI, using short-tau inversion recovery (STIR) sequences, to evaluate muscle signal characteristics in a variety of peripheral nerve disorders. A total of 32 patients were studied, and 12 representative cases are discussed in detail. Increased STIR signal in muscle was seen in cases of severe axonotmetic injuries involving the transection of axons producing severe denervation changes on electromyography. The increased STIR signal in denervated muscles was seen as early as 4 days after the onset of clinical symptoms, which is significantly earlier than changes detected on electromyography. The MRI signal changes were reversible when the recovery of motor function occurred as a result of further muscle innervation. In cases of neurapraxic nerve injuries, characterized by conduction block without axonal loss, the STIR signal in muscle was normal. These findings show that MRI using STIR sequences provides a panoramic visual representation of denervated muscles useful in localizing and grading the severity of peripheral nerve injury secondary to either disease or trauma. MRI using STIR sequences may therefore play an important role in the prediction of clinical outcome and the formulation of appropriate therapy early after peripheral nerve injury
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0 |
Adjunctive Hyperbaric Oxygen Therapy (HBOT) for Lower Extermity Diabetic Ulcer
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DoD LSA (Limb Salvage vs Amputation)
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1 KHUH Research Center The Premise of the study: Hyperbaric Oxygen as adjunctive therapy is effective towards the healing of diabetic lower extremity ulcers and has a role to play in major amputation prevention for persons with Diabetes Mellitus. Title of the project: Adjunctive Hyperbaric Oxygen Therapy (HBOT) for Lower Extremity Diabetic Ulcers: A Prospective, Doubleâ?Blind, Randomized, Controlled Clinical Trial Background Diabetes Mellitus is a major health problem with significant morbidity and mortality. The number of people with diabetes mellitus worldwide is estimated at 285 million in 2010; and expected to increase to 438 million by 20301. In western countries, like the United Kingdom, diabetic foot ulcers are the most commonly found chronic wound2. A diabetic foot ulcer is defined as a 'full thickness' lesion of the skin, that is, a wound penetrating through the dermis below the ankle joint3. The lifetime risk of developing foot ulcers in diabetics is estimated to be 15%4. These ulcers may heal with proper wound care, but some may become chronic and others may lead to amputation. These different outcomes are influenced by several risk factors including, among others, peripheral arterial disease (ischemia), peripheral neuropathy, mechanical foot deformity, poor foot care and inappropriate shoe wear. Diabetic foot ulcers are associated with high risk of amputation. About 50% of patients undergoing nonâ?traumatic lower limb amputations are diabetics5. The 5â?year amputation rate is estimated to be 19% with a mean time to amputation 58 months since the onset of an diabetic foot ulcer6.Because infection and tissue hypoxia are the major contributing factors for nonâ?healing diabetic foot ulcers, hyperbaric oxygen therapy (HBO) carries a potential benefit for treating these problematic wounds that do not respond to standard therapy7. Vascular: Approximately 35% of diabetic foot ulcers result from peripheral vasculopathy with an additional 15â?20% caused by mixed neuropathicâ?vasculopathic pathology8. There is an accelerated development of atherosclerosis in the distal arteries (tibial and peroneal arteries) of diabetic patients with the dorsalis pedis artery often spared. Abnormal smooth muscle tone and decreased perfusion exacerbate these changes. On a macrovascular level, thickening of the basement membrane and abnormal endothelial function is often found. Tissue ischemia may be worsened by capillary thrombosis and by impaired neurogenic control.9 The microcirculation of diabetic patients exhibits characteristic structural changes such as the reduction in the size of capillaries and thickening in basement membrane that impairs the normal hyperemic or vasodilatory response to injury10, 11 and interferes with transportation of nutrients and oxygen. Arterial thrombosis commonly develops in the presence of preâ?existing atherosclerotic 2 changes in the vascular endothelium, as a result of low blood flow and increased blood viscosity or a proâ?coagulative state. All of these changes are exacerbated by a smoking habit (cigarettes, cigars or water pipes) by inducing peripheral vasoconstriction that reduces available oxygen to tissue by 20â?30% per cigarette for one hour.12 It induces alterations in lipid metabolism, increases platelet aggregation, and increase blood viscosity.12 Pressure: Peripheral neuropathy is the most common cause of foot ulcers and is present in 78% of the ulcer formation pathway.8 Foot deformity is the most common underlying cause and that is leading to unequal pressure redistribution and subsequent ulceration. Poor glycemic control and poor glycemic control increase the risk of neuropathy and is directly linked to the duration of living with diabetes (>15 years carrying a higher risk for developing neuropathy13), manifesting in all three components of the nervous system (autonomic, motor and sensory). Autonomic neuropathy of the foot results in loss of sweat and oil gland function leading to dry cracked skin prone to bacterial infections; the loss of sympathetic vascular tone that lea s to vasodilatation and the development of edema8. Motor neuropathy causes loss of nerve supply to the intrinsic foot muscles with subsequent imbalance of the long flexor and extensor tendons. This produces an anatomic foot deformity with hyperextension of the toes, dropdown of the metatarsal heads and distal movement of the protective fat pad leading to pressure imbalance, callus formation and underlying skin breakdown. In sensory neuropathy the loss of the protective components of the foot is rendering patients unaware of repeated traumas and small injury as a pain response is absent. A wound remain undetected, worsen, becomes secondarily infected with the patient usually late in presenting to formal health care, adding to the severity of the foot condition on assessment. The role of oxygen in the wound healing cascade and subsequent combatting action against bacterial invasion, especially anaerobes, is well documented.14 Delayed or arrested healing and the development of infection is a direct result from decreased perfusion and poor oxygenation of tissue.15 The presence of wound hypoxia is an major etiological pathway in the development of chronic nonâ?healing diabetic foot ulcers.16 Measurement of tissue oxygenation is done with transcutaneous oximetry (TcPO2) and provides a simple, noninvasive diagnostic technique for an objective assessment of local tissue perfusion and oxygenation.17 TcPO2 measurements are frequently used in the assessment of diabetic ulcers to: 1. Assess the severity of tissue hypoxia; 2. Determine a saturation response to 100% oxygen; 3. Serve as a predictor for response to HBO therapy; 4. Provide a guideline on when to stop therapy; and 5. Define healable levels for lower limb amputation18. Studies have shown that an achieved value below 40 mmHg on breathing normal air, is associated with poor healing of diabetic foot ulcers adding to amputation risk, while values higher than 40 mmHg is likely to yield spontaneous resolution of foot ulcers.19 Saturated TcPO2 values (breathing 100% oxygen via a nonâ?rebreather mask for 15 minutes) that exceeds a cutoff value of 200 mmHg, is associated with a positive predictive value to the extent of 74% for wound healing improvement, or limb salvage following a therapeutic course of hyperbaric oxygen therapy.20 Level 1A evidence of the beneficial effect of HBO therapy on diabetic foot outcomes was initially scant with only two prospective RCT studies available before 2000.21, 22 One study was added in 200323 and 3 then a gap existed that was only filled in 201324 due to the difficulties associated with a trial using HBO as adjunctive modality. All of these studies have shown efficacy of HBO with the systematic review from Liu et al in 201325 showing a reduction of major limb amputations (minor amputations though present) and establishing a foundation for wound healing to progress (neovascularization and granulation stimulation). The retrospective cohort study of Margolis et al26 though, has disproved the effectiveness of HBO as modality in management of diabetic foot ulcers. Major limitations were identified on doing a systematic critique27 of that study with design, sample selection with inappropriate inclusions, unequal study arms, statistical usage of a propensity score to adjust for wound severity and unclear expected endpoints the most prevalent. This study has highlighted the difference between effectiveness (if something has been beneficially employed in the day to day setting) and efficacy (does it work) and that is the answer would like to provide with an effectiveness study in a prospective, rather than retrospective design. Objectives of the study: Study aim and objectives The aim of this study is to determine the effectiveness of 30 sessions of adjunctive hyperbaric oxygen therapy on the healing rate of diabetic lower extremity ulcers. Primary objectives: To compare between the treatment and control group: The reduction of wound size at 4 weeks (granulation formation) as measured by the Silhouette three dimensional photography Time to achieve 80% ound surface reduction as measured by the Silhouette trajectory Time to achieve bipedal ambulation on an offloading device crossing the ankle joint The level of neovascularization achieved as measured by transcutaneous oximetry The proportion of patients ending up with a below knee amputation. Secondary objectives: Determine the TCpO2 criteria by which treatment response could be measured.Determine the TCpO2 criteria by which optimal treatment is assessed (to indicate completion of therapy). Evaluate the role of minor amputations (one or more toes up to the mid foot) in saving the major limb (integrity of the knee and ankle joint) Evaluate the role of HBO in resolution of infection/osteomyelitis in conjunction with appropriate systemic antibiotics. To determine and describe the sideâ?effects of HBO therapy. 4 Improvement of quality of life with particular attention to pain. Setting: The hyperbaric and wound care unit of King Hamad University hospital, Kingdom of Bahrain Design: A parallel prospective doubleâ?blind randomized placeboâ?controlled trial. Sample size: 100â?120 patients equally divided between the two treatment arms Sampling technique: Randomization by sealed envelope method to either Arm A or Arm B, both blinded to all apart from the primary researcher. Timeframe of the study: 12â?24 months in order to fill the appropriate sample size on an 80% confidence interval Data Collection methods, instruments used and measurements: 1. Transcutaneous oxygen measurements on air and saturated values preâ?treatment, 10 sessions, 20 sessions and 30 sessions 2. Silhouette 3 dimensional wound surface photography on each dressing change to determine % wound size reduction and create a healing trajectory in a quantifiable manner 3. Standard battery of HBO investigations preâ?HBO: CBC, CXR, Foot xâ?ray, HbA1c, BMI 4. Daily preâ? and post HBO chamber investigations: Vital signs, random blood glucose, Pain scale 5 Data management and analysis plan: 1. Basic descriptive statistics to describe the sample demographics and randomization achieved 2. Tâ?test with Chiâ?square with confidence interval for healing achieved 3. Logistic regression with linear markers for neovascularization achieved 4. Analysis of coâ?variants for influence of confounding factors.
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Bone Graft Necessity in Opening-Wedge High Tibial Osteotomy
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OAK 3 - Non-arthroplasty tx of OAK
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Openingâ?Wedge High Tibial Osteotomy is a classic procedure,but the use of autologous bone graft from iliac crest causes pain and bleeding. Bone union occur even without bone graft, but no clinical trials compared results of the twoo procedures.
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Haemopoiesis of transplanted patients with autologous marrows assessed by long-term marrow culture
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MSTS 2022 - Metastatic Disease of the Humerus
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We assessed the effect of antitumoural therapy at intensive doses on the haemopoietic system using long-term marrow cultures (LTMC) established from 33 patients (25 with haematological diseases and eight with solid tumours) after autologous bone marrow transplantation (ABMT). When compared to 42 pre-graft patients, a decreased CFU-GM production and a defect in stromal layer (SL) confluence were found after ABMT on day 90 but also on day 365. However, these abnormalities were observed only in patients with haematological diseases and no differences between pre-graft and post-graft results were found in patients with solid tumours. Among the patients with haematological diseases, on day 90 those with acute lymphoid leukaemias showed lower CFU-GM production whereas patients with non-Hodgkin's lymphomas developed more frequently subconfluent or confluent SL. Other factors studied such as sex, patient age, disease status, marrow purging and post-graft administration of growth factors did not appear to influence post-graft LTMC results. Multivariate analysis including all the patients has shown (a) that solid tumours were associated with higher CFU-GM production, and (b) that conditioning regimens with total body irradiation (TBI) or busulfan led more frequently to non-confluent SL. In conclusion, high-dose therapy followed by ABMT can induce a persistent impairment of the stem cell and stromal cell compartments, particularly in patients with haematological diseases conditioned with TBI, despite the absence of any alloimmune reaction and post-graft immunosuppressive therapy.
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New concepts in acute and extended postoperative pain management in children
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DOD - Acute Comp Syndrome CPG
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Increased knowledge of the pathophysiology of pain in children and an improved understanding of the pharmacology and pharmacodynamics of multiple agents have provided the clinician with a wide variety of tools to treat postoperative pain in children. The interest in a multimodal approach is kindled by the realization that the combination of a number of therapies can enhance analgesia with fewer untoward side effects. The expertise of other health care professionals should be tapped to open new avenues of treatment. Many therapies still require critical evidence-based evaluations to assess how well they work in larger patient populations. Dedication to research, compassionate patient care, and a willingness to teach the next generation of clinicians will bring us closer to the goal of safe and pain-free surgery.
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Is anterior glenoid bone block position reliably assessed by standard radiography? A cadaver study
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Glenohumeral Joint OA
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Background Standard radiography with an antero-posterior view and Bernageau's glenoid profile view is the method most widely reported in the literature to assess coracoid bone block position and fusion. Objective The aim of this cadaver study was to determine whether the antero-posterior and Bernageau's radiographs provide a reliable and reproducible evaluation of the position of a coracoid bone block and its fixation screws. Method An isolated scapula showing no evidence of osteoarthritis or other abnormalities was used. The coracoid process was transferred to the anterior glenoid rim. Fixation was with two slightly diverging malleolar screws, chosen of different sizes for ease of identification. Computed tomography (CT) was performed as the reference imaging technique. The standard radiographs were then obtained, using fluoroscopy to accurately position the scapula for the antero-posterior and Bernageau's views. This position was defined as 0°, and radiographs were taken at angles of 5°, 10°, and 15° in all three planes. All radiographs were taken during a single session to ensure that the distance separating the tube from the scapula remained unchanged. The images were exported to OsiriX for analysis. We measured the angles formed by the screws and the glenoid surface, as well as bone block position and overhang. Finally, we used 1-mm thick disks to evaluate bone-to-bone contact. Results No correlations were found between values by CT and by standard radiography (both views) for the screw angles or overhang. A space � 1 mm between the neck of the scapula and the bone block was not visible on the standard radiographs in any of the positions. Conclusion Standard radiography does not provide an accurate analysis of bone block position or bone-to-bone contact. CT is needed to assess bone block and screw position and bone-to-bone contact. Level of evidence Level III.
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Pancytopeni{dotless}a and sepsi{dotless}s due to meropenem: A case report
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PJI DX Updated Search
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Meropenem is one of the most commonly used antibacterial agents with relatively few side effects. Serious adverse reactions reported with meropenem are rare with an incidence of 1 %. Recently we came across two rare adverse effects of meropenem in one patient with acute renal failure. There was pancytopenia and sepsis, respectively. To the best of our knowledge, a only few cases have been reported in the literature that document an association between meropenem administration and pancytopenia, and about half of these cases were sepsis. With the use of meropenem becoming more widespread, these two rare but fatal complications of meropenem should be borne in mind. é Pharmacotherapy Group, Faculty of Pharmacy, University of Benin, Benin City, 300001 Nigeria. All rights reserved
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Health-related quality of life 5 years after carpal tunnel release among patients with diabetes: a prospective study with matched controls
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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BACKGROUND: Carpal tunnel syndrome (CTS) is the most common entrapment neuropathy encountered in diabetes. The short-term improvement after carpal tunnel release has previously been demonstrated not to differ between patients with and without diabetes, despite a marked impairment in health-related quality of life (HRQL) among the former. In this study, we compare HRQL 5 years after carpal tunnel release between these two groups of patients. METHODS: In a prospective series, 35 patients with diabetes and CTS were matched with 31 control patients with idiopathic CTS but no diabetes. At the 5-year follow-up patients completed the Medical Outcomes Short-Form 36 (SF-36) and Antonovsky's sense of coherence (SOC) questionnaire. Differences in changes over time were compared between patients with and without diabetes using mixed model analysis. RESULTS: Although patients with diabetes reported a significant decrease in physical functioning (p =0.004) as compared to patients without diabetes, postoperative improvement was maintained in the physical domains, role physical and bodily pain. A more pronounced decline in the mental health domain, social function (p =0.03), was demonstrated among patients with diabetes. There was no evidence of any difference in SOC between the patient groups. CONCLUSION: Patients with diabetes retained their improvement in physical domains sensitive to changes after carpal tunnel release in the long-term, despite a decline in other domains of both physical and mental HRQL. This differed from patients without diabetes. Differences in SOC could not explain the sharper decline in these domains among patients with diabetes
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Characterization of 3 oral squamous cell carcinoma cell lines with different invasion and/or metastatic potentials
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MSTS 2018 - Femur Mets and MM
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PURPOSE: Proteolytic enzymes may confer specific types of invasion and metastasis in patients with oral squamous cell carcinoma (OSCC). The purpose of this study was to determine if OSCC that invades adjacent bone has different proteolytic enzyme expression profiles than OSCC that metastasizes to lymph nodes or distant organs. Three OSCC cell lines, BHY, HSC-3, and HN, with known behavior regarding bone invasion and lymph node and distant metastatic profiles, were evaluated. The characteristics of a control, human normal nasal epithelial cell line (HNEC), and BHY, HSC-3 and HN were evaluated with regard to their expression of the matrix metalloproteinases and cathepsins.
MATERIALS AND METHODS: Expressions of proteolytic enzymes including matrix metalloproteinase, MMP-1, MMP-2, MMP-3, MMP-9, extracellular matrix metalloproteinase inducer (EMMPRIN), cathepsin B, and cathepsin L were compared using immunocytochemistry and flow cytometry in 3 OSCC cell lines and HNEC. The cell morphologies of these 4 cell lines were compared using transmission electron microscopy (TEM).
RESULTS: All OSCC cell lines showed higher expression of all the proteolytic proteins when compared with HNEC, except the HSC-3 cell line showed no difference in the expression of MMP-9. There was no detectable difference at the expression level of MMP-1, MMP-2, MMP-3, cathepsin B, and cathepsin L in any of the OSCC cell lines. However, MMP-9 and EMMPRIN levels were higher in the BHY cell line. According to electron microscopy, the cells of the HSC-3 cell line were the smallest and least differentiated among the 3 OSCC cell lines. The BHY cell line was the most highly differentiated showing interdigitation and numerous cell junctions.
CONCLUSIONS: MMPs play an important role in the invasion and metastasis of oral cancer. MMP-9 might play a more important role than MMP-2 during invasion. Increased expression of MMP-1, MMP-9, and EMMPRIN proteins might be involved in invasion of OSCC to adjacent bone, as they are necessary for the collagen matrix degradation. Increased expression of MMP-3, cathepsin B and L in OSCC might be associated with both invasion and a high incidence of metastasis.
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Sarcopenia: Pharmacology of today and tomorrow
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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Sarcopenia remains largely undiagnosed and undertreated because of the lack of a universally accepted definition, effective ways to measure it, and identification of the outcomes that should guide treatment efficacy. An ever-growing number of clinicians and researchers along with funding and regulatory agencies have gradually recognized that sarcopenia is a human condition that requires both prevention and treatment. In this article, we review sarcopenia and its common and less known pharmacological treatments, attempt to define sarcopenia in its broader context, and present some new ideas for potential future treatment for this devastating condition. Copyright (copyright) 2012 by The American Society for Pharmacology and Experimental Therapeutics
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Acute kidney injury following operative repair of hip fracture
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Management of Hip Fractures in the Elderly
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Background: Most elderly patients who sustain hip fracture have chronic kidney disease. Operative blood loss, and probably the haemodynamic instability caused by cement in some operations, can result in acute kidney injury (AKI). The objective of this work is to study kidney function following the operative repair of hip fracture. Methods: Retrospective analysis of records of 185 consecutive hip fracture patients. Data collected include the demographics, eGFR within 24 hours of admission and within 48 hours postoperatively. The eGFR was derived from the serum creatinine using the MDRD equation. RIFLE criteria were used to define AKI. Some deterioration of eGFR was considered as > 0 to < 25% reduction of eGFR. The data was filtered for missing values, excluding 11 patients so 174 patients were included in the study. The Decline in eGFR post operatively was analysed. A multivariate binomial logistic regression model is constructed considering Age, Gender, admission eGFR, type of operation,
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Differential diagnosis and management of hip pain in childhood
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Developmental Dysplasia of the Hip CPG
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Hip pain in children is always potentially serious. Different specialists see a different spectrum of hip diseases. Acute hip pain is usually referred to the surgeons, and the principal concern is to distinguish sepsis of the hip joint or pelvic bones from irritable hip: untreated sepsis can destroy the hip within days, but its presentation may be atypical or mild and investigations misleading. A reliable protocol for the management of acute hip pain in children is now available. Perthe's disease and slipped capital femoral epiphysis is usually evident on the initial radiograph. Hip disorders with a subacute or chronic presentation are usually referred to the paediatrician or rheumatologist. If examination shows restriction of hip movement or there are radiographic abnormalities, many will have a serious disorder requiring long-term management. The diagnosis is often apparent on the initial radiographs, although special imaging techniques may be needed. In a monoarticular presentation of juvenile arthritis, the hip radiograph will be normal but the diagnosis evident from other clinical features or blood investigations. Recognition of non-organic syndromes presenting with hip pain requires the exclusion of organic causes and an alertness to the incongruity of the physical signs
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Cartilage cell clusters
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Osteochondritis Dissecans 2020 Review
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Cell organization in clusters represents an interesting and, as yet, not well-characterized phenomenon in normal articular cartilage, in tissue responses to chemical or mechanical injury, and prominently in cartilage affected by diseases such as OA. Cluster formation also occurs readily in culture models, suggesting an intrinsic tendency and capacity of certain cartilage cells to assume this cellular organization. It can be proposed that repair of cartilage lesions that include both ECM damage and cell death would require replication of some of the cells adjacent to the damaged area, followed by migration, differentiation, and new matrix formation (140). It appears that cluster formation represents the first phase of this response. Clusters are seen with a remarkable uniformity in cartilage exposed to a broad range of injuries that are always associated with some degree of cell death. Whether any surviving cell or only certain subsets of cells are able to proliferate and form clusters is unknown. An interesting hypothesis is that proliferation is a function of immature or progenitor cells. The triggers for cell proliferation may include loss of cell-cell interactions due to cell death. Liberation of growth factors such as FGF-2 from damaged tissue appears to be an important mechanism for the generation of mitogenic stimuli, at least during the initial stages of cluster formation (Figure 6). The rate and size of cluster formation depend on the type of injury and maturity of cartilage. Cells within clusters have certain features suggesting that they can migrate, but whether cells do indeed migrate from the clusters to acellular areas of cartilage is an unresolved question that is important in order to understand intrinsic cartilage repair and cartilage engineering approaches. Movements of single cells or collective movements of interconnected groups or clusters of cells have recently been characterized as important mechanisms in tissue and organ development (142). Cell-cell adhesions, cell-matrix interactions, contractility, and the ability of cells to form protrusions and migrate as described for the cluster cells contribute to active motility. Tissue engineering of chondral and osteochondral grafts is being actively pursued as a potential method of surgically repairing cartilage lesions. Cluster formation occurs in 3-dimensional cultures of chondrocytes and needs to be carefully evaluated in engineered constructs using scaffolds with stem cells. Spontaneous chondrocyte cluster formation has also been noted in osteochondral allografts in several animal models (66). These clusters did not appear to express the abnormal markers seen in OA clusters. However, it must be noted that these studies were conducted in tissue or cells from young adult animals and in joints that did not have an inflammatory response. Collectively, the findings raise a concern regarding tissue engineering during the preimplantation cell proliferation and matrix generation phases, as well as the postoperative phase after implantation in the chondral lesion. Clusters that form in arthritic articular cartilage contain cells that express a large number of pathogenic mediators and thus appear at the site of much of the increased biosynthetic activity that characterizes OA cartilage. The activation patterns are those of a disordered or mixed differentiation phenotype. This may be due to the influence of inflammation mediators produced in the clusters or by other inflamed joint tissues. The activation of cluster cells and their products appear to contribute to the manifestations of cartilage diseases such as ECM degradation and calcification, and joint inflammation. The cluster cells illustrate the ability of a subpopulation of cartilage cells to undergo activation and proliferation, even in older individuals. Correcting the abnormal differentiation and harnessing the reparative potential of these cells pharmacologically may offer new approaches to cartilage repair and OA therapy. © 2010, American College of Rheumatology.
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Neutrophil-derived MRP-14 is up-regulated in infectious osteomyelitis and stimulates osteoclast generation
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PJI DX Updated Search
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Bone infections of patients with joint replacement by endoprosthesis (so called "periprosthetic joint infection") pose a severe problem in the field of orthopedic surgery. The diagnosis is often difficult, and treatment is, in most cases, complicated and prolonged. Patients often require an implant exchange surgery, as the persistent infection and the accompanying inflammation lead to tissue damage with bone degradation and consequently, to a loosening of the implant. To gain insight into the local inflammatory process, expression of the proinflammatory cytokine MRP-14, a major content of neutrophils, and its link to subsequent bone degradation was evaluated. We found MRP-14 prominently expressed in the affected tissue of patients with implant-associated infection, in close association with the chemokine CXCL8 and a dense infiltrate of neutrophils and macrophages. In addition, the number of MRP-14-positive cells correlated with the presence of bone-resorbing osteoclasts. MRP-14 plasma concentrations were significantly higher in patients with implant-associated infection compared with patients with sterile inflammation or healthy individuals, advocating MRP-14 as a novel diagnostic marker. A further biologic activity of MRP-14 was detected: rMRP-14 directly induced the differentiation of monocytes to osteoclasts, thus linking the inflammatory response in implant infections with osteoclast generation, bone degradation, and implant loosening
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Assessment of Post-operative Physical Performance in Patients after Resection Arthroplasty of the Proximal Femur
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MSTS 2018 - Femur Mets and MM
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BACKGROUND: Resection arthroplasty is increasingly used in the treatment of proximal femur metastates. How-ever, a coherent, unified rehabilitation protocol of such patients is yet to be developed. The aim of this study was to present the early treatment outcomes of modular endoprosthetic replacement. MATERIAL AND METHODS: A total of 42 resections of proximal femur tumour, followed by modular endoprosthetic replacement, were performed at the Orthopaedic Oncology Department in Brzozów between 2012 and 2015. The mean age of the patients was 63 ± 11 years, with females accounting for 54% of the group. All the patients were rehabilitated in accordance with the protocol developed by Shehadeh et al. Pain intensity was measured using the VAS scale, while the HHS, MSTS and an original scale designed by the authors were used to assess overall physical performance and gait efficiency. RESULTS: Thirty GMRS and 12 MUTARS endoprostheses were implanted. The implants were fixed with bone cement in 36 (85%) cases and cementless in 8 (15%). Mean pain severity assessed at 6 weeks after the surgery with the VAS scale was 3.8. Mean gait efficiency and physical performance assessed with the HHS and MSTS scores were 75 and 20 points, respectively. Two patients experienced complications. A total of 39 patients were evaluated post-operatively at 6 weeks after the surgery, of whom 37 (95%) patients could walk efficiently using crutches or with physical assistance of others. CONCLUSION: Modular arthroplasty performed in patients after metastatic tumour resection allows for early rehabi-li-ta-tion and ambulation which significantly improves their quality of life.
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Functional outcome of arthroscopic rotator cuff repairs: a correlation of anatomic and clinical results
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Optimizing the Management of Full-Thickness Rotator Cuff Tears
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Even though several studies have revealed excellent clinical results with arthroscopic repair of rotator cuff tendons, poor healing of the repair and retearing of the tendon occur in many cases. Patterns of outcome correlating functional capacity and anatomic integrity of the repaired rotator cuff are not well defined. The goal of this prospective study was to determine the pattern of anatomic and functional outcomes among patients undergoing single-row arthroscopic rotator cuff repair. This study confirmed that single-row arthroscopic repair of small- and medium-sized supraspinatus tendon tears significantly improves rotator cuff integrity and functional outcomes. A completely healed tendon was observed in 60% of the cases. Age is a predictor of cuff integrity after the operation. Functional improvement was greater and significant in patients with complete healing at follow-up; however, a recurrent tear did not preclude positive functional results
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Transcutaneous electrostimulation for osteoarthritis of the knee
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SR for PM on OA of All Extremities
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BACKGROUND: Osteoarthritis is the most common form of joint disease and the leading cause of pain and physical disability in the elderly. Transcutaneous electrical nerve stimulation (TENS), interferential current stimulation and pulsed electrostimulation are used widely to control both acute and chronic pain arising from several conditions, but some policy makers regard efficacy evidence as insufficient. OBJECTIVES: To compare transcutaneous electrostimulation with sham or no specific intervention in terms of effects on pain and withdrawals due to adverse events in patients with knee osteoarthritis. SEARCH STRATEGY: We updated the search in CENTRAL, MEDLINE, EMBASE, CINAHL and PEDro up to 5 August 2008, checked conference proceedings and reference lists, and contacted authors. SELECTION CRITERIA: Randomised or quasi-randomised controlled trials that compared transcutaneously applied electrostimulation with a sham intervention or no intervention in patients with osteoarthritis of the knee. DATA COLLECTION AND ANALYSIS: We extracted data using standardised forms and contacted investigators to obtain missing outcome information. Main outcomes were pain and withdrawals or dropouts due to adverse events. We calculated standardised mean differences (SMDs) for pain and relative risks for safety outcomes and used inverse-variance random-effects meta-analysis. The analysis of pain was based on predicted estimates from meta-regression using the standard error as explanatory variable. MAIN RESULTS: In this update we identified 14 additional trials resulting in the inclusion of 18 small trials in 813 patients. Eleven trials used TENS, four interferential current stimulation, one both TENS and interferential current stimulation, and two pulsed electrostimulation. The methodological quality and the quality of reporting was poor and a high degree of heterogeneity among the trials (I(2) = 80%) was revealed. The funnel plot for pain was asymmetrical (P < 0.001). The predicted SMD of pain intensity in trials as large as the largest trial was -0.07 (95% CI -0.46 to 0.32), corresponding to a difference in pain scores between electrostimulation and control of 0.2 cm on a 10 cm visual analogue scale. There was little evidence that SMDs differed on the type of electrostimulation (P = 0.94). The relative risk of being withdrawn or dropping out due to adverse events was 0.97 (95% CI 0.2 to 6.0). AUTHORS' CONCLUSIONS: In this update, we could not confirm that transcutaneous electrostimulation is effective for pain relief. The current systematic review is inconclusive, hampered by the inclusion of only small trials of questionable quality. Appropriately designed trials of adequate power are warranted
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Occupational Health Research in Taiwan
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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This article gave a brief introduction of population, labor force, general status of occupational safety and health in Taiwan. Statistics of occupational injuries and health disorders, laws and regulations relevant to occupational health were also covered. Research activities driven by universities, research institutes, society/association were provided. Two multi-lateral collaborative research examples were presented: an intoxication outbreak-initiated CS (2) study and an information-demand-motivated 2-methoxy-ethanol study. Industrial hygienists, engineers, epidemiologists, and occupational physicians from both universities and research institutes, governmental agencies, and from non-profit R&D organizations and academic associations were involved in these researches, presenting a promise that integrated collaboration of inter-disciplinary specialty cooperated with governmental participation could benefit not only academic achievement, governmental policy-makeup, but also to the employees themselves
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Effects of escharotomy as abdominal decompression on cardiopulmonary function and visceral perfusion in abdominal compartment syndrome with burn patients
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DOD - Acute Comp Syndrome CPG
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BACKGROUND: Abdominal compartment syndrome (ACS) can become fatal; however, it has rarely been described as a complication of burn injury. This study clarified the physiologic results of abdominal decompression (AD) for ACS in patients with burn injury in detail.
METHODS: Extensively burned patients admitted to our burn unit between January 2003 and February 2004 were prospectively monitored by pulmonary artery catheter. Physiologic parameters from the catheter, blood gas analysis, intrabladder pressure as a parameter of intra-abdominal pressure (IAP), peak inspiratory pressure, and urine output (UO) were compared before and after escharotomy as AD in patients with ACS.
RESULTS: Eight of 36 patients who had sustained more than 30% total body surface area burn developed ACS requiring AD in 18.3 +/- 4.9 hours. AD significantly decreased IAP (52 +/- 9 cm H2O vs. 26 +/- 7 cm H2O), peak inspiratory pressure (53 +/- 13 cm H2O vs. 35 +/- 6 cm H2O), heart rate, and Paco2, and increased cardiac index (1.6 +/- 0.7 L/min/m2 vs. 2.5 +/- 0.9 L/min/m2), abdominal perfusion pressure (50 +/- 11 mm Hg vs. 72 +/- 17 mm Hg), UO (0.45 +/- 0.46 mL/h/kg vs. 2.0 +/- 2.1 mL/h/kg), and oxygen delivery index (290 +/- 195 mL/m2/min vs. 455 +/- 218 mL/m2/min). Impaired oxygen consumption index increased (86 +/- 43 mL/m2/min vs. 153 +/- 58 mL/m2/min) after AD.
CONCLUSION: In patients with severe burn injury, elevated IAP makes pulmonary artery wedge pressure and UO unreliable indices of preload or intravascular volume, and decreases abdominal perfusion in the resuscitation period. AD in these patients significantly improves the ventilation, hemodynamic parameters, and oxygen metabolism.
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The evaluation of post-operative alignment in total knee replacement using a CT-based navigation system
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Surgical Management of Osteoarthritis of the Knee CPG
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We compared the alignment of 39 total knee replacements implanted using the conventional alignment guide system with 37 implanted using a CT-based navigation system, performed by a single surgeon. The knees were evaluated using full-length weight-bearing anteroposterior radiographs, lateral radiographs and CT scans. The mean hip-knee-ankle angle, coronal femoral component angle and coronal tibial component angle were 181.8(degrees) (174.2(degrees) to 188.3(degrees)), 88.5(degrees) (84.0deg; to 91.8(degrees)) and 89.7(degrees) (86.3(degrees) to 95.1(degrees)), respectively for the conventional group and 180.8(degrees) (178.2(degrees) to 185.1(degrees)), 89.3(degrees) (85.8deg; to 92.0(degrees)) and 89.9(degrees) (88.0(degrees) to 93.0(degrees)), respectively for the navigated group. The mean sagittal femoral component angle was 85.5(degrees) (80.6(degrees) to 92.8(degrees) ) for the conventional group and 89.6(degrees) (85.5(degrees) to 94.0(degrees) ) for the navigated group. The mean rotational femoral and tibial component angles were -0.7(degrees) (-8.8(degrees) to 9.8(degrees)) and -3.3(degrees) (-16.8(degrees) to 5.8(degrees)) for the conventional group and -0.6(degrees) (-3.5(degrees) to 3.0(degrees)) and 0.3(degrees) (-5.3(degrees) to 7.7(degrees)) for the navigated group. The ideal angles of all alignments in the navigated group were obtained at significantly higher rates than in the conventional group. Our results demonstrated significant improvements in component positioning with a CT-based navigation system, especially with respect to rotational alignment. (copyright)2008 British Editorial Society of Bone and Joint Surgery
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1 |
A comparison of fasciotomy wound closure methods following extremity compartment syndrome at a regional trauma centre
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DOD - Acute Comp Syndrome CPG
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Background: Extremity fasciotomy wound closure following acute compartment syndrome is often prohibited by residual swelling, producing wounds that significantly contribute to patient morbidity. The aim of this study was to assess patient and fasciotomy wound outcomes associated with dynamic closure (DYN), delayed primary closure (DPS) and split skin grafting (SSG) techniques. Methods: A retrospective review of all trauma-related compartment syndrome patients managed between January 2000 and March 2010 was conducted, and a comprehensive patient and wound outcomes analysis was performed. Results: DYN was employed in 109 wounds, DPS in 66 wounds and SSG in 7 wounds. DPS wounds achieved closure in a significantly shorter timescale than other methods (p = <0.05). DYN and SSG group wound closure times were comparable; however, SSG techniques were employed later post-fasciotomy. SSG patients had longer hospital stays (p = <0.05) and the lowest wound complication rate (0Â %). Wound complication rates were significantly higher in the DYN (55Â %) and DPS groups (15Â %) (p = <0.05), and these wounds required a higher number of further surgical procedures. The need for repeated wound debridements was higher in the DYN group than any other (p = <0.05). Conclusions: DPS provided the fastest method of fasciotomy wound closure and the shortest inpatient stay. DYN techniques were associated with higher wound complication rates and the need for further surgical procedures. SSG techniques were associated with low complication rates and fewer surgical procedures and, if applied earlier, could result in shorter inpatient stay. Level of evidence IV, therapeutic study.
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Long-term rates of knee arthroplasty in a cohort of 834 393 patients with a history of arthroscopic partial meniscectomy
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AMP (Acute Meniscal Pathology)
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AIMS: The aim of this study was to determine the long-term risk of undergoing knee arthroplasty in a cohort of patients with meniscal tears who had undergone arthroscopic partial meniscectomy (APM).
PATIENTS AND METHODS: A retrospective national cohort of patients with a history of isolated APM was identified over a 20-year period. Patients with prior surgery to the same knee were excluded. The primary outcome was knee arthroplasty. Hazard ratios (HRs) were adjusted by patient age, sex, year of APM, Charlson comorbidity index, regional deprivation, rurality, and ethnicity. Risk of arthroplasty in the index knee was compared with the patient's contralateral knee (with vs without a history of APM). A total of 834 393 patients were included (mean age 50 years; 37% female).
RESULTS: Of those with at least 15 years of follow-up, 13.49% (16 256/120 493; 95% confidence interval (CI) 13.30 to 13.69) underwent subsequent arthroplasty within this time. In women, 22.07% (95% CI 21.64 to 22.51) underwent arthroplasty within 15 years compared with 9.91% of men (95% CI 9.71 to 10.12), corresponding to a risk ratio (RR) of 2.23 (95% CI 2.16 to 2.29). Relative to the general population, patients with a history of APM were over ten times more likely (RR 10.27; 95% CI 10.07 to 10.47) to undergo arthroplasty rising to almost 40 times more likely (RR 39.62; 95% CI 27.68 to 56.70) at a younger age (30 to 39 years). In patients with a history of APM in only one knee, the risk of arthroplasty in that knee was greatly elevated in comparison with the contralateral knee (no APM; HR 2.99; 95% CI 2.95 to 3.02).
CONCLUSION: Patients developing a meniscal tear undergoing APM are at greater risk of knee arthroplasty than the general population. This risk is three-times greater in the patient's affected knee than in the contralateral knee. Women in the cohort were at double the risk of progressing to knee arthroplasty compared with men. These important new reference data will inform shared decision making and enhance approaches to treatment, prevention, and clinical surveillance. Cite this article: Bone Joint J 2019;101-B:1071-1080.
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Child sexual abuse and adult romantic adjustment: comparison of single- and multiple-indicator measures
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DoD PRF (Psychosocial RF)
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This study compared the usefulness of single- and multiple-indicator strategies in a model examining the role of child sexual abuse (CSA) to predict later marital satisfaction through attachment and psychological distress. The sample included 1,092 women and men from a nonclinical population in cohabiting or marital relationships. The single-item measure assessed the presence or absence of CSA. The multiple-indicator measure included items relating to level of force, relationship with perpetrator, number of abusive experiences, and nature of assault. Structural equation modeling indicated that, for research purposes, a dichotomized item provided as much information as a complex measure to predict the relationship between sexual abuse and marital adjustment through attachment representations and psychological distress. However, when analyses were conducted strictly within the CSA victims group, no correlation was found between abuse severity and psychosocial measures. The present results show that in a community sample, CSA may be an important risk factor that develops couple difficulties, regardless of the severity of the trauma.
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The distribution of hand fractures at the university hospital of north Norway
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Hip Fx in the Elderly 2019
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BACKGROUND: The objective of this study was to describe the fracture pattern for hand fractures in the Arctic region of Norway.
MATERIALS AND METHODS: Using the hospital's radiological information system and picture archiving and communication system all traumatic hand fractures in the year of 2010 were registered. Fractures in the carpal, metacarpal, and phalangeal bones were included in the study.
RESULTS: A total of 593 patients with 691 fractures including 80 carpal, 200 metacarpal, and 411 phalangeal fractures were registered. The most commonly affected bone was the 5th metacarpal bone with a total of 99 fractures (14%), 22 of these (22%) were classified as subcapital or "boxer's fracture". Among male patients, the highest frequency of fractures was seen in the age group 10-60 years with a peak between 10-24 years. Adult female patients had most fractures in the age group 50-70 years. Generally, there were no seasonal variations, although a marked decrease of fractures could be seen in December. Triquetral fractures were more common during the winter season. Falling was the most common trauma mechanism.
CONCLUSION: With a few exceptions, hand fractures were not related to particular seasons or weekdays in this material. The distribution of hand fractures was related to age and gender, and some trauma mechanisms were dominating.
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1 |
Ageing with spinal cord injury: cross-sectional and longitudinal effects
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DoD PRF (Psychosocial RF)
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STUDY DESIGN: Longitudinal and cross-sectional.
OBJECTIVE: To determine whether, for studies of ageing with a spinal cord injury, the cross-sectional differences in outcomes across both age and years post injury (YPI) differ from the longitudinal change.
SETTING: Two SCI centres in England: the National Spinal Injuries Centre in Aylesbury, and the Regional Spinal Injuries Centre in Southport.
METHODS: A total of 315 people who sustained spinal cord injuries prior to 1971 underwent comprehensive health and psychosocial status interviews at one or more of the study assessments (1990, 1993, 1996, and 1999). A range of continuous and dichotomous outcomes was analyzed to detect both cross-sectional differences by age and average individual changes over multiple measurements.
RESULTS: Frequently, outcomes changed longitudinally without showing any cross-sectional differences. Cross-sectional age was more commonly associated with the worsening of a condition while cross-sectional YPI was commonly associated with improvement. After controlling for cross-sectional effects, psychological measures generally showed minor deterioration, measures of community integration both improved and deteriorated, upper extremity pain increased, lower enxtremity pain decreased, and participants tended to quit smoking.
CONCLUSION: Using longitudinal findings that control for cross-sectional differences produces a more complete description of ageing with a spinal cord injury.
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0 |
Predicting, Understanding and Speeding Recovery After TKA
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AAHKS (5) Gabapentinoids
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The objective of this research study is to better understand patterns of recovery after Total Knee Arthroplasty (TKA). The study will evaluate how pain, activity and cognitive (i.e., thinking style) responses determine patterns of recovery, and the study will evaluate the efficacy of gabapentin versus placebo for improving recovery after surgery.
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0 |
Corticosteroid use and risk of hip fracture: a population-based case-control study in Denmark
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Management of Hip Fractures in the Elderly
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OBJECTIVE: To examine the association between cumulative CS dose and risk of hip fracture. DESIGN: Population-based case-control design. SUBJECTS AND METHODS: A total of 6660 subjects with hip fracture and 33,272 age-matched population controls were identified using the County Hospital Discharge Registry in North Jutland County, Denmark and the Danish Central Personal Registry, respectively. Data on redeemed prescriptions for CS within the last 5 years before the index date were retrieved from a population-based prescription database, and recalculated to prednisolone equivalents. Cases and controls were categorized according to cumulative CS dose: (i) no use; (ii) <130 mg (e.g. equivalent to 30 mg of prednisolone for 4 days given for an acute exacerbation of asthma); (iii) 130-499 mg (e.g. equivalent to a short course of prednisolone of 450 mg for acute asthma); (iv) 500-1499 mg (e.g. equivalent to 7.5 mg prednisolone daily for 6 months or 800 microg day(-1) of inhaled budesonide for 1 year); and (v) > or =1500 mg (e.g. equivalent to >4.1 mg day(-1) for 1 year, a long-term high dose). Data were analysed using conditional logistic regression adjusted for potential confounders including gender, redeemed prescriptions for hormone replacement therapy, antiosteoporotic, anxiolytic, antipsychotic and antidepressant drugs. RESULTS: Compared with never users, an increased risk of hip fracture was found for CS users, with increasing cumulative doses of any type of CS use during the preceding 5 years [adjusted odds ratio (OR)=0.96, 95% confidence interval (CI)=0.89-1.04] for <130 mg prednisolone; OR=1.17 (CI=1.01-1.35) for 130-499 mg; OR=1.36 (CI=1.19-1.56) for 500-1499 mg; and OR=1.65 (CI=1.43-1.92) for > or =1500 mg. An increased risk was also found when the study population was stratified according to gender, age and type of CS (systemic or topical). CONCLUSIONS: Even a limited daily dose of CS (more than an average dose of approximately 71 microg prednisolone per day) was associated with an increased risk of hip fracture
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0 |
Changes in the Prevalence of Rheumatic Diseases in Shantou, China, in the Past Three Decades: A COPCORD Study
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Glenohumeral Joint OA
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This study aimed to clarify changes in the prevalence of rheumatic diseases in Shantou, China, in the past 3 decades and validate whether stair-climbing is a risk factor for knee pain and knee osteoarthritis (KOA). The World Health Organization-International League Against Rheumatism Community Oriented Program for Control of Rheumatic Diseases (COPCORD) protocol was implemented. In all, 2337 adults living in buildings without elevators and 1719 adults living in buildings with elevators were surveyed. The prevalence of rheumatic pain at any site and in the knee was 15.7% and 10.2%, respectively; both types of pain had a significantly higher incidence in residents of buildings without elevators than was reported by people who lived in buildings with elevators (14.9% vs. 10.6% and 11.32% vs. 8.82%, respectively) (both P < 0.0001). The prevalence of rheumatic pain in the neck, lumbar spine, shoulder, elbow, and foot was 5.6%, 4.5%, 3.1%, 1.4%, and 1.8%, respectively; these findings were similar to the data from the 1987 rural survey, but were somewhat lower than data reported in the urban and suburban surveys of the 1990s, with the exception of neck and lumbar pain. The prevalence of KOA, gout, and fibromyalgia was 7.10%, 1.08%, and 0.07%, respectively, and their prevalence increased significantly compared with those in previous studies from the 20th century. There were no significant differences in the prevalence of rheumatoid arthritis (RA) (0.35%) or ankylosing spondylitis (AS) (0.31%) compared to that reported in prior surveys. The prevalence of KOA was higher in for residents of buildings without elevators than that in those who had access to elevators (16-64 years, 5.89% vs. 3.95%, P = 0.004; 16->85 years, 7.64% vs. 6.26%, P = 0.162). The prevalence of RA and AS remained stable, whereas that of KOA, gout, and fibromyalgia has increased significantly in Shantou, China, during the past 3 decades. Stair-climbing might be an important risk factor for knee pain and KOA.
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1 |
Diabetic wound healing and limb salvage in an outpatient wound care program
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DoD LSA (Limb Salvage vs Amputation)
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Healing wounds and preventing amputations in diabetic patients is a challenge. Baptist Hospital in Nashville, Tennessee, developed an outpatient Wound Care Center program to treat patients with chronic wounds. This comprehensive program includes wound assessment, vascular studies, revascularization, antibiotic therapy, wound debridement, a topical growth factor solution of platelet-derived wound healing factors, protection devices, and patient education. A retrospective study of wound healing and limb salvage was conducted on 54 diabetic patients with 86 wounds. Average previous wound duration was 8 months. Amputation had previously been recommended for 15 limbs. Healing occurred in 88% of the wounds in an average of 15.8 weeks. Ninety-three percent of the limbs for which amputation had been recommended were salvaged. Healing efficacy and amputation reduction have been demonstrated in this program.
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Multicompartmental pressures in the knee joint during arthroscopy
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AMP (Acute Meniscal Pathology)
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It is well known that fast changes of position of the knee joint cause high instantaneous intraarticular pressures. During arthroscopy, rotation and flexion of the leg can create a closed-off compartment, increasing the risk of capsular rupture. To evaluate the risk of compartmentation, a study has been conducted in which the intraarticular pressure in 12 knee joints of three women and nine men was measured with Myopress catheters (ATOS Medical AB, Horby, Sweden) located in the suprapatellar pouch, and the anteromedial and the posteromedial recesses during arthroscopy. This study showed that a starting pressure of 100 mm Hg causes a significantly higher peak pressure than does 75 mm Hg. The pressure varies simultaneously in all compartments without signs of local compartmentation in any position of the joint within the range of 0-90 degrees of flexion. With a positive pressure in the knee joint, no compartmentation occurs within the suprapatellar pouch or anteromedial posteromedial compartments during an arthroscopic procedure.
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0 |
Endothelins induce CCR7 expression by breast tumor cells via endothelin receptor A and hypoxia-inducible factor-1
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MSTS 2018 - Femur Mets and MM
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Endothelin expression is increased in breast tumors and is associated with invasion and metastasis, whereas CCR7 expression by breast tumor cells may have a role in the organ specificity of breast cancer spread. In this article, we have analyzed whether endothelins influence breast tumor cell expression of the chemokine receptor CCR7. Stimulation of human breast tumor cell lines with endothelins increased cell surface expression of CCR7 via endothelin receptor A. The iron chelators desferrioxamine and cobalt chloride, which induce hypoxia-inducible factor (HIF)-mediated transcription, also increased CCR7 expression; transfection of a dominant-negative version of the HIF regulatory subunit, HIF-1alpha, into MCF-7 cells abolished CCR7 induction by endothelins, indicating that increased expression is due to HIF-1 stabilization. Endothelin stimulation promoted invasion toward the CCR7 ligands CCL19 and CCL21. Endothelin-mediated chemokine-independent invasion itself is dependent on CCR7 activity and could be abolished using a CCR7-neutralizing monoclonal antibody. In human breast carcinomas, mRNA expression of endothelins correlated with the level of CCR7 expression, both of which were associated with the presence of lymph node metastases. Expression of the CCR7 ligands CCL19 and CCL21 was also higher in breast cancer patients with lymph node involvement compared with those without, but expression of these chemokines did not correlate with endothelin expression. These data show that CCR7 may be regulated by the breast tumor microenvironment and further support the use of endothelin receptor antagonists in the treatment of invasive and metastatic breast cancer.
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0 |
Effects of physical exercise prescribed by a medical support team on elderly lower extremity osteoarthritis combined with metabolic syndrome and/or type 2 diabetes
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OAK 3 - Non-arthroplasty tx of OAK
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AIM: The aims of the present study were to investigate the effectiveness of exercise intervention provided by a medical support team specializing in lifestyle-related diseases in the treatment of elderly lower extremity osteoarthritis and to examine the influence of bodyweight decrease on changes in the evaluation indexes.
METHODS: Participants were 61 patients (57 women and 4 men, aged 68.3 +/- 9.6 years) with lower extremity osteoarthritis (109 total diseased joints) and either one or more of the following diseases: obesity, metabolic syndrome and type 2 diabetes. Indexes relating to metabolic diseases, orthopedic disorders, lifestyle activity level and health-related quality of life (HRQOL) were obtained before and after exercise intervention.
RESULTS: The numbers of patients with obesity, metabolic syndrome, type 2 diabetes, gonarthrosis and coxarthrosis were 56, 49, 32, 56 and 9, respectively. The mean intervention period was 4.7 +/- 1.6 months (2-10.8 months). Indexes relating to metabolic diseases and orthopedic disorders, activity level and HRQOL were all significantly improved after intervention (P < 0.05). Bodyweight decreased by 10.3% and showed a correlation with other evaluated items. Five explanatory variables were extracted through multiple regression analysis that bodyweight reduction rate was set as the criterion variable: changes of bodyweight, body mass index, percent body fat, glycated hemoglobin and total energy expenditure per bodyweight.
CONCLUSION: The exercise intervention provided by our medical support team clearly improved indexes relating to metabolic diseases and orthopedic disorders. In addition, decreased bodyweight was related to improvements in metabolic factors, motor function and HRQOL.
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0 |
Cutaneous ulcers associated with hydroxyurea therapy
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Reconstruction After Skin Cancer
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Hydroxyurea is an antitumoral drug mainly used in the treatment of Philadelphia chromosome-negative myeloproliferative syndromes and sickle-cell disease. Ulcers represent a rare but severe long-term adverse effect of hydroxyurea therapy. Hydroxyurea-induced ulcers are often multiple and bilateral, typically developing in the perimalleolar region, although any cutaneous district is potentially affected. They generally look small, well-defined, shallow with an adherent, yellow, fibrinous necrotic base. A constant finding is also an extremely intense, treatment-resistant pain accompanying these ulcerations. Withdrawal of the drug generally leads to spontaneous healing of these lesions. Care providers tend to show insufficient awareness of this highly debilitating cutaneous side effect, and late or missed diagnoses are frequent. Instead, regular dermatologic screening should be performed on hydroxyurea-treated patients. This article will present a comprehensive review of indexed case reports and clinical studies, followed by a discussion about treatment options aiming at increasing knowledge about this specific topic. © 2013 Tissue Viability Society. Published by Elsevier Ltd. All rights reserved.
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Determination of osteoporosis in patients with fractured femoral neck using the Singh index: a Jerusalem study
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Management of Hip Fractures in the Elderly
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The Singh index was used to measure the degree of osteoporosis in patients with fracture of the neck of the femur and to compare its prevalence with a random population sample in Jerusalem. The frequency of osteoporosis was 22.7% among women in the fracture series as compared with 1% in the control group. These figures are much lower than those in comparable series. The Singh index was not as sensitive an indicator of spinal osteoporosis as a direct measurement of vertebral bone density and could not be correlated with the incidence of hip fractures
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