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Ways to prevent infection after open fracture of the lower limb
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DoD SSI (Surgical Site Infections)
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BACKGROUND AND AIMS: Despite the great effectiveness of antibiotics, no principle is more important in the care of open fractures than aggressive irrigation and debridement. Fixation of open fractures has a number of beneficial effects, including even the reduction of the risk of infection.
MATERIALS AND METHODS: This prospective study of the treatment of 116 open fractures of the lower limb offered us the possibility to determine the ways to prevent the infection. All the patients were studied prospectively and the type of treatment and the rate of infection were evaluated.
RESULTS: In the course of the treatment, 96 wounds were closed by primary closure (82.8%) and 2 wounds were closed by secondary closure on the 5(th) postoperative day (1.7%). There were 14 skin grafts (12.1%), 2 muscle flap closures (1.7%) and 2 healings by granulation (1.7%). The antibiotics used were ceftriaxone + gentamycin for type I, II fractures; metronidazole was added for type III fractures. The duration of the antibiotic therapy was 7-10 days, according to the severity of the fracture. The infection rate was 0% for type I, 0% for type II and 5.17% for type III fractures (6/116).
CONCLUSIONS: The treatment of open fractures by intensive debridement of the wound and immediate fixation, as well as by primary closure of the wound with prolonged use of antibiotics, led to a dramatic decrease of the rate of infections.
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Total knee arthroplasty and Crigler-Najjar syndrome: A case report
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Surgical Management of Osteoarthritis of the Knee CPG
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Crigler-Najjar (CN) syndrome is a rare genetic disease characterized by hyperbilirubinemia due to a deficiency in the hepatic enzyme UDP-glucuronosyl-transferase. We describe the first case of total knee arthroplasty in a patient with CN syndrome (type II). This procedure was complicated by kernicterus 1week after hospital discharge. He also developed Klebsiella bacteremia and sepsis, requiring a brief ICU stay. He was discharged in good condition 2months later. It is evident that physicians involved in the care of patients with CN syndrome in the peri-operative period need to have a high index of suspicion for the development of severe hyperbilirubinemia and kernicterus in order to appropriately manage and, possibly, prevent this complication. A literature review and intra-operative observations provide insight into the possible relationship between hyperbilirubinemia and osteoarthritis as well as the peri-operative considerations to be made for this group of patients. (copyright) 2009 Elsevier B.V
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Serum Bupivacaine Concentration After Periarticular Injection With a Mixture of Liposomal Bupivacaine and Bupivacaine HCl During Total Knee Arthroplasty
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AAHKS (9/10) Regional Nerve Blocks
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BACKGROUND AND OBJECTIVES: A relatively new technique to reduce postoperative pain for total knee arthroplasty is to inject a mixture of 266 mg of liposomal bupivacaine and 125 mg of 0.25% bupivacaine HCl with epinephrine 1:300,000 around the knee joint at the time of surgery. Currently, no publications report serum bupivacaine concentrations over time after periarticular injection of liposomal mixed with free bupivacaine. This information is important to ensure safe serum bupivacaine concentrations are maintained especially when considering supplemental or rescue peripheral nerve blocks.
METHODS: A total of 40 subjects scheduled for primary unilateral total knee arthroplasty with intraoperative periarticular injection of the liposomal bupivacaine and bupivacaine HCl mixture were included. Total serum bupivacaine concentrations were measured after the last injection at selected time points and calculated by gas chromatography. Quantile regression techniques were used to analyze the data over time. This study is registered with ClinicalTrials.gov (ID NCT02626559).
RESULTS: Peak serum concentration ranged from 0.17 to 1.2 mug/mL and occurred from 10 minutes to 48 hours. Across all time points, the 48-hour interval had the highest mean concentration of total serum bupivacaine at 0.55 mug/mL (SD, 0.27). Quantile regression showed total serum bupivacaine concentrations increased over the 48 hours measured. None of the participants demonstrated signs or symptoms of local anesthetic toxicity.
CONCLUSIONS: Total serum concentrations of bupivacaine after periarticular administration of liposomal bupivacaine mixed with bupivacaine HCl remained below the described toxicity threshold (2.5 mug/mL) within the first 48 hours, and no patients demonstrated signs or symptoms of toxicity. However, peak serum concentration time was not achieved within the 48-hour interval. Additional studies are needed to describe the course of serum bupivacaine levels after 48 hours and to ascertain the risk of toxicity when combining this method of periarticular injection with peripheral nerve blocks.
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1 |
Office-based outpatient plastic surgery utilizing total intravenous anesthesia
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Panniculectomy & Abdominoplasty CPG
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Background: Office-based plastic surgery procedures continue to increase in popularity and a range of anesthetic techniques can be utilized, from light conscious sedation to general anesthesia requiring intubation. Total intravenous anesthesia (TIVA) is well suited for the office environment because it allows for moderate to deep sedation without the need for intubation. Objective: The authors review plastic surgery procedures performed in an outpatient office-based operating room under TIVA to assess patient outcomes and complications. Methods: A retrospective chart review was conducted of patients who underwent surgical procedures performed by 2 senior surgeons at American Association for Accreditation of Ambulatory Surgery Facilities-certified outpatient operating rooms between 2003 and 2011. TIVA was always administered by a board-certified anesthesiologist because it required the use of propofol. Conscious sedation with midazolam and fentanyl was always administered by the plastic surgeon. Patient outcomes and complications were analyzed to assess the safety of TIVA in an office operating room. Results: A total of 2611 procedures were performed on 2006 patients. No deaths, cardiac events, or transfers to the hospital occurred in any patients, regardless of the type of sedation utilized. Six hundred forty-two patients were given TIVA, which included propofol and/or ketamine, in addition to midazolam and fentanyl. The remaining 1364 patients received conscious sedation. There was 1 documented case (0.05%; 1/2006) of deep vein thrombosis/pulmonary embolism in a patient who had an implant exchange under TIVA; this patient was taking oral contraceptive pills at the time of surgery. Conclusions: Office-based surgery is an attractive option for many patients. This review suggests that a variety of procedures can be performed in a safe manner under TIVA. Although patient selection for outpatient surgery is paramount, TIVA offsets the risks of general anesthesia and is associated with minimal postoperative complications. © 2013 The American Society for Aesthetic Plastic Surgery, Inc.
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Allogeneic- blood-sparing effect of tranexamic acid versus acute normovolemic hemodilution for total hip replacement
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AAHKS (8) Anesthetic Infiltration
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Objective: To compare the blood conservation of Tranexamic acid and Acute normovolemic hemodilution for total hip replacement. This is a prospective randomized clinical study was done in the department of Orthopedic Surgery, Sohag university hospital. Methods: we investigated 30 patients who underwent total hip replacement (THR) in a prospective, double-blinded study protocol. In Group TA (Tranexamic acid), an intravenous (IV) infusion of TA, 10 mg/kg, was administered over a 30-min period. Thereafter, a constant IV infusion of 10 mg kg. hr. was administered for 10 h. Before induction of anesthesia, normovolemic hemodilution (NVHD) patients were bled to a target hematocrit of approximately 28%. Intravascular blood volume was maintained with colloid solution in a 1:1 (blood/Hes-steril). All autologous blood was transfused at the end of the surgery. Analytical tests before operation, postoperative and on the 3 rd and 7th day after surgery. In all cases, a hematocrit <27% was the postoperative transfusion trigger. Before discharge, deep vein thrombosis was excluded by Echo Doppler. Three months after surgery, the incidence of delayed thrombo-embolic events was assessed. Results: Both groups were comparable as regard to demographic data. In Group NVHD, 760±245 mL of autologous blood was removed. Despite autologous blood transfusion, during the late intraoperative period had significantly (P <0.001) greater allogeneic blood requirement in the NVHD group . Hematocrit values were significantly lowered in NVHD group intraoperative and early postoperative. 24 hours postoperatively, blood accumulation in the surgical drain was significantly (P<0.05) higher in the NVHD group (478 mL ±156) when compared with the TA group (257 mL ± 62). During the postoperative period allogeneic blood transfusion was significantly (P < 0.001) larger in the NVHD group (11 patients received 19 U) when compared with the TA group (two patients each received1 U). A clinical DVT was suspected in one patient in the TA study group. However, no abnormal Echo Doppler studies were reported. In the 3 months follow-up, one patient in the NVHD group was documented as having developed a DVT. In the TA group no postoperative thromboembolic events were documented. Conclusion: Tranexamic acid administration is associated with superior perioperative hemodynamic stability and allogeneic blood sparing.
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Juvenile osteochondritis dissecans
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Diagnosis and Treatment of Osteochondritis Dissecans AUC
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Juvenile osteochondritis dissecans is a diagnosis based on plain radiographic appearance. Although it is on occasion difficult to decide whether the observed radiographic abnormality represents osteochondritis dissecans or physiologic irregular ossification, 50% of children should evidence healing with nonoperative activity modification management. In those who fail this regimen, the majority require simple drilling of the lesion through intact articular cartilage
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Long-term results of resection of the distal ulna for post-traumatic conditions
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Distal Radius Fractures
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Sixty-two patients underwent resection of the distal ulna because of pain or limited motion after wrist trauma. The median length of resection was 23 mm. Injury to the distal radioulnar joint occurred primarily during fractures of the distal radius. Followup time averaged 87 months. The primary surgical indication was pain, but some procedures were performed in an effort to increase motion. All patients improved after surgery. Three patients had residual pain, 25 had mild pain, and 34 had no pain. Supination was greatly improved, with only modest improvement in other wrist motions. Four patients developed ulnar translation of the carpus (from 1 to 3 mm). Pseudoarticulation and ulnar regrowth of the carpus were noted, but neither pseudoarticulation nor regrowth was clinically symptomatic. Grip strength improved significantly after surgery, the average from 45.3 to 78.9% of the unaffected wrist. The presence or absence of radiocarpal arthritis preoperatively had no significant effect on the patients' estimates of results. Overall, 51 patients (82%) had satisfactory results. The primary gains were pain relief, increased supination, and increased strength.
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Preventive analgesia in hip or knee arthroplasty: a systematic review
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SR for PM on OA of All Extremities
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OBJECTIVE: To analyze the efficacy and safety of preventive analgesia in patients undergoing hip or knee arthroplasty due to osteoarthritis. METHODS: A systematic literature review was performed, using a defined a sensitive strategy on Medline, Embase and Cochrane Library up to May 2013. The inclusion criteria were: patients undergoing knee and/or hip arthroplasty, adults with moderate or severe pain (>/=4 on a Visual Analog Scale). The intervention, the use (efficacy and safety) of pharmacological treatment (preventive) close to surgery was recorded. Oral, topical and skin patch drugs were included. Systematic reviews, meta-analysis, controlled trials and observational studies were selected. RESULTS: A total of 36 articles, of moderate quality, were selected. The patients included were representative of those undergoing knee and/or hip arthroplasty in Spain. They had a mean age >50 years, higher number of women, and reporting moderate to severe pain (>/=4 on a Visual Analog Scale). Possurgical pain was mainly evaluated with a Visual Analog Scale. A wide variation was found as regards the drugs used in the preventive protocols, including acetaminophen, classic NSAID, Cox-2, opioids, corticosteroids, antidepressants, analgesics for neuropathic pain, as well as others, such as magnesium, ketamine, nimodipine or clonidine. In general, all of them decreased post-surgical pain without severe adverse events. CONCLUSIONS: The use or one or more pre-surgical analgesics decreases the use of post-surgical drugs, at least for short term pain
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Imaging of the disease process
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AMP (Acute Meniscal Pathology)
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Until recently, imaging evaluation of osteoarthritis (OA) has relied primarily on conventional radiography. Using radiography in clinical practice or clinical research, however, has been fraught with difficulty. Techniques for reproducibly acquiring serial radiographs of joints have improved considerably over the past several years. However, the greatest promise for advancing knowledge about OA and its treatment lies in magnetic resonance imaging (MRI) and its unique ability to examine the joint as a whole organ. In contrast to conventional radiography, MRI can directly visualize the articular cartilage, synovium, menisci, and other intra-articular structures important to the functional integrity of joints. There have been considerable advances in MRI of articular cartilage in particular over the past several years. However, much of this has come from small cross-sectional studies, and published longitudinal studies remain quite scant. The following discussion reviews the current status of imaging in OA and points to where changes might be anticipated in the future. [References: 66]
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1 |
Valgus osteotomy with anterior cruciate ligament laxity
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Anterior Cruciate Ligament Injuries CPG
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Some patients with medial joint degeneration post-medial meniscectomy also have a significant anterior cruciate ligament (ACL) instability. Ten patients were treated by a combined high tibial valgus osteotomy with ACL reconstruction. All patients had relief of instability and decreased pain, although only one returned to full activity. The operation is recommended as a salvage procedure for an ACL deficient knee with instability and medial joint degeneration
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Risk Factors for Initiation of Potentially Inappropriate Medications in Community-Dwelling Older Adults with and without Alzheimerâ??s Disease
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Hip Fx in the Elderly 2019
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Background: Various criteria have been created to define potentially inappropriate medications (PIMs) to help improve the quality and safety of medicine use in older patients. Individuals with Alzheimerâ??s disease (AD) may be at higher risk of adverse drug events associated with PIMs (such as falls). Objective: Our objective was to determine the risk factors for PIM initiation in a nationwide cohort of community dwellers aged â?¥65 years with and without AD. Methods: The Finnish nationwide MEDALZ cohort includes all patients diagnosed with AD in 2005â??2011 (n = 70,718) and two comparison individuals without AD (non-AD) matched for age, sex and region of residence for each person with AD. After a 1-year washout period for PIM use and exclusion of those aged <65 years, we included 50,494 patients with AD and 106,306 comparison subjects. PIM use was defined according to Finnish criteria. Results: Subjects without AD initiated PIMs more frequently than those with AD (16.4 vs. 12.2%, respectively; p < 0.001). The most common PIMs were muscle relaxants and urinary antispasmodics. Older individuals (aged â?¥75 years) were less likely to initiate PIMs. In the AD group, women were less likely to initiate PIMs than men. More comorbidities were associated with PIM initiation, especially in the non-AD group. The use of opioids or psychotropic medicines was associated with PIM initiation in both cohorts. Regional differences between university hospital districts were observed. Conclusion: PIM initiation was dependent on patient characteristics and possibly also some healthcare system-related factors such as differing regional treatment practices. It is important that medicines prescribed to the older vulnerable population are assessed regularly to avoid adverse effects and ensure safe pharmacotherapy, especially in those with multiple comorbidities.
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Does early wound infection after elective orthopaedic surgery lead on to chronic sepsis?
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DoD SSI (Surgical Site Infections)
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Infection is an uncommon, but occasionally devastating, complication of orthopaedic surgery. The definition of post-operative infection remains problematic. A high rate of early post-operative sepsis has previously been reported using a clinical definition of wound infection as recommended by the Surgical Infection Study Group. The purposes of this study is to determine the rate of ongoing wound problems and deep sepsis 1 year after these early wound infections. Of 1131 consecutive orthopaedic procedures, there were 70 wound infections occurring within 30 days of surgery. Adequate follow-up data were obtained in 67 (97%) of the 69 patients alive at 1 year. Of these 67, three had definite evidence and two possible evidence of ongoing wound problems and/or deep sepsis. It is concluded that early post-operative wound infection as defined by the Surgical Infection Study Group is a poor predictor (4-10%) of ongoing wound problems and deep sepsis at 1 year. All of the confirmed cases of late sepsis were found to be associated with revision arthroplasty and/or pin tract sepsis.
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Bone morphogenetic protein 2/SMAD signalling in human ligamentocytes of degenerated and aged anterior cruciate ligaments
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OAK 3 - Non-arthroplasty tx of OAK
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OBJECTIVE: Anterior cruciate ligament (ACL) degeneration leads to knee instability and favors osteoarthritis (OA) progression. During ageing the growth factor sensitivity of ligaments changes but nothing is known about BMP2-signalling and -sensitivity in degenerated ACLs. This study addressed the question whether a dysregulated BMP2 signalling might contribute to age- and OA-dependent ACL degeneration.
METHOD: ACL samples from patients with/without OA of different ages (<60 and >=60 years, males, females) were graded histopathologically (n = 45). After stimulation of cultured ACL fibroblasts with 5 nM BMP2 for different time points, phosphorylation of SMAD1/5/8 and gene expression of crucial BMP2 signalling proteins, ligamentogenic and chondrogenic transcription factors, scleraxis (SCX) and SOX9, were analyzed.
RESULTS: ACL samples displayed different grades of degeneration, often associated with synovitis and calcium deposits. Degeneration correlated significantly with synovitis. ACL fibroblasts expressed BMP type I receptors ALK3 and ALK6 and the BMP type II receptor BMPRII. Donors could be divided into "responders" and "non responders" since their BMP2 mediated SMAD1/5/8 phosphorylation level differed. Basal ID1 expression was lower in cells derived from OA compared with non-OA patients and BMP2 led to an ID1 induction in both. Irrespective of BMP2 stimulation, the donor age significantly influenced the expression profile of BMP6 and SCX but not BMP signalling. The BMP2-mediated SMAD6 expression differed between OA and healthy ACL fibroblasts.
CONCLUSION: Our data indicate that the expression level of BMP2/SMAD target genes such as ID1 and SMAD6 was reduced in ACL fibroblasts derived from OA compared with non OA patients.
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Sonographic Assessment of Reduction in Colles' Fracture
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Distal Radius Fractures
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Fractures of the distal radius are a frequent cause for presentation to United Kingdom (UK) Emergency Departments, and the Colles' fracture is the most commonly encountered type. These injuries frequently occur in isolation, or associated with only minor injuries, and reduction of displaced fractures is typically performed by Emergency Physicians at the time of first attendance to the hospital. The usually sequence of events is clinical examination, xâ?ray imaging to confirm the fracture, then the reduction is performed with appropriate analgesia or anaesthesia, the arm placed in a plaster backslab, and repeat imaging is taken to confirm adequacy of reduction. If the reduction is not satisfactory, repeat manipulation is required. Haematoma block and Biers block permit xâ?ray imaging of the manipulated wrist while the anaesthetic action is still effective, permitting reâ?manipulation without further administration of local anaesthetic. Sedation is usually kept to as short a time as possible, and is not usually maintained while imaging is performed. There is usually some degree of delay while xâ?rays are taken and made available for viewing, and this wait prolongs the procedure for the patient and the treating clinician. In addition, Biers block cannot be tolerated for long by most patients, so any delay makes it less likely that a reâ?manipulation can be achieved within the time the patient can tolerate. If a patient has been sedated, a reâ?manipulation will require a further sedative (or alternative) procedure with the concomitant risks that entails. Ideally, imaging would be performed rapidly, immediately at the end of the manipulation, prior to application of plaster, allowing confirmation of the reduction or immediate reâ?manipulation if necessary. This description of imaging provided at the point of care by the treating clinician, aimed at answering a clearly defined question ('is this an adequate reduction?') matches the description of focussed emergency ultrasound in other applications. If ultrasound could be used to assess fracture reduction, it would have potential to save clinician time, patient time and discomfort, and reduced the need for repeated manipulations and surgical repair. This study intends to assess the feasibility of a full trial of efficacy comparing ultrasound with xâ?ray to guide the reduction of these fractures.
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Percutaneous cystolithotomy in a patient with a Mitrofanoff urinary diversion
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DoD SSI (Surgical Site Infections)
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Introduction and objectives Bladder stones are the most common calculi of the lower genitourinary tract. The most common predisposing factor is the bladder outlet obstruction. The present case concerns a patient who suffered urethral trauma after a pelvis fracture, requiring a Mitrofanoff urinary diversion, and was diagnosed with multiple cystolithiasis up to 1 cm. The objective of these paper is to show the possibility of performing a percutaneous cystolithotomy in a patient with a complex urinary diversion, being an intervention with low morbidity, and with shorter recovery time and comparable results in terms of stone free percentage rate. Materials y methods The procedure starts with a prior Mitrofanoff catheterisation with a Foley catheter 12. An ultrasound-guided suprapubic left paramedian puncture was performed, followed by Chiba needle hydrophilic guidewire, stiletto, telescoped Alken dilators 9Fr-22Fr, and 28Fr Amplatz sheath. Once the percutaneous tract is established, the nephroscope and foreign body forceps were introduced and complete stone removal was achieved. The procedure ended with the extraction of the Amplatz sheath and occlusion of the wound with gauze dressing, maintaining the bladder diversion with the Foley catheter to a draining collector system. Discharge was given at day 1 post-operative, nad the Foley catheter was removed after 5 days. Results No complications occurred, the operative time was 1 hour, and 1 day of hospital stay. Satisfactory recovery with a successful outcome in terms of complete stone removal in only 1 surgery. Conclusions Percutaneous cystolithotomy is a management option which offers advantages comparable with other techniques. It should not just be considered in patients with urethral restricted access.
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Cabozantinib targets bone microenvironment modulating human osteoclast and osteoblast functions
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MSTS 2018 - Femur Mets and MM
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Cabozantinib, a c-MET and vascular endothelial growth factor receptor 2 inhibitor, demonstrated to prolong progression free survival and improve skeletal disease-related endpoints in castration-resistant prostate cancer and in metastatic renal carcinoma. Our purpose is to investigate the direct effect of cabozantinib on bone microenvironment using a total human model of primary osteoclasts and osteoblasts.Osteoclasts were differentiated from monocytes isolated from healthy donors; osteoblasts were derived from human mesenchymal stem cells obtained from bone fragments of orthopedic surgery patients. Osteoclast activity was evaluated by tartrate resistant acid phosphatase (TRAP) staining and bone resorption assays and osteoblast differentiation was detected by alkaline phosphatase and alizarin red staining.Our results show that non-cytotoxic doses of cabozantinib significantly inhibit osteoclast differentiation (p=0.0145) and bone resorption activity (p=0.0252). Moreover, cabozantinib down-modulates the expression of osteoclast marker genes, TRAP (p=0.006), CATHEPSIN K (p=0.004) and Receptor Activator of Nuclear Factor k B (RANK) (p=0.001). Cabozantinib treatment has no effect on osteoblast viability or differentiation, but increases osteoprotegerin mRNA (p=0.015) and protein levels (p=0.004) and down-modulates Receptor Activator of Nuclear Factor k B Ligand (RANKL) at both mRNA (p<0.001) and protein levels (p=0.043). Direct cell-to-cell contact between cabozantinib pre-treated osteoblasts and untreated osteoclasts confirmed the indirect anti-resorptive effect of cabozantinib.We demonstrate that cabozantinib inhibits osteoclast functions "directly" and "indirectly" reducing the RANKL/osteoprotegerin ratio in osteoblasts.
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Adductor Canal Block With Bupivacaine Liposome Versus Ropivacaine Pain Ball for Pain Control in Total Knee Arthroplasty: A Retrospective Cohort Study
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AAHKS (9/10) Regional Nerve Blocks
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BACKGROUND: Appropriate postoperative pain control following total knee arthroplasty is important in patient recovery. Adductor canal block (ACB) is a novel method to deliver anesthesia. There are currently no studies using bupivacaine liposome with ACB while also taking into account cost.
OBJECTIVE: To compare the efficacy and cost of using bupivacaine liposome to ropivacaine pain ball (RPB) for postsurgical pain control in total knee replacement surgery. The primary efficacy endpoint is mean pain score. Secondary endpoints include opioid and nonopioid pain medication consumption and cost per patient case.
METHODS: This was a retrospective, matched cohort study with data collected from electronic medical records from February 2013 to June 2014. Mean pain score was measured by the 11-point Visual Analogue Scale over a 72-hour period. Cost analysis was also done looking at medication, direct, indirect, and total cost per patient case.
RESULTS: Mean pain score over the 72 hours was 3.24 in the bupivacaine liposome group compared with 3.83 in the RPB group (P < 0.001). Lower mean pain scores were found in the bupivacaine liposome group during the first 36-hour interval postsurgery (3.1 vs 4.0, respectively, P < 0.001). Mean total cost was $20,919.53 with bupivacaine liposome versus $22,574.17 with RPB (P = 0.03).
CONCLUSION: Liposomal bupivacaine demonstrated statistically significant impact in pain control in the first 36 hours, but by the end of the 72-hour interval, it was comparable to RPB in postoperative pain management. Using bupivacaine liposome did provide direct and total cost savings compared with RPB.
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A population-based study of the pattern of terminal care and hospital death in patients with non-small cell lung cancer
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MSTS 2022 - Metastatic Disease of the Humerus
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Non-small cell lung cancer (NSCLC) is a major cause of cancer-related death and utilization of health care resources worldwide. Significant costs are generated in the months before death, with hospitalization being a major cost driver. Moreover, hospital death causes physical and emotional distress. We analyzed factors predicting the likelihood of hospital death from NSCLC. Patients who died from NSCLC (any stage and treatment) during the recent 5-year interval up to 31.12.2010, within a defined geographical region of northern Norway, were included (n=112). Only 15% of all patients did not require any hospitalization during their last 3 months. A minority of patients (24%) died at home, 53% in hospital and 23% in nursing homes. The likelihood of hospital death was independent of initial management and time between diagnosis and death. Even 45% of patients treated with best supportive care died in hospital. Multivariate analysis showed that initial tumor stage of T4 (RR 1.64), systemic therapy during the last 3 months of life (RR 2.60) and any active therapy during the last 4 weeks (RR 1.63) significantly increased the likelihood of hospital death, while early discussion of resuscitation preferences reduced it (RR 0.21). These four parameters suggest that early focus on symptom palliation and resuscitation preferences are crucial components of strategies improving terminal care. Patients with T4 tumors might experience unsatisfactory symptom control and should be offered a part in prospective studies addressing these issues.
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Treatment strategies for central low-grade chondrosarcoma of long bones: a systematic review of the literature and meta-analysis
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MSTS 2022 - Metastatic Disease of the Humerus
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The need for wide local excision (WLE) versus intralesional (IL) treatment of low-grade chondrosarcomas (CS) of the appendicular skeleton remains controversial. We sought to perform a systematic review and meta-analysis to compare different conventional types of surgical treatments for grade I CS in terms of: (1) rate of local recurrence (LR) and metastases, (2) functional outcome as measured by the Musculoskeletal Tumor Society (MSTS) score, (3) complication rate. Eighteen studies enrolling 695 patients met our criteria. Studies reported on WLE versus IL treatment (n = 7), and IL treatment with or without different adjuvants (N = 11). The LR rate was not significantly different between WLE and IL treatment (OR 2.31; 95% CI, 0.85-6.2; P = 0.1). On the contrary, complication rates were significantly lower in favor of IL treatment (OR 2.27; 95% CI, 0.07-0.72; P = 0.012). The mean reported MSTS score ranged from 21.8 to 28.2 for WLE and from 26.5 to 29.7 for IL treatment, with a significant difference in favor of IL treatment. IL treatment as an alternative to WLE does not greatly increase the risk of LR or metastasis and has lower complication rates with better functional scores. In light of the retrospective nature of the studies available, our findings should be interpreted with caution.
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Clinical Correlates of Computationally Derived Visual Field Defect Archetypes in Patients from a Glaucoma Clinic
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Upper Eyelid and Brow Surgery
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PURPOSE: To assess the clinical validity of visual field (VF) archetypal analysis, a previously developed machine learning method for decomposing any Humphrey VF (24-2) into a weighted sum of clinically recognizable VF loss patterns. MATERIALS AND METHODS: For each of 16 previously identified VF loss patterns ("archetypes," denoted AT1 through AT16), we screened 30,995 reliable VFs to select 10-20 representative patients whose VFs had the highest decomposition coefficients for each archetype. VF global indices and patient ocular and demographic features were extracted retrospectively. Based on resemblances between VF archetypes and clinically observed VF patterns, hypotheses were generated for associations between certain VF archetypes and clinical features, such as an association between AT6 (central island, representing severe VF loss) and large cup-to-disk ratio (CDR). Distributions of the selected clinical features were compared between representative eyes of certain archetypes and all other eyes using the two-tailed t-test or Fisher exact test. RESULTS: 243 eyes from 243 patients were included, representative of AT1 through AT16. CDR was more often >/= 0.7 among eyes representative of AT6 (central island; p = 0.002), AT10 (inferior arcuate defect; p = 0.048), AT14 (superior paracentral defect; p = 0.016), and AT16 (inferior paracentral defect; p = 0.016) than other eyes. CDR was more often < 0.7 among eyes representative of AT1 (no focal defect; p < 0.001) and AT2 (superior defect; p = 0.027), which was also associated with ptosis (p < 0.001). AT12 (temporal hemianopia) was associated with history of stroke (p = 0.022). AT11 (concentric peripheral defect) trended toward association with trial lens correction > 6D (p = 0.069). CONCLUSIONS: Shared clinical features between computationally derived VF archetypes and clinically observed VF patterns support the clinical validity of VF archetypal analysis.
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Management of distal radius fractures â?? A new concept of closed reduction and standardised percutaneous 5-pin fixation
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Distal Radius Fractures
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Introduction: Management of distal radial fractures is a controversial topic, with poor reported outcomes in up to 30% of cases and a wide variety of treatment options such as closed reduction and POP cast, internal fixation, external fixation and percutaneous pin fixation in many configurations. Over the last 13 years, we have used a novel standardised 5-pin configuration of percutaneous K-wire fixation, which can be used in most types of distal radial fractures, where closed reduction is possible, and the ulna is intact or re-constructible. This study reports the outcomes of this technique. Methods: All patients presenting to our unit with distal radial fracture in a 126-month period from June 2005 to December 2015 managed by closed reduction and 5-pin fixation were evaluated for complications including wire loosening and infection, tendon or nerve injury, reflex sympathetic dystrophy and functional outcome. Results: A total of 490 consecutive patients with 496 distal radial fractures were treated in the study period with a mean age of 49.4 years; 57% were female and 57% were due to domestic falls. After death from unrelated causes and loss to follow-up, 418 patients were reviewed in clinic, and a further 40 were patients contacted by telephone at one year, and clinical outcome was evaluated using Cooneyâ??s modification of Green and Oâ??Brienâ??s score. All fractures healed and 95.7% had an â??excellentâ?? outcome and 3.9% were â??goodâ??; only two patients achieved a â??fairâ?? outcome, both of whom had comminuted intra-articular fractures with metaphyseal comminution. Complications were minimal and temporary with no cases of deep infection, tendon or nerve injury or reflex sympathetic dystrophy. Conclusions: This study proved that our novel customised 5-pin percutaneous fixation was sufficiently stable and controlled all fragments of distal radial fractures effectively to allow early mobilisations to prevent stiffness and reflex sympathetic dystrophy with excellent functional outcomes.
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0 |
Salivary immunoglobulins and prevalent coronary artery disease
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Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures
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Previous studies examined the serum immunoglobulin levels in relation to coronary artery disease (CAD). We hypothesized that the salivary immunoglobulins might better estimate oral infections in this relationship. Multivariate logistic regression analyses utilizing the data from 256 angiographically confirmed CAD patients and 250 non-CAD individuals that controlled for age, sex, smoking, diabetes, total/HDL cholesterol ratio, hypertension, and education revealed the trends that salivary IgA was positively and salivary IgG was inversely associated with CAD. The odds ratios (OR) of each increasing quartile of salivary IgA were 1.00 (first and second quartiles combined), 1.97, and 1.37 (p-value for trend = 0.06), while those for salivary IgG were 1.00, 0.77, 0.60, and 0.51 (p-value for trend = 0.02). Additionally, salivary IgA correlated positively with C-reactive protein and Asymptotic Dental Score (dental infection score), while IgG was inversely associated with these inflammation markers. Salivary IgA warrants further studies to confirm its role in the risk assessment of CAD
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1 |
Safety Comparison of Abdominoplasty and Brazilian Butt Lift: What the Literature Tells Us
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Panniculectomy & Abdominoplasty CPG
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BACKGROUND: Although abdominoplasty is a mainstay of the plastic surgeon, the safety of the Brazilian butt lift (BBL) has been questioned, effectively being prohibited in some countries. The central rationale for the safety concern over the BBL stems from a publication stating a mortality rate of one in 3000. The question remains: What is the real safety of these procedures? METHODS: Focusing on mortality, literature searches were performed for BBL and for abdominoplasty. The 2017 Aesthetic Surgery Education and Research Foundation survey data and publication were examined and analyzed. Additional data from the American Association for Accreditation of Ambulatory Surgical Facilities were obtained independently. RESULTS: Abdominoplasty and BBL appear to have similar safety based on mortality; however, the nature of their mortalities is different. Although most abdominoplasty deaths are secondary to deep venous thrombosis/pulmonary embolism-inherent circulatory thrombotic abnormality-BBL mortality is associated with iatrogenic pulmonary fat embolism. BBL mortality rates from more recent surveys on BBL safety demonstrate a mortality of one in 15,000. CONCLUSIONS: Although deep venous thrombosis/pulmonary embolism will always remain an abdominoplasty risk, intraoperative BBL pulmonary fat embolism has the potential to be reduced dramatically with a better understanding of dynamic anatomy, surgical instrumentation, and technique. The authors are now presented with a better lens with which to view a more accurate safety profile of BBL surgery, including its place among other commonly performed aesthetic procedures.
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Premature Therapeutic Antimicrobial Treatments Can Compromise the Diagnosis of Late Periprosthetic Joint Infection
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PJI DX Updated Search
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BACKGROUND: In the absence of positive cultures and draining sinuses, the diagnosis of periprosthetic joint infection (PJI) relies on laboratory values. It is unknown if administration of antibiotics within 2 weeks before diagnostic evaluations can affect these tests in patients with PJI. QUESTIONS/PURPOSES: The purpose of this study was to investigate the correlation of antibiotic administration with (1) fluctuations in the synovial fluid and serology laboratory values; and (2) sensitivity of the diagnostic tests in patients with late PJI (per Musculoskeletal Infection Society [MSIS] criteria). METHODS: Synovial white blood cell (WBC) count, polymorphonuclear neutrophil (PMN) percentage, and serum erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) as well as culture results were investigated in 161 patients undergoing total knee arthroplasty with late PJI diagnosed with the MSIS criteria. Depending on whether presampling antibiotics were used, patients were divided in two groups (53 [33%] patients were on antibiotics). The median laboratory values and the false-negative rates were compared between the two groups. RESULTS: The median of all variables were lower in the antibiotic group compared with the other group: ESR (mm/hr): 70 versus 85, difference of medians (DOM) = 15 mm/hr, p = 0.018; CRP (mg/L): 72 versus 130, DOM = 58 mg/L, p = 0.038; synovial WBC (cells/muL): 29,170 versus 46,900, DOM = 17,730, p = 0.022; and synovial PMN%: 88.5% versus 92.5%, DOM = 4%, p = 0.012. Furthermore, using the MSIS cutoffs, the false-negative rates of several parameters were higher in the antibiotic group; ESR: 19.2% (nine of 47) versus 6.1% (six of 99) (relative risk, 3.1; 95% confidence interval [CI], 1.2-8.3; p = 0.020); CRP: 14.9% (seven of 47) versus 2.00% (two of 100) (relative risk, 7.4; 95% CI, 1.6-34.4); PMN%: 23.1% (12 of 52) versus 9.4% (10 of 106) (relative risk, 2.4; 95% CI, 1.1-5.2; p = 0.027). Patients in the antibiotic group also had higher rates of negative cultures: 26.4% (14 of 53) versus 12.9% (14 of 108) (relative risk, 2.0; 95% CI, 1.05-3.9; p = 0.046). CONCLUSIONS: It appears that premature antibiotic treatments are associated with lower medians of diagnostic laboratory values. Thus, and in line with the guideline recommendations of the American Academy of Orthopaedic Surgeons, patients with suspected late-PJI should not receive antibiotics until the diagnosis is reached or refuted. LEVEL OF EVIDENCE: Level III, diagnostic study
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The Mayo Conservative Hip: experience from a district general hospital
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Management of Hip Fractures in the Elderly
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The Mayo Conservative Hip femoral prosthesis has been designed to optimise proximal femoral loading as well as preserving proximal femoral bone stock. Between October 2003 and May 2006, 42 patients (49 hips) underwent total hip replacement (THR) using the Mayo Conservative Hip femoral component. The mean age at operation was 57.8 years (range 44 to 74) and the mean clinical follow up was 3.1 years (range 2.3 to 4.7 years). The aim of our study was to review the short term results of this unorthodox femoral component. We found that 18% degrees of stems were malaligned >or= 5 degrees and the prevalence of intra-operative femoral fracture was 4%. We feel this prosthesis is difficult to implant and has an unacceptable fracture rate
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Cordycepin modulates inflammatory and catabolic gene expression in interleukin-1beta-induced human chondrocytes from advanced-stage osteoarthritis: an in vitro study
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OAK 3 - Non-arthroplasty tx of OAK
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Cordycepin is widely used as for its various pharmacological activities, such as anti-inflammation, anti-angiogenesis, anti-aging, anti-tumor and anti-proliferation. However, the precise role of cordycepin on chondrocytes is not clear. In the present study, we examined the inhibitory effects of cordycepin on interleukin-1 beta (IL-1beta)-induced glycosaminoglycan (GAG) release, nitric oxide production as well as gene expressions of inflammatory and catabolic mediators in human cartilage and chondrocytes. Cartilage explants and human chondrocytes were cultured in the absence or in the presence of IL-1beta (10 ng/ml) and with or without cordycepin (5-100 muM). GAG content in the cartilage explants was measured by using the dimethylmethylene blue method and Safranin O staining. Nitric oxide level was determined by Griess reaction. Expressions of MMP-1, MMP-13, cathepsin K, cathepsin S, ADAMTS-4 (a disintegrin and metalloproteinase with thrombospondin motifs-4) and ADAMTS-5, inducible nitric oxide synthase (iNOS) and cyclooxgenase-2 (COX-2) were evaluated by real-time quantitative PCR. We found that cordycepin suppressed IL-1beta-stimulated GAG release. Gene expressions of catabolic enzymes, including MMP-1, MMP-13, cathepsin K, cathepsin S, ADAMTS-4 and ADAMTS-5, were decreased by cordycepin in a dose-dependent manner. In addition, cordycepin inhibited IL-1beta-induced COX-2 and iNOS expression at the transcript level as well as blocked NO production. Our results suggest that cordycepin may possess chondroprotective effect by preventing cartilage denegation and interfering inflammatory response in the pathogenesis of OA.
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Prospective 5- to 6-year follow-up study of a cementless acetabular cup
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Management of Hip Fractures in the Elderly
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Twenty-seven patients in whom the Ti-Bac acetabular cup (Zimmer, Warsaw, IN) was placed were examined 5 to 6 years alter surgery. The cup was inserted line to line, after reaming without further fixation. In all operations, a cemented Muller straight-stem Protazul femur stem (Zimmer) was used. The patients had good pain relief and improved mobility after the operation. Radiographically, only one hip showed radiolucency in the bone-metal interface after 5 to 6 years. One patient was reoperated 3 days alter surgery because of dislocation of the acetabular cup. Apart from this, there were no signs ill aseptic loosening of any of these uncemented cups
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Guidewire fracture during orbital atherectomy for peripheral artery disease: Insights from the Manufacturer and User Facility Device Experience database
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DoD SSI (Surgical Site Infections)
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BACKGROUND/OBJECTIVES: Orbital atherectomy (OA) is routinely being used for plaque modification to facilitate percutaneous revascularization in patients with peripheral arterial disease (PAD) and arterial calcification. Guidewire fracture (GWF) during OA, though anecdotally described, has not been studied in a systematic manner. We conducted a review of the Manufacturer and User Facility Device Experience (MAUDE) database to study the reports of wire fracture and its management and consequences.
METHODS: We queried the MAUDE database for all events involving the current generation of the OA device: "Diamondback 360 Peripheral Orbital Atherectomy System", and "Stealth 360degree Orbital PAD System".
RESULTS: We identified 62 reports of GWF during OA for PAD. The superficial femoral artery was the most commonly involved atherectomy site. The wire fractured at the soft tip in a majority of cases (68%). Embolized wire fragments were left in the patient in 36 cases (58%), retrieved percutaneously in 10 cases (16%), and trapped by a stent against the arterial wall in eight cases (13%). Lastly, eight patients (13%) underwent surgery for removal of the wire fragment.
CONCLUSIONS: This is the first published report to study the complication of GWF during peripheral OA. GWF is an uncommon but has significant procedural and clinical consequences. It results in a high rate of ancillary rescue procedures (including surgery) and is associated with a higher risk of arterial thrombosis and complications from wire retrieval attempts. The risk of wire fracture may be avoided with carefully adherence to the IFU.
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Long-standing bacteremia caused by oral Actinobacillus actinomycetemcomitans in a patient with a pacemaker
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Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures
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A case of symptomatic Actinobacillus actinomycetemcomitans bacteremia in a patient with an implanted pacemaker is presented. Attacks of fever occurred for at least 1 year. Oral examination revealed a mild form of periodontitis. A. actinomycetemcomitans was isolated from several oral sites. DNA fingerprinting of strains from the blood and the oral cavity showed identical profiles. This finding strongly suggests that the oral cavity was the primary source of A. actinomycetemcomitans bacteremia in this case. The patient was treated with the combination of metronidazole plus amoxicillin for 7 days, which resulted in a rapid cure and elimination of A. actinomycetemcomitans from the blood and the oral cavity
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The Advancing Role of Neuromodulation for the Management of Chronic Treatment-Refractory Pain
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Pediatric Supracondylar Humerus Fracture 2020 Review
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Neuropathic pain is a common cause of disability and health care utilization. While judicious pharmacotherapy and management of comorbid psychological distress can provide for improved quality of life, some patients with treatment-refractory disease require more invasive therapies. Spinal cord stimulation can provide for improvement in pain and decrease in medication utilization, with level 1 evidence supporting its use across various pain etiologies including persistent postoperative neuropathic pain, complex regional pain syndrome, chronic inoperable limb ischemia, treatment refractory angina, and painful diabetic neuropathy. These procedures can be done with acceptably low morbidity and provide a cost-effective solution for those patients in whom medical therapies have failed. Technological innovation in lead design, implantable pulse generator capability, and stimulation algorithms and parameters may further enhance the success of this therapy. Neuromodulation of distal targets such as dorsal root ganglion may permit greater anatomic specificity of the therapy, whereas subthreshold stimulation with high-frequency or burst energy delivery may eliminate noxious and off-target paresthesiae. Such new technologies should be subject to rigorous evaluation as their mechanisms of action and long-term outcomes remain hitherto undefined.
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Retrograde removal of an incarcerated solid titanium femoral nail after subtrochanteric fracture
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Management of Hip Fractures in the Elderly
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Intramedullary nailing with a solid titanium nail can result in significant bone ingrowth. Failure of an implant requires removal for replacement with another device. Previous methods have included use of extractors for cannulated nails. When extractors are not available or are inadequate, a simple retrograde push-out method can be used as described here
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Serum levels of 25-hydroxyvitamin D, 24,25-dihydroxyvitamin D and parathyroid hormone in patients with femoral neck fracture in southern Finland
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Management of Hip Fractures in the Elderly
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Serum concentrations of 25-hydroxyvitamin D (25-OHD), 24,25-dihydroxyvitamin D [24,25(OH)2D] and immunoreactive parathyroid hormone (PTH) were determined in elderly patients with fracture of the femoral neck and in age-matched controls during summer, winter and early spring in southern Finland. The expected seasonal variation in 25-OHD values was observed in both patients and controls, though the patient group had significantly lower values during winter (P less than 0.02) and spring (P less than 0.01). The 24,25(OH)2D:25-OHD ratio remained constant in both patients and controls throughout the study. A significant negative correlation between PTH and 25-OHD values was found in the patient group. Thus, vitamin D deficiency may contribute to the high incidence of femoral neck fractures in elderly people, and the increased PTH activity, observed in many patients with these fractures, is secondary to vitamin D deficiency
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Clinical and radiological follow-up of the Aequalis third-generation cemented total shoulder replacement: a minimum ten-year study
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Glenohumeral Joint OA
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There are no long-term published results on the survival of a third-generation cemented total shoulder replacement. We describe a clinical and radiological study of the Aequalis total shoulder replacement for a minimum of ten years. Between September 1996 and May 1998, 39 consecutive patients underwent a primary cemented total shoulder replacement using this prosthesis. Data were collected prospectively on all patients each year, for a minimum of ten years, or until death or failure of the prosthesis. At a follow-up of at least ten years, 12 patients had died with the prosthesis intact and two had emigrated, leaving 25 available for clinical review. Of these, 13 had rheumatoid arthritis and 12 osteoarthritis. One refused radiological review leaving 24 with fresh radiographs. Survivorship at ten years was 100% for the humeral component and 92% for the glenoid component. The incidence of lucent lines was low. No humeral component was thought to be at risk and only two glenoid components. The osteoarthritic group gained a mean 65 degrees in forward flexion and their Constant score improved by a mean 41.4 points (13 to 55). The rheumatoid group gained a mean of 24 degrees in flexion and their Constant score improved by 29.4 points. This difference may have been due to failure of the rotator cuff in 75% of the patients with rheumatoid arthritis. Thus a third-generation total shoulder replacement gives an excellent result in patients with osteoarthritis and an intact rotator cuff. Patients with rheumatoid arthritis have a 75% risk of failure of the rotator cuff at ten years.
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Three-Dimensional Bioprinting of Cartilage by the Use of Stem Cells: A Strategy to Improve Regeneration
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Osteochondritis Dissecans 2020 Review
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Cartilage lesions fail to heal spontaneously, leading to the development of chronic conditions which worsen the life quality of patients. Three-dimensional scaffold-based bioprinting holds the potential of tissue regeneration through the creation of organized, living constructs via a "layer-by-layer" deposition of small units of biomaterials and cells. This technique displays important advantages to mimic natural cartilage over traditional methods by allowing a fine control of cell distribution, and the modulation of mechanical and chemical properties. This opens up a number of new perspectives including personalized medicine through the development of complex structures (the osteochondral compartment), different types of cartilage (hyaline, fibrous), and constructs according to a specific patient's needs. However, the choice of the ideal combination of biomaterials and cells for cartilage bioprinting is still a challenge. Stem cells may improve material mimicry ability thanks to their unique properties: the immune-privileged status and the paracrine activity. Here, we review the recent advances in cartilage three-dimensional, scaffold-based bioprinting using stem cells and identify future developments for clinical translation. Database search terms used to write this review were: "articular cartilage", "menisci", "3D bioprinting", "bioinks", "stem cells", and "cartilage tissue engineering".
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[Clinical research of hyperbaric, isobaric, and hypobaric solutions of bupivacaine in continuous spinal anesthesia]
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Management of Hip Fractures in the Elderly
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OBJECTIVE: To compare the anesthesia properities of hyperbaric bupivacaine with those of isobaric and hypobaric solutions when administered in the supine position undergoing hip surgery or lower limb surgery using continuous spinal anesthesia.METHODS: Sixty patients( ASA I approximately III ) scheduled for hip or lower limb surgery were randomly divided into 3 groups with 20 patients in each group: Group A: 0. 375% hyperbaric bupivacaine solutions; Group B :0.375% isobaric bupivacaine solutions; and Group C: 0. 375% hypobaric bupivacaine solutions. The following variables were measured every 2 minutes during the first 30 minutes after the intrathecal injection : the onset time of sensation block, the highest plane of analgesia, the time to reach complete motor blockade, and the plane of analgesia and the extent of lower extremities' movement (modified bromage score, BMS) at different time after the administration. Meanwhile the changes of hemodynamics were recorded.RESULTS: There was no statistical difference among the basic conditions ( P > 0.05). The onset time of sensation block, and the time to reach complete motor blockade, and the time receiving the highest sharp pain sensory block in Group A were significantly shorter than those in Group B and Group C ( P < 0.01 ). The plane of analgesia obtained in the hyperbaric group was significantly higher than in both the isobaric and the hypobaric groups ( P < 0.01). The mean arterial pressure(MAP) , HR in the hyperbaric group decreased significantly after the intrathecal injection( P < 0.05 ).CONCLUSION: The 0.375% Isobaric bupivacaine used during contiuous spinal anesthesia in the supine position produces a suitable and a more "controllable" anesthesia, but a minimum dosage of 10 approximately 12.5 mg is required to obtain adequate anesthesic conditions with moderate hemodynamic changes and satisfying analgesia effects. Under similar conditions, 0. 375% hyperbaric bupivacaine produces major hemodynamic consequences with high cephalad spread and 0. 375% hypobaric bupivacaine has a too long onset time
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0 |
The epidemiology of osteosarcoma
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MSTS 2022 - Metastatic Disease of the Humerus
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Osteosarcoma derives from primitive bone-forming mesenchymal cells and is the most common primary bone malignancy. The incidence rates and 95% confidence intervals of osteosarcoma for all races and both sexes are 4.0 (3.5-4.6) for the range 0-14 years and 5.0 (4.6-5.6) for the range 0-19 years per year per million persons. Among childhood cancers, osteosarcoma occurs eighth in general incidence and in the following order: leukemia (30%), brain and other nervous system cancers (22.3%), neuroblastoma (7.3%), Wilms tumor (5.6%), Non-Hodgkin lymphoma (4.5%), rhabdomyosarcoma (3.1%), retinoblastoma (2.8%), osteosarcoma (2.4%), and Ewing sarcoma (1.4%). The incidence rates of childhood and adolescent osteosarcoma with 95% confidence intervals areas follows: Blacks, 6.8/year/million; Hispanics, 6.5/year/million; and Caucasians, 4.6/year/million. Osteosarcoma has a bimodal age distribution, having the first peak during adolescence and the second peak in older adulthood. The first peak is in the 10-14-year-old age group, coinciding with the pubertal growth spurt. This suggests a close relationship between the adolescent growth spurt and osteosarcoma. The second osteosarcoma peak is in adults older than 65 years of age; it is more likely to represent a second malignancy, frequently related to Paget's disease. The incidence of osteosarcoma has always been considered to be higher in males than in females, occurring at a rate of 5.4 per million persons per year in males vs. 4.0 per million in females, with a higher incidence in blacks (6.8 per million persons per year) and Hispanics (6.5 per million), than in whites (4.6 per million). Osteosarcoma commonly occurs in the long bones of the extremities near the metaphyseal growth plates. The most common sites are the femur (42%, with 75% of tumors in the distal femur), the tibia (19%, with 80% of tumors in the proximal tibia), and the humerus (10%, with 90% of tumors in the proximal humerus). Other likely locations are the skull or jaw (8%) and the pelvis (8%). Cancer deaths due to bone and joint malignant neoplasms represent 8.9% of all childhood and adolescent cancer deaths. Death rates for osteosarcoma have been declining by about 1.3% per year. The overall 5-year survival rate for osteosarcoma is 68%, without significant gender difference. The age of the patient is correlated with the survival, with the poorest survival among older patients. Complete surgical excision is important to ensure an optimum outcome. Tumor staging, presence of metastases, local recurrence, chemotherapy regimen, anatomic location, size of the tumor, and percentage of tumor cells destroyed after neoadjuvant chemotherapy have effects on the outcome.
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Dietary vitamin K intakes are associated with hip fracture but not with bone mineral density in elderly men and women
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Management of Hip Fractures in the Elderly
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BACKGROUND: Vitamin K has been associated with bone mineral density (BMD) and risk of hip fracture. The apolipoprotein (apo) E4 allele (APOE*E4) has been associated with bone fracture through a putative effect on vitamin K transport in blood. OBJECTIVE: The objective was to determine the associations between vitamin K intake, apo E genotype, BMD, and hip fracture in a population-based cohort of elderly men and women. DESIGN: Dietary vitamin K intake was assessed with a food-frequency questionnaire in 335 men and 553 women (average age: 75.2 y) participating in the Framingham Heart Study in 1988-1989. Incidence of hip fractures was recorded from 1988 to 1995. BMD at the hip, spine, and arm was assessed on 2 separate occasions (1988-1989 and 1992-1993). Comparisons between apo E genotype and BMD were made relative to E4 allele status (at least 1 epsilon4 allele compared with no epsilon4 allele). RESULTS: Individuals in the highest quartile of vitamin K intake (median: 254 microg/d) had a significantly lower fully adjusted relative risk (0.35; 95% CI: 0. 13, 0.94) of hip fracture than did those in the lowest quartile of intake (median: 56 microg/d). There were no associations between vitamin K intake and BMD in either men or women. No association was found between the E4 allele and BMD, and there were no significant interactions between the E4 allele and phylloquinone intake and BMD or hip fracture. CONCLUSIONS: Low vitamin K intakes were associated with an increased incidence of hip fractures in this cohort of elderly men and women. Neither low vitamin K intake nor E4 allele status was associated with low BMD
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Low Level Laser Therapy for chronic knee joint pain patients
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OAK 3 - Non-arthroplasty tx of OAK
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BACKGROUND AND AIMS: Chronic knee joint pain is one of the most frequent complaints which is seen in the outpatient clinic in our medical institute. In previous studies we have reported the benefits of low level laser therapy (LLLT) for chronic pain in the shoulder joints, elbow, hand, finger and the lower back. The present study is a report on the effects of LLLT for chronic knee joint pain.
MATERIALS AND METHODS: Over the past 5 years, 35 subjects visited the outpatient clinic with complaints of chronic knee joint pain caused by the knee osteoarthritis-induced degenerative meniscal tear. They received low level laser therapy. A 1000 mW semi-conductor laser device was used to deliver 20.1 J/cm(2) per point in continuous wave at 830nm, and four points were irradiated per session (1 treatment) twice a week for 4 weeks.
RESULTS: A visual analogue scale (VAS) was used to determine the effects of LLLT for the chronic pain and after the end of the treatment regimen a significant improvement was observed (p<0.001). After treatment, no significant differences were observed in the knee joint range of motion. Discussions with the patients revealed that it was important for them to learn how to avoid postures that would cause them knee pain in everyday life in order to have continuous benefits from the treatment.
CONCLUSION: The present study demonstrated that 830 nm LLLT was an effective form of treatment for chronic knee pain caused by knee osteoarthritis. Patients were advised to undertake training involving gentle flexion and extension of the knee.
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Occult posttraumatic avascular necrosis of hip revealed by MRI
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Management of Hip Fractures in the Elderly
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Three hips with avascular necrosis in two patients had associated traumatic lesions noted on magnetic resonance imaging. Location of stress fracture in two femoral necks and acetabular contusion development prior to avascular necrosis favors these processes as being etiologic. These cases are particularly noteworthy in that nondisplaced fractures or other musculoskeletal trauma not visible on plain films has rarely been associated with subsequent development of avascular necrosis
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MR diagnosis of recurrent tears in the knee: value of intraarticular contrast material
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AMP (Acute Meniscal Pathology)
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OBJECTIVE: After surgical resection or repair of a torn meniscus, the healed area may have areas of abnormal signal intensity on MR images. Consequently, routine MR imaging is not reliable for detecting recurrent meniscal tears. As a result, we studied the efficacy of MR imaging with intraarticular contrast material (MR arthrography) for detecting recurrent tears of the meniscus.
SUBJECTS AND METHODS: Thirty-seven patients who previously had a meniscal tear treated by either meniscal resection or repair had conventional MR imaging and MR arthrography with 40-50 ml of a 1:100 solution of gadopentetate dimeglumine in saline. All patients had arthroscopy shortly after the MR studies. Follow-up arthroscopic surgery was performed within an average of 6.6 weeks after the MR arthrograms. The routine MR images and MR arthrograms were reviewed separately and randomly, and these results were compared with the arthroscopic findings. Meniscal morphology, signal intensity, and the presence of joint fluid tracking into recurrent tears were evaluated.
RESULTS: The overall accuracy in diagnosing recurrent meniscal tears in the post-operative meniscus was 66% when conventional MR imaging was used and 88% when MR arthrography was used. In patients who had only minimal meniscal resection, both methods had an accuracy of 89%. In patients who had more extensive meniscal resection, accuracy was 65% with conventional MR imaging and 87% with MR arthrography. In four patients who had only a small meniscal remnant, the accuracy was 50% with routine MR imaging and 100% with MR arthrography. On conventional MR images, the presence of an effusion tracking into a meniscal tear had a sensitivity and positive predictive value of 90% for detection of recurrent meniscal tears; however, the sensitivity was only 41%.
CONCLUSION: Our results show that the sensitivity of MR imaging in detecting meniscal tears after surgery varies with the extent of the resection. Sensitivity was considerably improved when intraarticular contrast material was used. MR arthrography should be considered as an alternative to arthroscopy in patients who have had resection or repair of the meniscus.
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Upper blepharoplasty: a novel approach to improving progressive myopathic blepharoptosis
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Upper Eyelid and Brow Surgery
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OBJECTIVE: To describe the results of upper blepharoplasty for the treatment of progressive myopathic upper eyelid blepharoptosis. DESIGN: Retrospective, noncomparative case series. PARTICIPANTS: Six consecutive patients treated bilaterally. INTERVENTION: Upper blepharoplasty in 6 patients (12 eyelids) with progressive myopathic ptosis. MAIN OUTCOME MEASURES: Subjective visual improvement, ocular comfort, preoperative and postoperative margin reflex distances, lagophthalmos, and degree of corneal keratopathy at last follow-up date. RESULTS: All patients had subjective visual improvement and denied ocular discomfort. Upper eyelid ptosis, measured by margin reflex distances, was improved. No worsening of lagophthalmos or corneal keratopathy was noted. CONCLUSIONS: Upper blepharoplasty may be an excellent alternative for ptosis treatment in patients with progressive myopathies. Improvement in ptosis, margin reflex distance, without concomitant lagophthalmos, and corneal keratopathy can be achieved.
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Intertrochanteric fractures in high risk geriatric patients treated by external fixation
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Management of Hip Fractures in the Elderly
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Conservative treatment in intertrochanteric fractures of the high risk patient carries a high rate of mortality and morbidity. In the present study external fixation of the fracture was performed under local or light general anaesthesia. This is a safe procedure and permits immediate full weight bearing
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Percutaneous cyst aspiration with injection of two different bioresorbable bone cements in treatment of simple bone cyst
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MSTS 2022 - Metastatic Disease of the Humerus
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Introduction: Simple bone cysts (SBCs) are common in children and adolescents. The risk of refracture and the probability of spontaneous healing in SBCs are mainly dependent on the activity of the cyst and can be quantified with the Cyst-Index. Avoiding pathological fractures is the primary goal. Our study presents a comparison of two different bioresorbable bone graft substitutes (BGSs) in the minimally-invasive treatment of SBC in the active stage by percutaneous cyst aspiration and injection.
Methods: Between 2006 and 2017, 38 patients (aged two to 37 years; mean age 12.4 (sd 5.6)) were treated with percutaneous cyst aspiration and refilled with bioresorbable BGSs in three hospitals. The cysts of 21 patients (11 humerus, five femur, four calcaneus, one fibula) were refilled with porous beta-tricalcium phosphate (PB-TP group) (ChronOS Inject) and of 17 patients (nine humerus, six femur, one calcaneus, one fibula) with hydroxyapatite/calcium sulphate (H/CS group) (CERAMENT
BONE VOID FILLER). There were 13 (62%) preceding fractures in the PB-TP group and eight (47%) in the H/CS group. The follow-up of all patients was at least two years. During follow-up, radiological healing (modified Neer classification), activity level, refracture rates, recurrence rates, resorption period and complications were analyzed.
Results: In all, 21 patients treated with PB-TP group experienced 27 operations (one refracture, three recurrences and one persistent cyst). A total of 17 patients treated with H/CS experienced 20 operations (one refracture and one recurrence). After six weeks, 95% in the PB-TP group returned to unrestricted activity with one refracture in the femur due to insufficient biomechanical stability and all returned to unrestricted activity in the H/CS group. Partial or complete radiological response was observed in 81% after 13 months (sd 3.4). Three recurrences (14%) occurred in the PB-TP group and one recurrence (6%) occurred in the H/CS group. The refracture rates were similar in both groups; one (5%) in the PB-TP group and one (6%) in the H/CS group. All H/CS treated cysts showed completed resorption after two years, whilst in PB-TP treated cysts no resorption occurred in five cases (25%) (p = 0.031). Two (10%) wound infections occurred in the PB-TP group and no infections occurred in the H/CS group.
Conclusion: Both PB-TP and H/CS can provide stability and prevent refracture in patients with single bone cysts at the upper extremity or the foot. For the proximal femur, additional stabilization is necessary, due to the weight-bearing and associated high refracture rate. The H/CS bone graft substitute has a better resorption rate than the PB-TP graft.
Level of Evidence: III.
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1 |
Healthcare resources attributable to methicillin-resistant Staphylococcus aureus orthopedic surgical site infections
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DoD SSI (Surgical Site Infections)
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The number of orthopedic surgeries is increasing as populations steadily age, but surgical site infection (SSI) rates remain relatively consistent. This study aimed to quantify the healthcare resources attributable to methicillin-resistant Staphylococcus aureus (MRSA) SSIs in orthopedic surgical patients. The analysis was conducted using a national claims database comprising data from almost all Japanese residents. We examined patients who underwent any of the following surgeries between April 2012 and March 2018: amputation (AMP), spinal fusion (FUSN), open reduction of fracture (FX), hip prosthesis (HPRO), knee prosthesis (KPRO), and laminectomy (LAM). Propensity score matching was performed to identify non-SSI control patients, and generalized estimating equations were used to estimate the differences in outcomes between the case and control groups. The numbers of MRSA SSI cases (infection rates) ranged from 64 (0.03%) to 1,152 (2.33%). MRSA SSI-attributable increases in healthcare expenditure ranged from $11,630 ($21,151 vs. $9,521) for LAM to $35,693 ($50,122 vs. $14,429) for FX, and increases in hospital stay ranged from 40.6 days (59.2 vs. 18.6) for LAM to 89.5 days (122.0 vs. 32.5) for FX. In conclusion, MRSA SSIs contribute to substantial increases in healthcare resource utilization, emphasizing the need to implement effective infection prevention measures for orthopedic surgeries.
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0 |
Ewing's sarcoma of the proximal femur
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DoD LSA (Limb Salvage vs Amputation)
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The cases of 16 patients with Ewing's sarcoma of the proximal femur treated in the era of multiagent chemotherapy were reviewed, with emphasis on the mechanical problem of tumor involvement in this structurally demanding site. Fourteen patients received chemotherapy and local radiotherapy as the initial primary treatment. One patient had chemotherapy and radiotherapy, followed by wide local resection. One patient had amputation, followed by chemotherapy, for pathologic fracture and extensive soft tissue involvement at presentation. Two local reccurrences occurred. Excluding the 2 patients whose femurs were fixed prophylactically, the pathologic fracture rate was 79%. In addition, by excluding the 2 patients who died before fracture, the pathologic fracture rate was 92%. Nonunion occurred in 5 (71%) of the 7 pathologic fractures not treated by resection and required as many as 5 additional surgical procedures to obtain union. At latest followup evaluation (average, 6.3 years), 10 patients had no evidence of disease, 1 was alive with disease, and 5 had died of their disease. Options for management should include primary resection and reconstruction or prophylactic internal fixation after completion of chemotherapy plus or minus radiotherapy.
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Is the impact of knee osteoarthritis diminishing because of knee replacements? The multi-center osteoarthritis study
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Surgical Management of Osteoarthritis of the Knee CPG
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Background/Purpose: Rates of knee replacement (KR) have increased so much that they may have an effect on the overall impact of symptomatic knee osteoarthritis (SxOA). Specifically, as more persons with severe knee SxOA get KR and get it at an earlier disease stage, only a limited number of persons with severely disabling SxOA are left in the population. Thus, there might be a secular trend of improvement in functional score among persons with SxOA. We described the secular trend of function among subjects with SxOA in the Muliticenter Osteoarthritis (MOST) Study in which > 300 subjects had KR over 5 years. Methods: The MOST Study is a cohort study of 3026 persons with or at high risk of knee OA drawn from the community. Subjects had knee radiographs, filled out WOMAC surveys, and reported knee surgery every 30 months. Self reported KR was confirmed on radiographs or medical records. At each visit, a subject was defined as having SxOA if >=1 knee had frequent knee pain plus K/L grade >=2 at that time or had any KR prior to the visit. The WOMAC function score at 0M, 30M and 60M among subjects who currently had SxOA at the visit were compared by
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0 |
Efficacy of chlorhexidine and nystatin rinses in prevention of oral complications in leukemia and bone marrow transplantation
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Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures
|
The goal of reducing oral complications during chemotherapy and bone marrow transplantation has received attention at several centers. The current randomized study of 86 adults with leukemia treated with chemotherapy or bone marrow transplantation assessed the potential role of chlorhexidine, nystatin, and saline solution rinses to reduce the findings of oral mucositis, gingivitis, and oral infection. The results of this study did not show a reduction in mucositis with the use of these rinses. However, potential bacterial and fungal pathogens were identified less frequently in the patients using chlorhexidine rinse
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0 |
A single stage liposuction and dermopexy for grade 3b and grade 4 pseudogynecomastia after massive weight loss: an observational study
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Reduction Mammoplasty for Female Breast Hypertrophy
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Nineteen middle-aged males with grade 3b and grade 4 pseudogynecomastia following severe weight loss were treated by liposuction and simultaneous skin reduction. From 1997 through 2005 nine males with grade 3 and ten with grade 4 pseudogynecomastia were included in this study. Ages ranged from 23 to 48 years. Author used two techniques for skin reduction: 1-the dermal mastopexy (keyhole design) for grade 4, and 2-the complete circum-areolar technique (concentric reduction) with de-epithelialization for grade 3b. The current technique offers a proper treatment for the pendulous female-like breast with inelastic and redundant skin. It obviates the need for secondary revision by providing a viable nipple-areola complex at the desired location and eliminating the dish-type deformity that may result from subcutaneous mastectomy. Patients were monitored for the following 18 to 39 months. While reviewing the literature other methods are compared and discussed but it is suggested that the method reported here has a number of advantages and is the treatment of choice in many such cases.
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0 |
Fractures of the distal radius and scaphoid
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Distal Radius Fractures
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Simultaneous fractures of the distal radius and scaphoid is an uncommon wrist injury. During the period 1980 to 1993, 23 patients with a median age of 39 years were treated for this injury. The median follow-up period was 7 years. All scaphoid fractures were undisplaced and located in the waist or distal third. An extraarticular distal radial fracture was observed in 15 wrists. A below elbow cast including the thumb was applied in 18 wrists for a mean duration of 9 weeks, and operative treatment was used in only 5 patients. All scaphoid fractures healed without complications. During conservative treatment there were three redisplacements of distal radial fractures. The final functional results were good in 18, fair in four, and poor in one patient. Because complications occurred at the distal radius we have changed our conservative treatment policy from a below elbow cast including the thumb to a dorsal splint for 6 weeks.
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1 |
Premedication of patients undergoing dental procedures causing bacteremia after total joint arthroplasty
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Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures
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INTRODUCTION: More than 1 million total joint replacements, mostly hip and knee, are performed each year in the United States, and the number is increasing. The American Academy of Orthopedic Surgeons has issued a new information statement that dramatically changes the need for premedication with antibiotics before dental appointments. METHODS: The prior advisory statements, jointly released in 1997 and 2003 by the American Dental Association and American Academy of Orthopedic Surgeons, recommended premedication for only 2 years after the surgical placement of the implant(s) for patients undergoing total arthroplasty and/or for immune-compromised patients. The current information statement indicates that those patients with total joint replacement should be premedicated for any dental procedure with a risk of causing bacteremia for the lifetime of the patient. RESULTS: There is no well-documented, convincing published evidence with modern molecular methods of species identification in which the reported species was specific to a dental procedure in the orofacial region to the subsequently infected total joint replacement. CONCLUSIONS: Further discussions between orthopedic surgeons, general medical practitioners, and dental practitioners should be encouraged to reach a mutual consensus on this controversial issue to provide the best protection for patients receiving dental treatment potentially resulting in transient bacteremia. Moreover, difficult randomized controlled trials must be conducted to determine the best treatment to minimize infections of total joint replacements and reduce morbidity and mortality
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0 |
Abdominal contouring procedures increase activity of the coagulation cascade
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Panniculectomy & Abdominoplasty CPG
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One of the most serious complications in plastic surgery is a thromboembolic event. However, little physiologic evidence exists to support the observed hypercoagulable state seen in contouring procedures. Twenty-one consecutive patients were enrolled prospectively to assess thrombin generation, which measures activity of the coagulation cascade, at baseline, intraoperative, and 24 hours after surgery. Compared with preoperative values, total thrombin generation increased by a mean of 997 nM intraoperatively (1.3-fold, P<0.004) and 1406 nM postoperatively (1.4-fold, P<0.001) in 9 patients undergoing abdominoplasty without deep venous thrombosis (DVT) chemoprophylaxis. The mean thrombin generation did not significantly change during or after surgery in 12 patients who received heparin for DVT prophylaxis (P=0.3). Thrombin generation was significantly less in patients receiving chemoprophylaxis compared with those who received no prophylaxis (P<0.01). This suggests abdominal contouring procedures induce a significant increase in the activity of the coagulation cascade that can be prevented by DVT chemoprophylaxis.
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0 |
Multicentric giant cell tumour of bone
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MSTS 2022 - Metastatic Disease of the Humerus
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Although giant cell tumour (GCT) is seen quite frequently, multicentric giant cell tumour (MCGCT) is a rare entity occurring in less than 1% of patients with GCT. The pathogenesis of MCGCT is debated; various mechanisms have been postulated, including contiguous spread, iatrogenic tumour cell seeding, benign metastasis, malignant transformation and de novo formation. A literature review revealed 101 cases of MCGCT reported worldwide, of which we could trace and review 83 cases. We noted that MCGCT, unlike the solitary GCT, more frequently involves the short bones of the hand and feet and is commoner in the meta-diaphyseal region of long bones. The present literature review noted a higher incidence in females and skeletally immature patients (21%). Individual lesions in a patient with MCGCT are radiologically and histologically indistinguishable from the solitary GCT. In our review we noted 42 recurrences in 157 lesions (26%), thus negating the commonly held point of view that MCGCT was clinically more aggressive. Four lung metastases and two histologically malignant lesions were found. The literature does not define the exact time period beyond which a lesion can be classified as metachronous; however a significant number of the subsequent lesions occur within 2-3 years of the index lesion. We recommend from our review, that with the present state of knowledge, special care should be taken in cases with primary meta-diaphyseal lesions, GCTs seen at atypical locations, and in females of younger age group, to ensure that multicentricity is picked up earlier. [References: 77]
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0 |
Prescription of opioids to post-operative orthopaedic patients at time of discharge from hospital: a prospective observational study
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AAHKS (4) Acetaminophen
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BACKGROUND AND AIMS: Excessive opioid prescribing can lead to adverse consequences including stockpiling, misuse, dependency, diversion and mortality. Increased prescriptions to post-operative inpatients as part of their discharge planning may be a significant contributor. Primary aims included comparing the amount of opioids prescribed, consumed, left unused and their relationship with pain and functionality.
METHODS: A total of 132 consecutive patients who underwent elective orthopaedic surgery were prospectively audited. Daily oral morphine equivalent (DME) of opioids prescribed was compared with opioids consumed and amount left unused 7-10 days after discharge. For analysis, patients were split into three groups: total knee replacement (TKR), hand surgery (Hands), and miscellaneous (Misc).
RESULTS: The mean dose of opioid prescribed per patient was 108.5 mg DME. TKR consumed 33-35% more opioids than Misc (p=0.0283) and Hands (p=0.0975). Age was a significant independent factor for opioid consumption in the 50th and 75th percentiles of Hands (p<=0.05). An average of 36 mg DME per patient was left unused with Hands having the highest median DME (37 mg) unused. In the total cohort, 26% of patients were discharged with more DME than their last 24 h as an inpatient and had at least 50% of their tablets left unused at follow-up.
CONCLUSIONS: Over-prescription of opioids occurs at discharge which can increase the risk of harm. New intervention is needed to optimise prescribing practises.
IMPLICATIONS: Changes to prescribing habits and workplace culture are required to minimise unnecessary opioid prescribing but will be challenging to implement. A multi-layered approach of electronic prescribing, opioid stewardship and targeted educational awareness programmes is recommended.
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0 |
Can bisphosphonates improve outcomes in patients with newly diagnosed multiple myeloma?
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MSTS 2018 - Femur Mets and MM
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Preclinical and clinical evidence suggests that bisphosphonates have anticancer activities both within and outside bone. Early clinical trials of bisphosphonates provided evidence for antimyeloma effects in exploratory analyses in high-risk subsets, and recent trials of zoledronic acid (ZOL) have provided further support of antimyeloma activity The MRC Myeloma IX trial is an innovative 2 x 2 factorial trial comparing ZOL and clodronate (CLO) in patients with newly diagnosed multiple myeloma receiving either intensive or non-intensive therapy regimens. Results showed that ZOL significantly reduced skeletal morbidity and significantly improved both progression-free and overall survival versus CLO. Notably, the survival benefit with ZOL remained significant after adjustment for skeletal-related events, consistent with clinically meaningful antimyeloma activity. Further analyses of these data will provide greater insight into ZOL interactions with primary treatment regimens for multiple myeloma.
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0 |
An Exploratory Study of PRX167700 in Patients With Knee Osteoarthritis
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OAK 3 - Non-arthroplasty tx of OAK
|
Up to 74 subjects will receive either PRX167700 or placebo (a dummy treatment) for 15 days. Subjects will need to stop taking their usual pain reliever medicines for at least 7 days before starting treatment to induce a 'flare' in osteoarthritis symptoms (but they will be allowed to continue to use paracetamol for immediate pain relief as needed throughout the trial). The effect of PRX167700 or placebo on knee pain will be assessed before and after exercise on Days 1, 3, 7 and 14. On Day 15, blood samples will be collected to measure levels of PRX167700 and assess its activity.
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0 |
Arthroscopic versus open tennis elbow release: 3- to 6-year results of a case-control series of 305 elbows
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Glenohumeral Joint OA
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PURPOSE: The purpose of this study was to compare the outcome of arthroscopic and open tendon release in tennis elbow (TE).
METHODS: We compared the outcome of patients treated by an open tendon release in the period from 2002 to 2005 (n = 80) with that of patients treated by an arthroscopic release of the extensor carpi radialis brevis in the period from 2005 to 2008 (n = 225). In both groups the inclusion criteria were symptomatic TE refractory to conservative care for a minimum of 6 months and a clinical follow-up of at least 3 years. The diagnosis was based on a typical history and positive clinical findings. Patients with previous surgery in the elbow, chondral or osteochondral lesions, osteoarthritis, or free bodies were excluded. To have a similar follow-up period in the 2 groups (median, 4 years), the follow-up was conducted at 2 different time points.
RESULTS: The groups did not differ significantly with regard to the age of the patients, distribution of gender, distribution of affected side, duration of symptoms, or baseline score on the short version of Disabilities of the Arm, Shoulder and Hand questionnaire (QuickDASH). We did not observe any major complications. The failure rate was not significantly different between the 2 groups. At follow-up, the mean QuickDASH score was statistically significantly better (P = .004) in the arthroscopic group (11.6 points; SD, 15.6 points) compared with that in the open group (17.8 points; SD, 19.4 points). The percentage of elbows with an excellent outcome at follow-up (QuickDASH score <20 points) was significantly higher in the arthroscopic group (78%) than in the open group (67%) (P = .04).
CONCLUSIONS: Both a traditional open approach and the newer arthroscopic method provide an effective treatment of recalcitrant TE without major complications. The arthroscopic method offers a small, but not insignificant, improvement in the outcome as evaluated by the QuickDASH score.
LEVEL OF EVIDENCE: Level III, therapeutic case-control study.
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1 |
Anticoagulation management in hip fracture patients on warfarin
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Management of Hip Fractures in the Elderly
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The management of patients admitted with a fracture requiring surgery who are taking warfarin anticoagulation is unclear. We examined the anticoagulation management for 33 hip fracture patients on warfarin at the time of admission. Hospital course and complications were recorded on all patients. The mean INR on admission was 3.2 and prior to surgery 2.2. Eight patients (24%) had percutaneous cancellous screws for an intracapsular fracture regardless of the admission INR. In 21 (64%) patients, surgery was delayed whilst the INR came down, with an average delay of 72 h from admission to surgery. No specific treatment to lower the INR, other than wait and watch policy adopted in 11 (33%) of these patients. Pharmacological methods used to reduce the INR were fresh frozen plasma in nine cases, and intravenous Vitamin K in four patients. One patient died from post-operative haematemesis and three died from medical complications unrelated to the warfarin therapy. There were no wound haematomas or other bleeding complications. Delaying surgery whilst waiting for the INR to fall to acceptable levels may result in significant delays to surgery and we would recommend a more aggressive policy to enable earlier surgery
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0 |
Targeting CXCR4 and FAK reverses doxorubicin resistance and suppresses invasion in non-small cell lung carcinoma
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MSTS 2018 - Femur Mets and MM
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BACKGROUND: Current high lung cancer mortality rates are mainly due to the occurrence of metastases and therapeutic resistance. Therefore, simultaneous targeting of these processes may be a valid approach for the treatment of this type of cancer. Here, we assessed relationships between CXC chemokine receptor type 4 (CXCR4) and focal adhesion kinase (FAK) gene expression levels and expression levels of the drug resistance-related genes ABCB1 and ABCC1, and tested the potential of CXCR4 and FAK inhibitors to reverse doxorubicin (DOX) resistance and to decrease the invasive capacity of non-small cell lung carcinoma (NSCLC) cells.
METHODS: qRT-PCR was used for gene expression analyses in primary lung tissue samples obtained from 30 NSCLC patients and the human NSCLC-derived cell lines NCI-H460, NCI-H460/R and COR-L23. MTT, flow cytometry, cell death and beta-galactosidase activity assays were used to assess the in vitro impact of CXCR4 and FAK inhibitors on DOX sensitivity. In addition, invasion and gelatin degradation assays were used to assess the in vitro impact of the respective inhibitors on metastasis-related processes in combination with DOX treatment.
RESULTS: We found that ABCB1 over-expression was significantly associated with CXCR4 and FAK over-expression, whereas ABCC1 over-expression was associated with increased FAK expression. We also found that CXCR4 and FAK inhibitors strongly synergized with DOX in reducing cell viability, arresting the cell cycle in the S or G<sub>2</sub>/M phases and inducing senescence. Additionally, we found that DOX enhanced the anti-invasive potential of CXCR4 and FAK inhibitors by reducing gelatin degradation and invasion.
CONCLUSIONS: From our data we conclude that targeting of CXCR4 and FAK may overcome ABCB1 and ABCC1-dependent DOX resistance in NSCLC cells and that simultaneous treatment of these cells with DOX may potentiate the anti-invasive effects of CXCR4 and FAK inhibitors.
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0 |
Epidemiology of hip fractures in The Netherlands: women compared with men
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Management of Hip Fractures in the Elderly
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In this retrospective study the epidemiology of hip fractures in The Netherlands was evaluated. The number of hip fractures over the period 1972-1987 was collected from the Dutch Centre for Health Care Information (Stichting Informatiecentrum voor de Gezondheidszorg, SIG). The demographic data were collected from the Dutch Centre for Statistics (Centraal bureau voor de Statistiek, CBS). The age-adjusted incidence of hip fractures for both women and men 50 years of age and over, increased linearly over the period 1972-1987. There was also a linear rise in the age-adjusted incidence of hip fractures in women and men 65 years of age and over, but the rise in incidence was equal in both sexes. After the age of 50 years women and men showed an equal proportional increase in the age-specific incidence of hip fractures by 5-year age groups. This proportional increase was independent of the calendar year studied during the period 1972-1987. The increase over time in the age-adjusted incidence of hip fractures in inhabitants 50 years of age and over is the result of changes that act well before the age of 50 years, because the proportional increase in the age-specific incidence of these fractures after the age of 50 years did not change over the period studied. The cohort analysis showed that the age-specific incidence of hip fractures in more recently born birth cohorts is higher than that in birth cohorts born long ago. This observation agrees with the other observations.(ABSTRACT TRUNCATED AT 250 WORDS)
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0 |
No difference in quality-of-life outcomes after mobile and fixed-bearing medial unicompartmental knee replacement
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Surgical Management of Osteoarthritis of the Knee CPG
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This is a retrospective study comparing the clinical outcomes of mobile vs fixed medial unicompartmental knee replacements. Patients were identified from a prospectively collected database. Demographic data and pre- and postoperative outcomes (Oxford, Western Ontario and McMaster Universities Osteoarthritis Index, Short Form Health Survey-12, and satisfaction) were collected-104 knees (90 patients) with minimum 2-years of follow-up: 37 mobile and 67 fixed-bearing. At baseline, the median age was 60 years (mobile) and 66 (fixed); body mass index was significantly higher (32) for the mobile group than for the fixed (28). At follow-up, the groups differed only in the Oxford score: median 83 (mobile) and 90 (fixed). There is no difference in outcomes between mobile and fixed unicompartmental knee replacements
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Closed suction drainage has no benefits in revision total hip arthroplasty: a randomized controlled trial
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PJI DX Updated Search
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PURPOSE: Several studies have failed to show significant benefits of closed suction drainage (CSD) in routine primary total hip arthroplasty (THA). However, blood loss, haematoma formation and wound complications are generally much greater in revision THA as compared to primary THA. The purpose of this study was to determine if CSD is beneficial for revision THA patients. METHODS: We conducted a prospective, randomized, controlled trial at our institution between July 2013 and July 2014. Eighty-eight patients undergoing revision THA were enrolled and randomly assigned to receive a CSD (n = 44) or to not receive a CSD (n = 44). All first-stage revision surgeries for infection were excluded. Primary outcomes were haemoglobin loss and number of patients transfused. Secondary outcomes included functional outcome evaluated with Harris hip score (HHS), pain evaluated with visual analogue scale (VAS), and length of hospital stay. RESULTS: There were significantly more patients in the CSD group that required blood transfusions (20/44 as compared to 11/44, p = 0.04). Patients in the no CSD group were discharged earlier than patients in the CSD group (4.3 days as compared to 5.4 days, p = 0.002). No statistical significant difference was found in the HHS or pain VAS between the groups. CONCLUSIONS: This study did not demonstrate any benefit with the use of CSD for revision THA with regard to wound related complications, infection or early functional outcome. Post-operative blood loss, transfusion rate, and length of hospital stay may be higher with CSD
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0 |
Reduction mammaplasty followed by development of a bilateral nonsynchronous carcinoma of the breast
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Reduction Mammoplasty for Female Breast Hypertrophy
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Case report of a woman who at the age of 26 underwent mammary reduction (Strombeck) for macromastia. A primary bilateral non synchronous carcinoma of the breast was discovered 20 mths and 5 yrs after the plastic surgery. On pathological examination in both instances, no lymph node metastases were found. There was a positive family history of the occurrence of carcinoma. Mammography prior to mammary reduction is recommended.
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0 |
Physiologic amputation prevents myoglobinuria from lower extremity myonecrosis
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DoD LSA (Limb Salvage vs Amputation)
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Myoglobinuria secondary to myonecrosis is a proven cause of renal failure, especially in critically ill patients. Physiologic amputation or cryoamputation has been used at our institution for the past two decades as a safe and effective treatment for lower extremity infection, intractable rest pain, and irreversible myonecrosis. We retrospectively studied five critically ill patients with myonecrosis of lower extremities associated with myoglobinuria. The etiology of myonecrosis included preexisting peripheral vascular disease or crush injury to the lower extremities. It was determined that all five patients were too ill to undergo emergency amputation. Myoglobinuria was documented in all five patients and cleared within 24 hours of physiologic amputation in four patients. All five patients had elevated creatine phosphokinase levels (mean 20,270 mU/mL, range 12,090 to 43,164 mU/mL) that significantly decreased within 48 hours of physiologic amputation (mean 6,488 mU/mL, range 2,250 to 13,580 mU/mL). Mechanical ventilation and cardiovascular support were required in four patients. All patients had transient episodes of renal insufficiency with two progressing to anuric renal failure and requiring dialysis. One patient's renal failure resolved after 56 days, but the other patient died of a cerebrovascular accident 22 days after initiation of physiologic amputation. The mean duration of physiologic amputation was 15.6 days (range 5 to 32 days) with no significant complication due to physiologic amputation. All five patients had surgical amputation successfully. Three patients survived. The two deaths in the study were due to a cerebrovascular accident in one patient and a cardiopulmonary arrest in another. Physiologic amputation is a treatment option that halts myonecrosis, prevents myoglobinuria, and lessens the risk of associated acute renal failure. Physiologic amputation may be appropriately used in patients with myoglobinuria due to extremity myonecrosis who are deemed too critically ill to survive emergency amputation.
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1 |
An outcomes analysis and satisfaction survey of 199 consecutive abdominoplasties
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Panniculectomy & Abdominoplasty CPG
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Abdominoplasty is a popular body-contouring procedure. In this study the authors review retrospectively 199 abdominoplasty patients during a 15-year period to identify factors that affect overall outcome. Patients included 190 women and 9 men. The complication rate was 32% with few major complications (1.4%). The revision rate was 43%, and was related to fine-tuning the aesthetic appearance. Patients were divided into four groups based on tobacco use and history of diabetes and hypertension. There was no significant difference in revision rates or major complications between the subgroups. Minor complication rates, however, were significantly higher in smokers and patients with diabetes and/or hypertension. Complication and revision rates in patients undergoing intra-abdominal procedures combined with abdominoplasty were not significantly different from those patients undergoing abdominoplasty alone. A patient survey revealed symptom improvement in 95% of patients. Eighty-six percent of patients were satisfied with their result, and 86% would recommend abdominoplasty to a friend. The authors conclude that abdominoplasty is a safe and satisfying procedure, whether performed alone or in conjunction with another procedure. Patients are pleased with the outcome and have improvement in their symptoms, with minimal health risk. There is, however, a significant incidence of minor complications, related primarily to wound healing. These complications are increased significantly in smokers and patients with diabetes and/or hypertension. Revision rates are not different significantly between the subgroups. When complications do occur or revisions are required, they are minor and managed easily in an office setting.
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0 |
Comparison of single-injection and continuous infusion adductor canal block initial ambulation times and distance after total knee arthroplasty (TKA)
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Surgical Management of Osteoarthritis of the Knee CPG
|
Background and aims: Adductor canal blockade (ACB) has emerged as an alternative with less motor blockade for postoperative analgesia after TKA, potentially facilitating rehabilitation and early ambulation. We compared the efficacy of a continuous adductor canal block (cACB) for 48 hours to the efficacy of a single-shot ACB (sACB). Methods: Retrospective analysis of all patients that underwent total knee arthroplasty and received anACB from September 2013 to February 2014. Outcomes studied were post-operative time from block placement to time of first ambulation, time to ambulation . 50 feet and total ambulation distance during the first two postoperative days. Results: 59 patients (n= 31 for sACB and n=28 cACB) underwent TKA. Average ages were 65.29 for SACB and 65.60 years in the CACB group. In the sACB group, time to first ambulation was 19.56 and 29.45 hours (hrs) in the cACB group. Average time to meet the milestone of 50 ft of ambulation (surrogate marker for discharge readiness/disposition by physical therapy) was 42.01 (cACB) and 34.65 hours (sACB) groups. 2/28 (7%) of the CACB and 7/31 (22.6%) of sACB patients failed to reach this endpoint. Total ambulation distance during the first 48 hours was 44.70 m (cACB) and 62.93 m (sACB). Conclusions: Patients with a continuous adductor canal block ambulated later than patients receiving a single-injection adductor canal block but are more likely to meet physical therapy endpoints that might affect discharge disposition and/or outcomes for TKA patients
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0 |
Vascular complications from resuscitative endovascular balloon occlusion of the aorta: Life over limb?
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DoD LSA (Limb Salvage vs Amputation)
|
BACKGROUND: Vascular complications from resuscitative endovascular balloon occlusion of the aorta (REBOA) have been reported in as high as 13% with some patients requiring lower-extremity amputation. We sought to review our institution series of REBOA and assess our vascular complications. METHODS: Retrospective review of all patients undergoing REBOA from October 2011 through July 2016. Data were gathered from the Memorial Hermann Trauma Registry and the hospital electronic medical records. Operative details and vascular injuries from arterial access for REBOA insertion were recorded. RESULTS: Forty-eight patients underwent REBOA during our study period. Thirty-eight had the 14 Fr. system placed and 10 had the 7 Fr. system placed. Of the 24 surviving the removal of the 14 Fr. sheath, 19 had primary repair of the arteriotomy without vascular complication. The other five required additional vascular procedures to repair arteriotomy with no lower-extremity amputations. There were no vascular complications of sheath removal with the 7 Fr. system, with no amputations. CONCLUSION: Implementation of REBOA can be done safely without increased risk of vascular access complications or limb loss. The 14 Fr. system will more likely require further vascular procedures to address the access site, whereas the 7 Fr. system will not. LEVEL OF EVIDENCE: Therapeutic/care management, level II.
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0 |
Patient preferences in print advertisement marketing for plastic surgery
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Reduction Mammoplasty for Female Breast Hypertrophy
|
Background: Plastic surgeons are competing for their share of a growing but still limited market, thus making advertising an important component in a successful plastic surgery practice. Objective: The authors evaluate the variables, characteristics, and presentation features that make print advertisements most effectively pique the interest of individuals selecting a plastic surgeon. Methods: An online survey was administered to 404 individuals with active interest in plastic surgery from 10 major metropolitan areas. Participants were presented with 5 different advertisements from plastic surgeons throughout the country and were asked a series of both closed- and open-ended questions to assess verity, quality, and marketability of each advertisement. Reponses to open-ended questions were analyzed using the Wordle program (www.wordle.net). Results: The most frequent themes identified for all 5 ads were Being beautiful is possible (41%), I could be beautiful (24%), Some people need surgery to be beautiful (16%), and Being beautiful is important (14%). Advertisement 1 featuring 3 women and no pre- or posttreatment photography, no physician photography, and a listing of the 3 physicians credentials but not a list of the services provided received the highest overall preference rating. Conclusions: Factors including emotions felt while reading, unique qualities of the advertisement, list of procedures performed, use of models versus actual patients, and pictures of the plastic surgeons were found to contribute to the respondents overall perception of advertisements used to market a plastic surgery practice. © 2013 The American Society for Aesthetic Plastic Surgery, Inc.
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0 |
Efficiency of HEPA-filtered extra-oral suction unit on aerosols during prosthetic dental preparation: A pilot study
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Dental Implant Infection
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OBJECTIVES: Aerosols formed during dental treatments have a huge risk for the spread of bacteria and viruses. This study is aimed at determining which part of the working area and at what size aerosol is formed and ensuring more effective use of HEPA-filtered devices., MATERIALS AND METHODS: Anterior tooth preparation was performed by one dentist with one patient. Particle measurements were made using an airborne particle counter and were taken at four different locations: the chest of the patient, the chest of the dentist, the center of the room, and near the window. Three groups were determined for this study: group 1: measurement in a 24-h ventilated room (before the tooth preparation, empty room), group 2: measurement with the use of saliva ejector (SE), and group 3: measurement with the use of saliva ejector and HEPA-filtered extra-oral suction (HEOS) unit., RESULTS: The particles generated during tooth preparation were separated according to their sizes; the concentration in different locations of the room and the efficiency of the HEOS unit were examined., CONCLUSIONS: The present study showed that as the particle size increases, the rate of spread away from the dentist's working area decreases. The HEPA-filtered extra-oral suction unit is more effective on particles smaller than 0.5 microns. Therefore, infection control methods should be arranged according to these results., CLINICAL RELEVANCE: The effective and accurate use of HEPA-filtered devices in clinics significantly reduces the spread of bacterial and viral infections and cross-infection. Copyright © 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.
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0 |
Comparative gait analysis of ankle arthrodesis and arthroplasty: initial findings of a prospective study
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Surgical Management of Osteoarthritis of the Knee CPG
|
BACKGROUND: Little is known about functional outcomes of ankle arthroplasty compared with arthrodesis. This study compared pre-surgical and post-surgical gait measures in both patient groups. METHODS: Eighteen patients with end-stage ankle arthritis participated in an ongoing longitudinal study (pre-surgery, 12 months post-surgery) involving gait analysis, assessment of pain and physical function. Outcome measures included temporal-distance, kinematic and kinetic data, the Short Form 36 (SF-36) body pain score, and average daily step count. A mixed effects linear model was used to detect effects of surgical group (arthrodesis and arthroplasty, n = 9 each) with walking speed as a covariate (alpha = 0.05). RESULTS: Both groups were similar in demographics and anthropometrics. Followup time was the same for each group. There were no complications in either group. Pain decreased (p < 0.001) and gait function improved (gait velocity, p = 0.02; stride length, p = 0.035) in both groups. Neither group increased average daily step count. Joint range of motion (ROM) differences were observed between groups after surgery (increased hip ROM in arthrodesis, p = 0.001; increased ankle ROM in arthroplasty, p = 0.036). Peak plantar flexor moment increased in arthrodesis patients and decreased in arthroplasty patients (p = 0.042). CONCLUSION: Initial findings of this ongoing clinical study indicate pain reduction and improved gait function 12 months after surgery for both treatments. Arthroplasty appears to regain more natural ankle joint function, with increased ROM. Long-term follow up should may reveal more clinically meaningful differences
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0 |
Can fresh osteochondral allografts restore function in juveniles with osteochondritis dissecans of the knee?
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Diagnosis and Treatment of Osteochondritis Dissecans AUC
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BACKGROUND: Failure of initial treatment for juvenile osteochondritis dissecans (OCD) may require further surgical intervention, including microfracture, autograft chondrocyte implantation, osteochondral autografting, and fresh osteochondral allografting. Although allografts and autografts will restore function in most adults, it is unclear whether fresh osteochondral allograft transplantations similarly restore function in skeletally immature patients who failed conventional treatment. QUESTIONS/PURPOSES: Therefore, we determined function in (1) daily activity; (2) sports participation; and (3) healing (by imaging) in children with juvenile OCD who failed conventional therapy and underwent fresh osteochondral allograft transplantation. METHODS: We retrospectively reviewed 11 children with OCD of the knee treated with a fresh stored osteochondral allograft between 2004 and 2009 (six males and five females). The average age of the children at the time of their allograft surgery was 15.2 years (range, 13-20 years). The clinical assessments included physical examination, radiography, MRI, and a modified Merle D'Aubigne-Postel score. The size of the allograft was an average of 5.11 cm(2). The minimum followup was 12 months (average, 24 months; range, 12-41 months). RESULTS: All patients had returned to activities of daily living without difficulties at 6 months and returned to full sports activities between 9 and 12 months after surgery. The modified Merle D'Aubigne-Postel score improved from an average of 12.7 preoperatively to 16.3 at 24 months postoperatively. Followup radiographs at 2 years showed full graft incorporation and no demarcation between the host and graft bone. CONCLUSIONS: Our observations suggested fresh osteochondral allografts restored short-term function in patients with juvenile OCD who failed standard treatments. LEVEL OF EVIDENCE: Level IV, case series. See Guidelines for Authors for a complete description of levels of evidence
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Salvage procedures for failed compression hip screw fixation of intertrochanteric femoral fractures: analysis of 50 cases
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Management of Hip Fractures in the Elderly
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We retrospectively studied 50 patients who underwent salvage procedures for failed compression hip screw (CHS) fixation of intertrochanteric fractures from January 1991 to July 2000. Among these patients, seven underwent revision fixed angle plate surgery; 16 patients underwent bipolar hemiarthroplasty; five patients underwent Austin-Moore hemiarthroplasty; another nine patients underwent total hip arthroplasty; and 13 patients underwent removal of the implant. The age, gender, type of falling accident, osteoporosis status and post-operative ambulation status were recorded. The incidence of failed fixation of CHS was estimated at around 9.7%. A fall was recorded in 52% of cases. There was a significant difference in osteoporosis grade between the failed and successful CHS groups (p < 0.005). There was also better postoperative ambulation in the total hip replacement group compared to the other groups (p = 0.03). Surgical management of nonhealed intertrochanteric fractures is a challenge to orthopedic surgeons. The authors suggest multiple factors, such as fracture geometry, bone quality, preservation of acetabulum cartilage and individual patient factors, be considered when performing salvage procedures for failed CHS
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Dental surgery before liver transplantation: Is it really necessary?
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Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures
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A detailed dental examination and surgical treatment of oral septic foci are recommended in patients awaiting liver transplantation (LT). This standard procedure is based on the idea that patients with untreated dental disease may have an increased risk for post-LT infections. Aim of this study was to evaluate the influence of dental diseases and pre-LT treatment on the infection rates in patients after LT. Patients and methods: From April 2003 until November 2009, 216 patients (154m, 51(plus or minus)11yrs) underwent LT in our centre. The underlying causes were alcohol (45.4%), alcohol + viral hepatitis (6.5%), viral hepatitis (15.3%), biliary tract diseases (14.8%) and others. The patients were divided into 4 groups. Group 1: patients with bad dental status and following dental surgery; group 2: patients with bad dental status without dental treatment; group 3: patients with good dental status; group 4: no pre-LT dental examination available. The medical data were assessed on patients' records and analyzed retrospectively. Results: Mean follow-up after LT was 43(plus or minus)28 months. 58 patients (27%) belonged to group 1, 43 patients (20%) to group 2, 54 patients (25%) to group 3 and 61 patients (28%) to group 4. Bacterial infections, mostly cholangitis and pneumonia, were observed in 49% of all transplanted patients 0-72 months (mean 12 months) after LT. In 46% enterococcus spp. was the most detectable pathogen in the blood and different tissues. However, there was no significant difference in the frequency of bacterial infections and the pathogen spectrum in the 4 different groups. 68 patients died 0-63 months after LT, thereby 25 patients due to bacterial sepsis. Furthermore, significantly (p< 0.001) more patients with alcohol toxic liver cirrhosis suffered from a bad dental status in comparison to patients with other liver diseases. Conclusions: Our data suggest, that there is no significant effect of pre-LT dental status on the outcome of liver transplant patients. Standard dental restoration obviating prophylactic teeth extraction seems sufficient for patients undergoing LT
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Timing of access to secondary healthcare services and lower extremity amputations in patients with diabetes: a case-control study
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DoD LSA (Limb Salvage vs Amputation)
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OBJECTIVE: To investigate the association between timing of patient access to secondary healthcare services for diabetes management and lower extremity amputation (LEA) among patients with diabetes. RESEARCH DESIGN AND METHODS: A case-control study was conducted in the secondary healthcare system in Ireland. Cases were 116 patients with diabetes who underwent a first major non-traumatic LEA between 2006 and 2012. Controls were 348 patients with diabetes, over 45 years, admitted to the same hospital as an emergency or electively, frequency-matched for gender, type of diabetes, and year. Data were collected for 7 years prior to the event year. ORs for LEA in patients with diabetes comparing early versus late referral from primary to secondary healthcare were calculated. RESULTS: Statistically significant risk factors associated with LEA in patients with diabetes included being single, chronic kidney disease, hypertension, and hyperglycemia. Documented retinopathy was a significant protective factor. In unconditional logistic regression analysis adjusted for potential confounders, there was no evidence of a reduced risk of LEA among patients referred earlier to secondary healthcare for diabetes management. CONCLUSIONS: Specialist referral may need to occur earlier than the 7-year cut-off used to demonstrate an effect on reducing LEA risk. Documented retinopathy was associated with reduced risk of LEA, most likely as a proxy for better self-care. Variation in the management of diabetes in primary care may also be impacting on outcomes. Efforts to develop more integrated care between primary and secondary services may be beneficial, rather than focusing on timing of referral to secondary healthcare.
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Knee Osteoarthritis after Arthroscopic Partial Meniscectomy: Prevalence and Progression of Radiographic Changes after 5 to 12 Years Compared with Contralateral Knee
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OAK 3 - Non-arthroplasty tx of OAK
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The purpose of this study was to study the clinical and radiographic changes in the knee after arthroscopic partial meniscectomy (APM) at a long-term follow-up compared with the contralateral knee. We assessed 57 patients (38 males and 19 females) with pre- and postoperative weight-bearing radiography with a follow-up ranging from 5.1 to 12.1 years (mean: 8.1) to analyze prevalence and progression of knee osteoarthritis (OA) after APM. We stratified patients according to body mass index (BMI), type of lesion (degenerative vs. traumatic), and side of meniscectomy (medial, lateral, and medial plus lateral). Patients were evaluated both clinically with Knee Osteoarthritis Outcome Score (KOOS) and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score and radiographically with the Kellgren and Lawrence (K/L) score. Radiographic OA was defined as K/L grade 2 or worse. The prevalence of knee OA was 62.69% in the tibiofemoral compartment. The progression of knee OA was statistically significant, ranging from 17.2% preoperatively to 65.95% postoperatively (p = 0.001) in the medial compartment and from 17.64% preoperatively to 58.82% postoperatively (p = 0.0324) in the lateral compartment. The progression of knee OA in the patellofemoral compartment ranged from 5.26 to 42.10% (p = 0.001). The OA progression regarding BMI was higher into the obese group than the normal-weight group and greater in the degenerative group than the traumatic one. The mean KOOS was 72.01 and the mean WOMAC was 73.84. The Spearman's test showed a statistical significance between clinical and radiographic results. Patients in the obese, overweight, and degenerative tear group had a greater predisposition to OA in the tibiofemoral and patellofemoral compartments after meniscectomy. The level of evidence is III, retrospective study.
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Closed locked intramedullary nailing of femoral shaft fractures in the elderly
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Management of Hip Fractures in the Elderly
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A review was performed of all patients over the age of 60 years who were treated with a locked intramedullary nail for a femoral shaft fracture. There were 15 patients with 16 femoral shaft fractures. Four patients died perioperatively. Of the surviving 11 patients with 12 fractures, union occurred in 100 percent. Knee range of motion was greater than 100 degrees in 11 of the 12 knees. Nine of the 11 patients returned to their preoperative level of ambulation. Intramedullary nailing of femoral shaft fractures in patients over the age of 60 years is an effective method of treatment. The mortality rate in elderly patients who sustain this injury is comparable to that seen after a femoral neck fracture in this age
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Development and Validation of a Preoperative Surgical Site Infection Risk Score for Primary or Revision Knee and Hip Arthroplasty
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PJI DX Updated Search
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BACKGROUND: Surgical site infection (SSI) is a major complication following total joint arthroplasty. Host susceptibility to infection has emerged as an important predictor of SSI. The purpose of this study was to develop and validate a preoperative SSI risk-assessment tool for primary or revision knee and hip arthroplasty. METHODS: Data for 6,789 patients who underwent total joint arthroplasty (from the years 2000 to 2011) were obtained from a single hospital system. SSI was defined as a superficial infection within 30 days or deep infection within 1 year. Logistic regression modeling was utilized to create a risk scoring system for a derivation sample (n = 5,789; 199 SSIs), with validation performed on a hold-out sample (a subset of observations chosen randomly from the initial sample to form a testing set; n = 1,000; 41 SSIs). RESULTS: On the basis of logistic regression modeling, we created a scoring system to assess SSI risk (range, 0 to 35 points) that is the point sum of the following: primary hip arthroplasty (0 points); primary knee (1); revision hip (3); revision knee (3); non-insulin-dependent diabetes (1); insulin-dependent diabetes (1.5); chronic obstructive pulmonary disease (COPD) (1); inflammatory arthropathy (1.5); tobacco use (1.5); lower-extremity osteomyelitis or pyogenic arthritis (2); pelvis, thigh, or leg traumatic fracture (2); lower-extremity pathologic fracture (2.5); morbid obesity (2.5); primary bone cancer (4); reaction to prosthesis in the last 3 years (4); and history of staphylococcal septicemia (4.5). The risk score had good discriminatory capability (area under the ROC [receiver operating characteristic] curve = 0.77) and calibration (Hosmer-Lemeshow chi-square test, p = 0.34) and was validated using the independent sample (area under the ROC curve = 0.72). A small subset of patients (5.9%) had a >10% estimated infection risk. CONCLUSIONS: The patient comorbidities composing the risk score heavily influenced SSI risk for primary or revision knee and hip arthroplasty. We believe that infection risk can be objectively determined in a preoperative setting with the proposed SSI risk score
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IV vs. Oral Acetaminophen as a Component of Multimodal Analgesia After Total Hip Arthroplasty
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AAHKS (4) Acetaminophen
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A) Opioid use after THA. Opioid use after THA can be 90 mg (+/â?79) in morphine equivalents when using epidural bupivacaine / hydromorphone and multimodal analgesia. Less than 1/3 of this was via the epidural (26/90 mg). Patients reported ORSDS composite scores of 0.58 B) IV vs oral acetaminophen. The therapeutic blood concentration of acetaminophen for pain relief is 10 mcg/ml. After an oral, single dose: In 24 fasting adult subjects, the maximal blood concentration (Cmax) of 7.7 to 17.6 mcg/mL occurred within 1 hour following a single 1000â?mg dose of oral acetaminophen (liquid or caplet). Acetaminophen crosses the bloodâ?brain barrier. Central diffusion to the brain and spinal fluid occurs within 15 to 45 minutes with maximum cerebrospinal fluid concentrations occurring at 2 to 4 hours. [Product Information: TYLENOL(R) oral, acetaminophen oral. McNeil Consumer Healthcare, Skillman, NJ, 2010]. In a randomized, doubleâ?blind, placeboâ?controlled, singleâ?dose study, acetaminophen 1,000 mg provided significantly greater efficacy in treating postsurgical dental pain compared with acetaminophen 650 mg and placebo. Oral, multipleâ?dose, immediateâ?release, elderly patients: In 12 very elderly patients (mean age, 89 years), the Cmax was 23.9 mcg/mL following the administration of acetaminophen 1000 mg orally 3 times daily for 5 days. In adult subjects, the mean Cmax was 28 +/â? 21 mcg/mL at the end of a 15â?minute IV infusion of acetaminophen 1000 mg. [Product Information: OFIRMEV(TM) intravenous infusion, acetaminophen intravenous infusion. Cadence Pharmaceuticals Inc., San Diego, CA, 2010]. The oral medication has an excellent absorption and at least 85% bioavailability, but peak concentration occurs later than the IV, and the therapeutic blood concentration for pain relief (10mcg/ml) may not be achieved after one oral dose (7â?17mcg/ml).A full stomach delays the absorption. With multiple doses, in elderly patients, or with renal/ liver failure, the blood concentration is higher. Epidural bupivacaine / clonidine (Liu). Pain scores (NRS) after THA with activity on POD1 can be 3.4 mean (2.6 SD) when using epidural bupivacaine / clonidine and multimodal analgesia. Lowâ?opioid protocol (oxycodone may be too strong for some; cannot use Vicodin due to acetaminophen) Choice of instruments (CAM, ORSDS, Pain OUT). The ORSDS is a 4â?point scale that evaluates 12 symptoms (nausea, vomiting, constipation, difficulty passing urine, difficulty concentrating, drowsiness or difficulty staying awake, feeling lightheaded or dizzy, feeling confused, feelings of general fatigue or weakness, itchiness, dry mouth and headache) via 3 symptom distress dimensions (frequency, severity, bothersomeness). It is validated for use after orthopaedic surgery, specifically including TKA patients receiving epidural analgesia and femoral nerve blockade. Patients can meet criteria for delirium by CAM by having acute onset of inattention as well as either disorganized thinking or altered level of consciousness.Patients without acute onset can also meet criteria for delirium if inattention, disorganized thinking and altered level of consciousness are all present, with at least one factor judged to be fluctuating. CAM has been widely applied and has been specifically used to evaluate elderly TKA patients receiving epidural analgesia and femoral nerve blockade. The Patient Outcome Questionnaire by the American Pain society is used for quality improvement, and measures 6 aspects of quality, including (1) pain severity and relief; (2) impact of pain on activity, sleep, and negative emotions; (3) side effects of treatment; (4) helpfulness of information about pain treatment; (5) ability to participate in pain treatment decisions; and (6) use of nonpharmacological strategies.
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Meniscal allograft transplantation without bone plugs: a 3-year minimum follow-up study
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AMP (Acute Meniscal Pathology)
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BACKGROUND: Meniscal allograft transplantation is a viable option for subtotally meniscectomized and totally meniscectomized symptomatic patients and potentially results in pain relief and increased function.
HYPOTHESIS: The use of a single tibial tunnel arthroscopic technique without bone plugs will reduce symptoms (pain) and improve knee function at a minimum 3-year follow-up.
STUDY DESIGN: Case series; Level of evidence, 4.
METHODS: Thirty-two meniscal transplantations (16 medial, 16 lateral; 23 men, 9 women) were prospectively evaluated at a minimum of 36 months (mean, 40.4 +/- 6.90 months; range, 36-66 months) after surgery. The average age at the time of surgery was 35.6 +/- 10.3 years (range, 15-55 years). The transplantation was performed using an arthroscopic bone plug-free technique with a single tibial tunnel plus "all-inside" meniscal sutures. The anterior meniscal horn was sutured to the capsule. Follow-up included a visual analog scale (VAS) score for knee pain and subjective and objective International Knee Documentation Committee (IKDC), Lysholm, Tegner, and SF-36 scores. All patients underwent radiographic and magnetic resonance imaging (MRI) evaluation of the involved knee before the surgery and at the final follow-up. The MRI outcomes were evaluated with the modified Yulish score.
RESULTS: Regarding clinical evaluation, there was a significant improvement in scores at follow-up compared with preoperatively: the VAS score decreased from 70.6 +/- 21.7 to 25.2 +/- 22.7 (P < .0001), the SF-36 physical component score increased from 37.31 +/- 7.2 to 49.69 +/- 8.3 (P < .0001), the SF-36 mental component score increased from 49.69 +/- 10.8 to 53.53 +/- 7.5 (P = .0032), the Tegner activity score increased from 3 (range, 3-5) to 5 (range, 3-6) (P < .0121), the Lysholm score increased from 59.78 +/- 18.25 to 84.84 +/- 14.4 (P < .0001), the subjective IKDC score increased from 47.44 +/- 20.60 to 77.20 +/- 15.57 (P < .0001), and the objective IKDC score changed from 1 A, 21 B, 6 C, and 4 D to 22 A, 9 B, and 1 C (P < .0001). No significant difference was found in this study between patients who received medial allografts and patients who received lateral allografts. There was no significant difference between outcomes of patients with isolated and combined procedures. The MRI findings showed 69% extruded allografts (8 medial and 14 lateral). In detail, we found 50% of the medial allografts and 87% of the lateral allografts extruded. No significant difference in clinical outcomes and modified Yulish score was found between patients with extruded allografts and with in situ allografts. The MRI results also showed a significant decrease of the modified Yulish score from baseline to 3-year minimum follow-up (P < .0001 for femur and P < .0001 for tibia). Only one patient underwent arthroscopic selective meniscectomy because of a medial posterior horn retear of the graft. One patient developed lack of flexion and underwent an arthroscopic arthrolysis. These 2 patients did not draw benefit from allografting and therefore were considered failures. In all remaining cases (94%), meniscal allograft transplantation was able to reduce symptoms (pain measured by VAS) and improve knee function (as measured by IKDC and Lysholm scores).
CONCLUSION: This study found that a single tibial tunnel arthroscopic technique without bone plugs for meniscal allograft transplantation significantly reduced pain and improved knee function in 94% of patients at a minimum 3-year follow-up.
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Post-traumatic stress disorder in women: current concepts and treatments
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DoD PRF (Psychosocial RF)
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In the US, 13% of women develop post-traumatic stress disorder (PTSD) during their lifetime. An accurate diagnosis of PTSD requires screening for trauma and symptoms of PTSD. Current research in the neurobiologic and psychologic responses to traumatic stress supports the use of pharmacologic and psychosocial interventions. Selective serotonin reuptake inhibitors are the current first-line pharmacotherapy. Efficacious psychosocial interventions include exposure therapy and cognitive processing therapy. [References: 154]
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Preliminary experience of the Cannulok revision hip prosthesis in late periprosthetic fracture management
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Management of Hip Fractures in the Elderly
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We report our preliminary experience of a cannulated, distally locked revision femoral component to manage peri-prosthetic fractures in the elderly. The majority of cases in our series were further complicated by osteolysis secondary to aseptic loosening, the original hip arthroplasties having been in situ for several years. Sixteen patients with an average age of 77 underwent treatment of periprosthetic fractures with the Cannulok Hip. The device combines techniques of revision hip surgery with locked intramedullary nailing. We describe our initial evaluation of this modular prosthesis which has enabled us to satisfactorily treat periprosthetic fractures with early mobilisation and discharge from hospital. In all of our surviving patients the fractures have united within four to six months. All cases were in addition treated with proximal femoral impaction allografting leading to improved local bone stock. We believe this implant may provide a satisfactory alternative for the management of periprosthetic fracture in the presence of a loose femoral component
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Organized nanofibrous scaffolds that mimic the macroscopic and microscopic architecture of the knee meniscus
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AMP (Acute Meniscal Pathology)
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The menisci are crescent-shaped fibrocartilaginous tissues whose structural organization consists of dense collagen bundles that are locally aligned but show a continuous change in macroscopic directionality. This circumferential patterning is necessary for load transmission across the knee joint and is a key design parameter for tissue engineered constructs. To address this issue we developed a novel electrospinning method to produce scaffolds composed of circumferentially aligned (CircAl) nanofibers, quantified their structure and mechanics, and compared them with traditional linearly aligned (LinAl) scaffolds. Fibers were locally oriented in CircAl scaffolds, but their orientation varied considerably as a function of position (P<0.05). LinAl fibers did not change in orientation over a similar length scale (P>0.05). Cell seeding of CircAl scaffolds resulted in a similar cellular directionality. Mechanical analysis of CircAl scaffolds revealed significant interactions between scaffold length and region (P<0.05), with the tensile modulus near the edge of the scaffolds decreasing with increasing scaffold length. No such differences were detected in LinAl specimens (P>0.05). Simulation of the fiber deposition process produced "theoretical" fiber populations that matched the fiber organization and mechanical properties observed experimentally. These novel scaffolds, with spatially varying local orientations and mechanics, will enable the formation of functional anatomic meniscus constructs.
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Treatment of Ankle Fracture Complications and Subacute or Malreduced Ankle Fractures
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DoD SSI (Surgical Site Infections)
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Rotational ankle fractures are among the most prevalent intra-articular fractures of the body. When managed appropriately, they have favorable outcomes with relatively low complication rates. The proper management of these injuries requires an understanding of the radiographic imaging, surgical anatomy, and biomechanics of both the tibiotalar and distal tibiofibular joint. Some of the most common and impactful complications of operatively treated ankle fractures include wound necrosis, surgical site infection, malunion, nonunion, and posttraumatic ankle arthritis. The management of these complications must be assessed on an individual case basis, but often requires a thorough preoperative evaluation and meticulous surgical planning to insure a successful outcome. This chapter provides a review of the management of subacute and malreduced ankle fractures as well as a brief review of the rates, risk factors, and management of other common complications associated with ankle fractures.Level of Evidence: Diagnostic Level V. See Instructions for Authors for a complete description of levels of evidence.
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Pain and functional status differences between rural and urban patients with end-stage knee OA
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Surgical Management of Osteoarthritis of the Knee CPG
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Purpose: Knee osteoarthritis (OA) is a frequent cause of disability around the world. During the last years, its undoubted public health impact has become more relevant as consequence of the aging population growth. Severe disability and pain lead these patients to knee joint replacement surgery. Different areas of residence imply distinct living and health care environments, and they may influence divergently the intensity of symptoms in knee OA. Very few studies have addressed this issue. We aimed to identify differences in functional status in patients with severe knee OA between rural and urban settings. Methods: Cross sectional study design involving 78 outpatients with endstage disease of knee OA from the San Cecilio Hospital and Primary health care centers of urban and rural areas of Granada province, Andalusia, Spain. Patients included were on waiting list for arthroplasty surgery due to knee OA diagnosis, with no more than 6 months on list, and aged 40 years or more. Patients excluded were those with inflammatory arthritis, previous knee arthroplasty, serious concomitant medical condition, any intra-articular injection - hyaluronic acid or corticosteroids - during the previous 2 months, lower limb biomechanical alteration not related to knee OA, and those not available by phone. Primary outcomes were the disease-specific WOMAC function and pain subscales. These and secondary outcomes were assessed in a face-to-face interview using a structured questionnaire. Results: Disability and pain were significantly greater in rural patients compared to urban patients. After adjustment for socio-demographic variables (SV) - age, sex, education and income - the effect of living in rural area persists (p=0.001 for pain, p=0.002 for function). Furthermore, this effect persisted after additional adjustment for some health-related variables (HV) such as BMI, mental health, and co-morbidity (p=0.004 for pain, p=0.007 for function). Subsequently, the adjustment for SV and/or HV was done with and without inclusion of occupation. The negative effect of living in rural area disappeared when both SV and HV are adjusted for and if the model included agricultural occupation (p= 0.092 for pain, p= 0.059 for function). Conclusions: Differences were found in pain and function among rural and urban patients with end-stage knee OA, as measured by a disease-specific scale (WOMAC index). In fact, living in rural area rather than urban residence matters beyond socio-demographic differences. Agricultural occupation is the disparity point between the two contexts, when other health conditions are also taken into account (BMI, mental health and co-morbidity). It is necessary to focus on the quality of care and be sure that the rural population is not being under treated. This study was carried out during the Master studies of L.A. Mendoza-Torres at Andalusian School of Public Health, Granada, Spain, and Copenhagen University, Copenhagen, Denmark
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Mechanical diagnosis and therapy and Morton's neuroma: a case-series
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Pediatric Supracondylar Humerus Fracture 2020 Review
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Objectives: Morton's neuroma (MN) is a neuralgia involving the common plantar digital nerves of the metatarsal region. Evidence-based treatment options for MN are sparse, and utility of physical therapy (PT) is unknown. Mechanical Diagnosis and Therapy (MDT) is a classification system utilizing direction-specific treatment for orthopedic conditions based on mechanical and symptomatic response to repeated end range movements. The purpose of this case series is to describe the management of three patients with a medical diagnosis of MN using the MDT classification system.Methods: Three female patients aged 54-75Â years with unilateral plantar forefoot pain for 6 weeks to 8 years were referred by a podiatrist following positive clinically accepted diagnostic criteria for MN including radiological imaging and provocation testing. Patients were evaluated and treated utilizing MDT assessment and treatment principles. The intervention consisted of repeated movements matched to the patient's directional preference at either the lumbar spine (1 patient) or distal extremity (2 patients).Results: Immediate and one-year outcomes were excellent, demonstrating rapid and lasting improvement. Following discharge, the patients have been asymptomatic or able to self-manage without seeking additional medical intervention for this condition. Total visit frequency per patient averaged 2-3 visits total across 8-16Â days.Discussion: Responses to repeated end range movements testing allowed for classification and prescription of exercise to rapidly improve symptoms and function in three patients referred to PT services with medically diagnosed MN. This series provides preliminary evidence that MDT may be effective in classifying and treating patients with MN.
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Endoscopic median nerve decompression: early experience
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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Open median nerve decompression is the gold standard for carpal tunnel syndrome; endoscopic median nerve decompression is an alternative. We compared our first 20 consecutive endoscopic releases with our last 20 open releases. The endoscopic procedure employed the two-portal Chow technique; the open procedure employed the Taleisnik technique. Postoperative patient assessment was performed by an independent occupational therapist blinded to the technique. There was no difference between the groups with respect to both subjective and objective outcomes. The time of return to work and to all activities averaged 3 and 6 weeks, respectively, for both groups. The choice between techniques should be based on informed consent by the patient in light of available data
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Targeting the Wnt signaling pathway for the development of novel therapies for osteoporosis
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MSTS 2018 - Femur Mets and MM
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A number of anti-osteoporotic drugs, predominantly inhibitors of bone resorption, are currently used in the management of patients with osteoporosis to reduce the risk of fractures. While the management of the disease has improved significantly, there are still unmet needs, mainly due to a lack of agents able to replace bone that has already been lost. Human and animal genetics have identified the pivotal role of the Wnt signaling pathway in the regulation of bone formation by the osteoblasts and have made it a very attractive target for the development of novel treatments for osteoporosis. In this article, we review evidence that supports the targeting of components of the Wnt signaling pathway for the design of bone-forming treatments for osteoporosis. © 2010 Expert Reviews Ltd.
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Factors delaying surgical treatment of hip fractures in elderly patients
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Management of Hip Fractures in the Elderly
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BACKGROUND: Published guidelines recommend early surgical treatment of hip fractures in elderly patients. Understanding the factors that delay surgical intervention is essential in order to introduce changes that will facilitate early treatment. AIM: To determine the factors delaying surgical treatment of hip fractures in elderly patients for more than 24 h. PATIENTS AND METHODS: Assessment of 163 consecutive patients undergoing surgery for hip fractures at the trauma unit of Manchester Royal Infirmary. RESULTS: Only 72/163 (44.2%) patients had their operation within 24 h of presenting to hospital. The remaining 91 patients had a total of 239 days delay (in excess of the initial 24 h) for surgical treatment. Active medical problems (56.5%) and a wait for medical investigations (19.7%) caused most delays. Lack of operating theatre time and Sunday trauma lists caused 23.8% of delays. CONCLUSIONS: Medical problems account for most delays of surgical treatment of hip fractures. A multidisciplinary approach, with early input by medical and anaesthetic teams, is essential in managing such patients. Established protocols may reduce waiting times for essential investigations
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Preoperative angio-CT preliminary study of the TRAM flap after selective vascular delay
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Panniculectomy & Abdominoplasty CPG
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BACKGROUND: The pedicled TRAM (pTRAM) flap is one of the best options for autologous breast reconstruction, but vascular complications reported in the standard versions are about 30%. To reduce complication rate, especially in high-risk patients, surgical delay has been suggested.Individual precise preoperative location and evaluation of perforating vessels and of variations of the diameter of the deep superior epigastric artery (DSEA) are highly desirable for improving surgical strategy. Previous reports using color duplex scanning, although generally confirming the validity of the delay maneuver, have showed several pitfalls. The aim of this report was to demonstrate the usefulness of multidetector computed tomography angiography (MDCTA) for preoperative planning in patients undergoing pTRAM flap breast reconstruction after selective vascular delay. METHODS: Three patients were considered for breast reconstruction with the pTRAM flap. An MDCTA was performed before and after selective delay to locate the muscle perforators and to show increase in DSEA diameter. Axial images, multiplanar reconstruction, and 3D volume images were analyzed. RESULTS: Accurate identification of the main perforators was achieved. Location, course, and anatomic variations of DSEA were reported. The average increase in diameter of the DSEA was 29.3%. CONCLUSION: Preoperative planning of pTRAM flap with MDCTA allows surgeons to visualize and locate the dominant perforators and to select the best DSEA. Consequently, the choice between the homolateral or contralateral rectus muscle is facilitated. The high sensitivity and specificity and the ease of interpreting data have made MDCTA a highly promising diagnostic tool for planning a pTRAM flap. © 2007 Lippincott Williams & Wilkins, Inc.
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Association of interleukin-6 promoter polymorphism with knee osteoarthritis: A meta-analysis
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SR for PM on OA of All Extremities
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Background: Osteoarthritis (OA) is the most common form of human polyarthritis. Many genetic factors have been implicated in OA. It was reported that a polymorphism in the gene of interleukin-6 (IL-6) was associated with OA of knee. The aim of this study was to determine whether functional IL-6 promoter -174G/C (rs1800795) polymorphisms confer susceptibility to knee OA. Methods: A meta-analysis was conducted on the association between the IL-6 polymorphism and knee OA. Electronic search at PubMed, EMBASE, Weipu database, and Wanfang database was conducted to select studies. Case-control studies containing available genotype frequencies of IL-6 -174G/C were chosen, and odds ratio (OR) with 95% confidence interval (CI) was used to assess the strength of this association. Results: A total of seven studies involving 6 464 subjects (knee OA 3 331 and controls 3 133) were considered in this study. The results suggested that the variant genotypes were not associated with knee OA risk in all genetic models (additive model: OR=1.144, 95% CI 0.934-1.402, P=0.194; recessive model: OR=1.113, 95% CI 0.799-1.550, P=0.526; dominant model: OR=1.186, 95% CI 0.918-1.531, P=0.191). A symmetric funnel plot, the Begg's test (P >0.05), suggested that the data lacked publication bias. Conclusions: This meta-analysis does not support the idea that rs1800795 genotype is associated with increased risk of knee OA. However, to draw comprehensive and more reliable conclusions, further prospective studies with larger numbers of participants worldwide are needed to examine the association between rs1800795 polymorphism and knee OA
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Early complications of anterior supine intermuscular total hip arthroplasty
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Hip Fx in the Elderly 2019
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Anterior supine intermuscular total hip arthroplasty (THA) performed on a fracture table has been increasingly used for primary THA. Accurate cup placement, low incidence of dislocation, shorter hospital stay, and faster return of function are potential benefits of the technique. However, a high complication rate, particularly during a surgeon's learning curve, has been reported. A retrospective analysis of 61 consecutive anterior supine intermuscular primary THAs with at least 6-month follow-up was performed. All procedures were performed using the anterior supine intermuscular approach with cementless implants under fluoroscopic guidance on a fracture table. Prospectively collected data were retrospectively reviewed to evaluate the early complication rate and radiographic accuracy of implant placement. Five (8.2%) intraoperative complications were observed: including 3 trochanteric fractures and 2 calcar fractures, 4 of which required cable fixation during the index procedure. One nondisplaced trochanteric fracture was treated conservatively. One patient sustained an injury of the lateral femoral cutaneous nerve. Postoperative complications included 1 anterior dislocation, 1 infected superficial hematoma, 1 stem subsidence, and 1 loose stem, with the latter 2 presenting as increasing thigh pain postoperatively and requiring stem revision. The overall complication rate was 16.4% (10/61). Overall, 3 patients (4 hips; 6.5%) required reoperation. No femoral or sciatic nerve injuries occurred, and no patient was diagnosed with venous thromboembolism. All intraoperative fractures occurred during the first 32 cases, and none during the last 29 cases. A potentially high incidence of complications with the anterior supine intermuscular THA exists during a surgeon's learning curve in an academic setting.
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Is there still a place for continuous closed irrigation in the management of periprosthetic total knee infection?
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PJI DX Updated Search
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In recent decades, many technical improvements have been achieved in the use of prosthetic joints, and the risk of infection has been greatly reduced, to current rates of 0.4-2.0% following primary knee replacement. However, the increasing rate of joint replacements being performed means that the absolute number of such infections remains significant and poses substantial costs to healthcare systems worldwide. Accordingly, further strategies to treat and prevent total joint infections should be investigated. Infections following knee replacements can compromise the function and durability of arthroplasty. When these infections occur during the immediate postoperative period, irrigation and debridement with component retention can be attempted to salvage the implant. This is an attractive, cheap, low-morbidity treatment for periprosthetic knee infection. However, the results published regarding this procedure are uneven; some studies report the eradication of prosthetic joint infection by debridement alone in 70-90% of cases but conversely, others have reported a high failure rate for this procedure, averaging 68% (61-82%). The difference could be attributed in part to the multiplicity of variables that may influence the success of the procedure. One such is that of treatment with a continuous irrigation system, which has the theoretical advantage of enabling the administration of antimicrobial agents, as well as the drainage of debris and blood clots. The objective of this study is to elucidate the overall efficacy of irrigation and debridement with prosthesis retention in infected total knee arthroplasty and to determine whether the addition of a continuous irrigation system influences this efficacy
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Prevalence and prognosis of synchronous distant metastatic tonsil squamous cell carcinomas
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MSTS 2022 - Metastatic Disease of the Humerus
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BACKGROUND: To analyze the prevalence proportions and prognostic factors of synchronous distant metastases in patients with tonsil squamous cell carcinomas (TSCC).
METHODS: TSCC patients were extracted from the Surveillance, Epidemiology and End Results (SEER) database between 2010 and 2014. We examined the association between clinical manifestations and distant metastases using Chi-squared tests. Predictors of 5-year survival were assessed using univariate and multivariate analyses.
RESULTS: A total of 6193 patients were analyzed and lung was the most common site of distant metastases. Poorly/undifferentiated differentiation was found to be significantly correlated with lung metastasis (p=0.033) and liver and bone metastases were associated with African American (p=0.000 and p=0.000, respectively). A higher T classification was associated with higher prevalence of lung, liver, bone and brain metastasis (p=0.000, p=0.000, p=0.000 and p=0.007, respectively). The same results were found in N classification in lung, liver, and bone metastasis (p=0.000, p=0.000, and p=0.000, respectively). Worse prognosis was associated with older age, Blacks, lower grade, higher T and N classification, no surgery therapy and more metastatic sites.
CONCLUSION: Lung was the most frequent lesion of synchronous distant metastases and liver and bone metastases were associated with African American. Higher T and N classification were independent prognostic parameters for higher prevalence of lung, bone, liver and brain metastasis. Worse prognosis was associated with older age, African Americans, lower grade, higher T and N classification, no surgery therapy and more metastatic sites.
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Knee tissue lesions and prediction of incident knee osteoarthritis over 7 years in a cohort of persons at higher risk
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OAK 3 - Non-arthroplasty tx of OAK
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OBJECTIVE: Among high risk individuals, whether knee lesions in tissues involved in osteoarthritis (OA) can improve prediction of knee OA is unclear. We hypothesized that models predicting (1) incident osteophytes and (2) incident osteophytes and joint space narrowing can be improved by including symptoms or function, and further improved by lesion status.
DESIGN: In Osteoarthritis Initiative (OAI) participants with normal knee X-rays, we assessed cartilage damage, bone marrow lesions (BMLs), and menisci. Cox proportional hazards models were used to develop risk prediction models for risk of each outcome. Nested models (increasingly larger baseline covariable sets) were compared using likelihood ratio tests and Schwarz Bayesian Information Criterion (SBC). Model discrimination used receiver operating characteristic (ROC) curves and area under the curve (AUC).
RESULTS: In 841 participants [age 59.6, body mass index (BMI) 26.7, 55.9% women] over up to 7 years follow-up, each larger set improved prediction (+hand OA, injury, surgery, activities; +symptoms/function). Prediction was further improved by including cartilage damage both compartments, BMLs both compartments, meniscal tear, meniscal extrusion, sum of lesion types, number of subregions with cartilage damage, number of subregions with BMLs, and (concurrently) subregion number with cartilage damage, subregion number with BMLs, and meniscal tear. AUCs were >=0.80 for both outcomes for number of subregions with cartilage damage and the combined model.
CONCLUSIONS: Among persons at higher risk for knee OA with normal X-rays, MRI tissue lesions improved prediction of mild as well as moderate disease. These findings support that disease onset is likely occurring during the "high-risk" period and encourage a reorientation of approach.
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Radiographic evaluation of short-stem press-fit total shoulder arthroplasty: Short-term follow-up
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PJI DX Updated Search
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Background: Humeral loosening is an uncommon etiology for revision shoulder arthroplasty. We aimed to evaluate the radiographic and clinical outcomes of a short-stem press-fit humeral component after primary total shoulder arthroplasty. Methods: We reviewed our patient database, from January 2008 to December 2011, for primary total shoulder arthroplasties performed with a short-stem press-fit humeral component. Radiographs and clinical outcomes were evaluated in the immediate postoperative period and at the most recent follow-up, with at least 24 months of data for all patients. Results: There were 73 shoulders that met our inclusion criteria, but 4 underwent revision before 2 years' follow-up. Only 1 of these 4 was revised for aseptic humeral loosening. Sixty-nine shoulders had at least 24 months of radiographic follow-up, and 62 had radiographic and clinical follow-up. Of the 69 shoulders, 5 underwent revision for humeral loosening: 1 for aseptic loosening and 4 for infection. Two other shoulders with humeral loosening were asymptomatic, and the patients refused revision surgery. The overall revision rate for humeral loosening was 8.2% (6 of 73 shoulders). Radiolucent zones of any size were seen in 71.0%, with 8.7% of these shoulders identified as having humeral stems at risk of future loosening. Significant improvements were made in most of the measured clinical outcomes. Conclusions: A high percentage of radiolucency was seen around the short-stem press-fit humeral components evaluated in this study at short-term follow-up. The overall rates of loosening and revision for the humeral implant examined in this study are higher than those noted in other recent studies evaluating press-fit stems. The cause of radiolucency and humeral loosening for this implant is not fully understood
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Implant surface factors and bacterial adhesion: a review of the literature
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Dental Implant Infection
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The microbiota that forms on implant surfaces placed in the human body can be highly resistant to antimicrobial agents and in some cases cause life-threatening infections. Consequently, to limit bacterial attachment to these surfaces and thereby minimize the risk of implant infection, the process of biofilm formation and bacterial attachment must be well-understood. The oral environment is considered to be an excellent model for research into biofilm formation and implant infection, accounting for many studies carried out in the field of dental medicine. Those studies show that the roughness, free energy, and material characteristics of the implant surface largely determine initial bacterial adhesion. This article reviews the relevant literature on these aspects of biofilm formation.
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The ultrasonic image of the acetabular rim in infants. An experimental and clinical investigation
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Developmental Dysplasia of the Hip CPG
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We report about the possibilities to evaluate the fine structures of the area around the acetabular rim in infants using ultrasound. The identification of the rim within the joint capsule, limbus and cartilagineous preformed acetabular rim is explained by experimental investigations. The clinical use of ultrasound provides a diagnostic method which is painless, non invasive and especially avoids X-ray exposure. It also can be repeated as often as possible. First statements could be made about the above mentioned structures, not visible on the radiograph, according to routine ultrasonic examinations of infantile hip joints, performed to exclude a luxation. We also point out the prognostic value of the cartilagineous acetabular rim demonstrated by ultrasound
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Discrimination between cases of hip fracture and controls is improved by hip structural analysis compared to areal bone mineral density. An ex vivo study of the femoral neck
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Management of Hip Fractures in the Elderly
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In vivo bone densitometry is affected by measurement inaccuracies arising from the assumptions made about soft tissue and marrow composition. This study tested the hypothesis that section modulus (SM, a measure of bending resistance) when measured ex vivo, would discriminate cases of hip fracture from controls better than areal bone mineral density (aBMD). The biopsies were from (n = 22, female) subjects that had suffered an intracapsular hip fracture. The control material (n = 24, female) was from post-mortem subjects. Serial peripheral quantitative computed tomography (pQCT) 1-mm thick cross-sectional images of femoral neck previously embedded in methacrylate were obtained with the Densiscan 1000 pQCT densitometer and matched for lateral location. The image voxels were converted to units of bone mass, which were then used to derive the section modulus. The data were used to derive means from which receiver operating characteristic (ROC) curves could be generated. The area under the curves (AUC) showed that discrimination between the fracture cases and controls was better for SM than aBMD [SM: AUC = 0.83 (95% confidence interval: 0.71, 0.96), aBMD: AUC = 0.70 (0.54, 0.85); P = 0.034]. To simulate the forces experienced during a sideways fall, the model's neutral axis was rotated by 210 degrees. The results for section modulus were predictable from those at 0 degrees (r(2) = 0.97). We conclude that biomechanical analysis of the distribution of bone within the femoral neck may offer a marked improvement in the ability to discriminate patients with an increased risk of intracapsular fracture. Progress towards implementing this form of analysis in clinical densitometry should improve its diagnostic value, but may depend in part on better image resolution and more accurate corrections for the variability between subjects in regional soft tissue composition
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Neurologic and vascular injuries associated with knee ligament injuries
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DOD - Acute Comp Syndrome CPG
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Background: Multiple ligament knee injuries are commonly associated with neurovascular complications such as popliteal artery, common peroneal nerve, and tibial nerve injuries. Hypothesis: While the importance of identifying these complications in association with bicruciate and triligamentous injuries has been well established, it is important to recognize that any biligamentous and some single ligament knee injuries present with neurological and vascular complications as well. Study Design: Literature review. Conclusion: Popliteal artery injuries require immediate intervention to help prevent limb loss. Peroneal and tibial nerve injuries can be a significant cause of morbidity and, therefore, require an understanding of their natural history, anatomy, and pathophysiologic implications to maximize functionality. Clinical Relevance: This review explores the types, mechanisms, and classifications of common neurovascular complications of knee ligament injuries, discusses their diagnosis, and reviews the therapeutic options available to optimize patient outcomes. © 2008 American Orthopaedic Society for Sports Medicine.
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Management of early-stage cutaneous melanoma
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Reconstruction After Skin Cancer
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Melanoma is a significant health problem, particularly in areas of high sun exposure. In North America, the per capita incidence is rising at an alarming rate. Fortunately, development of techniques for the diagnosis, staging, and treatment of patients with early-stage melanoma have paralleled the rise in melanoma incidence. Approximately 85% of patients diagnosed with melanoma have clinically localized disease at presentation and have their disease classified as early stage. In general, this group has a favorable prognosis. There are, however, multiple known and as yet unknown prognostic factors that lead to heterogeneity in clinical course and outcome for patients with earlystage melanoma. The results of multiple large studies have helped to clarify the optimal margins of resection for primary cutaneous melanomas. To adhere to these margin-width guidelines, the melanoma surgeon must be facile with several techniques for soft tissue defect closure. In addition to techniques for the most commonly performed primary closures, other important techniques used to repair defects resulting from wide local excision include skin grafting and the use of rotational flaps, local advancement flaps, and free flaps. Over the past 3 decades, the approach to patients with clinically negative regional lymph node basins has undergone considerable evolution. Initially, ELND was advocated for patients with intermediate and thick primary melanoma. Although randomized clinical trials overall failed to demonstrate a survival advantage for this more aggressive approach, a survival benefit for certain subsets of patients undergoing ELND was observed in some studies, suggesting that early surgical treatment of the involved regional lymph node basin might be advantageous. This approach, however, exposes patients - the majority of whom do not harbor microscopic disease - to the potential morbidity of a lymph node dissection. Subsequently, the technique of lymphatic mapping and SLNB was introduced. Its ability to identify patients with microscopic lymph node involvement using a minimally invasive approach has obvious advantages over a treatment algorithm that includes routine ELND. Overall, the technique of lymphatic mapping and SLNB has been shown to reliably identify those patients who are most likely to benefit from completion lymph node dissection while sparing patients with negative nodes the morbidity of an additional surgical procedure. It cannot be overemphasized, however, that the prognostic power and ultimate success of this procedure is dependent on excellent communication and coordination between the surgeon, nuclear medicine physician, radiologist, and pathologist. The advent of the SLNB technique has helped to usher in a new era of molecular pathologic analysis of SLNs. Rather than traditional routine histologic examination, SLNs are now subjected to more extensive pathologic examination with serial sectioning, immunohistochemical staining, and, in clinical trials, RT-PCR analysis. In the future, cDNA microarray technology may make possible a genomic approach to melanoma classification, potentially allowing the identification of genetic markers or expression profiles that might be important for diagnosis, determination of prognosis, and even therapy. The particular combination of SLN pathologic and molecular examinations that maximize both sensitivity and specificity (ie, the overall clinical accuracy of metastasis detection) remains a topic of active investigation. Recent reports suggest that the extent of microscopic tumor burden in the SLNs not only is a strong predictor of clinical outcome but also may be a key determinant of likely involvement of additional nodes in the same basin. Indeed, one may conjecture that in a setting of truly submicroscopic disease, the SLNB procedure itself may be both therapeutic and diagnostic; however, this requires further study. Long-term results of studies such as the Sunbelt Melanoma Trial and the Multicenter Selective Lymphadenectomy Trial will address and hopefully answer many of these ques ions. Other frontiers in the treatment of early-stage melanoma include defining the role of SLNB in patients with T1 primary tumors and determining which patients benefit the most and the least from a completion lymph node dissection following identification of a positive SLN. These are a few of the many questions that remain unanswered in this complex disease.
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Bio-mimicking nano and micro-structured surface fabrication for antibacterial properties in medical implants
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Dental Implant Infection
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Orthopaedic and dental implants have become a staple of the medical industry and with an ageing population and growing culture for active lifestyles, this trend is forecast to continue. In accordance with the increased demand for implants, failure rates, particularly those caused by bacterial infection, need to be reduced. The past two decades have led to developments in antibiotics and antibacterial coatings to reduce revision surgery and death rates caused by infection. The limited effectiveness of these approaches has spurred research into nano-textured surfaces, designed to mimic the bactericidal properties of some animal, plant and insect species, and their topographical features. This review discusses the surface structures of cicada, dragonfly and butterfly wings, shark skin, gecko feet, taro and lotus leaves, emphasising the relationship between nano-structures and high surface contact angles on self-cleaning and bactericidal properties. Comparison of these surfaces shows large variations in structure dimension and configuration, indicating that there is no one particular surface structure that exhibits bactericidal behaviour against all types of microorganisms. Recent bio-mimicking fabrication methods are explored, finding hydrothermal synthesis to be the most commonly used technique, due to its environmentally friendly nature and relative simplicity compared to other methods. In addition, current proposed bactericidal mechanisms between bacteria cells and nano-textured surfaces are presented and discussed. These models could be improved by including additional parameters such as biological cell membrane properties, adhesion forces, bacteria dynamics and nano-structure mechanical properties. This paper lastly reviews the mechanical stability and cytotoxicity of micro and nano-structures and materials. While the future of nano-biomaterials is promising, long-term effects of micro and nano-structures in the body must be established before nano-textures can be used on orthopaedic implant surfaces as way of inhibiting bacterial adhesion.
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