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Spanish consensus for the management of patients with anaplastic cell thyroid carcinoma
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MSTS 2018 - Femur Mets and MM
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Anaplastic thyroid cancer (ATC) is the most aggressive solid tumor and almost uniformly lethal in humans. The Boards of the Thyroid Cancer Group of the Spanish Society of Endocrinology and Nutrition and the Grupo Español de Enfermedades Huérfanas e Infrecuentes of the Spanish Society of Oncology requested that an independent task force draft a more comprehensive consensus statement regarding ATC. All relevant literature was reviewed, including serial PubMed searches together with additional articles. This is the first, comprehensive Spanish consensus statement for ATC and includes the characteristics, diagnosis, initial evaluation, treatment goals, recommendations and modalities for locoregional and advanced disease, palliative care options, surveillance, and long-term monitoring. Newer systemic therapies are being investigated, but more effective combinations are needed to improve patient outcomes. Though more aggressive radiotherapy has reduced locoregional recurrences, median overall survival has not improved in more than 50 years.
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0 |
Comparison of MRI- and CT-based patient-specific guides for total knee arthroplasty
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OAK 3 - Non-arthroplasty tx of OAK
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Background: The patient-specific guide for total knee arthroplasty (TKA) is created from the data provided by magnetic resonance imaging (MRI) or computed tomography (CT) scans. It remains unknown which imaging technology is suitable for the patient-specific guide. The purpose of this study was to compare the accuracy of implant positioning and operative times between the two types of patient-specific guides for TKA. Methods: Forty arthritic knees were divided into two treatment groups using MRI-based (PS-MRI group) or CT-based (PS-CT group) patient-specific guides in this prospective, comparative study. The guide in the PS-MRI group had a cutting slot, whereas that in the PS-CT group only had a pin locator. The operative times were compared between the two groups. The angular error and number of outliers (deviations > 3°) of the implant position using pre- and postoperative CT were investigated in both groups. Results: The mean operative time was significantly shorter in the PS-MRI group (109.2. ± 16.5. min) than in the PS-CT group (129.5. ± 19.4. min) (p< 0.001). There were no significant differences in the accuracy of the implant position regarding the coronal, sagittal, and axial planes between the groups (p> 0.05). Conclusions: To reduce the operative time, guides with additional functions, such as cutting and positioning, should be used. Both CT- and MRI-based-guides would result in the same accuracy in three planes but high inaccuracy in the sagittal plane. The use of patient-specific guide based on MRI might not be cost-effective.
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0 |
Proximal humerus reconstructions for tumors
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MSTS 2022 - Metastatic Disease of the Humerus
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UNLABELLED: The optimal method for reconstructing the proximal humerus in patients with tumors is controversial. To determine functional outcomes and complication rates after different types of reconstructions, we reviewed a consecutive series of 49 patients who underwent proximal humerus resection and osteoarticular allograft (17 patients), allograft-prosthetic composite (16), or endoprosthetic (16) reconstruction. Operative indications included primary malignancies (24 patients), metastatic disease (19), and benign aggressive disease (six). Implant revision was more common after osteoarticular reconstruction (five of 17) than after allograft-prosthetic composite (one of 16) or endoprosthetic (zero of 16) reconstructions. At a minimum followup of 24 months (median, 98 months; range, 24-214 months) in surviving patients, Musculoskeletal Tumor Society functional scores averaged 79% for the allograft-prosthetic composite, 71% for the osteoarticular allograft, and 69% for the endoprosthetic reconstruction cohorts. Shoulder instability was associated with abductor mechanism compromise and was more common after endoprosthetic reconstruction. Allograft fractures occurred in 53% of patients receiving osteoarticular allografts. We recommend allograft-prosthetic composite reconstruction for younger patients with primary tumors of bone and endoprosthetic reconstruction for older patients with metastatic disease. Because of the unacceptable complication rate, we do not recommend osteoarticular allograft reconstruction for routine use in the proximal humerus.
LEVEL OF EVIDENCE: Level III, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.
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0 |
Autologous osteochondral mosaicplasty grafting
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Diagnosis and Treatment of Osteochondritis Dissecans AUC
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Successful management of chondral and osteochondral defects of the weight-bearing joint surfaces has always been a challenge for orthopedic surgeons and rehabilitation specialists. Autologous osteochondral mosaic transplantation technique is one of the recently evolved methods to create hyaline or hyaline-like repair tissue in the pathologic area. Clinical evaluation, various imaging techniques, arthroscopy (second look), histological examination of biopsy samples, and measurements of cartilage mechanical properties are used to evaluate the merits of outcomes and quality of the transplanted cartilage. According to our investigations, good to excellent results were achieved in more than 92% of patients treated with femoral condylar implantations, 87% of those treated with tibial resurfacing, 79% of those treated with patellar and/or trochlear mosaicplasties, and 94% of those treated with talar procedures. Long-term donor-site discrepancies, assessed with use of the Bandi Score, showed that patients had 3% morbidity after mosaicplasty. Sixty-nine of 89 patients who were followed up with a second-look arthroscopy showed congruent gliding surfaces, histological evidence of the survival of the transplanted hyaline cartilage, and fibrocartilage filling of the donor sites. In a series of 831 consecutive patients, very few complications have been observed. These included 4 deep infections and 36 painful postoperative intra-articular bleedings. On the basis of these results and those of other similar studies, autologous osteochondral mosaicplasty appears to be a promising alternative for the treatment of small- and medium-sized focal chondral and osteochondral defects of the weight-bearing surfaces of the knee and other weight-bearing synovial joints
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0 |
Immediate Great Toe Transfer for Thumb Reconstruction After Tumor Resection: Report of 3 Cases
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Reconstruction After Skin Cancer
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BACKGROUND: Modern oncologic surgery aims not only to obtain tumor-free margins but also to spare or reconstruct limb function and preserve quality of life. A negative tumor margin in the digit generally requires amputation; therefore, function is preserved with reconstruction. We report results of simultaneous ablative tumor resection and reconstruction with a great toe transfer in patients requiring surgery for aggressive benign and malignant thumb tumors. METHODS: Between 2000 and 2009, three patients with extensive soft tissue tumors of the distal thumb underwent amputation to obtain wide negative surgical margins. In each case, an immediate trimmed toe-to-thumb transfer was performed. Results, evaluated retrospectively, included a review of perioperative complications, donor-site morbidity, oncologic status, objective functional outcomes, and subjective patient satisfaction. RESULTS: Three patients were found with either locally aggressive benign (n = 1) or malignant (n = 2) tumors of the thumb. All patients underwent immediate reconstruction after amputation through the base of the proximal phalanx for tumor eradication. No perioperative complications were encountered, and all toes survived. Full thumb opposition and protective sensation were achieved in all patients. All patients returned to their previous occupation without functional limitations. There is no local or distant tumor recurrence. Delayed wound healing at the ipsilateral foot donor site occurred in all 3 patients. Wet-to-dry dressing changes were successful in 2 patients, whereas the third patient required full-thickness skin grafting. All patients were satisfied with their reconstruction. CONCLUSIONS: An immediate great toe-to-thumb transfer should be considered when thumb amputation is required to satisfy adequate oncologic margins. Such a transfer provides simultaneous restoration of digit length, position, sensation, and acceptable esthetics. This procedure is technically demanding and requires an experienced microsurgical team as well as appropriate patient counseling and consent before surgery.
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1 |
Microfracture and osteochondral autograft transplantation are cost-effective treatments for articular cartilage lesions of the distal femur
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Osteochondritis Dissecans 2020 Review
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BACKGROUND: Multiple techniques have been suggested for the treatment of isolated knee articular cartilage injuries. For smaller lesions (<2-5 cm(2)), microfracture and osteochondral autograft transplantation (OAT) are commonly used options. With an increasing focus on health care efficiency, analyzing the cost-effectiveness of treatment modalities has become increasingly important. PURPOSE/HYPOTHESIS: The purpose of this study was to analyze the costs and outcomes of microfracture and OAT to compare their cost-effectiveness. The hypothesis was that microfracture would be more cost-effective. STUDY DESIGN: Economic and decision analysis; Level of evidence, 2. METHODS: A literature search was performed to identify studies comparing microfracture and OAT for the treatment of articular cartilage lesions of the distal femur in an adult population. Data from these studies including surgical time, failure rates, revision surgeries, outcome scores, and return to athletics were then incorporated into a constructed cost model using standard accounting methodology. The model was based on actual 2013 cost figures (in US dollars) for all procedure, operating room, and instrumentation costs. RESULTS: Three studies, with a mean follow-up of 8.7 years, met the inclusion criteria of having evidence level 1 or 2 comparing microfracture and OAT. There was a cumulative 28.6% reoperation rate among patients undergoing microfracture compared with 12.5% among patients undergoing OAT. While both groups demonstrated significant improvements compared with preoperative levels, the only significant differences in any outcome score reported between the 2 procedures were the International Cartilage Repair Society (ICRS) score and patient-reported return to their previous sports activity level. While microfracture had a lower initial cost ($3100), these savings lessened over 1 year ($1843) and 10 years ($996). Microfracture was more cost-effective when comparing Lysholm and Hospital for Special Surgery scores, whereas OAT was more cost-effective when comparing Tegner and ICRS scores. There was a significantly lower cost for return to play in athletes after OAT versus microfracture at 1 year ($11,428 vs $16,953, respectively), 3 years ($12,856 vs $38,000, respectively), and 10 years ($32,141 vs $60,799, respectively). CONCLUSION: Published level 1 and 2 clinical studies with a 10-year follow-up demonstrated that the net cost and cost-effectiveness of microfracture and OAT are comparable for the treatment of isolated articular cartilage lesions of the distal femur. CLINICAL RELEVANCE: Given similar clinical outcomes, microfracture and OAT are both viable, cost-effective first-line treatment options for these injuries.
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0 |
Blepharoptosis Associated with Third Cranial Nerve Palsy
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Upper Eyelid and Brow Surgery
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Purpose: To evaluate the demographics and outcomes of management for blepharoptosis associated with third cranial nerve palsy at a tertiary eye center. Methods: This retrospective cross-sectional and interventional study was performed on hospital records of patients with ptosis associated with third cranial nerve palsy who were referred to Labbafinejad Medical Center from January 1999 to January 2009. The authors evaluated age, sex, laterality, severity of involvement, etiology, clinical findings, and treatment modalities and outcomes in patients with blepharoptosis due to third cranial nerve palsy over a 10-year period. Results: Of a total of 45 subjects, 25 cases (55.6%) were males and 20 subjects (44.4%) were females. Mean age of enrolled subjects was 21.1 ± 15.5 years. Etiologies included trauma in 21 (46.7%), congenital in 16 (35.6%), and other causes in 8 (17.7%) cases. Overall, 18 of 45 patients (40%) underwent ptosis surgery: of these, 15 (83.3%) subjects improved with one procedure, whereas 3 (16.7%) subjects required more than one operation. For initial ptosis surgery, 5 (27.7%) patients underwent levator resection and 13 (72.3%) cases underwent frontalis sling; all second and third procedures were frontalis sling. One-step, 2-step, and 3-step ptosis surgery was accomplished in 15 (83.3%), 1 (5.6%), and 2 (11.1%) patients, respectively. Eventually, an open visual axis was attained in all cases following 1-3 operations. Conclusions: Trauma was the most common cause of ptosis associated with third cranial nerve palsy in the current series. Surgical management of ptosis in patients with third nerve palsy may be challenging but most subjects achieve good results following appropriate and stepwise surgical plans.
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A dental view of controversies in the prophylaxis of infective endocarditis
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Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures
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Dental care of patients at risk of endocarditis must reflect changes in dental disease prevalence and in patients' expectations. Simplified recommendations on antibiotic prophylaxis are being widely applied
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Intraoperative angiography provides objective assessment of skin perfusion in complex knee reconstruction
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AAHKS (2) Corticosteroids
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BACKGROUND: Wound necrosis is a potentially devastating complication of complex knee reconstruction. Laser-assisted indocyanine green angiography (LA-ICGA) is a technology that has been described in the plastic surgery literature to provide an objective assessment of skin perfusion in the operating room. This novel technology uses a plasma protein bound dye (ICG) and a camera unit that is calibrated to view the frequency emitted by the dye. The intention of this technology is to offer real-time visualization of blood flow to skin and soft tissue in a way that might help surgeons make decisions about closure or coverage of a surgical site based on blood flow, potentially avoiding soft tissue reconstruction while preventing skin necrosis or wound breakdown after primary closures, but its efficacy is untested in the setting of complex TKA.
QUESTIONS/PURPOSES: The purpose of this study was to evaluate perfusion borders and tension ischemia in a series of complex knee reconstructions to guide optimal wound management.
METHODS: Beginning in mid-2011, an LA-ICGA system was used to evaluate soft tissue viability in knee reconstruction procedures that were considered high risk for wound complications. Seven patients undergoing complex primary or revision TKA from 2011 to 2013 were included. These patients were chosen as a convenience sample of knee reconstruction procedures for which we obtained consultation with the plastic surgery service. The perfusion of skin and soft tissue coverage was evaluated intraoperatively for all patients with the LA-ICGA system, and the information was used to guide wound management. Followup was at a mean of 9 months (range, 6-17 months), no patients were lost to followup, and the main study endpoint was uneventful healing of the surgical incision.
RESULTS: All seven closures went on to heal without necrosis. One patient, however, was subsequently revised for a deep periprosthetic infection 4 months after their knee reconstruction and underwent flap coverage at the time of that revision.
CONCLUSIONS: Implementation of LA-ICGA provides an objective intraoperative assessment of soft tissue perfusion. This technology may help guide the surgeon's decisions about wound closure in real-time to accommodate the perfusion challenges unique to each patient. Specifically, patients with medical risk factors for poor perfusion or wound healing (such as diabetes, peripheral vascular disease, tobacco use, corticosteroid therapy, infection) or anatomical/surgical risk factors (ie, previous surgery about the reconstruction site, trauma wounds, or reconstruction of severe deformity) may benefit from objective intraoperative information regarding perfusion of the wound site. Furthermore, LA-ICGA could be used to prospectively evaluate the physiologic impact of different wound closure techniques.
LEVEL OF EVIDENCE: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
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0 |
Osteonecrosis: current perspectives on pathogenesis and treatment
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AAHKS (2) Corticosteroids
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Nontraumatic osteonecrosis results from impairment of circulation to the affected bone. The femoral head is affected most frequently. The underlying cause for the circulatory defect in osteonecrosis varies and may involve both local and systemic changes. Steroid use, alcohol consumption, pancreatitis, and lipid disorders appear to lead to bone death either by development of fat emboli in the microcirculature surrounding the affected bone or by fatty infiltration of the marrow. Decompression syndrome results from the presence of gaseous emboli in the microcirculature. In Legg-Calve-Perthes disease other associated features are present such as short stature, suboptimal growth velocity, and/or hormonal imbalances, and it is likely that osteonecrosis may be secondary to systemic abnormalities, although specific factors have not been identified. Other frequently suggested pathogenic factors that play a role in the development of osteonecrosis include increased intraosseous pressures, the presence of cytotoxic cellular factors, intravascular coagulation, venous stasis, and the hyperviscosity syndrome. Some investigators have attempted, without success, to find a common etiology for all cases of osteonecrosis. In addition, patients have developed osteonecrosis without any known risk factors; this syndrome has been coined idiopathic avascular necrosis. In advanced stages of femoral head osteonecrosis, total hip arthroplasty appears to be the best therapeutic modality, particularly in older individuals. [References: 222]
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Vitamin D and calcium supplementation prevents osteoporotic fractures in elderly community dwelling residents: a pragmatic population-based 3-year intervention study
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Management of Hip Fractures in the Elderly
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This study of 9605 community-dwelling residents supports that vitamin D and calcium supplementation may prevent osteoporotic fractures in elderly in a northern European region known to be deficient in vitamin D, especially during winter periods. INTRODUCTION: We evaluated the effect of two programs for the prevention of osteoporotic fractures leading to acute hospital admission in a population of elderly community-dwelling residents. MATERIALS AND METHODS: This was a factorial, cluster-randomized, pragmatic, intervention study. We included 9605 community-dwelling residents aged 66+ years. We offered a prevention program of a daily supplement of 1000 mg of elemental calcium as calcium carbonate and 400 IU (10 microg) of vitamin D3 to a total of 4957 participants. Another program with evaluation and suggestions for the improvement of the domestic environment was offered to a total of 5063 participants. Both programs included revision of the resident's current pharmaceutical treatment. We achieved information on osteoporotic fractures in the study population from the Danish Hospital Registration Database. We defined osteoporotic fractures as low energy fractures of the proximal humerus, distal forearm, vertebral column, pelvis, cervical femur, and intertrochanteric femur. RESULTS: Active participation was 50.3% in the Calcium and Vitamin D Program and 46.4% in the Environmental and Health Program. We observed a 16% reduction in fracture incidence rate (relative risk [RR], 0.84; CI, 0.72-0.98; p < 0.025) among male and female residents offered the Calcium and Vitamin D Program (intention-to-prevent analysis). CONCLUSIONS: This study supports that vitamin D and calcium supplementation may prevent osteoporotic fractures in community-dwelling elderly people in a northern European region known to be deficient in vitamin D, especially during winter periods
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1 |
Internal fixation versus hemiarthroplasty for the displaced subcapital fracture of the femur. A prospective randomised study
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Management of Hip Fractures in the Elderly
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A prospective randomised trial of surgical treatment for the displaced subcapital femoral fracture in patients of 70 years or more is presented. Two hundred and eighteen patients were randomly allocated into one of three treatment groups: manipulative reduction and internal fixation using Garden screws; Thompson hemiarthroplasty through a posterior (Moore) approach; and Thompson hemiarthroplasty through an anterolateral (McKee) approach. There is no significant difference in the mortality of the internal fixation and posterior arthroplasty groups. Both groups showed a significantly higher mortality than patients operated on through the anterior approach. The technical results of operation were worse in the internally fixed group, with only 40 per cent being satisfactory. Mobilisation was best achieved after the posterior approach. It is concluded that Thompson hemiarthroplasty, using an anterolateral approach, is the safest operation in this group of patients
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0 |
Use of human acellular dermal matrix in implant- based breast reconstruction: evaluating the evidence
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Reduction Mammoplasty for Female Breast Hypertrophy
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The use of acellular dermal matrix (ADM) in implant based breast reconstruction has become increasingly popular to the point that a subset of surgeons use ADM for virtually every tissue expander/implant based reconstruction. While there may be a number of perceived and anecdotal advantages such as decreased post-operative pain, increased initial expander fill volume, and improved aesthetic outcome, it remains unclear as to whether there is sufficient evidence to support these as well as other claims or its routine use. In this review, we identified all papers in the PubMed and Medline databases that addressed outcomes of the use of ADM in single and multiple staged implant based breast reconstruction. Papers were evaluated for any claim of benefit in using ADM in breast reconstruction. The following perceived advantages were supported solely by anecdotal reports and opinions: reduction in post-op pain, decreased operative time, precise control of the lateral and IMF, maximal use of mastectomy skin flaps, and improved lower pole expansion. There was inconsistent data for commonly perceived advantages, such as: eliminating the need for expanders, increased initial fill volumes, fewer expansions, faster time to reconstruction completion, decreased rate of revision, and improved aesthetic outcome. We found consistent support for a decreased incidence of capsular contracture; however the existing reports have limited long term follow-up. Despite the many heralded benefits of ADM in breast reconstruction, the data supporting these claims is mostly anecdotal. Both long term outcomes and randomized controlled prospective studies are needed in order to definitively evaluate the perceived advantages of ADM in breast reconstruction.
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0 |
Do biologic agents increase the risk of infection in patients undergoing lower limb arthroplasty surgery?
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OAK 3 - Non-arthroplasty tx of OAK
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Background: Biologic agents have contributed significantly to the management of patients with in rheumatoid arthritis (RA). A significant proportion of patients with RA still require arthroplasty procedures however. It is unclear whether these agents increase the risk of post operative infection after lower limb arthroplasty. Method: A literature search was performed for articles published over the last 10 years in the English language examining the association between anti-tumour necrosis factor inhibitors and the incidence of post operative infection in patients with RA undergoing hip and knee arthroplasty procedures. Results: One large meta-analysis has been published suggesting a 2-fold increase in infection rates following orthopaedic surgery in patients receiving biological agents. When subgroup analysis of arthroplasty cases alone was performed the finding failed to reach significance. However, several further studies have demonstrated both an increased risk for surgical site infection with the use of biological agents and several conflicting articles argue the opposite. Conclusion: There is no current consensus on this topic. The safety of continuation of perioperative anti-TNF-α therapy in patients undergoing lower limb arthroplasty procedures is unclear. There is also little robust guidance from specialist rheumatologic societies. There is need for large scale multicentre randomised controlled trials to address this issue.
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0 |
Osteoarthritis year in review 2015: Mechanics
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AMP (Acute Meniscal Pathology)
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Motivated by the conceptual framework of multi-scale biomechanics, this narrative review highlights recent major advances with a focus on gait and joint kinematics, then tissue-level mechanics, cell mechanics and mechanotransduction, matrix mechanics, and finally the nanoscale mechanics of matrix macromolecules. A literature review was conducted from January 2014 to April 2015 using PubMed to identify major developments in mechanics related to osteoarthritis (OA). Studies of knee adduction, flexion, rotation, and contact mechanics have extended our understanding of medial compartment loading. In turn, advances in measurement methodologies have shown how injuries to both the meniscus and ligaments, together, can alter joint kinematics. At the tissue scale, novel findings have emerged regarding the mechanics of the meniscus as well as cartilage superficial zone. Moving to the cell level, poroelastic and poro-viscoelastic mechanisms underlying chondrocyte deformation have been reported, along with the response to osmotic stress. Further developments have emerged on the role of calcium signaling in chondrocyte mechanobiology, including exciting findings on the function of mechanically activated cation channels newly found to be expressed in chondrocytes. Finally, AFM-based nano-rheology systems have enabled studies of thin murine tissues and brush layers of matrix molecules over a wide range of loading rates including high rates corresponding to impact injury. With OA acknowledged to be a disease of the joint as an organ, understanding mechanical behavior at each length scale helps to elucidate the connections between cell biology, matrix biochemistry and tissue structure/function that may play a role in the pathomechanics of OA.
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Impact of Timing of Lobectomy on Survival for Clinical Stage IA Lung Squamous Cell Carcinoma
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Reconstruction After Skin Cancer
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BACKGROUND: Because the relationship between the timing of surgery following diagnosis of lung cancer and survival has not been precisely described, guidelines on what constitutes a clinically meaningful delay of resection of early-stage lung cancer do not exist. This study tested the hypothesis that increasing the time between diagnosis and lobectomy for stage IA squamous cell carcinoma (SCC) would be associated with worse survival. METHODS: The association between timing of lobectomy and survival for patients with clinical stage IA SCC in the National Cancer Data Base (2006-2011) was assessed using multivariable Cox proportional hazards analysis and restricted cubic spline (RCS) functions. RESULTS: The 5-year overall survival of 4,984 patients who met study inclusion criteria was 58.3% (95% CI, 56.3-60.2). Surgery was performed within 30 days of diagnosis in 1,811 (36%) patients, whereas the median time to surgery was 38 days (interquartile range, 23, 58). In multivariable analysis, patients who had surgery 38 days or more after diagnosis had significantly worse 5-year survival than patients who had surgery earlier (hazard ratio, 1.13 [95% CI, 1.02-1.25]; P = .022). Multivariable RCS analysis demonstrated the hazard ratio associated with time to surgery increased steadily the longer resection was delayed; the threshold time associated with statistically significant worse survival was approximately 90 days or greater. CONCLUSIONS: Longer intervals between diagnosis of early-stage lung SCC and surgery are associated with worse survival. Although factors other than the timing of treatment may contribute to this finding, these results suggest that efforts to minimize delays beyond those needed to perform a complete preoperative evaluation may improve survival.
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Infection after knee arthroplasty a prospective study of 1509 cases
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Surgical Management of Osteoarthritis of the Knee CPG
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We report a prospective study of 1509 consecutive total knee arthroplasties looking at risk factors for infection in modern surgical practice. The overall deep infection rate was 1%. A further 51 patients had a superficial infection (3.3%). Statistical analysis revealed no correlation between risk of infection and age and sex. Those who had poor health as assessed by the American Society of Anesthesiologists score had no increased risk of infection. Neither did patients undergoing arthroplasty for rheumatoid arthritis. Diabetic patients and those with morbid obesity (body mass index, >40 kg/m(2)) had an increased odds ratio for deep and superficial infection, but these results did not reach statistical significance
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Clodronate reduces the incidence of fractures in community-dwelling elderly women unselected for osteoporosis: results of a double-blind, placebo-controlled randomized study
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Management of Hip Fractures in the Elderly
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A 3-year prospective, randomized, placebo-controlled trial of oral clodronate 800 mg showed that the incidence of clinical fractures was decreased by 20% in 5596 elderly women unselected for osteoporosis. The effect occurred in the absence of systematic calcium and vitamin D supplementation and was observed across a wide range of BMDs. INTRODUCTION: To date, most studies with bisphosphonates have reported on their use in individuals selected to be at high risk for fracture usually by the presence of low BMD or a prior fragility fracture, usually of the spine. We wished to determine the effect of the bisphosphonate, clodronate, on the rate of fractures in women > or =75 years of age living in the community. MATERIALS AND METHODS: Women > or =75 years of age living in the general community in South Yorkshire and North Derbyshire, identified from general practice registers, were recruited by letter of invitation to a randomized, double-blind, controlled trial of 800 mg oral clodronate (Bonefos) or matching placebo daily over 3 years. The main outcomes were the incidences of hip and any clinical fracture. RESULTS: Of the 5579 elderly women included in the intention-to-treat analysis of efficacy, 114 had a new hip fracture during the 3-year treatment phase: 56 (2.0%) women in the clodronate group and 58 (2.1%) women in the placebo group (hazard ration [HR], 1.02; 95% CI, 0.71-1.47). Clodronate did, however, decrease the incidence of any clinical fracture by 20% (264 women [9.5%] versus 337 [12.1%] in the placebo group; HR, 0.80; 95% CI, 0.68-0.94). The incidence of osteoporosis-associated nonhip fractures was also significantly decreased by 29% (5.2% versus 7.4%; HR, 0.71; 95% CI, 0.57-0.87). The ability of clodronate to reduce the risk of osteoporotic fracture was independent of baseline BMD, but the number needed-to-treat was lower in the presence of osteoporosis. CONCLUSIONS: Oral daily clodronate can prevent fractures without significant adverse effects in elderly women living in the general community. The effect on hip fracture risk is not significant, but an effect similar to that at other nonvertebral sites cannot be excluded. This study suggests that antiresorptive therapies can reduce fracture incidence in high-risk individuals even in the presence of a normal or osteopenic BMD
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1 |
Local infiltration analgesia adds no clinical benefit in pain control to peripheral nerve blocks after total knee arthroplasty
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AAHKS (9/10) Regional Nerve Blocks
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PURPOSE: To evaluate the effect of the local infiltration of analgesics for pain after total knee arthroplasty in patients treated with femoral and sciatic peripheral nerve blocks. The secondary objective was to detect differences in analgesic consumption as well as blood loss after local infiltration of analgesics.
METHODS: Prospective randomized double-blinded study in patients who underwent a TKA for knee osteoarthritis under spinal anesthesia and treated with femoral and sciatic nerve blocks. This study compared 50 patients treated with local infiltration with ropivacaine, epinephrine, ketorolac and clonidine and 50 patients treated with a placebo with the same technique. The visual analogic score was registered postoperatively at 2, 6, 12, 24, 36, 48 and 72 h after surgery. Analgesic consumption was also registered. Both groups of patients were treated with the same surgical and rehabilitation protocols.
RESULTS: A significant difference of one point was found in the visual analogic pain scores 12 h after surgery (0.6 +/- 1.5 vs. 1.7 +/- 2.3). There were no significant differences in the visual analogic pain scores evaluated at any other time between 2 and 72 h after surgery. No significant differences were found in the required doses of tramadol or morphine in the postoperative period. Postoperative hemoglobin and blood loss were also similar in both groups.
CONCLUSION: Adding local infiltration of analgesics to peripheral nerve blocks after TKA surgery only provides minimal benefit for pain control. This benefit may be considered as non-clinically relevant. Moreover, the need for additional analgesics was the same in both groups. Therefore, the use of local infiltration of analgesics treatment in TKA surgery cannot be recommended if peripheral nerve blocks are used.
Level of evidence: I.
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Birmingham hip resurfacing: a minimum follow-up of ten years
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PJI DX Updated Search
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We report the survival, radiological and functional outcomes of a single surgeon series of his first 144 consecutive Birmingham hip resurfacing procedures (130 patients) at a minimum of ten years. There were ten revisions during this time. Although no patients were lost to follow-up some did not complete the scoring assessment or undergo radiological assessment at ten years. The ten-year survival for male patients was 98.0% (95% confidence interval 95.2 to 100). The ten-year survival for the total cohort with aseptic revision as the endpoint was 95.5% (95% confidence interval 91.8 to 99.0) and including revisions for sepsis was 93.5% (95% confidence interval 89.2 to 97.6). The median modified Oxford hip score at ten years was 4.2% (interquartile range 0 to 19) and the median University of California, Los Angeles score was 7.0 (interquartile range 5.0 to 8.0). This study confirms the midterm reports that metal-on-metal hip resurfacing using the Birmingham Hip provides a durable alternative to total hip replacement, particularly in younger male patients wishing to maintain a high level of function, with low risk of revision for at least ten years
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0 |
Biliopancreatic diversion: Clinical experience
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Panniculectomy & Abdominoplasty CPG
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Background: Biliopancreatic diversion (BPD), by ad hoc stomach resection (AHS-BPD) has been accepted as an effective surgical treatment for morbid obesity. Methods: Between 1.1.1992 and 31.7.1996, 59 patients (54 females, five males, mean age 40.3 years, range 23-61 years) underwent AHS-BPD. Mean preoperative body-weight was 121.2 kg (range 94-160), with a mean body mass index of 48.6 (range 35-64). Three of these patients were converted from a previous vertical banded gastroplasty to AHS-BPD (one patient with stomach preservation). After at least 36 months follow-up, seven patients underwent abdominal dermolipectomy (five with associated incisional hernia repair, one with thigh dermolipectomy). Results: Mean post-operative hospital stay was 13 days (range 10-30 days). Follow-up is currently in progress in all patients. Excess body weight-loss was 78% in 33 patients with 24 months follow-up, with excellent long-term weight loss maintenance. Protein deficiency was the main specific complication, encountered in two patients.(3.4%). Mortality was one patient (1.7%), due to pulmonary embolus. Conclusions: This clinical experience supports the effectiveness and safety of AHS-BPD, despite some criticism. This procedure appears to be suitable for patients with clinically severe obesity who will poorly tolerate food intake restriction but will accept long-term follow-up. Careful preoperative clinical assessment and selection of patients who will be reliable in long-term follow-up are the keys to success with AHS-BPD, both in terms of weight loss and reduction of specific metabolic complications.
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A comparative study between closed reduction and cast application versus percutaneous K-wire fixation for extraarticular fracture distal end of radius
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Distal Radius Fractures
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Introduction: In extra-articular distal radius fractures closed reduction and casting has been the mainstay of treatment, difficulty lies in predicting and maintaining the proper reduction at final union. Percutaneous K-wire stabilization is also a widely accepted treatment option, but there is no consensus on its outcome in comparison to closed reduction and casting. Aim: To evaluate the results of closed reduction and casting versus closed reduction with percutaneous K wire fixation and casting in the treatment of the distal radius extra-articular fracture with reference to the restoration of radial height, radial inclination, volar tilt of the distal articular surface and to assess the functional outcome of the same measured by the Gartland and Werley demerit scoring system. Materials and Methods: Prospective study was conducted on 60 patients attending the Department of Orthopaedics, from December 2013 to May 2015 with extra-articular fractures (AO type 23-A2 and 23-A3) of distal radius and fulfilling all the inclusion and exclusion criteria. The cases were randomly divided into two equal groups of 30 patients, the first group treated by closed reduction and below elbow cast application, while the second group were treated by closed reduction percutaneous K-wire application and below elbow cast application. The radiological outcome of both groups were evaluated by measuring the Volar inclination, Radial inclination and Radial height, while the functional outcome was evaluated by the demerit scoring system of Gartland and Werley. Results: The Cast application group had 13 excellent, 9 good, 8 fair and 1 poor result the mean outcome score of the group was 5.2 The K wiring group had 11 excellent, 13 good, 5 fair and 1 poor result, the mean score of the group was 5.17.The unpaired studentâ??s t-test on the values obtained from both groups yielded a p-value of 0.9816 The mean radial height in the Cast application group was 8.033mm while the mean in the k wiring group was 11.783mm.The mean volar tilt was 4.867 degrees and 7.5 degrees respectively. The mean radial inclination was 14.23 degrees and 19.1respectively. Unpaired studentâ??s t-test on the values revealed a p-value of 0.0001 for all three. Conclusion: Weconcluded that closed reduction with percutaneous K-wire fixation under C-arm for treatment of extra articular fractures of distal radius gives statistically significantly better radiological outcome than treatment with closed reduction and casting alone, but there is no statistically significant difference in functional outcome.
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Does early treatment by abduction splintage improve the development of dysplastic but stable neonatal hips?
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Developmental Dysplasia of the Hip CPG
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A prospective trial was carried out to assess the outcome of children aged from 2 to 6 weeks with stable but dysplastic hips, treated with abduction splintage or by observation. Forty-four patients with 63 dysplastic hips were entered into the study and allocated into the two treatment groups at random. The ultrasound measured percentage acetabular cover in the splinted group improved in the first 3 months from an average of 32.8 to 54.3%. In the unsplinted group, the increase in cover was from 36.7 to 48.6%. The changes in cover for the splinted group were significantly more than those for the unsplinted group (p < 0.003) There was, however, no significant difference between the two groups in acetabular angle measurements on plain radiographs taken at 3 months. At 24 months, similarly, there was no significant difference in the acetabular angles of the two groups. These results support the view that stable dysplastic hips will correct with growth and that there is no sustained benefit from early splintage
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Plasma concentration of bupivacaine after spinal anesthesia with single shot femoral nerve block in total knee arthroplasty
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Surgical Management of Osteoarthritis of the Knee CPG
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Introduction: Femoral nerve block is commonly established for postoperative analgesia in total knee arthroplasty but no evidence of plasma bupivacaine level has been reported. Objectives: The aim of our study was to determine the plasma concentrations of bupivacaine in patients who had single-injection of femoral nerve block. Methods: A prospective observational study was undertaken with 25 patients scheduled for unilateral total knee arthroplasty under spinal anesthesia and single shot femoral nerve block with 20 mL of 0.5% bupivacaine. Venous blood samples were collected at 0, 5, 10, 15, 30, 60, 90, and 120 minutes after femoral nerve block. Plasma bupivacaine levels were analyzed by using a high performance liquid chromatography with tandem mass spectrometry method. Results: Four male and 21 female, ASA I-II were enrolled in this study. Mean age, body mass index and serum albumin level were 69.9(plus or minus)5.95 years, 27(plus or minus)3.67 kg/m2 and 4.46(plus or minus)0.26 mg/dL respectively. The median of peak plasma concentration was 538.35 ng/mL (min = 176.30, max = 1,383.99) at 60 minutes after femoral nerve block, while the maximal plasma concentration of bupivacaine was 1,883.39 ng/mL at 10 minutes. Nobody showed signs and symptoms of bupivacaine toxicity. Discussion: The peak plasma concentration of bupivacaine after femoral nerve block alone was similar to the peak plasma bupivacaine level following combined sciatic block and femoral 3 in 1 block reported by Misra et al.1 (60(plus or minus)7 min) but was little different from the conclusion of Moore et al.2 which was peak at 15 minutes and persisted up to 60 minutes. However, the plasma bupivacaine level between 5 to 10 minutes and 60 to 90 minutes in our study were significantly changed (p = 0.00 and 0.02 respectively). We postulated that the blood level started rising within 10 min and reached its peak at 60 min before decreasing. Conclusion: Peak plasma concentrations of bupivacaine were demonstrated at 60 minutes after single shot femoral nerve block, and no signs and symptoms of bupivacaine toxicity
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Functional outcome of open distal femoral fractures managed with lateral locking plates
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DoD SSI (Surgical Site Infections)
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Purpose: This prospective study evaluated the functional outcome and union rates of open distal femoral fractures managed with anatomic lateral locking plates. Methods: Thirty-four patients with open distal femur fractures with mean age of 40.8 years (range 20–65 years) were included in the study. Patients with Gustilo–Anderson grade IIIC fractures and those managed with non-locking modalities were excluded. In total, 70.6% (n = 24) of the fractures were Type IIIA and 55.9% (n = 19) were AO/OTA Type C3 fractures. In 23.5% (n = 8) patients, knee spanning external fixator was applied initially before definitive fixation. Patients were followed up for a mean period of 11.6 months (range 8–22.5 months). Functional outcome was evaluated using Sanders Score. Results: In the primary plating group, 69.2% (n = 18) fractures united at an average of 27 weeks (range 21–40 weeks), while eight patients had non-union and required bone grafting. All eight patients with external fixator underwent lateral locked plating with bone grafting and united at an average time of 39.6 weeks (range 31–50 weeks). There were two cases each of infection and screw failure. The final mean Sanders Score was 30.1 (range19–40) with 73.5% (n = 25) patients having good to excellent functional outcomes. Conclusions: Lateral locking plates offer excellent stability to allow fracture union in open distal femoral fractures. A proactive approach to identify and manage potential healing difficulties is advisable to promote bone healing.
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The role of imaging in osteoarthritis
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OAK 3 - Non-arthroplasty tx of OAK
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Osteoarthritis (OA) is the most prevalent joint disorder with no approved disease-modifying treatment available. The importance of imaging in assessing all joint structures involved in the disease process, including articular cartilage, meniscus, subarticular bone marrow, and synovium for diagnosis, prognostication, and follow-up, has been well recognized. In daily clinical practice, conventional radiography is still the most commonly used imaging technique for the evaluation of a patient with known or suspected OA and radiographic outcome measures are still the only approved end point by regulatory authorities in clinical trials. The ability of magnetic resonance imaging (MRI) to visualize all joint structures in three-dimensional fashion including tissue ultrastructure has markedly deepened our understanding of the natural history of the disease. This article describes the roles and limitations of different imaging modalities for clinical practice and research in OA, with a focus on radiography and MRI and an emphasis on the knee joint. © 2014 Elsevier Ltd. All rights reserved.
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Meniscus allograft transplantation: a comparison of medial and lateral procedures
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AMP (Acute Meniscal Pathology)
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BACKGROUND: Because of the anatomic and biomechanical differences between the lateral and medial menisci, it is believed that the indications, combined injuries, techniques, and outcomes of the 2 meniscus allograft transplantation (MAT) procedures may be different.
HYPOTHESIS: Medial meniscus transplantation (medial group) usually combines concomitant surgeries, such as anterior cruciate ligament (ACL) reconstruction, so the medial group will have worse clinical results than the lateral group (lateral meniscus transplantation).
STUDY DESIGN: Cohort study; Level of evidence, 3.
METHODS: A retrospective study was conducted on 91 patients who underwent MAT (lateral group, n = 56; medial group, n = 35). There were 33 patients with an absence of a concurrent injury (isolated group) and 58 patients with the presence of a concurrent injury (combined group). The mean follow-up was 40 months (range, 24-125 months). Clinical outcomes for range of motion (ROM), visual analog scale (VAS) for pain score, International Knee Documentation Committee (IKDC) subjective score, Lysholm score, and Tegner activity score were evaluated, and an objective evaluation was performed using magnetic resonance imaging (MRI) and second-look arthroscopic surgery.
RESULTS: At final follow-up, the mean results for ROM, VAS score, IKDC subjective score, Lysholm score, Tegner activity score, and patient subjective satisfaction were not statistically different between the lateral and medial groups (P > .05). The VAS and Lysholm scores of the isolated group were significantly better than those of the combined group. Follow-up MRI was performed on 35 patients (24 in the lateral group and 11 in the medial group). Mean graft extrusion was 1.7 mm in the lateral group and 2.6 mm in the medial group (P = .075). The relative percentage of extrusion was 19.4% in the lateral group and 32.0% in the medial group (P = .011). Anterior cruciate ligament reconstruction occurred more commonly in the medial group, and cartilage procedures occurred more commonly in the lateral group.
CONCLUSION: The clinical results of the lateral group were not different from those of the medial group. More graft extrusion was found in the medial group on MRI, and second-look arthroscopic surgery results of the lateral group were not as good as those of the medial group. The VAS and Lysholm scores of the combined group were worse than those of the isolated group. With regard to concomitant surgery, ACL reconstruction was most common in the medial group and cartilage procedures in the lateral group.
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Soft-tissue reconstruction in orthopedic surgery
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Panniculectomy & Abdominoplasty CPG
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A wide variety of tissues are now available for closing soft-tissue defects of all sizes. The choice of the donor site is dictated by the size and shape of the defect, the proximity of blood and nerve supply in the recipient area, and the need for primary or secondary bone grafting or lengthening. The position and orientation of the vascular and nerve supplies must be documented carefully to prevent damage during the secondary elevation of the flap for bone grafts, revisions, or the placement of distracting or immobilizing pins.
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The Comparative Efficacy of Peri-articular and Intraarticular Tranexamic Acid in Total Knee Arthroplasty
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OAK 3 - Non-arthroplasty tx of OAK
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Patients scheduled for unilateral primary TKA; 108 patients were randomly assigned to receive periâ?articular TXA, intraarticular TXA and control group. 36 patients received either: (I) 15 mg/kg periâ?articular TXA combined with multimodal local anesthetic infiltration (bupivacaine, morphine, ketorolac and epinephrine) into the anterior soft tissue, medial gutter area, lateral gutter area prior to capsular closure and tourniquet deflation (group 1). (II) 2 g of intraarticular TXA after complete capsular closure just before tourniquet deflation (group 2). (III) Don't receive any route of TXA in control group (group 3). Hemoglobin (Hb) concentrations were measured at 24 and 48 hour, and the number of blood transfusions and knee circumference measurements were recorded. Serum TXA was recorded at 2 and 24 hours after operation. The reviewers were blinded to treatment group.
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Comparative analysis of intramedullary nail fixation versus casting for treatment of distal radius fractures
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Distal Radius Fractures
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PURPOSE: Intramedullary fixation is one treatment option for distal radius fractures. Our purpose was to compare the outcomes of intramedullary nailing to those of casting for these injuries.
METHODS: From 2006 to 2009, we reviewed 63 adult patients with isolated distal radius fractures. Thirty-one patients had surgical fixation with an intramedullary device (IMN group) within 4 weeks of the injury, and 32 (cast group) had casting as definitive treatment of the fracture. Clinical outcomes (grip strength; Disabilities of the Arm, Shoulder, and Hand scores; active wrist range of motion; and complications) and radiographic indices (radial inclination, radial height, ulnar variance, and tilt) of both groups were analyzed for the 1-, 2-, 4-, 6-, and 12-month follow-up periods.
RESULTS: The flexion-extension arc was significantly higher in the IMN group than in the cast group at 2-, 6-, and 12-month follow-up. The IMN group exhibited significantly greater grip strength and lower DASH scores throughout the follow-up period. At final follow-up, all radiographic indices were significantly better in the IMN group than in the cast group. There was no significant difference between the initial reduction to final position in the IMN group, but the cast group showed an increase in ulnar variance and a significant change in dorsal-volar tilt. In addition, the cast group experienced more clinical complications in the delayed period compared to the IMN group.
CONCLUSIONS: Intramedullary nail fixation, as compared to casting, results in less functional disability, not only in the early postoperative period but also up to a year after treatment. On the basis of our data, intramedullary fixation should be considered for patients with unstable extra-articular or simple intra-articular distal radius fractures.
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(Effect of early rehabilitation on the hip joint function in patients with comminuted posterior wall fractures of the acetabulum after internal fixation) [Chinese - simplified characters]
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Management of Hip Fractures in the Elderly
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BACKGROUND: Treatment for acetabular fracture becomes a hot point in orthopaedic trauma, but ignorance of rehabilitative treatment that effect therapeutic efficacy is to be seen repeatedly. Normative rehabilitation therapy is one indispensable procedure of acetabular fracture treatment. OBJECTIVE: To investigate the effect of early rehabilitation on the hip joint function in patients with comminuted posterior wall fractures of the acetabulum after internal fixation. METHODS: Forty patients of comminuted posterior wall fractures of the acetabulum at the Department of Orthopedics, Third Hospital of Hebei Medical University, were selected, including 36 males and 4 females, aged 23 to 61 years, mean aged 35.3 years. All patients were randomly divided into rehabilitation and control group, with 20 patients in each group. All the patients were fixed with reconstruction plate, the patients in the rehabilitation group received early standard rehabilitation exercises intervention and those in control group received usual care. The clinical result was evaluated with the scores of Merle d'Aubigne and Postel. RESULTS AND CONCLUSION: The scores of Merle d'Aubigne and Postel of the rehabilitation group were (13.10 +/- 2.05), (14.50 +/- 1.32), and (15.80 +/- 1.36) points at months 3, 6, and 12 after operation, which were greater than those of the control group (11.20 +/- 2.80), (13.00 +/- 2.10), and (14.25 +/- 1.74) points, respectively (p < 0.05). The early rehabilitation exercises may improve the hip joint function for patients of the comminuted posterior wall fractures of the acetabulum after surgery
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Preparing and responding to major accidents and disasters
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DoD PRF (Psychosocial RF)
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After major incidents and disasters psychosocial support for the people affected is urgent and sometimes predominant. To plan and train staff for psychosocial intervention European and national guidelines have been developed. The European Policy Paper "Psychosocial support in situations of mass emergencies" offers guidance for policy-makers and health-planners. The quality and time of early psychosocial interventions after a traumatic event are important factors for the coping capacity of the people affected. To meet the needs of those affected crisis intervention teams for psychosocial acute care have been established and trained in almost all federal provinces of Austria acccording to the principles of the Policy Paper.
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The "Good, Bad and Ugly" pin site grading system. A reliable and memorable method for documenting and monitoring ring fixator pin sites
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DoD SSI (Surgical Site Infections)
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Although there is much in the literature regarding pin site infections, there is no accepted, validated method for documenting their state. We present a system for reliably labelling pin sites on any ring fixator construct and an easy-to-remember grading system to document the state of each pin site. Each site is graded in terms of erythema, pain and discharge to give a 3-point scale, named "Good", "Bad" and "Ugly" for ease of recall. This system was tested for intra- and inter-observer reproducibility. 15 patients undergoing elective limb reconstruction were recruited. A total of 218 pin sites were independently scored by 2 examiners. 82 were then re-examined later by the same examiners. 514 pin sites were felt to be "Good", 80 "Bad" and 6 "Ugly". The reproducibility of the system was found to be excellent. We feel our system gives a quick, reliable and reproducible method to monitor individual pin sites and their response to treatment. Crown Copyright © 2009.
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Blood loss in total knee arthroplasty
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Surgical Management of Osteoarthritis of the Knee CPG
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Over a two-year period, 112 consecutive primary total knee arthroplasties (TKA) were performed according to a standard protocol and were evaluated to determine the effects of intraoperative tourniquet deflation, suction drainage, and immediate continuous passive motion (CPM) on blood loss and the need for blood transfusions. It has been reported that these measures lead to increased morbidity following TKA. The tourniquet was deflated before closure, hemostasis was obtained, and two suction drains were placed for 24 to 48 hours. CPM was started immediately, and continued for a mean of seven days. Serial hematocrits (Hct) were obtained. Mean age of the 64 males and 48 females was 65 years. The diagnosis was osteoarthritis in 86% and rheumatoid arthritis in 14%. Seventy-three percent of the prostheses were cemented and 27% were uncemented. The mean tourniquet time was 104 minutes and the mean length of surgery was 140 minutes. Blood loss measured at surgery averaged 222 ml. Total calculated blood loss averaged 794 ml, but was higher for patients with a cemented versus uncemented prosthesis (p less than .05), and males versus females (p less than .005). It was not related to diagnosis, tourniquet time, or length of surgery. Of the 38% of patients requiring a transfusion (mean, 2.2 units), there was not a significantly greater drop in Hct (from 36.6 to 26.5; change, 10.1) when compared to patients not receiving a transfusion (from 43.1 to 32.5; change, 10.6). Therefore, the need for transfusion was related to preoperative Hct and not the intraoperative or postoperative blood loss.(ABSTRACT TRUNCATED AT 250 WORDS)
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Does the surgery time affect the final outcome of type III supracondylar humeral fractures?
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Pediatric Supracondylar Humerus Fracture 2020 Review
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INTRODUCTION: Supracondylar humeral fractures are common in the pediatric population, with displaced fractures requiring operative intervention. The purpose of this study was to look at our practice and assess whether a difference in clinical outcomes and requirement for open reduction was observed if surgery was delayed. METHODS: This was a retrospective medical record and plain radiograph review of patients admitted with type III Gartland supracondylar fractures between January 2014 and December 2015. The patients were seen for up to 12 months postoperatively, and clinical assessment was performed at this stage. RESULTS: There were 116 supracondylar humeral fractures admitted between January 2014 and December 2015, 23 of which were Gartland type III. The mean age of the patients was 6 years, and the mean time from emergency department presentation to surgery was 14Â h. Seven of the 23 patients required conversion to open reduction. There were no reported complications and all fractures demonstrated radiographic union. The length of time to surgery did not increase the number of cases requiring open reduction. The results demonstrated that there was no difference in clinical outcomes found between those that had closed manipulation or required conversion to open reduction, nor the time taken to surgery. CONCLUSION: This study suggest that patients who present with type III supracondylar humeral fractures and have no neurovascular deficit, a delay in pinning of 12Â h or more may not result in a significant difference in the need for open reduction or clinical outcomes. LEVEL OF EVIDENCE: Level IV.
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Carpal tunnel syndrome: evaluation of median nerve circulation with dynamic contrast-enhanced MR imaging
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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PURPOSE: To identify mechanism(s) responsible for carpal tunnel syndrome (CTS). MATERIALS AND METHODS: At dynamic gadolinium-enhanced magnetic resonance (MR) imaging, the enhancement pattern of the sagittal section of the median nerve in 10 wrists of nine patients with CTS (two men and seven women, aged 43-60 years [mean, 52 years 10 months]) was studied while each wrist was in a neutral, flexed, and/or extended position. Five asymptomatic volunteers (four men and one woman, aged 23-54 years [mean, 31 years 5 months]) also underwent MR imaging to establish the normal enhancement patterns. RESULTS: Two distinctly abnormal patterns of median-nerve enhancement were revealed: marked or no enhancement. Marked enhancement was attributed to nerve edema, and the lack of enhancement was attributed to ischemia. Marked enhancement changed to no enhancement changed to no enhancement when the wrists were in a flexed or extended position. This change was associated with an aggravation of the symptoms of CTS. CONCLUSIONS: CTS may result from a circulatory disturbance rather than from deformation or compression of the nerve
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Long-term results of remodeling of lateral condylar prominence after lateral closed-wedge osteotomy for cubitus varus
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The Treatment of Pediatric Supracondylar Humerus Fractures AUC
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BACKGROUND: Despite the ability of lateral closed-wedge osteotomy for cubitus varus deformity to restore carrying angle and preserve elbow motion, there have been reports of poor cosmetic appearance of the elbow because of lateral condylar prominence. METHOD: We evaluated long-term results of remodeling of lateral condylar prominence after osteotomy in 11 patients (7 of the prepuberty group, 4 of the postpuberty group). The follow-up period ranged from 4.7 to 14.2 years (average, 10). RESULTS: The mean preoperative and postoperative lateral condylar prominence index (LCPI) of the affected elbow were -1.2% and 36%, respectively. At final follow-up, the mean LCPI of the corrected elbow was 11.1%. In the prepubertal group, the mean LCPI decreased from 41.2% after surgery to 5.2% at final follow-up, whereas it decreased from 26.8% to 21.3% in the postpubertal group. The difference in reduction between the mean postoperative LCPI and the mean LCPI at final follow-up in the prepubertal group (36%) was greater than in the postpubertal group (5.4%) (P = .006). CONCLUSION: Lateral closed-wedge osteotomy is a relatively simple and effective procedure for correction of cubitus varus deformity before puberty, allowing cosmetically pleasing remodeling of lateral condylar prominence
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An electrophysiological exploration of the double crush hypothesis
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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The double crush hypothesis has not been rigorously evaluated in humans. We therefore analyzed cases of C6, C7, and C8 radiculopathy and exploited the fact that the median sensory response is of C6/C7 origin and the median motor response is primarily of C8 origin. We hypothesized that C6 and/or C7 cases would demonstrate an increased frequency of median mononeuropathy by sensory criteria, and C8 cases would demonstrate an increased frequency of median mononeuropathy by motor criteria. We also hypothesized that median sensory and motor response parameters among these same groups would be altered in ways consistent with a proximal influence on distal nerve conduction studies. Although median mononeuropathy was unexpectedly common (22.1%) among cases of cervical radiculopathy (which may explain the clinical acceptance of the double crush hypothesis), none of the hypotheses was supported. This study identified no evidence to support a neurophysiological explanation for the double crush hypothesis
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Nonoperative treatment of rotator cuff tears
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Optimizing the Management of Full-Thickness Rotator Cuff Tears
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In this study, 33 patients with full-thickness tears of the rotator cuff were given a supervised nonoperative program of rotator strengthening exercises and then were seen at followup an average of 3.8 years later. Of the 14 patients who were dissatisfied with nonoperative care, 12 eventually had opted for surgery and 2 were dissatisfied with their status at followup. In attempting to identify patients who would benefit from nonoperative care, the authors were unable to show that individual parameters such as rotator strength, symptom duration, or functional impairment were useful to predict outcome. However, it was found that those who have an insurance claim or who experience significant sleep loss due to shoulder pain are unlikely to be satisfied with nonoperative treatment. Patient satisfaction with nonoperative treatment is best correlated with improved pain relief, the ability to carry a 10- to 15-pound suitcase at one's side, the ability to use the arm at shoulder level, and the ability to eat using a utensil. Objective variables such as rotator strength and active motion are not correlated with ultimate patient satisfaction
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Interventions for treating acute elbow dislocations in adults
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SR for PM on OA of All Extremities
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Background: Dislocation of the elbow joint is a relatively uncommon injury.Objectives: To assess the effects of various forms of treatment for acute simple elbow dislocations in adults.Search methods: We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (April 2011), the Cochrane Central Register of Controlled Trials (The Cochrane Library, 2011 Issue 1), MEDLINE (1948 to March Week 5 2011), EMBASE (1980 to 2011 Week 14), PEDro (April 2011), CINAHL (April 2011), various trial registers, various conference proceedings and bibliographies of relevant articles.Selection criteria: Randomised or quasi-randomised controlled trials of conservative and surgical treatment of dislocations of the elbow in adults. Excluded were trials involving dislocations with associated fractures, except for avulsion fractures.Data collection and analysis: Data extraction and assessment of risk of bias were independently performed by two review authors. There was no pooling of data.Main results: Two small randomised controlled trials, involving a total of 80 participants with simple elbow dislocations, were included. Both trials were methodologically flawed and potentially biased.One trial, involving 50 participants, compared early mobilisation at three days post reduction versus cast immobilisation. At one year follow-up, the recovery of range of motion appeared better in the early mobilisation group (e.g. participants with incomplete recovery of extension: 1/24 versus 5/26; risk ratio 0.22, 95% confidence interval 0.03 to 1.72). However, the results were not statistically significant. There were no reports of instability or recurrence. One person in each group had residual pain at one year.The other trial, involving 30 participants, compared surgical repair of the torn ligaments versus conservative treatment (cast immobilisation for two weeks). At final follow-up (mean 27.5 months), there were no statistically significant differences between the two groups in the numbers of patients who considered their injured elbow to be inferior to their non-injured elbow (10/14 versus 7/14; RR 1.43, 95% CI 0.77 to 2.66) or in other patient complaints about their elbow such as weakness, pain or weather-related discomfort. There were no reports of instability or recurrence. There were no statistically significant differences between the two groups in range of motion of the elbow (extension, flexion, pronation, and supination) or grip strength at follow-up. No participants had neurological disturbances of the hand but two surgical group participants had recurrent dislocation of the ulnar nerve (no other details provided). One person in each group had radiologically detected myositis ossificans (bone formation within muscles following injury).Authors' conclusions: There is insufficient evidence from randomised controlled trials to determine which method of treatment is the most appropriate for simple dislocations of the elbow in adults. Although weak and inconclusive, the available evidence from a trial comparing surgery versus conservative treatment does not suggest that the surgical repair of elbow ligaments for simple elbow dislocation improves long-term function. Future research should focus on questions relating to non-surgical treatment, such as the duration of immobilisation
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The giant aggressive chondroma: A rare entity, a difficult approach
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MSTS 2022 - Metastatic Disease of the Humerus
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Introduction: enchondromas rarely exceed 3-6cm in long bones. Although the risk of developing secondary chondrosarcoma has been reported up to 4% in solitary lesions, it is not known if size represents a risk factor for transformation.
Objective: to describe three exceptional cases of enchondromas of the entire femur whereof one dedifferentiated in chondrosarcoma.
Results: two patients present stable disease at 5 and 6 years of follow-up; the third, already diagnosed with a dedifferentiated chondrosarcoma, died 14 months after the index surgery for systemic disease.
Conclusion: based on these observations, our hypothesis is that lesion size is an important risk factor for malignant transformation.
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Posterior minimally invasive plate osteosynthesis for humeral shaft fractures
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Distal Radius Fractures
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Fractures of the humeral shaft are common. Most of them can be successfully treated without surgery. In some cases, an operative intervention may offer faster and better functional results. One of the major problems with the open plating osteosynthesis is the extensive soft tissue stripping and disruption of periosteal circulation, caused by extensive surgical exposure, resulting in a relatively high rate of nonunion. Minimally invasive plate osteosynthesis (MIPO) techniques were developed to achieve a biologic fixation, although minimizing the complications of an open reduction. The incisions are small and remote from the fracture site to avoid direct fracture exposure. Thereby, MIPO technique obtains, theoretically, higher rates of union, lower infection risk, and decreases the need for bone graft. In the last years, MIPO has gained popularity with satisfactory clinical outcomes in the treatment of long bone fractures, especially in lower extremity. MIPO for humeral shaft fractures, however, could be a surgically dangerous procedure because of the risk of radial nerve injury. It was described by anterior and lateral approach. Humeral middle shaft fractures are possible to treat with a MIPO technique through an anterior, lateral, or a posterior approach. However, when the fracture is near the olecranon fossa, anterior approach is not possible as there is not enough space in the distal fragment to insert the amount of screws required to achieve stability. In this case, the posterior approach may be a good option for treatment. This article describes the MIPO technique through a posterior approach for the treatment of humeral shaft fractures.
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A turbulent year at the agency
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MSTS 2018 - Femur Mets and MM
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If there's a positive message to take away from the FDA's seemingly endless troubles in 2005, it may be that smaller companies are increasingly registering on the agency's radar. © 2006 Nature Publishing Group.
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A randomized controlled trial evaluating an alternative mouse or forearm support on change in median and ulnar nerve motor latency at the wrist
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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Background The purpose of this study was to determine the effects of an alternative mouse and/or a forearm support board on nerve function at the wrist among engineers. Methods This randomized controlled intervention trialfollowed 206 engineers for 1 year. Distal motor latency (DML) at baseline and follow-up was conducted for the median and ulnar nerves at the right wrist. Results One hundred fifty-four subjects agreed to a nerve conduction study at the beginning and end of the study period. Those who received the alternative mouse had a protective effect (OR = 0.47, 95% CI 0.22-0.98) on change in the right ulnar DML. There was no significant effect on the median nerve DML. The forearm support board had no significant effect on the median or ulnar nerve DML. Conclusions In engineers who use a computer for more than 20 hr per week, an alternative mouse may have a protective effect for ulnar nerve function at the wrist. No protective effect of a forearm support board was found for the median nerve. (copyright) 2009 Wiley-Liss, Inc
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Arthroscopy-assisted tibial plateau fracture surgery - Minimum 2 years follow up results
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DoD SSI (Surgical Site Infections)
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Background: Accurate anatomical reduction plays a crucial role in the surgical management of tibial plateau fractures. Arthroscopic visualization of the articular surface can allow for a precise reduction. Objectives: To evaluate the outcome of arthroscopy-assisted reduction and internal fixation for tibial plateau fractures, Schatzker Type III to VI. Methods: Thirty-five patients with tibial plateau fractures treated by arthroscopy-assisted fixation were enrolled in this prospective study. According to the Schatzker classification, the fractures types were as follows: type III (n=15); type IV (n=6); type V (n=8); type VI (n=6). The mean age was 36 years (range 24–58 years). The mean follow-up period was 38 months (range, 26–72 months). During surgery, initial arthroscopic evaluation was done, followed by provisional reduction using fluoroscopy. Subsequently, a final arthroscopic confirmation was done before definitive fixation. Bone grafting was done in all except 6 patients. Clinical and radiologic outcomes were scored by the Knee society score and Rasmussen system. Results: The Knee society functional score and Knee society knee score assessed at 6 months, 1 year and 2 years. Final follow up results showed good to excellent outcome in three out of four patients. With increasing severity of injury (from Schatzker types III to VI), the functional score deteriorated. The Rasmussen's Radiological Score at 24 months showed good to excellent scores in 86% individuals. The association between the condylar widening and functional score was found to be significant (p value < 0.05). The radiological and functional scoring was found to have a percentage agreement of 24%. Persistence of condylar widening had a less favorable functional outcome. Postoperative wound breakdown and infection are among major complications. Conclusions: Arthroscopic assisted fracture fixation for complex tibial plateau fractures with associated soft-tissue injuries is a safe and effective procedure that provides good functional outcomes.
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Combined arcus marginalis release, preseptal orbicularis muscle sling, and SOOF plication for midfacial rejuvenation
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Upper Eyelid and Brow Surgery
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Improvements have been made throughout the history of medicine, causing physicians to abandon a technique or medications clearly shown to be suboptimal. Unfortunately, this has not happened with rejuvenative surgery. Conventional lower eyelid procedures continue to include removal of orbital fat in most cases, and facelift procedures remain primarily a lateral vector pull. The unfortunate results of these traditional procedures are becoming easy to recognize. Optimal rejuvenation of the lower eyelid complex should be based on the principle that the contour changes characterizing aging involve not only prolapse of orbital fat, but also descent of the cheek tissues, resulting in accentuation of the orbital rim and tear trough groove. Although the necessity of preserving fat and repositioning the soft tissues of the midface has been widely accepted, there still is wide disagreement among authors as to the best approach and surgical technique. This report describes a surgical technique for lower lid midfacial rejuvenation that is a composite of several previously published approaches with some modifications, particularly in the way the Sub-Superficial Musculo Aponeurotic System (SMAS) fat pad is plicated and the midfacial tissues suspended. The technique is simple and safe, resulting in a pleasing natural midface contour.
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Vitamin D supplementation in cutaneous malignant melanoma outcome (ViDMe): a randomized controlled trial
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Reconstruction After Skin Cancer
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Background: Previous studies have investigated the protective effect of vitamin D serum levels, at diagnosis and during the follow-up period after treatment, on melanoma outcome. In the present study we assess whether vitamin D supplementation, in the follow-up period after diagnosis and surgical resection of the primary tumor, has a protective effect on relapse of cutaneous malignant melanoma and whether this protective effect correlates with vitamin D levels in serum and Vitamin D Receptor immunoreactivity in the primary tumor. Methods/design: This study is a multicenter randomized double blind placebo- controlled phase III trial. Patients between the age of 18 and 80years diagnosed and treated surgically for a melanoma stage IB-III are eligible for randomization in a 1:1 ratio to active treatment or placebo. The study drug is taken each month and consists of either 100,000 International Unit cholecalciferol or arachidis oleum raffinatum used as a placebo. The primary endpoint is relapse free survival. The secondary endpoints are 25 hydroxyvitamin D3 serum levels at diagnosis and at 6month intervals, melanoma subtype, melanoma site and stage of melanoma at diagnosis according to the 2009 American Joint Committee on Cancer melanoma staging and classification. At randomization a bloodsample is taken for DNA analysis. The study is approved by the local Ethics Committees. Discussion: If we can confirm our hypothesis that vitamin D supplementation after removal of the tumor has a protective effect on relapse of cutaneous malignant melanoma we may reduce the burden of CMM at several levels. Patients, diagnosed with melanoma may have a better clinical outcome and improved quality of life. There will be a decrease in health care costs related to treatment of metastatic disease and there will be a decrease in loss of professional years, which will markedly reduce the economic burden of the disease. Trial registration: Clinical Trial.gov, NCT01748448 , 05/12/2012 Copyright â? 2017 The Author(s).
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1 |
Ethnic and racial differences in patients with Ewing sarcoma
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MSTS 2022 - Metastatic Disease of the Humerus
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BACKGROUND: Ewing sarcoma (ES) was a malignant tumor of bone or soft tissue. One of the few risk factors for developing ES is race, with a higher incidence noted in populations of European rather than African or Asian ancestry. The goal of the current study was to evaluate racial and ethnic differences in presentation and overall survival (OS) among patients diagnosed with ES before age 40 years.
METHODS: Data from the Surveillance, Epidemiology, and End Results database identified 1715 patients aged <40 years who were diagnosed with ES between 1973 and 2005. Racial and ethnic group differences were compared using chi-square tests. OS was estimated by Kaplan-Meier analysis and compared using log-rank tests and Cox models.
RESULTS: Black patients had significantly more soft-tissue tumors compared with white non-Hispanic patients (P <.0001). Asian and white Hispanic patients were found to have an intermediate frequency of soft-tissue tumors that also differed from white non-Hispanic patients (P <.0001). White Hispanic patients presented with a higher proportion of larger tumors compared with white non-Hispanic patients (P = .042). Black patients tended to be older than white non-Hispanic patients (P = .012). Sex, frequency of pelvic tumors, and metastatic status did not appear to differ by ethnicity or race. OS was found to differ according to race and ethnicity. Even after controlling for known confounders, OS was significantly worse for black, Asian, and white Hispanic patients compared with white non-Hispanic patients (P = .0031, P = .0182, and P = .0051, respectively).
CONCLUSIONS: Ethnic and racial differences in characteristics and outcomes of patients with ES do exist. Understanding the etiology of these differences will require further study.
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Implementation of a co-managed Geriatric Fracture Center reduces hospital stay and time-to-operation in elderly femoral neck fracture patients
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Hip Fx in the Elderly 2019
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PURPOSE: To evaluate changes in hospital length-of-stay and time-to-operation of older hip fracture patients before and after the foundation of a co-managed Geriatric Fracture Center (GFC).
METHODS: A co-managed GFC was established in a German level-1 trauma center. In a retrospective cohort study, we analyzed femoral neck fracture patients >60 years treated with hemiarthroplasty. Patients treated within the first year after foundation of the GFC were compared to the patients treated during the year before. One-way ANOVA was performed to identify differences regarding time-to-operation and hospital length-of-stay.
RESULTS: One hundred and fourteen patients of the GFC were compared to 169 patients previously treated without co-management. Mean patient age did not significantly differ (81.9 vs. 81.5 years; p = 0.7), nor did gender distribution. Hospital length-of-stay was significantly shorter after foundation of the GFC (13.9 vs. 16.8 days; p = 0.007). The same is true for the interval between hospital admission and operation, which decreased from 3.1 to 2.1 days (p = 0.029). Early surgical complication rate was not significantly affected by GFC foundation (7.7 % pre-GFC vs. 9.6 % GFC; p = 0.6), nor was inpatient mortality (5.9 % pre-GFC vs. 4.4 % GFC; p = 0.6). Subgroup analysis revealed that GFC patients without early surgical complications displayed a reduced length-of-stay (LOS), whereas LOS was even prolonged in GFC patients with surgical complications.
CONCLUSIONS: A co-managed GFC offering an organized fracture program for the elderly can reduce hospital length-of-stay and time-to-operation in hip fracture patients. A significant effect can be observed within the first year after establishment of a GFC.
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Retrograde Intramedullary Nailing for Femoral Shaft Fractures in Elderly Patients with Previous Ipsilateral Dynamic Hip Screw Fixation
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Hip Fx in the Elderly 2019
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PURPOSE: We present our experience in managing femoral shaft fractures in elderly patients with previous ipsilateral dynamic hip screw fixation for extracapsular neck of femur fractures using retrograde intramedullary nailing implants.
METHODS: This was a prospective consecutive study of patients presenting with a femoral shaft fracture and an ipsilateral dynamic hip screw fixation treated with unreamed retrograde femoral nailing. The Wilde modification of the Neer knee score was used as a primary outcome measure.
RESULTS: A total of 16 patients were included (5 males, 11 females), with a mean age of 82 years (range 74-101). All fractures were closed and were due to low-energy trauma. There were 7 patients with 32-A1 fractures, 5 patients with 32-A2 fractures and 4 patients with 32-B1 fractures. All patients had an ipsilateral 4-hole plate dynamic hip screw implant. Minor surgical complications were recorded in 5 patients. Two patients died due to medical complications and were excluded from the final analysis. All remaining 14 patients achieved satisfactory outcomes at 12 months of follow-up with a mean Wilde modification of the Neer knee score of 15.5 (SD 2.53; range 13-20).
CONCLUSIONS: Unreamed retrograde femoral nailing can achieve good functional recovery in elderly patients with a femoral shaft fracture and a previous ipsilateral dynamic hip screw fixation.
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Randomized clinical trial of topical tranexamic acid after reduction mammoplasty
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Reduction Mammoplasty for Female Breast Hypertrophy
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BACKGROUND: The antifibrinolytic drug tranexamic acid is currently being rediscovered for both trauma and major surgery. Intravenous administration reduces the need for blood transfusion and blood loss by about one-third, but routine administration in surgery is not yet advocated owing to concerns regarding thromboembolic events. The aim of this study was to investigate whether topical application of tranexamic acid to a wound surface reduces postoperative bleeding.
METHODS: This was a randomized double-blind placebo-controlled trial on 30 consecutive women undergoing bilateral reduction mammoplasty. On one side the wound surfaces were moistened with 25mg/ml tranexamic acid before closure, and placebo (saline) was used on the other side. Drain fluid production was measured for 24h after surgery, and pain was measured after 3 and 24h. Postoperative complications including infection, seroma, rebleeding and suture reactions were recorded.
RESULTS: Topical application of tranexamic acid to the wound surface after reduction mammoplasty reduced drain fluid production by 39 per cent (median 12.5 (range 0-44) versus 20.5 (0-100) ml; P=0.038). Adverse effects were not observed. There were no significant differences in postoperative pain scores or complications.
CONCLUSION: Topical application of dilute tranexamic acid reduced bleeding in this model. The study adds to the evidence that this simple procedure may reduce wound bleeding after surgery.
REGISTRATION NUMBER: NCT01964781 ( http://www.clinicaltrials.gov).
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Peripheral refraction with different designs of progressive soft contact lenses in myopes
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Upper Eyelid and Brow Surgery
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Aim: The purpose of this study was to compare the changes in relative peripheral refractive error produced by two different designs of progressive soft contact lenses in myopic schoolchildren. Methods: Twenty-seven myopic schoolchildren age between 13 to 15 years were included in this study. The measurements of central and peripheral refraction were made using a Grand-Seiko WR-5100K open-field autorefractometer without correction (baseline), and two different designs of progressive contact lenses (PCLs) (Multistage from SEED & Proclear from Cooper Vision) with an addition power of +1.50 D. Refractive power was measured at center and at eccentricities between 35 masculine temporal to 35 masculine nasal visual field (in 5 masculine steps). Results: Both PCLs showed a reduction in hyperopic defocus at periphery. However, this reduction was only significant for the Multistage PCL (p= 0.015), (Proclear PCL p= 0.830). Conclusion: Multistage PCLs showed greater reduction in peripheral retinal hyperopic defocus among myopic schoolchildren in comparison to Proclear PCLs.
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Cognitive development in children born preterm: Implications for theories of brain plasticity following early injury
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DoD PRF (Psychosocial RF)
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The human brain is functionally altered through experience, a phenomenon known as plasticity. Relevant experiences may be negative, as in brain injury. Adult brain injury results in permanent impairment. However, it has been assumed that early injury leads to substantial functional recovery. Animal studies suggest several predictions regarding whether this principle generally holds true. These studies indicate that the timing of brain injury, relative to the expected course of neurodevelopment, impacts the extent of recovery. Injuries occurring during the period of cell migration are particularly detrimental. However, outcome must be assessed longitudinally because apparent recovery in childhood may reverse as the brain matures. Moreover, recovery of one function may come at the expense of others. Whether these findings characterize outcome following preterm birth is the focus of this review. Preterm birth is associated with high rates of neurodevelopmental disability, primarily due to hypoxic-ischemic events. Periventricular brain structures and white matter tracts are particularly vulnerable to damage. Through school age, preterm children exhibit diminished levels of global intellectual function, attention, memory, and reasoning skills relative to full-term peers. It is questionable whether these deficits persist. Because few studies have followed recent cohorts into young adulthood, it is argued that outcome cannot be reliably described based on the available literature. Moreover, important contributors to later development have been neglected, including both genetic and experiential factors. With improved assessment, it may be possible to develop interventions based on the individual child's constellation of genetic, biological, and sociodemographic risks. Copyright © 2003 Cambridge University Press.
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One-stage revision surgery to treat hip infected nonunion after stabilization with a sliding compression screw
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DoD SSI (Surgical Site Infections)
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INTRODUCTION: Extracapsular hip infected nonunion after stabilization with a sliding hip screw (SCS) is uncommon and a convincing treatment method has not yet been reported in the literature.
PATIENTS AND METHODS: Thirteen consecutive patients who sustained such a disability were treated with removal of SCS, local radical debridement, vancomycin powder with or without gentamicin solution application, re-insertion of a new SCS, and autogenous cancellous bone grafting. Postoperatively, ambulation with regulated weight bearing was encouraged as early as possible. Infectious microorganisms in 76% (10/13) of the lesion sites were oxacillin-resistant staphylococcus aureus (ORSA).
RESULTS: Twelve patients were followed-up for at least 2 years (range, 2~6 years; median, 4 years) and all nonunions healed. The union rate was 100% (12/12) with a median union period of 4 months (range, 3~6 months). No wound infection recurred at the last follow-up. The satisfactory rate of hip function was 92% (11/12, P<0.001).
CONCLUSIONS: We, therefore, recommend this surgical procedure to treat all patients with a similar disability because of its high success rate and low complication rate.
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Predictors of inactive lifestyle among adult survivors of childhood cancer: A report from the Childhood Cancer Survivor Study
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DoD PRF (Psychosocial RF)
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Background: Participation in physical activity is important for childhood cancer survivors, because inactivity may compound cancer/treatment-related late effects. However, some survivors may have difficulty participating in physical activity, and these individuals need to be identified so that risk-based guidelines for physical activity, tailored to specific needs, can be developed and implemented. The objectives of the current study were to document physical activity patterns in the Childhood Cancer Survivor Study (CCSS) cohort, to compare the physical activity patterns with siblings in the CCSS and with a population-based sample from the Behavioral Risk Factor Surveillance System, and to evaluate associations between diagnosis, treatment, and personal factors in terms of the risk for an inactive lifestyle. Methods: Percentages of participation in recommended physical activity were compared among survivors, siblings, and population norms. Generalized linear models were used to evaluate the associations between cancer diagnosis and therapy, sociodemographics, and the risk for an inactive lifestyle. Results: Participants included 9301 adult survivors of childhood cancer and 2886 siblings. Survivors were less likely than siblings (46% vs 52%) to meet physical activity guidelines and were more likely than siblings to report an inactive lifestyle (23% vs 14%). Medulloblastoma (35%) and osteosarcoma (27%) survivors reported the highest levels of inactive lifestyle. Treatments with cranial radiation or amputation were associated with an inactive lifestyle as were being a woman, black race, older age, lower educational attainment, underweight or obese status, smoking, and depression. Conclusions: Childhood cancer survivors were less active than a sibling comparison group or an age- and sex-matched population sample. Survivors who are at risk for an inactive lifestyle should be considered high priority for developing and testing of intervention approaches. (PsycINFO Database Record (c) 2016 APA, all rights reserved)
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Arthroscopy update #1. Treatment of osteochondrosis dissecans of the knee by arthroscopic curettage, follow-up study
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Diagnosis and Treatment of Osteochondritis Dissecans AUC
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Thirty-seven patients with osteochondrosis dissecans involving the femoral condyles of the knee were treated with arthroscopic removal of all partially or completely detached osteochondral fragments and with curettage of the crater to bleeding bone. Ten patients underwent a repeat arthroscopy five to 15 months later. All defects had filled with fibrocartilage
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Factors influencing the range of motion for total knee arthropathy in hemophilic patients
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Surgical Management of Osteoarthritis of the Knee CPG
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Introduction and Objectives: Recurrent hemoarthrosis causes arthropathy in many hemophilic patients, leading to stiff painful joints. Knees and ankles are the major target joints,which start to show symptoms of arthropathy as early as the third decade of life. Currently the only established treatment for severe knee arthropathy is total knee arthroplasty (TKA). However, it is well known amongst surgeons that TKAs in hemophilic patients result in less mobility compared to that in TKA with osteoarthritis. Here, we analyzed data to determine factors affecting the surgical outcome focusing on postoperative range of motion. Materials and Methods: Nineteen hemophilic patients (hemophilia A = 16; hemophilia B = 3; all male) who received 20 TKAs, and who were followed for more than 6 months were included. The grading used was severe=3; moderate=2; mild=2, and 5 had inhibitors. The mean age (plus or minus) SD was 44.0 (plus or minus) 10.8 and mean BMI (plus or minus) SD was 22.9 (plus or minus) 2.9. Range of motion was analyzed thoroughly and the outcome was defined as good when all three, fair when two, poor when one or fewer of the following conditions were satisfied: (1) Flexionnull100(degrees), (2) Flexion contracture null10(degrees), (3) active range of motion (ROM) null80(degrees). We also assessed preoperative ADL i.e. walking with or without assistive devices, perioperative data (operation time, blood loss, gap balance), quadricep and hamstring muscle strength, ambulatory function (80 m test), duration of hospital admission, to evaluate the influence on ROM. Gap balance was measured using Stryker(registered trademark) JDK-mini system. Wilcoxon rank sum test, Fisher's exact test, and Spearman's rank correlation were used appropriately to evaluate statistical significance. Results: The final outcome was good=12; fair=3; poor=5. The average gain in active ROM was 29.3(degrees) (plus or minus) 30.7(degrees). Overall, 16 knees showed a gain in ROM post-operatively. Factors affecting the outcome were preoperative ADL, pre- and intra-operative ROM, and extensor lag on hospital discharge. Hospital stay was significantly shorter for those with better ROM. Neither the gap balance nor muscle strength had any correlation with the final outcome. Conclusions: The study findings show that the mobility of the patient, and pre- and intra-operative ROM are important factors in determining outcome, which gives us suggestions on the timing of TKAs for hemophilic patients. Operations should be carried out while the patients and their knees are mobile
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Median nerve neuralgia caused by a fibrovascular band in the distal forearm
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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A 67-year-old woman had experienced exquisite focal pain and tenderness for more than 1 year in the distal forearm 4.5 cm proximal to the distal wrist crease. Surgical exploration showed a venous fibrovascular band adherent to and transversing the epineurium of the median nerve precisely at the point of maximal tenderness. Resection of the fibrovascular band completely relieved the symptoms of focal pain and tenderness
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Arthroscopic and computer-assisted high tibial osteotomy using standard total knee arthroplasty navigation software
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Surgical Management of Osteoarthritis of the Knee CPG
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Opening-wedge high tibial osteotomy is an increasingly performed procedure for treatment of varus gonarthrosis and correction of malalignment during meniscal transplantation or cartilage restoration. Precise preoperative planning and meticulous surgical technique are required to achieve an appropriate mechanical axis correction. We describe our technique of arthroscopic and computer-assisted high tibial osteotomy using commonly available total knee arthroplasty navigation software as an intraoperative goniometer. We believe that our technique, by providing intraoperative real-time guidance of the degree of correction that is accurate and reliable, represents a useful tool for the surgeon who uncommonly performs high tibial osteotomy
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Pedicled medial sural perforator flap for the reconstruction of knee defects
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PJI DX Updated Search
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Soft tissue defects exposing the patellar tendon or bone are common in patients who have experienced trauma or implant infection. The purpose of this article is to present our experience of six patients who underwent reconstruction of soft tissue defects of the knee using a pedicled medial sural perforator flap. Between November 2013 and November 2015, six patients who presented with a soft tissue defect overlying the knee were admitted to our hospital. After adequate debridement or wide excision of the tumour, these patients underwent pedicled medial sural perforator flap placement to resurface the complex soft tissue defects and to provide a gliding surface for the exposed patellar tendon. The patients' age, comorbidity, aetiology, defect size and location, flap size, perforator numbers and lengths, outcome and follow-up period were reviewed. The six medial sural perforator flaps survived completely, and the wounds healed satisfactorily over a mean follow-up of 21.5 months (range, 6-51 months). Donor sites were closed primarily or covered with a split-thickness skin graft. The medial sural perforator flap is a reliable flap for coverage of defects overlying the knee. The thin and pliable flap, long pedicle length and less donor site mobility benefit patients. Thus, the medial sural perforator flap may be a valuable alternative for defect reconstructions overlying the knee, which produces satisfactory results both functionally and cosmetically
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Reconstruction of the anterior cruciate ligament: timing of surgery and the incidence of meniscal tears and degenerative change
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AMP (Acute Meniscal Pathology)
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We reviewed 183 patients who had undergone reconstruction of the anterior cruciate ligament. The incidence of meniscal tears and degenerative change was assessed and related to the timing from injury to surgery. Degenerative change was scored using the French Society of Arthroscopy system. The patients were divided into an early (surgery within 12 months of injury) and a late group (surgery more than 12 months from injury). The late group was also subdivided into four groups of 12-month periods ranging from one year to more than four years after injury. There was a significantly higher incidence of meniscal tears in patients undergoing reconstruction after 12 months compared with those in the early group (71.2% vs 41.7%; p < 0.001). This was due to a large increase in medial meniscal tears in the late group. An increased incidence of degenerative change was also found in the late group (31.3% vs 10.7%; p < 0.001). Analysis of the subgroups showed that the incidence of meniscal tears and degenerative change did not differ significantly when surgery was performed after 12 months from injury. We conclude that reconstruction of the anterior cruciate ligament should be carried out within 12 months of injury to minimise the risk of meniscal tears and degenerative change.
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Investigation of bacterial communities associated with asymptomatic and symptomatic endodontic infections by denaturing gradient gel electrophoresis fingerprinting approach
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Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures
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The purpose of the present study was to investigate the bacterial communities associated with asymptomatic and symptomatic endodontic infections and to compare denaturing gradient gel electrophoresis (DGGE) fingerprinting patterns of these two clinical conditions. The root canal microbiota of teeth associated with asymptomatic or symptomatic periradicular lesions was profiled by the PCR-DGGE method and then compared, taking into consideration the banding patterns. Bacteria were present in all examined cases. Comparative analysis of the two clinical conditions revealed bands that were common to both symptomatic and asymptomatic cases, but most DGGE bands appeared to be unique for each clinical condition. No single band occurred in all profiles. The mean number of bands detected in the 16S rDNA community profiles were 12.1 +/- 9.4 (range 2-29) for symptomatic samples and 6.7 +/- 2.7 (range 2-11) for asymptomatic ones. Clustering methods and principal component analysis of DGGE banding pattern placed the samples according to the presence or absence of symptoms. Four intense bands that were excised from the gel and sequenced showed similarities to species of the Campylobacter genus (found in 5/12 asymptomatic and in 3/11 symptomatic cases), Fusobacterium genus (4/11 symptomatic cases), Acinetobacter genus (5/12 asymptomatic cases), and Enterobacteriaceae family (11/12 asymptomatic and 2/11 symptomatic cases). The profiles of the predominant bacterial community appeared to be unique for each individual. These findings confirm that endodontic infections are polymicrobial and showed that there are significant differences in the predominant bacterial composition between asymptomatic and symptomatic cases
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Meniscal Root Injuries
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AMP (Acute Meniscal Pathology)
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Meniscal root tears are an increasingly recognized injury leading to notable functional limitations, potential rapid cartilage deterioration of the affected compartment, and subsequent risk of total knee arthroplasty if left untreated. Repair of these tears is advised when articular cartilage remains intact because both medial and lateral meniscus root repairs have demonstrated favorable results. Recent literature demonstrates decreased rates of osteoarthritis and arthroplasty after medial meniscus root repair compared with partial meniscectomy and nonsurgical management. The transtibial pull-out repair technique is most commonly used and provides a biomechanically strong suture construct with standard and familiar knee arthroscopy portals. Furthermore, repair has recently been shown to be economically effective by decreasing overall societal healthcare costs when compared with more conservative management strategies. This review outlines the evaluation, treatment, and documented outcomes of meniscal root repair, which is imperative to the preservation of knee function and maintaining quality of life.
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Management of displaced supracondylar fractures of the humerus in children
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DoD SSI (Surgical Site Infections)
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A series of 33 children with displaced supracondylar fractures of the humerus (SFH) were all treated operatively by open reduction and internal fixation or by closed reduction and percutaneous pinning. A follow-up study was performed on average 29 months (range 3-63 months) after the injury. In 18 per cent of cases primary neurovascular injury was observed and confirmed at operation. Of these patients 32 had open reduction and internal fixation by K-wires; in only one case was closed reduction and percutaneous pinning attempted. If there was preoperative neurological deficit, the nerves were visualized; however nerve suture was not required in our series. In one case we had to reconstruct both the brachial and radial arteries because of intimal lesions totally occluding the vessels. The average hospital stay was 9 days, including pin removal, which was usually performed about 4-5 weeks later, at the time of plaster removal. By Innocenti's criteria, 27 of 30 patients reviewed had an excellent result; three had a good result and three patients were lost to follow-up. There were no complications due to the operation, such as wound healing problems, infections or nerve lesions. In the light of our experience and of the good results, we recommend that displaced SFH be managed by open reduction and internal K-wire fixation. Percutaneous pinning is a good alternative method when closed reduction is successful at the first attempt.
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Partridge osteosynthesis: a prospective clinical study on the use of nylon cerclage bands and plates in the treatment of periprosthetic femoral shaft fractures
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Management of Hip Fractures in the Elderly
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OBJECTIVE: To evaluate the clinical use of the Partridge osteosynthesis in periprosthetic femoral fractures. DESIGN AND SETTING: Prospective nonrandomized clinical study. PATIENTS: Over a ten-year period, 222 patients presenting with femoral fractures near the tip of a hip prosthesis were treated with the Partridge system, which employs elevated cerclage nylon bands and flexible elevated nylon plates. Sixty-five fractures were located cranial to the tip of the prosthesis (Whittaker Type I), 116 at the tip (type II), and forty-one distal to the tip of the prosthesis (Type III). The population consisted of 172 female and fifty male patients, with a mean age of 79.5 years. The mean duration between the index procedure and occurrence of the second fracture was 1.5 years. In 78 percent of the patients (173 out of 222), surgery was undertaken within forty-eight hours. Fracture reduction was open, and two nylon plates set at right angles to each other were secured to the femur with six to eight nylon bands. The mean operating time was fifty-five minutes, with an average blood loss of 550 milliliters. RESULTS: There were minor wound healing problems in eighteen patients (12.6 percent); there were no deep wound infections. Thirty-three elderly patients died within the first month from medical complications. Of the 189 remaining patients, 60 percent regained their prefracture functional level within six months postoperatively, whereas 25 percent required a higher level of care. The mean time of the in-hospital stay was thirty-three days. Ninety-three percent of the fractures consolidated with abundant callus during the follow-up period of one year
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Is two-stage reimplantation effective for virulent pathogenic infection in a periprosthetic hip? A retrospective analysis
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PJI DX Updated Search
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AIM: To investigate the effectiveness of two-stage reimplantation using antibiotic-loaded bone cement (ALBC) and the risk factors associated with failure to control periprosthetic joint infection (PJI). METHODS: We retrospectively reviewed 38 consecutive hips managed using two-stage reimplantation with ALBC. The mean follow-up period was 5.4 years (range: 2.5-9 years). RESULTS: The causative pathogens were isolated from 29 patients (76%), 26 of whom were infected with highly virulent organisms. Sixteen patients (42%) underwent at least two first-stage debridements. An increased debridement frequency correlated significantly with high comorbidity (P < 0.001), a lower preoperative Harris hip score (HHS; P < 0.001), antimicrobial resistance, and gram-negative and polymicrobial infection (P = 0.002). Of the 35 patients who underwent two-stage reimplantation, 34 showed no signs of recurrence of infection. The mean HHS improved from 46 +/- 12.64 to 78 +/- 10.55 points, with 7 (20%), 12 (34%), 11 (32%) and 5 (14%) patients receiving excellent, good, fair and poor ratings, respectively. CONCLUSION: The current study demonstrated that two-stage reimplantation could successfully treat PJI after hip arthroplasty. However, the ability of ALBC to eradicate infection was limited because frequent debridement was required in high-risk patients (i.e., patients who are either in poor general health due to associated comorbidities or harbor infections due to highly virulent, difficult-to-treat organisms). LEVEL OF EVIDENCE: Level IV
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Serum and cerebrospinal fluid morphine pharmacokinetics after single doses of intravenous and intramuscular morphine after hip replacement surgery
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AAHKS (8) Anesthetic Infiltration
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AIM: To compare the time course of morphine and metabolite concentrations in serum and cerebrospinal fluid (CSF) after intravenous and intramuscular administration after surgery.
METHODS: This was a randomized double-blind, double-dummy study in patients who had undergone hip replacement surgery. Morphine (M, 10 mg) was administered intravenously (IV) or intramuscularly (IM). Arterial blood and CSF samples (from a spinal catheter) were drawn simultaneously at 10, 30, 60, and 120 min after administration. Morphine and metabolites [morphine-3-glucuronide (M-3-G), morphine-6-glucuronide (M-6-G), and normorphine (NM)] were determined by a validated liquid chromatography-tandem mass spectrometry method.
RESULTS: Thirty-eight patients were included: 13 men and 25 women, 20 in the IV, 18 in the IM group. Serum concentrations of M after 10 min were consistently higher after IM than IV, concentrations of M-3-G and M-6-G after IM surpassed those of IV after 45 min. NM was not found. None of the metabolites was found in CSF. CSF morphine concentrations and CSF/serum concentration ratios were consistently higher after IV compared to IM. The mean AUC(CSF)/AUC(serum) (0-120 min) concentration ratios were 0.18 and 0.09 after IV and IM, respectively.
CONCLUSIONS: The uptake of morphine to the CSF was consistently higher after IV administration than after IM already after 10 min. The higher CSF concentration may be caused by an initially higher morphine blood/CSF gradient following IV morphine injection. The pharmacokinetic findings are compatible with a more rapid and extensive initial effect of IV morphine compared with IM.
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A prospective randomized clinical study of mosaic osteochondral autologous transplantation versus microfracture for the treatment of osteochondral defects in the knee joint in young athletes
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Diagnosis and Treatment of Osteochondritis Dissecans AUC
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PURPOSE: The purpose of this study was to compare the outcomes of mosaic-type osteochondral autologous transplantation (OAT) and microfracture (MF) procedures for the treatment of the articular cartilage defects of the knee joint in young active athletes. TYPE OF STUDY: Prospective randomized clinical study. METHODS: Between 1998 and 2002, a total of 60 athletes with a mean age of 24.3 years (range, 15 to 40 years) and with a symptomatic lesion of the articular cartilage in the knee were randomized to undergo either an OAT or an MF procedure. Only those athletes playing in competitive sports at regional or national levels were included in the study. Fifty-seven athletes (95%) were available for a follow-up. There were 28 athletes in the OAT group and 29 athletes in the MF group. The mean duration of symptoms was 21.32 +/- 5.57 months and the mean follow-up was 37.1 months (range, 36 to 38 months), and none of the athletes had prior surgical interventions to the affected knee. Patients were evaluated using modified Hospital for Special Surgery (HSS) and International Cartilage Repair Society (ICRS) scores, radiograph, magnetic resonance imaging (MRI), and clinical assessment. An independent observer performed a follow-up examination after 6, 12, 24, and 36 months. At 12.4 months postoperatively, arthroscopy with biopsy for histologic evaluation was carried out. A radiologist and a pathologist, both of whom were blinded to each patient's treatment, did the radiologic and histologic evaluations. RESULTS: After 37.1 months, both groups had significant clinical improvement (P < .05). According to the modified HSS and ICRS scores, functional and objective assessment showed that 96% had excellent or good results after OAT compared with 52% for the MF procedure (P < .001). At 12, 24, and 36 months after surgery, the HSS and ICRS showed statistically significantly better results in the OAT group (P = .03; P = .006; P = .006). Younger athletes did better in both groups. No serious complications were reported. There was 1 failure in the OAT group and 9 in the MF group. The ICRS Cartilage Repair Assessment for macroscopic evaluation during arthroscopy at 12.4 months showed excellent or good repairs in 84% after OAT and in 57% after MF. Biopsy specimens were obtained from 58% of the patients and histologic evaluation of repair showed better scores (according to ICRS) for the OAT group (P < .05). MRI evaluation showed excellent or good repairs in 94% after OAT compared with 49% after MF. Twenty-six (93%) OAT patients and 15 (52%) MF patients returned to sports activities at the preinjury level at an average of 6.5 months (range, 4 to 8 months). Others showed a decline in sports activity level. CONCLUSIONS: At an average of 37.1 months (range, 36 to 38 months) follow-up, our prospective, randomized, clinical study in young active athletes under the age of 40 has shown significant superiority of OAT over MF for the repair of articular cartilage defects in the knee. We found that only 52% of MF athletes could return to sports at the preinjury level. Limitations of our study included a small number of athletes and a relatively short (3-year) follow-up. A long-term follow-up is needed to assess the durability of articular cartilage repair using these methods in young active athletes. LEVEL OF EVIDENCE: Level I, Therapeutic study, randomized controlled trial, significant difference (a)
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The timing of ankle fracture surgery and its effect on complications and hostpital stay- A prospective study in a tertiary centre
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DoD SSI (Surgical Site Infections)
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Ankle fracture is one of the most common injuries treated by an orthopaedic surgeon. Ankle fractures are common among young adults especially involved in RTA and extreme or contact sports. The aim of the study was to see whether timing of surgery affects the relative risk of complications and hospital stay following internal fixation of closed ankle fractures. Prospective Hospital based observational study done on 50 patients with closed ankle fractures, both male and female of 18-60 years age groups were treated by operative procedure, 25 patients (Group 1) were operated within 5 days and the other 25 patients were operated after 5 days (Group 2). Type C fractures according to weber classification were most common in both the groups. Complications were more in Group II. In group I, the mean duration of hospital stay was 5.92 days with ranging from 2-8 days. In group II, the mean duration of hospital stay was 8.56 days with ranging from 5-12 days.This study concluded that the timing of surgery affects the recovery and a delay of more than one week gives rise to infections and wound complications, which significantly lowers the final functional outcome including patient satisfaction with increase of financial burden.
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Changes in bone mass and metabolism after surgery for primary hyperparathyroidism
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Management of Hip Fractures in the Elderly
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BACKGROUND AND OBJECTIVE: Bone mass is often reduced in patients with primary hyperparathyroidism (pHPT) and is usually partially reversible after parathyroidectomy. However, site specific and overall skeletal benefits of surgery in mild asymptomatic pHPT remain uncertain. DESIGN: Cross-sectional and longitudinal studies. PATIENTS: Fourteen patients (12 women and 2 men) with pHPT. MEASUREMENTS: Baseline bone mass was assessed at the lumbar spine, left hip and whole body using dual-energy X-ray absorptiometry, and at the left os calcis using broad-band ultrasound attenuation. Changes in bone mass, serum intact PTH and osteocalcin, and urinary pyridinium cross-link excretion were recorded in 10 patients followed for 6 months after surgery. RESULTS: (1) Cross-sectional study: Baseline measurements at the lumbar spine and hip were inversely related to both the serum PTH concentration and the weight of the parathyroid gland removed at surgery. (2) Longitudinal study: Six months after adenectomy, bone mass had increased significantly at the femoral neck, greater trochanter, whole body and os calcis, but not at the lumbar spine or Ward's area. Serum PTH, osteocalcin and pyridinium cross-link excretion all fell significantly after surgery. The percentage increment in whole body bone mineral content at 6 months was proportional to the baseline PTH. CONCLUSION: In primary hyperparathyroidism, preoperative reductions and post-operative gains in bone mass are proportional to the initial serum PTH concentration. Mild primary hyperparathyroidism probably does not cause appreciable bone loss at clinically relevant fracture sites such as the spine and hip, and in such cases the overall skeletal benefits of surgery are likely to be negligible
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Posterior approach vertebrectomy in the thoracolumbar spine with expandable cage reconstruction: Indications and techniques based on eight cases
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Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures
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We present a series of eight patients undergoing circumferential neural decompression and stabilization of the thoracolumbar spine via a single midline posterior approach, with complete vertebrectomy for a variety of indications. Four had primary tumours, two secondary tumours, one patient had tuberculosis and one had delayed deformity due to trauma. This single posterior approach is made possible via the use of an expandable cage that may be expanded in situ to offer anterior and middle column reconstruction. There were no major neurological complications and all patients with deficits improved postoperatively. Extensive posterior fixation was avoided with five patients undergoing a one above/one below fixation and three undergoing a two above/two below fixation. When combined with pedicle screw and rod fixation this anterior reconstruction makes a sound construct. The flexibility of this approach in the thoracolumbar spine, some of the biomechanical advantages and pitfalls are considered. (copyright) The Neurosurgical Foundation
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Relationship between electrodiagnostic severity and neuropathic pain assessed by the LANSS pain scale in carpal tunnel syndrome
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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Objective: The aim of the study was to investigate the relationship between the presence of neuropathic pain assessed by the Leeds Assessment of Neuropathic Symptoms and Signs (LANSS) scale and electrophysiological findings in patients with carpal tunnel syndrome (CTS). Methods: We studied 124 hands with idiopathic CTS with pain complaints involving hand and wrist. All hands were assessed by the LANSS with which a score of 12 or more is defined as pain dominated by neuropathic mechanisms. These hands were assigned to minimal, mild, moderate, severe, or extreme severe groups according to the results of the median nerve conduction studies. Results: A
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Glenohumeral osteoarthritis: overview, therapy, and rehabilitation
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Glenohumeral Joint OA
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PURPOSE: Glenohumeral osteoarthritis (GHOA) is a common cause of pain and functional disability of the shoulder. Despite the limited evidence, there are several options for the treatment of this pathology. The aim of this article is to provide current information on the characteristics of the disease and the pathophysiology, evidence based on medical and surgical treatments with emphasis on the rehabilitation process.
METHODS: It was performed with an extensive literature review, mainly clinical practice guidelines, randomized controlled trials, reviews, focusing on the rehabilitation management.
RESULTS: There are few clinical practice guidelines that address GHOA as a pathology with unique characteristics. Evidence based treatment recommendations are mostly supported by low-quality evidence and experts' opinions, with few high levels of evidence studies guiding treatment decisions.
CONCLUSIONS: Despite the lack of good quality evidence, rehabilitation programs have proven to be efficient and reliable, and this revision provides information and recommendations in this field. Implication of Rehabilitation Glenohumeral osteoarthritis is a common cause of pain and functional disability of the shoulder There are few clinical practice guidelines that address Glenohumeral Osteoarthritis as a pathology with unique characteristics, and recommendations for rehabilitation and therapeutic exercise are poor The paper provides current information on the characteristics of the disease, its rehabilitation process, and could be of interest for rehabilitation professionals to direct their practices in this field.
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Does proximal femoral nail antirotation achieve better outcome than previous-generation proximal femoral nail?
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Hip Fx in the Elderly 2019
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BACKGROUND: There are few studies in the literature comparing the clinical outcomes and radiographic results of proximal femoral nail (PFN) and proximal femoral nail antirotation (PFNA) for pertrochanteric femoral fracture (PFF) in elderly patients.
AIM: To evaluate both clinical and radiographic outcomes after fixation with PFN and PFNA in an elderly patient population.
METHODS: One hundred fifty-eight patients older than 65 years with PFF who underwent fixation with either PFN or PFNA were included. Seventy-three patients underwent fixation with PFN, whereas 85 were fixed with PFNA. The mean follow-up was 2.4 years (range, 1-7 years). Clinical outcome was measured in terms of operation time, postoperative function at each follow-up visit, and mortality within one year. Radiographic evaluation included reduction quality after surgery, Cleveland Index, tip-apex distance (TAD), union rate, time to union, and sliding distance of the screw or blade. Complications including nonunion, screw cutout, infection, osteonecrosis of the femoral head, and implant breakage were also investigated.
RESULTS: Postoperative function was more satisfactory in patients who underwent PFNA than in those who underwent PFN (P = 0.033). Radiologically, the sliding difference was greater in PFN than in PFNA patients (6.1 and 3.2 mm, respectively, P = 0.036). The rate of screw cutout was higher in the PFN group; eight for PFN (11.0%) and two for PFNA patients (2.4%, P = 0.027). There were no differences between the two groups in terms of operation time, mortality rate at one year after the operation, adequacy of reduction, Cleveland Index, TAD, union rate, time to union, nonunion, infection, osteonecrosis, or implant breakage.
CONCLUSION: Elderly patients with PFF who underwent PFNA using a helical blade demonstrated better clinical and radiographic outcomes as measured by clinical score and sliding distance compared with patients who underwent PFN.
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Could external fixator become the ideal choice for the treatment of humeral shaft fracture?
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The Treatment of Pediatric Supracondylar Humerus Fractures AUC
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BACKGROUND: The treatment of humeral fractures remains many disputes, the incidence of radial nerve damage and fracture nonunion is still high, so how to treat complex humeral fracture is a headache problem for doctors
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SKP2 overexpression is associated with increased serine 10 phosphorylation of p27 (pSer10p27) in triple-negative breast cancer
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Reduction Mammoplasty for Female Breast Hypertrophy
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S-phase kinase-associated protein 2 (SKP2) is an important cell cycle regulator, targeting the cyclin-dependent kinase (CDK) inhibitor p27 for degradation, and is frequently overexpressed in breast cancer. p27 regulates G1 /S transition by abrogating the activity of cyclin/CDK complexes. p27 can undergo phosphorylation at serine 10 (pSer10p27). This phosphorylation event is associated with increased cell proliferation and poor prognosis in patients with glioma. The relationship between SKP2 and pSer10p27 in breast cancer has not been previously investigated. Immunohistochemistry (IHC) of SKP2, p27, pSer10p27, and other genes involved in this pathway, was analyzed in 188 breast tumors and 50 benign reduction mammoplasty samples. IHC showed SKP2 to be more highly expressed in estrogen receptor alpha (ERalpha)-negative breast cancers and demonstrated that triple-negative tumors were more likely to have high expression of SKP2 than were non-triple negative, ERalpha-negative tumors. A significant positive relationship was discovered for SKP2 and pSer10p27. High levels of SKP2 and pSer10p27 were observed significantly more often in ERalpha-negative and triple-negative than in ERalpha-positive breast cancers. Use of the triple-negative TMX2-28 breast cancer cell line to address the role of SKP2 in cell cycle progression confirmed that SKP2 contributes to a more rapid cell cycle progression and may regulates pSer10p27 levels. Together, the results indicate that presence of high SKP2 plus high pSer10p27 levels in triple-negative breast cancers is associated with aggressive growth, and highlight the validity of using SKP2 inhibitors as a therapeutic approach for treating this subset of breast cancers.
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The impact of hemocoagulase for improvement of coagulation and reduction of bleeding in fracture-related hip hemiarthroplasty geriatric patients: A prospective, single-blinded, randomized, controlled study
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Hip Fx in the Elderly 2019
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BACKGROUND: Uncontrolled bleeding is associated with poor outcomes and mortality in geriatric patients undergoing hemiarthroplasty. Hemocoagulase agkistrodon is a hemocoagulative, anti-hemorrhagic enzyme complex from Deinagkistrodon acutus snake venom. This study aimed to investigate the efficacy of hemocoagulase agkistrodon on coagulation and bleeding outcomes in fracture-related hemiarthroplasty.
PATIENTS AND METHODS: This was a prospective, single-blinded, randomized controlled trial carried out between October 2013 and September 2014 in 96 geriatric patients undergoing hemiarthroplasty for unilateral femoral neck fracture. Patients were administrated hemocoagulase agkistrodon (n=48) or normal saline (n=48). Intraoperative blood loss, transfusion volume and rate, and drainage were assessed. Hemoglobin (Hb) and coagulation parameters (prothrombin time [PT], thrombin time [TT], plasma fibrinogen [FIB], and activated partial thromboplastin time [aPTT]) were recorded preoperatively and 30min and 1, 3, and 5days after surgery. Complications were followed up for 4 weeks.
RESULTS: Compared to controls, hemocoagulase patients exhibited lower intraoperative blood loss (P<0.01) and postoperative blood loss, total drainage, mean transfusion volume, and transfusion rates (all P<0.05), with lower aPTT at 30min (P<0.05). No significant differences in postoperative FIB were observed. Controls exhibited significantly higher PP and TT on day 1, and Hb on days 1, 3, and 5 (P<0.05). No serious complications were reported.
CONCLUSIONS: Hemocoagulase reduced blood loss and transfusion in fracture-related hip hemiarthroplasty without increasing short-term adverse event rates. In geriatric populations, hemocoagulase could be used for limiting bleeding and related complications.
TRIAL REGISTRATION: This trial is registered in the Chinese Clinical Trial Register (no. ChiCTR-TRC-14004379).
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Acute percutaneous scaphoid fixation
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Distal Radius Fractures
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Fractures of the scaphoid are most common in young men; immobilisation in a cast usually means a long period away from work and athletic activities. Early rigid fixation has been shown to promote a rapid functional recovery, but open reduction and internal fixation is technically demanding with the dangers of damage to the radiocarpal ligaments, the scaphotrapezial joint, and the blood supply of the scaphoid. For minimally displaced or undisplaced B1 or B2 fractures, these problems can be overcome by percutaneous fixation. We report our technique and the results of a pilot study in 15 patients. There was no immobilisation; patients were allowed movement soon after operation, but union was obtained in all at a mean of 57 days (38 to 71). The range of movement after union was equal to that of the contralateral limb and grip strength was 98% of the contralateral side at three months. Patients were able to return to sedentary work within four days and to manual work within five weeks. Our initial results show that percutaneous scaphoid fixation for acute fractures is satisfactory and gives rapid functional recovery.
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Predicting recovery from common whiplash
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DoD PRF (Psychosocial RF)
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The present study aimed to establish criteria for delayed recovery after whiplash injury using a 1-year prospective cohort study. 117 whiplash patients referred from primary care and 16 whiplash patients recruited from the insurance company. At baseline all patients underwent neurological, radiological and psychosocial factors assessment and testing of personality traits, well-being, cognitive ability and cognitive functioning. According to the logistic regression in patients referred from primary care the following initial variables are in significant relationship with poor outcome at 1 year: impaired neck movement, history of pretraumatic headache, history of head trauma, higher age, initial neck pain intensity, initial headache intensity, nervousness score, neuroticism score and test score on focused attention. Employing these variables, correct prediction of outcome at 1 year was found in 88% of patients recruited from the insurance company. Authors conclude that a comprehensive assessment of whiplash patients early after trauma enables physicians to identify patients at risk of delayed recovery.
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Accurate limb-length equalization during total hip arthroplasty
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Management of Hip Fractures in the Elderly
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A method of equalization of limb lengths during total hip arthroplasty (THA) was developed that uses the concept of precise reproduction of the position of the femur in space (abduction/adduction) by use of a carpenter's level. Precise reproduction of the femoral position allows accurate measurement of the distance between the pelvis and femur before hip dislocation and after trial component placement allowing accurate measurement of the change in the distance between the femur and pelvis. Accordingly, limb length can be maintained or adjusted to match the contralateral side with increased accuracy. A prospective study was performed with 117 consecutive patients undergoing THA to assess the accuracy of an intraoperative limb- length measuring device. Patients were sequentially randomized into two groups. Group A patients underwent THA without the use of the measuring device, and group B underwent THA using the device. Radiographic assessments of limb lengths were measured using the method of Williamson and Reckling. The hips in group B had a statistically significant decrease in limb-length inequality after THA compared with group A (P<.01). Average postoperative limb-length inequality was 8.8 mm and 3.4 mm for groups A and B, respectively. Three (5%) of 58 group B patients and 18 (31%) of 59 group A patients had a radiographic postoperative limb-length inequality >12 mm (P<.01) Eighty-four of group B patients had limb lengths within 6 mm of the contralateral side compared with 30% of group A patients. Twenty-four percent of group A patients and 7% of group B patients had a symptomatic limb-length inequality that required a heel lift (P<.01)
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A retrospective cohort study of concomitant ipsilateral extra-capsular and intra-capsular fractures of the proximal femur. Are they casual findings or an undervalued reality?
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Hip Fx in the Elderly 2019
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BACKGROUND: Fractures of the proximal femur constitute a major public health problem, with an annual incidence in Spain of 7.6 cases per 1000 inhabitants over 65 years of age. Hip fractures are frequent in elderly patients, related to osteoporosis and with low energy trauma, which means that they can be considered a geriatric syndrome. Simultaneous ipsilateral extra- and intra-articular hip fractures are considered as very rare are, and generally speaking, classified as extra- or intra-capsular fractures. Moreover, there is no consensus with regard to treatment of these concomitant fractures.
AIM: To estimate the incidence of concomitant ipsilateral extra- and intra-capsular fractures of the proximal femur, and to describe the diagnostic process and the clinical characteristics of these concomitant fractures.
PATIENTS AND METHODS: Retrospective cohort study of patients with hip fractures. The incidence of combined extra- and intra-capsular fractures was estimated, a confidence interval of 95% (95%CI) was calculated and a descriptive analysis was drawn up.
RESULTS: Between May 2010 (the date on which the Orthopaedic and Trauma Surgery Department of our new Hospital began the surgical activity) and December 2016, 33 (median age, 86 years-old) of the 2625 hip fractures were classified as simultaneous extra- and intra-capsular ipsilateral fractures. The overall cumulative incidence was of 1.3% (95%CI:0.9-1.8%). In 32 (97%) of the patients, the fracture was a consequence of a low energy trauma (ground level fall), while the remainder was due to a medium energy trauma (skating). In all cases the two fracture lines seem to be independent of each other, which suggests different mechanisms of injury from that of isolated subcapital or intrertrochanteric fracture.
CONCLUSION: The incidence of concomitant ipsilateral extra- and intra-capsular fractures of the proximal femur must be taken into account in patients over 65 years of age. It is clinically relevant to identify these concomitant fractures in order to arrive at a correct diagnosis, which will facilitate preoperative planning and the choice of the best treatment to achieve a better outcome. Misdiagnosis may cause further problems, such as fixation failures, disability and, in a worst case scenario, an increased risk of death. Therefore, a good and complete preoperative study is important, along with both good quality X-ray projections and 2D and 3D Ct-Scans in case of doubt.
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Rapidly destructive arthrosis of the shoulder joints: radiographic, magnetic resonance imaging, and histopathologic findings
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Glenohumeral Joint OA
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BACKGROUND: Rapidly destructive arthrosis of the humeral head is a rare condition with an elusive pathophysiologic mechanism. In this study, radiographic and histopathologic findings were analyzed to determine the clinical characteristics of this rare condition.
METHODS: We retrospectively analyzed 189 patients who underwent total shoulder arthroplasty from January 2001 to August 2012. Among them, 9 patients showed a particular pattern of rapid collapse of the humeral head on plain radiography and magnetic resonance imaging (MRI) within 12 months from symptom onset. Patients with trauma, rheumatoid arthritis, steroid intake, neurologic osteoarthropathy, osteonecrosis, renal osteoarthropathy, or gout were excluded.
RESULTS: All patients were women, with a mean age of 72.0 years (range, 63-85 years). The right side was involved in 7 cases and the left in 2 cases. The mean duration of humeral head collapse was 5.6 months (range, 2-11 months) from the onset of shoulder pain. Plain radiographs of all patients showed a unique pattern of humeral head flattening, which appeared like a clean surgical cut with bone debris around the humeral head. MRI findings revealed significant joint effusion and bone marrow edema in the humeral head, without involvement of the glenoid. Pathologic findings showed both fragmentation and regeneration of bone matrix, representing fracture healing.
CONCLUSION: The important features of rapidly destructive shoulder arthrosis are unique flattened humeral head collapse with MRI showing massive joint effusion and bone marrow edema in the remnant humeral head. This condition should be considered in the differential diagnosis of elderly women with insidious shoulder pain.
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Perceived exercise self-efficacy as a predictor of exercise behavior in individuals aging with spinal cord injury
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DoD PRF (Psychosocial RF)
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OBJECTIVE: The purpose of this study was to test the hypothesized association between exercise self-efficacy and exercise behavior, controlling for demographic variables and clinical characteristics, in a sample of individuals with spinal cord injuries.
DESIGN: A cross-sectional national survey of 612 community-dwelling adults with spinal cord injury in the United States ranging from 18 to 89 yrs of age was conducted. Sample consisted of 63.1% men with a mean (SD) duration of 15.8 (12.79) yrs postinjury; 86.3% reported using a wheelchair.
RESULTS: Self-efficacy was the only independent variable that consistently predicted all four exercise outcomes. Self-efficacy beliefs were significantly related to frequency and intensity of resistance training (R(2) change = 0.08 and 0.03, respectively; P < 0.01 for all) and aerobic training (R(2) change = 0.07 and 0.05, respectively; P < 0.01 for all), thus explaining between 3% and 8% of the variance. Hierarchical linear regression analysis revealed that controlling for other demographic and physical capability variables, the age-related variables made statistically significant contributions and explained between 1% and 3% of the variance in aerobic exercise frequency and intensity (R(2) change = 0.01 and 0.03, respectively; P < 0.01 for all). Clinical functional characteristics but not demographic variables explained participation in resistance exercise.
CONCLUSIONS: Self-efficacy beliefs play an important role as predictors of exercise. Variations in exercise intensity along the age continuum have implications for exercise prescription and composition. Future research should replicate findings with objective activity measures.
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Age-related bone loss and senile osteoporosis: evidence for both secondary hyperparathyroidism and skeletal growth factor deficiency in the elderly
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Management of Hip Fractures in the Elderly
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Aging is characterized by a decrease in bone volume, implying that net bone resorption exceeds net bone formation. This age-related bone loss can be regarded as the main determinant of hip fracture risk in the elderly. In the concept of senile osteoporosis, a key role has been attributed to vitamin D deficiency. Lack of vitamin D activity may affect femoral strength through impaired mineralization as well as through a hyperparathyroidism-mediated increase in bone resorption. In addition to vitamin D-related mechanisms, recent evidence has indicated a decline in the skeletal content of anabolic growth factors--such as insulin-like growth factor-I (IGF-I)--in femoral (cortical) bone, suggesting that skeletal growth factor deficiency may contribute to the age-related bone loss in the proximal femur as well. It is tempting to speculate that skeletal IGF-I loss might, at least partially, be accounted for by growth hormone deficiency. However, critical evidence does not yet support the concept that the decreased activity of the growth hormone-IGF-I-axis alters bone remodeling, and the extent to which serum concentrations of growth factors are reflective of skeletal activity remains to be clarified
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Clinical evaluation of the effects of whirlpool on patients with Colles' fractures
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Distal Radius Fractures
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A clinical trial was conducted to investigate the efficacy of the whirlpool bath in the treatment of patients with Colles' fractures. The subjects were 24 patients, male and female, aged 40 to 80 years, who were referred to a physiotherapy department for treatment of a Colles' fracture with no other associated condition. The subjects were randomly assigned to one of two treatment groups - 'whirlpool' or 'towel' - following the immobilization phase. Patients in the whirlpool group (n = 12) had their hand, wrist and forearm immersed in the whirlpool for 15 minutes while, in the towel group (n = 12), patients had their hand and wrist wrapped in two towels (at room temperature) for 15 minutes. Following treatment by either modality, both groups of patients received a standard treatment of massage, joint mobilization, and active and resisted exercises. No occupational therapy was given. Pain, oedema, range of motion and strength were measured by independent evaluators before and after the application of the modality. Data were collected over a maximum period of 12 treatment sessions. While whirlpool patients experienced a significant increase in oedema on a short-term basis, no significant long-term differences between the two methods of treatment with regard to pain, oedema, range of motion or strength were noted. Until more definitive evidence on the benefits of whirlpool is provided, the common practice of using the expensive modality of whirlpool baths for the treatment of Colles' fractures post-immobilization is debatable.
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Medicare Accountable Care Organizations and Use of Potentially Low-Value Procedures
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Hip Fx in the Elderly 2019
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OBJECTIVE: To evaluate the effect of Accountable Care Organizations (ACOs) on the use of vertebroplasty and arthroscopic partial meniscectomy, 2 procedures for which randomized controlled trials suggest similar outcomes to sham surgery and therefore may provide low value. Medicare Shared Savings Program ACOs aim to improve quality and decrease health care spending. Reducing the use of potentially low-value procedures can accomplish both of these goals.
METHODS: We performed a retrospective cohort study of patients who underwent potentially low-value orthopedic procedures (vertebroplasty and partial meniscectomy) and a control (hip fracture) from 2010 to 2015 using a 20% sample of national Medicare claims. We performed an interrupted time-series analysis using linear spline models to evaluate the count of each procedure per 1000 patients, stratified by ACO participation.
RESULTS: We identified 76 256 patients who underwent arthroscopic partial meniscectomy, 44 539 patients who underwent vertebroplasty, and 50 760 patients who underwent hip fracture admission. Arthroscopic partial meniscectomy rates decreased, vertebroplasty rates remained stable, and hip fracture rates increased for both groups during the study period, with similar trends among ACO and non-ACO patients. After January 1, 2013, ACO and non-ACO populations had similar trends for vertebroplasty (ACO incidence rate ratio [IRR] = 1.15 [1.08-1.23] vs non-ACO IRR = 1.11 [1.05-1.16]), meniscectomy (ACO IRR = 1.06 [1.01-1.12] vs non-ACO IRR = 1.03 [0.99-1.07]), and hip fracture (ACO IRR = 1.08 [1.01-1.14] vs non-ACO IRR = 1.08 [1.03-1.13]).
CONCLUSIONS: ACOs were not associated with a reduction in the frequency of vertebroplasty and arthroscopic partial meniscectomy.
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1 |
Hardiness: an examination of its relationship with positive and negative long term changes following trauma
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DoD PRF (Psychosocial RF)
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Two models positing direct versus moderating effects of hardiness were examined in relation to long term positive and negative changes following exposure to traumatic stress. Participating in the study were 164 Israeli POWs and a matched group of 184 veterans of the 1973 Yom Kippur War. Participants completed a battery of questionnaires that included the Personal Views Survey (hardiness); the Trait, Attitude, and Behavior Change questionnaire; and questions related to their captivity/war experiences. Findings were consistent with a model that posits moderating effects of hardiness on both long term negative and positive changes. The discussion addresses the possible role of hardiness in relation to negative and positive outcomes of traumatic events.
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Impaired healing of fragility fractures in type 2 diabetes: clinical and radiographic assessments and serum cytokine levels
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Hip Fx in the Elderly 2019
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BACKGROUND: Diabetes induces bone alterations accompanied by altered cytokine expression patterns. These alterations lead to modified fracture healing, contributing to musculoskeletal fragility in the elderly.
AIMS: We evaluated the inflammatory immune response in diabetic patients during fracture healing relative to clinical and radiographic assessments.
METHODS: Fifty patients of both sexes with fragility fractures were studied: 30 diabetics (group A, mean age 73.4 +/- 11.2 years) and 20 normoglycemic controls (group B, mean age 75.1 +/- 16.9 years). Two subgroups comprised those with hip or wrist fragility fractures (25 and 16 patients, respectively). We evaluated serum concentrations of tumor necrosis factor alpha, interleukins 4 and 8, monocyte chemotactic protein-1 (MCP-1), vascular endothelial growth factor, and epidermal growth factor (EGF) before and at 4 and 8 weeks after surgery. We also determined the Radiographic Union Score for Hips and the Radius Union Scoring System score and applied the Physical Activity Scale for the Elderly test at the same time points. Each patient underwent bone densitometry.
RESULTS: MCP-1 and EGF levels were higher in group A than in group B at 4 weeks after surgery (p > 0.05). Radiographic evaluation showed lower scores in group A (p < 0.05). The main difference between the groups was evident 4 weeks after surgery. Changes in the serum concentrations of chemotactic and angiogenic factors could explain the radiographically proved impaired fracture healing in diabetic patients.
CONCLUSIONS: Fragility fracture healing is impaired in diabetic patients. Radiographic and molecular patterns confirmed that the most compromised fracture-healing phase is at 4 weeks after surgery, during callus mineralization.
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1 |
Social networks and marital status predict mortality in older women: Prospective evidence from the Study of Osteoporotic Fractures (SOF)
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DoD PRF (Psychosocial RF)
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Objective: To assess the relationship between social network size and prospective mortality risk among a large sample of older, Caucasian women. Method: The study included 7524 Caucasian community-dwelling women, age 65 or older (mean age=74.1), who participated from four U.S. communities. Study participants completed a protocol that included anthropomorphic and health assessments at baseline and the Lubben Social Network Scale at year 2. We followed participants for an average of 6 years after they had completed the year-2 assessment. We used hospital records and a copy of the participant's official death certificate to document mortality and cause of death in accordance to ICD-9 revision codes. Results: A total of 1451 deaths (19.3% of sample) were observed over follow-up, 215 (3.4%) due to cardiovascular causes. Higher social network scores were a robust predictor of lower multivariate-adjusted mortality (RR=0.92, 95% CI=0.86-0.98), controlling for age, comorbid disease, body mass, smoking, depression, and education. However, social network benefits were attenuated after controlling for marital status. Married participants showed lower total (RR=0.83, 95% CI=0.74-0.94) and CVD (RR=0.59, 95% CI=0.43-0.81) covariate-adjusted death rates compared with unmarried participants... (PsycINFO Database Record (c) 2016 APA, all rights reserved)
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Parecoxib sodium has opioid-sparing effects in patients undergoing total knee arthroplasty under spinal anaesthesia
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AAHKS (8) Anesthetic Infiltration
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BACKGROUND: This multicentre, double-blind, placebo-controlled study compared the opioid-sparing effectiveness and clinical safety of parecoxib sodium over 48 h, in 195 postoperative patients after routine total knee replacement surgery.
METHODS: Elective total primary knee arthroplasty was performed under spinal anaesthesia, with a single dose of spinal bupivacaine 10-20 mg, and intraoperative sedation with midazolam 0.5-1.0 mg i.v., or propofol <6 mg kg(-1)h(-1). Patients were randomized to receive either parecoxib sodium 20 mg twice daily (bd) i.v. (n=65), parecoxib sodium 40 mg bd i.v. (n=67), or placebo (n=63) at the completion of surgery, and after 12, 24, and 36 h. Morphine (1-2 mg) was taken by patient-controlled analgesia or by bolus doses after 30 min.
RESULTS: Patients receiving parecoxib sodium 20 mg bd and 40 mg bd consumed 15.6% and 27.8% less morphine at 24 h than patients taking placebo (both P<0.05). Both doses of parecoxib sodium administered with morphine provided significantly greater pain relief than morphine alone from 6 h (P<0.05). A global evaluation of study medication demonstrated a greater level of satisfaction among patients taking parecoxib sodium than those taking placebo. Parecoxib sodium administered in combination with morphine was well tolerated. However, a reduction in opioid-type side-effects was not demonstrated in the parecoxib sodium groups.
CONCLUSION: Parecoxib sodium provides opioid-sparing analgesic effects in postoperative patients.
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0 |
Acculturation and post-migration psychological symptoms among Iraqi refugees: A path analysis
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DoD PRF (Psychosocial RF)
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Refugees frequently experience symptoms of posttraumatic stress and depression, which impede their acculturation in the new host country where they are resettling. There are few longitudinal studies investigating predictors of mental health and acculturation during the early postmigration period. We conducted a longitudinal study of 298 Iraqi refugees, assessing them upon arrival to the U.S. and 1 year after migration. Premigration trauma was associated with increased PTSD and depressive symptoms at baseline, and with decreased acculturation 1 year later. Resilience was associated with depressive symptoms at 1-year follow-up, but not with other resettlement outcomes (PTSD symptoms, English-language skills, or acculturation). PTSD and depressive symptoms at baseline predicted the same symptoms at 1-year follow-up, but not any other resettlement outcomes. The number of chronic diseases at baseline predicted worse PTSD and depressive symptoms, acculturation, and English language skills at 1-year follow up. Postmigratory exposure to daily stressors and less social support predicted worse 1-year outcomes. Results suggest that interventions that aim to improve mental health and promote acculturation among refugees should assess their history of trauma, chronic disorders, and psychological symptoms soon after migration, and promptly provide opportunities for social support. (PsycINFO Database Record
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Future Treatment and Research Directions in Distal Radius Fracture
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Distal Radius Fractures
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Whether or not they will have their lives dramatically extended in the next few decades, it is clear that people are living longer, healthier, and more active lives. The two peak incidences of distal radius fractures will remain within the pediatric and geriatric age groups, with the latter experiencing a substantial increase in the coming years. This article attempts to project future developments with regard to epidemiology, risk and prevention, fracture assessment, and treatment of distal radius fractures, and the ever increasing concern for the economic impact of this prevalent injury. © 2012.
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0 |
Early infection after hip fracture surgery: risk factors, costs and outcome
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Management of Hip Fractures in the Elderly
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Prospective data on hip fracture from 3686 patients at a United Kingdom teaching hospital were analysed to investigate the risk factors, financial costs and outcomes associated with deep or superficial wound infections after hip fracture surgery. In 1.2% (41) of patients a deep wound infection developed, and 1.1% (39) had a superficial wound infection. A total of 57 of 80 infections (71.3%) were due to Staphylococcus aureus and 39 (48.8%) were due to MRSA. No statistically significant pre-operative risk factors were detected. Length of stay, cost of treatment and pre-discharge mortality all significantly increased with deep wound infection. The one-year mortality was 30%, and this increased to 50% in those who developed an infection (p < 0.001). A deep infection resulted in doubled operative costs, tripled investigation costs and quadrupled ward costs. MRSA infection increased costs, length of stay, and pre-discharge mortality compared with non-MRSA infection
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Enhanced recovery pathway reduces length of stay after hip and knee replacements in a large orthopaedic centre - Results after the first 3700 patients
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Surgical Management of Osteoarthritis of the Knee CPG
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Background and aims: The study aims to measure outcomes after introduction of an enhanced recovery pathway in an elective orthopaedic centre performing high volume arthroplasty surgery. We compared it to the year before. Methods: All consecutive primary hip(THR) and knee(TKR) replacements performed between April 2010-November 2011 were compared to all patients between March 09- March 10. Average inpatient stay(LOS) calculated from date of operation to discharge date was recorded along with % of patients discharged on day 3 for THRs and day 4 for TKRs. The primary analgesic technique for THRs in the 2009-10 group was 0.2mg intrathecal morphine and single shot femoral and sciatic blocks for TKRs. Details of the ER protocol are given in the table. (Table Presented) An attempt at mobilisation was made within 3-4 hours after surgery in the enhanced recovery group while this attempt was only made the next day in the historical group. Results: 3709 patients in the ER group were compared to 2022 patients in the historical group. Average LOS decreased from 6.8 to 4.9 for THRs and 7.1 to 5.1 for TKRs. (Figure presented) Conclusions: Enhanced recovery pathway has demonstrated a significant reduction in hospital stay. Readmissions were not increased and a 30% reduction in deep vein thrombosis was also seen
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A trabecular metal implant 4 months after placement: clinical-histologic case report
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Reduction Mammoplasty for Female Breast Hypertrophy
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INTRODUCTION: The aim of this case report was to histologically evaluate the behavior of a trabecular metal (TM) implant composed of titanium and spatial 3-dimensional tantalum (Ta) trabeculae. This study is the first human histologic case report of this implant. CASE PRESENTATION: A TM implant was placed in a 54-year-old woman exhibiting moderate chronic periodontitis. After periodontal treatment, the implant was inserted under favorable clinical conditions. Patient was not seen for 4 months because of unrelated breast reduction surgery. At the surgical reopening, periimplant inflammation affecting the coronal third of the implant was observed 4 months after implant placement. With patient's consent, the implant was removed for histologic analysis. Histology highlighted a greater amount of bone in close contact with Ta trabeculae than titanium surfaces. CONCLUSION: The finding of bone formation around the Ta trabeculae suggests that trabecular metal material promotes bone ingrowth for secondary implant stability. Additional evidence is needed to confirm this observation.
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War-related exposure and psychological distress as predictors of health and sleep: a longitudinal study of Kuwaiti children
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DoD PRF (Psychosocial RF)
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OBJECTIVES: To determine whether exposure to war-related trauma during childhood predicted posttraumatic stress, self-reported health, sleep, and obesity in adulthood, and whether psychological distress mediated the relationships.
METHODS: We assessed 151 Kuwaiti boys and girls aged 9 to 12 years in 1993 to determine their level of exposure to war-related trauma during the Iraqi occupation and Gulf war, health complaints, and psychological distress. In 2003, 120 (79%) of the initial participants reported on their posttraumatic stress, general health, body mass index (BMI), and sleep quality. We tested a structural model where exposure to war-related trauma predicted psychological distress and health complaints 2 years after the war, and posttraumatic stress, self-reported health, BMI, and sleep quality and duration 10 years later, controlling for intermediary life events. We also tested effects of exposure to war-related trauma on self-reported health and sleep factors mediated by psychological distress.
RESULTS: Results indicated a direct effect of exposure on poor sleep quality and BMI. Exposure also predicted poor sleep quality through its association with concurrent posttraumatic stress. The effect of exposure on self-reported health was mediated by health complaints and psychological distress, which included symptoms of depression, anxiety, and posttraumatic stress.
CONCLUSION: Exposure to war-related events during childhood is associated with posttraumatic stress, poor sleep quality, high BMI, and poor self-reported health in adulthood.
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0 |
Epinephrine Diluted Saline-Irrigation Fluid in Arthroscopic Shoulder Surgery: A Significant Improvement of Clarity of Visual Field and Shortening of Total Operation Time. A Randomized Controlled Trial
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Upper Eyelid and Brow Surgery
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PURPOSE: To determine the influence of epinephrine saline irrigation in therapeutic shoulder arthroscopy procedures on the clarity of arthroscopic view. Three subgroups were analyzed; (1) Bankart/SLAP repairs; (2) rotator cuff repairs; and (3) subacromial procedures without rotator cuff repair. Secondary objectives were to evaluate the influence on total operating time and potential cardiovascular adverse reactions. METHODS: The design of the study was a prospective, randomized, double-blind controlled trial. A total of 101 patients were included. Pressure pump-controlled regular saline irrigation fluid was used in the control group. In the epinephrine group, epinephrine (0.33 mg/L) was added to the saline-irrigation fluid. Visual clarity was rated by a Numeric Rating Scale. Total operation time, total use of irrigation fluid, increases in pump pressure, heart rate, blood pressure, and electrocautery use were registered. RESULTS: Visual clarity (P = .002) was significantly better and total operating time (P = .008) significantly shorter in the epinephrine group. Total irrigation fluid used was significantly lower in the epinephrine group (P = .001). The greatest effect on visual clarity and shortening of operation time up to 15 minutes was seen in Bankart and SLAP repairs. No significant effect of the addition of epinephrine on heart rate and blood pressure was observed. CONCLUSIONS: The addition of epinephrine (0.33 mg/L) to irrigation fluid significantly improves visual clarity in most common types of therapeutic shoulder arthroscopy. A significant reduction in total operating time and use of irrigation fluid was observed. The greatest effect on visual clarity and shortening of operation time was seen in Bankart and SLAP group. Therefore, one of our initial hypotheses that the greatest effect would be observed in subacromial and rotator cuff repair procedures was not supported by the data presented. No cardiovascular adverse reactions were seen. LEVEL OF EVIDENCE: Level 1, Randomized controlled trial.
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1 |
Analgesia for total hip and knee arthroplasty: a review of lumbar plexus, femoral, and sciatic nerve blocks
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AAHKS (9/10) Regional Nerve Blocks
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Use of peripheral nerve blocks (PNBs) during lower extremity surgery has evolved. In this article, we review the pertinent anatomy and the literature concerning the advantages and disadvantages of both PNBs and traditional methods of postoperative analgesia (neuraxial and patient-controlled) for total hip arthroplasty and total knee arthroplasty. We conclude that use of PNBs for total hip and total knee arthroplasty compares favorably with traditional methods of postoperative analgesia. As use of PNBs becomes more widespread, understanding their risks and benefits will be of great value to orthopedic surgeons. [References: 21]
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0 |
A Feasibility Study of Percutaneous Peripheral Nerve Stimulation for the Treatment of Postoperative Pain Following Total Knee Arthroplasty
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AAHKS (9/10) Regional Nerve Blocks
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INTRODUCTION: The objective of the present feasibility study was to investigate the use of a new treatment modality-percutaneous peripheral nerve stimulation (PNS)-in controlling the often severe and long-lasting pain following total knee arthroplasty (TKA).
METHODS: For patients undergoing a primary, unilateral TKA, both femoral and sciatic open-coil percutaneous leads (SPR Therapeutics, Cleveland, OH) were placed up to seven days prior to surgery using ultrasound guidance. The leads were connected to external stimulators and used both at home and in the hospital for up to six weeks total.
RESULTS: In six of seven subjects (86%), the average of daily pain scores across the first two weeks was <4 on the 0-10 Numeric Rating Scale for pain. A majority of subjects (four out of seven; 57%) had ceased opioid use within the first week (median time to opioid cessation for all subjects was six days). Gross sensory/motor function was maintained during stimulation, enabling stimulation during physical therapy and activities of daily living. At 12 weeks following surgery, six of seven subjects had improved by >10% on the Six-Minute Walk Test compared to preoperative levels, and WOMAC scores improved by an average of 85% compared to before surgery. No falls, motor block, or lead infections were reported.
CONCLUSIONS: This feasibility study suggests that for TKA, ultrasound-guided percutaneous PNS is feasible in the immediate perioperative period and may provide analgesia without the undesirable systemic effects of opioids or quadriceps weakness induced by local anesthetics-based peripheral nerve blocks.
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0 |
Quantitative computed tomography assessment of bone mineral density after 2 years' oral bisphosphonate treatment in postmenopausal osteoarthritis patients who underwent total knee arthroplasty
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Surgical Management of Osteoarthritis of the Knee CPG
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OBJECTIVES: To identify the effects of two years' oral bisphosphonate (alendronate) treatment in patients who underwent total knee arthroplasty (TKA); to determine whether significant responses seen after the first year of treatment changed during the second year. Additionally, the study tried to identify factors relating to bone mineral density (BMD) changes. METHODS: This was a prospective 2-year follow-up study of a previous 1-year report of postmenopausal women with knee osteoarthritis who underwent primary unilateral or staged bilateral TKA, after which they received 70 mg alendronate orally once-weekly. BMD was measured using quantitative computed tomography (QCT) on lumbar vertebrae at baseline (pre-TKA) and at 12 and 24 months. Factors associated with BMD changes were determined by regression analysis. RESULTS: Sixty-one patients entered the second year and continued treatment for >/= 24 months. Mean vertebral QCT BMDs at baseline and after 12 and 24 months' alendronate treatment were 71.8 mg/ml (41.9-97.5 mg/ml), 69.3 mg/ml (31.4-103.9 mg/ml), and 72.7 mg/ml (33.1-136.1 mg/ml), respectively. Patients undergoing bilateral TKA and who had more severe OA at baseline (bilateral severe [grade 4] OA) had a lower BMD response after 2 years' bisphosphonate treatment, compared with patients with less severe unilateral knee OA who underwent unilateral TKA. Improvements were, however, seen compared with year 1 levels. Low BMI was associated with BMD nonresponse. CONCLUSIONS: Patients with bilateral severe OA (grade 4) requiring bilateral knee replacement are at greater risk of nonresponse after 2 years' oral alendronate treatment. A longer duration of treatment may be necessary in these patients
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