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Loss of normal knee motion after anterior cruciate ligament reconstruction is associated with radiographic arthritic changes after surgery
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OAK 3 - Non-arthroplasty tx of OAK
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BACKGROUND: Meniscectomy and articular cartilage damage have been found to increase the prevalence of osteoarthritis after anterior cruciate ligament reconstruction, but the effect of knee range of motion has not been extensively studied.
HYPOTHESIS: The prevalence of osteoarthritis as observed on radiographs would be higher in patients who had abnormal knee range of motion compared with patients with normal knee motion, even when grouped for like meniscal or articular cartilage lesions.
STUDY DESIGN: Cohort study; Level of evidence, 3.
METHODS: We prospectively followed patients at a minimum of 5 years after surgery. The constant goal of rehabilitation was to obtain full knee range of motion as quickly as possible after surgery and maintain it in the long term. Range of motion and radiographs were evaluated at the time of initial return to full activities (early follow-up) and final follow-up according to International Knee Documentation Committee (IKDC) objective criteria. A patient was considered to have normal range of motion if extension was within 2degree of the opposite knee including hyperextension and knee flexion was within 5degree. Radiograph findings were rated as abnormal if any signs of joint space narrowing, sclerosis, or osteophytes were present.
RESULTS: Follow-up was obtained for 780 patients at a mean of 10.5 +/- 4.2 years after surgery. Of these, 539 had either normal or abnormal motion at both early and final follow-up. In 479 patients who had normal extension and flexion at both early and final follow-up, 188 (39%) had radiographic evidence of osteoarthritis versus 32 of 60 (53%) patients who had less than normal extension or flexion at early and final follow-up (P = .036). In subgroups of patients with like meniscal status, the prevalence of normal radiograph findings was significantly higher in patients with normal motion at final follow-up versus patients with motion deficits. Multivariate logistic regression analysis of categorical variables showed that abnormal knee flexion at early follow-up, abnormal knee extension at final follow-up, abnormal knee flexion at final follow-up, partial medial meniscectomy, and articular cartilage damage were significant factors related to the presence of osteoarthritis on radiographs. Abnormal knee extension at early follow-up showed a trend toward statistical significance (P = .0544). Logistic regression showed the odds of having osteoarthritis were 2 times more for patients with abnormal range of motion at final follow-up; these odds were similar for those with partial medial meniscectomy and articular cartilage damage.
CONCLUSION: The prevalence of osteoarthritis on radiographs in the long term after anterior cruciate ligament reconstruction is lower in patients who achieve and maintain normal knee motion, regardless of the status of the meniscus.
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Ethmoid mucocele: a new feature of primary ciliary dyskinesia
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Patrick’s pharmacoepidemiology project
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Primary ciliary dyskinesia (PCD) is a rare congenital autosomal recessive disease that produces impairment of mucosal ciliary movement. Children with this disorder usually manifest recurrent and chronic infections of the upper and lower airways. We describe the history of a 12-month-old boy in whom the correct diagnosis of PCD was achieved after the occurrence of ethmoid mucocele associated with omolateral proptosis. A careful description of this new feature of PCD and its dangerous complications are also presented
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Treatment of the before and after images in aesthetic surgery
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Panniculectomy & Abdominoplasty CPG
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The author presents a new system of treatment using instant photographs for imaging body and facial recontouring before and after aesthetic surgery. The surgeon draws on photocopies of the photograph, blotting out in black to get a sense of reduction and adding with a white corrector to get a sense of enlargement.
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Does surgeon volume for total hip arthroplasty affect outcomes after hemiarthroplasty for femoral neck fracture?
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Management of Hip Fractures in the Elderly
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We conducted a study to compare complication rates in patients treated with hemiarthroplasty for femoral neck fracture by surgeons with variable experience in primary total hip arthroplasty (THA) and revision THA. A cohort of Medicare beneficiaries (N = 115,352) was identified from Medicare part A claims from 1994 and 1995. All patients had undergone hemiarthroplasty for femoral neck fracture. Patients were grouped according to surgeon procedure volume (how many primary and revision THAs surgeon performed per year): 0 (no volume), 1-5 (low volume), 6-24 (mid volume), and 25+ (high volume). Claims were evaluated up to 5 years after surgery to identify patient encounters for complications, such as mortality, dislocation, and infection. Compared with patients treated by no-volume surgeons, patients treated by high-volume surgeons had significantly lower rates of mortality, prosthetic dislocation, and superficial infection. The difference was significant for mortality at 30 days (5.6% vs 6.5%), 90 days (10.8% vs 12.8%), and 1 year (22.3% vs 23.8%); for prosthetic dislocation at 1 year (1.2% vs 1.7%); and for superficial infection at 90 days (1.1% vs 1.6%), 1 year (1.4% vs 1.9%), and 5 years (1.5% vs 2.0%). Revision surgery rates, however, were statistically higher for the high-volume group than for the no-volume group at 90 days (0.9% vs 0.7%), 1 year (3.3% vs 2.9%), and 5 years (8.4% vs 7.7%). There were no differences in rates of venous thromboembolism or deep infection between the groups. Surgical experience in primary and revision THA has a significant effect on patient outcomes after hemiarthroplasty for femoral neck fracture
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The effect of body weight on the choice of material for the bearing couple in artificial hip joints
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PJI DX Updated Search
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The effect of body weight on the success of arthroplasty replacement of the hip joint is a controversial issue, particularly the question of whether the choice of bearing couple used should be adapted to individual patient characteristics. As part of this study, we carried out a literature-based meta-analysis of clinical results that referred to patient weight. The friction of various material combinations under different joint forces was also experimentally determined. Clinically, there are reports of unfavorable implant positioning, increased rate of dislocations, and increased noise developments for obese patients. The results of the friction measurements do not suggest a material choice adapted to body weight. For obese patients, therefore, the same argument applies as for patients with normal weight; provided a correct implantation situation can be ensured, ceramic-on-ceramic bearing couples should be favored from a tribological point of view. If the correct implant position-for example, based on the more complicated implant conditions in obese patients-cannot be achieved, a hard-soft bearing couple with a ceramic head appears to be preferable to a hard-hard bearing couple. é 2014 Elsevier Inc
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0 |
Review of the long-term disability associated with hip fractures
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Management of Hip Fractures in the Elderly
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Objectives To determine the proportion of hip fracture patients who experience long-term disability and to re-estimate the resulting burden of disease associated with hip fractures in Australia in 2003. Methods A literature review of the functional outcome following a hip fracture (keywords: morbidity, treatment outcome, disability, quality of life, recovery of function, hip fractures, and femoral neck fractures) was carried out using PubMed and Ovid MEDLINE. Results A range of scales and outcome measures are used to evaluate recovery following a hip fracture. Based on the available evidence on restrictions in activities of daily living, 29% of hip fracture cases in the elderly do not reach their pre-fracture levels 1 year post-fracture. Those who do recover tend to reach their pre-fracture levels of functioning at around 6 months. These new assumptions result in 8251 years lived with disability for hip fractures in Australia in 2003, a 4.5-fold increase compared with the previous calculation based on Global Burden of Disease assumptions that only 5% of hip fractures lead to long-term disability and that the duration of short-term disability is just 51 days. Conclusions The original assumptions used in burden of disease studies grossly underestimate the long-term disability from hip fractures. The long-term consequences of other injuries may similarly have been underestimated and need to be re-examined. This has important implications for modelling the cost-effectiveness of preventive interventions where disability-adjusted life years are used as a measure of health outcome
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0 |
Osteosynthesis of distal radius fractures with the Micronail
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Distal Radius Fractures
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INTRODUCTION: The Micronail() is a minimally invasive intramedullar titanium locking screw fixation for two-part dislocated extra-articular fractures and average displaced intra-articular fractures.
PATIENTS AND METHODS: In a retrospective study we analyzed the outcome of 20 distal radius fractures in 18 patients (17 female, mean age 78 years), which were treated by Micronail(). Average follow-up time was 4 months. We describe the operative technique. All fractures were classified according to AO guidelines. We studied the radiologic and clinical outcome.
RESULTS: According to the AO classification there were 12 A2, 3 A3, 1 B1, and 1 B3 fracture. Three patients had an antebrachii fracture. Mean American Society of Anesthesiologists (ASA) score was 2.4. Eight patients had associated lesions. Average operative time was 58 min. All fractures healed without major loss of alignment. There were two major complications: one patient developed a carpal tunnel syndrome and one device secondary dislocated. With the use of the Micronail(), we found no infections or complications due to the insertion of the osteosynthesis materials. Patients experienced good to excellent results, on an analogue scale, in function of their wrist from the procedure. All patients had a good range of motion of the operated wrist; the difference between their two wrists was maximal 10degree in all directions.
CONCLUSION: This intramedullary implant intends to minimize some of the disadvantages of other surgical options in the treatment of distal radius fracture; the Micronail() causes less tissue damage and has early load-carrying capacity. This minimally invasive technique seems suitable in selected, two-part dislocated extra-articular and average displaced intra-articular, distal radius fractures.
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0 |
Antibiotics for the prophylaxis of bacterial endocarditis in dentistry
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Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures
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BACKGROUND: Infective endocarditis is a severe infection arising in the lining of the chambers of the heart with a high mortality rate.Many dental procedures cause bacteraemia and it was believed that this may lead to bacterial endocarditis (BE) in a few people. Guidelines in many countries have recommended that prior to invasive dental procedures antibiotics are administered to people at high risk of endocarditis. However, recent guidance by the National Institute for Health and Care Excellence (NICE) in England and Wales has recommended that antibiotics are not required. OBJECTIVES: To determine whether prophylactic antibiotic administration, compared to no such administration or placebo, before invasive dental procedures in people at risk or at high risk of bacterial endocarditis influences mortality, serious illness or the incidence of endocarditis. SEARCH METHODS: The following electronic databases were searched: the Cochrane Oral Health Group's Trials Register (to 21 January 2013), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 12), MEDLINE via OVID (1946 to 21 January 2013) and EMBASE via OVID (1980 to 21 January 2013). We searched for ongoing trials in the US National Institutes of Health Trials Register (http://clinicaltrials.gov) and the metaRegister of Controlled Trials (http://www.controlled-trials.com/mrct/). No restrictions were placed on the language or date of publication when searching the electronic databases. SELECTION CRITERIA: Due to the low incidence of BE it was anticipated that few if any trials would be located. For this reason, cohort and case-control studies were included where suitably matched control or comparison groups had been studied. The intervention was the administration of antibiotic, compared to no such administration, before a dental procedure in people with an increased risk of BE. Cohort studies would need to follow those individuals at increased risk and assess outcomes following any invasive dental procedures, grouping by whether prophylaxis was received or not. Included case-control studies would need to match people who had developed endocarditis (and who were known to be at increased risk before undergoing an invasive dental procedure preceding the onset of endocarditis) with those at similar risk but who had not developed endocarditis. Outcomes of interest were mortality or serious adverse events requiring hospital admission; development of endocarditis following any dental procedure in a defined time period; development of endocarditis due to other non-dental causes; any recorded adverse events to the antibiotics; and cost implications of the antibiotic provision for the care of those patients who developed endocarditis. DATA COLLECTION AND ANALYSIS: Two review authors independently selected studies for inclusion then assessed risk of bias and extracted data from the included study. MAIN RESULTS: No randomised controlled trials (RCTs), controlled clinical trials (CCTs) or cohort studies were included. One case-control study met the inclusion criteria. It collected all the cases of endocarditis in the Netherlands over two years, finding a total of 24 people who developed endocarditis within 180 days of an invasive dental procedure, definitely requiring prophylaxis according to current guidelines, and who were at increased risk of endocarditis due to a pre-existing cardiac problem. This study included participants who died because of the endocarditis (using proxies). Controls attended local cardiology outpatient clinics for similar cardiac problems, had undergone an invasive dental procedure within the past 180 days, and were matched by age with the cases. No significant effect of penicillin prophylaxis on the incidence of endocarditis could be seen. No data were found on other outcomes. AUTHORS' CONCLUSIONS: There remains no evidence about whether antibiotic prophylaxis is effective or ineffective against bacterial endocarditis in people at risk who are about to undergo an invasive dental procedure. It is not clear whether the potential harms and costs of antibiotic administration outweigh any beneficial effect. Ethically, practitioners need to discuss the potential benefits and harms of antibiotic prophylaxis with their patients before a decision is made about administration
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Evaluating Postoperative Complications and Outcomes of Orthopedic Fracture Repair in Nonagenarian Patients
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Hip Fx in the Elderly 2019
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Introduction: The United States and the world are currently experiencing a tremendous growth in the elderly population. Moreover, individuals surpassing the ages of 80 and 90 are also continuing to increase. As this unique division of society expands, it is critical that the medical community best understands how to assess, diagnose, and treat this population. The purpose of this study was to analyze morbidity, mortality, and overall outcome of patients aged 90 years and older after orthopedic surgical fracture repair. Such knowledge will guide patients and their families in making decisions when surgery is required among nonagenarians.
Methods: The trauma registry of our level I academic medical center was queried to identify potential study participants over the past decade. Two hundred and thirty-three surgical procedures among 227 patients were included and retrospectively assessed. Parameters of specific interest were injury type, mechanism of injury (including high energy vs low energy and height of falls), injury severity score, preoperative comorbidities, postoperative complications, length of hospital stay, discharge destination, and postoperative mortality rate.
Results: Overall, 4.3% of the cohort died in the hospital following surgery. Of the patients who survived, 89.7% were discharged to a professionally supervised setting. The nonagenarian population displayed a considerable follow-up rate, as 82.8% of individuals returned for their first postoperative office visit.
Discussion: Historically, surgical morbidity and mortality are highly associated with this age group. However, the number of nonagenarians in the United States is increasing, as are these surgical procedures. The epidemiologic and clinical findings of our study support this trend and add further insight into the matter.
Conclusion: This investigation demonstrates that orthopedic surgery is an appropriate treatment in this population with an acceptable complication rate. Furthermore, nonagenarians have the potential to demonstrate a substantial follow-up rate, but postoperative discharge to a professionally supervised setting may be necessary.
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Meniscus transplantation in skeletally immature patients
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AMP (Acute Meniscal Pathology)
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UNLABELLED: Meniscal pathology in skeletally immature patients includes meniscal tears and discoid lateral meniscus. Total or subtotal meniscectomy may occur in patients with discoid lateral meniscus or severe meniscal tears. Meniscal transplantation may be an option in skeletally immature patients status after total or subtotal meniscectomy with knee symptoms or dysfunction. This study focuses on the surgical technique and short-term outcomes of meniscus transplantation in skeletally immature patients. We reviewed our clinical database for skeletally immature patients who had undergone meniscus transplantation with a minimum of 2 years of follow-up. Patients were contacted, invited for a physical exam, and asked to complete a Pedi-IKDC, Lysholm, and Tegner outcomes questionnaire. The study protocol was approved by the responsible institutional review board. Three patients (two females/one male) were eligible for the study, each of whom responded to our invitation indicating availability for physical exam and questionnaire. Two patients had undergone subtotal discoid meniscus resection, leading to early lateral compartment degeneration. One patient developed advanced degeneration after a delay in treatment for a medial bucket-handle tear associated with anterior cruciate ligament rupture. The mean age of the patients at the time of surgery was 12.6+/-2.3 years. At a mean follow-up of 31+/-20 months, the mean Pedi-IKDC score was 68.3+/-4, the mean Lysholm was 55.7+/-22.3, and the median Tegner was 7 points. There were no indications of growth deformity during the regular postoperative radiological assessments. One patient required subsequent lysis of adhesions along the lateral mini arthrotomy and mobilization under anesthesia. The other two patients were able to return to sports at the same level as before meniscus transplantation and were able to do so within 9 months postoperatively. Over-resection of discoid menisci as well as untreated meniscus injury, the latter typically in conjunction with ligamentous instability, can lead to advanced cartilage degeneration and recalcitrant complaints necessitating surgical treatment before skeletal maturity. We were able to show that meniscus transplantation in skeletally immature patients leads to acceptable clinical outcomes without growth deviation.
Level of evidence: Iv.
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The correlation of estrogen and progesterone receptor levels with response to chemotherapy for advanced carcinoma of the breast
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MSTS 2018 - Femur Mets and MM
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Estrogen and progesterone receptor levels were determined simultaneously in tumor samples obtained from 105 patients who subsequently received a trial of hormonal or chemotherapy for metastatic carcinoma of the breast. Twenty-three of 33 estrogen receptor positive patients in contrast with three of 22 estrogen receptor negative patients achieved an objective response to hormonal therapy. More significantly, it was found that 12 of 16 estrogen receptor positive patients compared with only six of 34 estrogen receptor negative patients responded to combination chemotherapy. Simultaneous measurement of progesterone receptor improved the selection of tumors responsive to chemotherapy, as only four of 30 patients who were estrogen receptor negative-progesterone receptor negative achieved a response. Furthermore, the cumulative survival time of 36 months after the first recurrence of carcinoma of the breast was significantly lower in estrogen receptor negative patients receiving chemotherapy. These data indicate that patients with estrogen receptor negative carcinoma of the breast are resistant to standard hormonal and chemotherapeutic measures for metastatic disease and carry a poor prognosis.
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Ultrasound-guided sciatic nerve block in overweight and obese patients: a randomized comparison of performance time between the infragluteal and subgluteal space techniques
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AAHKS (4) Acetaminophen
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BACKGROUND AND OBJECTIVES: Despite ultrasound (US) guidance, sciatic nerve block (SNB) remains among the least performed peripheral blocks. By targeting the tissue plane between the gluteus maximus and quadratus femoris muscles, the US-guided subgluteal space technique may facilitate the performance of US-guided SNB. We aimed to evaluate whether the subgluteal space technique shortens SNB performance time in overweight and obese patients compared with the conventional infragluteal technique.
METHODS: Overweight and obese patients (body mass index, >25 kg m) undergoing US-guided SNB for knee arthroplasty received 30 mL admixture (1:2 lidocaine 2%; bupivacaine 0.5% with 1:200,000 epinephrine) in the tissue plane between the gluteus maximus and quadratus femoris (subgluteal space group) or around the sciatic nerve at the infragluteal level (infragluteal group). All patients received spinal anesthesia, continuous femoral nerve block, and postoperative multimodal analgesia. The primary outcome was SNB performance time defined as the time interval between placement of the US transducer on skin, and needle withdrawal after injection. Number of needle passes, procedural pain, SNB-related complications, SNB success, postoperative pain, and opioid consumption were also assessed.
RESULTS: Twenty-seven patients were assessed (subgluteal space, 14; infragluteal, 13). Mean SNB performance time was 4.4 minutes (95% confidence interval, 3.7-5.0) for the subgluteal space group and 9.0 minutes (95% confidence interval, 7.7-10.3) for the infragluteal group (P < 0.0001). Number of needle passes and procedural pain scores were lower in the subgluteal space group. There were no differences in SNB success or analgesic outcomes.
CONCLUSIONS: The subgluteal space technique may be performed 50% faster, with no detectable differences in block success and analgesic efficacy, compared with the infragluteal technique for US-guided SNB in overweight and obese patients receiving multimodal analgesia. Injection of local anesthetics along tissue planes may produce similar block characteristics to perineural injection for US-guided SNB.
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Impact of forced displacement during World War II on the present-day mental health of the elderly: a population-based study
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DoD PRF (Psychosocial RF)
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BACKGROUND: The effects of traumatization among the elderly is a neglected topic in research and clinical settings. Forced displacement of civilians is one of the main traumatic features of modern armed conflict. Roughly 12 million German people were displaced in World War II (WWII) and to our knowledge there has been no representative study investigating the mental health outcomes of such trauma in the elderly population. The survey assessed whether current depression, anxiety, resilience and life satisfaction were significantly associated with forced displacement in WWII.
METHODS: A nationwide representative face-to-face household survey was conducted in Germany. A representative sample of the German population aged 61 years or older (N = 1513 participants, N = 239 displaced in WWII) was approached using 258 sample points. Measurements included depressive symptoms (PHQ-2), anxiety (GAD-7), resilience (RS-11), general and domain-specific life satisfaction (FLZ(M)) and sociodemographic variables.
RESULTS: Forced displacement in WWII is significantly associated with higher levels of anxiety and lower levels of resilience and life satisfaction 60 years later. In regression analyses, forced displacement in WWII significantly predicted current anxiety (beta 0.07; p < 0.01), life satisfaction (beta -0.06; p < 0.05) and resilience (beta -0.07; p < 0.01).
CONCLUSION: To our knowledge this is the first nationwide representative survey to examine the late-life effects of forced displacement, particularly of persons displaced during WWII in Germany. Further research is needed to identify mediating variables and to evaluate psychotherapeutic interventions in elderly trauma survivors.
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Biological acellular pericardial mesh regulated tissue integration and remodeling in a rat model of breast prosthetic implantation
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Acellular Dermal Matrix
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The use of biological meshes has proven beneficial in surgical restriction and periprosthetic capsular contracture following breast prosthetic-reconstruction. Three different types (smooth, texturized, and polyurethane) of silicone round mini prostheses were implanted under rat skin with or without two different bovine acellular pericardial biological meshes (APMs, BioRipar, and Tutomesh). One hundred eighty-six female rats were divided into 12 groups, sacrificed after 3, 6, and 24?weeks and tissue samples investigated by histology and immunohistochemistry. Implantation of both APMs, with or without prostheses, reduced capsular a-SMA expression and CD3(+) inflammatory cell infiltration, increasing capillary density and cell proliferation, with some differences. In particular, Tutomesh was associated with higher peri-APM CD3(+) inflammation, prosthetic capsular dermal a-SMA expression and less CD31(+) vessels and cell proliferation compared with BioRipar. None differences were observed in tissue integration and remodeling following the APM?+?prostheses implantation; the different prostheses did not influence tissue remodeling. The aim of our study was to investigate if/how the use of different APMs, with peculiar intrinsic characteristics, may influence tissue integration. The structure of APMs critically influenced tissue remodeling after implantation. Further studies are needed to develop new APMs able to optimize tissue integration and neoangiogenesis minimizing periprosthetic inflammation and fibrosis.
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0 |
Accounting for the correlation between fellow eyes in regression analysis
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Upper Eyelid and Brow Surgery
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Regression techniques that appropriately use all available eyes have infrequently been applied in the ophthalmologic literature, despite advances both in the development of statistical models and in the availability of computer software to fit these models. We considered the general linear model and polychotomous logistic regression approaches of Rosner and the estimating equation approach of Liang and Zeger, applied to both linear and logistic regression. Methods were illustrated with the use of two real data sets: (1) impairment of visual acuity in patients with retinitis pigmentosa and (2) overall visual field impairment in elderly patients evaluated for glaucoma. We discuss the interpretation of coefficients from these models and the advantages of these approaches compared with alternative approaches, such as treating individuals rather than eyes as the unit of analysis, separate regression analyses of right and left eyes, or utilization of ordinary regression techniques without accounting for the correlation between fellow eyes. Specific advantages include enhanced statistical power, more interpretable regression coefficients, greater precision of estimation, and less sensitivity to missing data for some eyes. We concluded that these models should be used more frequently in ophthalmologic research, and we provide guidelines for choosing between alternative models.
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The Lawrence D. Dorr Surgical Techniques & Technologies Award: Differences in Postoperative Outcomes Between Total Hip Arthroplasty for Fracture vs Osteoarthritis
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Hip Fx in the Elderly 2019
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BACKGROUND: Hip fracture is an increasingly common expanded indication for total hip arthroplasty (THA) and warrants outcome analysis so as to best inform risk assessment models, public reporting of outcome, and value-based reimbursement schemes.
METHODS: The National Surgical Quality Improvement Program data file from 2011 to 2014 was used to identify all patients undergoing THA via current procedural terminology code 27130. Propensity score matching in a 1:5 fashion was used to compare 2 cohorts: THA for osteoarthritis and THA for fracture. Primary outcomes included Centers for Medicare and Medicaid Services (CMS) reportable complications, unplanned readmission, postsurgical length of stay, and discharge destination. chi<sup>2</sup> tests for categorical variables and Student t test for continuous variables were used to compare the 2 cohorts and adjusted linear regression analysis used to determine the association between hip fracture and THA outcomes of interest.
RESULTS: A total of 58,302 patients underwent elective THA for osteoarthritis and 1580 patients underwent THA for hip fracture. Rates of CMS-reported complications (4.0% vs 10.7%; P < .001), non-homebound discharge (39.8% vs 64.7%; P < .001), readmission (4.7% vs 8.0%; P < .001), and mean days of postsurgical hospital stay (3.2 vs 4.4; P < .001) were greater in the hip fracture cohort. THA for hip fracture was significantly associated with increased risk of CMS-reportable complications (odds ratio [OR], 2.67; 95% confidence interval [CI], 2.17-3.28), non-homebound discharge (OR, 1.73; 95% CI, 1.39-2.15), and readmission (OR, 2.78; 95% CI, 2.46-3.12).
CONCLUSION: Our findings support recent advocacy for the exclusion of THA for fracture from THA bundled pricing methodology and public reporting of outcomes.
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1 |
Breast ptosis: causes and cure
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Reduction Mammoplasty for Female Breast Hypertrophy
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Breast ptosis is one of the most common conditions treated by plastic surgeons, but the causes are not clearly defined. A review was conducted of 132 consecutive patients presenting for breast augmentation or mastopexy. Information was obtained by chart review and telephone interview. Standardized photographs were examined to determine degree of ptosis by the Regnault classification. Of patients who had at least one pregnancy, 85% reported adverse changes in breast shape following pregnancy, 35% reported a reduction in breast size, and 30% reported an increase in size. Upon logistic regression, age, history of significant (>50 lbs) weight loss, higher body mass index, larger bra cup size, number of pregnancies, and smoking history were found to be significant risk factors for breast ptosis (P < 0.05). History of breast-feeding, weight gain during pregnancy, and lack of participation in regular upper body exercise were not found to be significant risk factors for ptosis.
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1 |
Ultrasound as the primary imaging method in the diagnosis of hip dysplasia in children aged < 2 years
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Developmental Dysplasia of the Hip CPG
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The aims of this study were to evaluate the usefulness of ultrasonography as the primary imaging method for hip joints and to establish the limits of normal variation of ultrasound measurements. Five hundred sixty-six children aged 1-23 months who had been referred for clinical suspicion of developmental dysplasia of the hip (DDH) were examined. In the youngest infants, the percentage cover of the cartilaginous femoral head by the bony acetabular roof (femoral head cover, FHC) was measured. When the ossification center had appeared, the cover was measured indirectly by the distance from the lateral tangent to the ossification center to the lateral acetabular rim (lateral head distance, LHD). The FHC of normal hips increased with age; the lower normal limit (mean -2 SD) was 46% in the youngest infants and 52% at age 4-5 months. The LHD also increased with age; the upper normal limit (mean +2 SD) was 3 mm in patients aged < 1 year of age and 4 mm in the oldest patients. Radiographs were obtained when ultrasound examination showed pathological hips and the radiographic findings were in good accordance with the ultrasound findings. Ultrasonography based on measurements of the cover of the femoral head represents a rapid and reliable technique for evaluation of hips in children in their first and second year of life. If ultrasonography is used as the primary imaging method, radiography can be omitted in approximately 95% of patients referred for clinical suspicion of DDH, because their hip joints are normal
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0 |
Cost-effective peri-operative pain management: Assuring a happy patient after total knee Arthroplasty
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AAHKS (9/10) Regional Nerve Blocks
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Aims The aim of this study was to determine the optimal regimen for the management of pain following total knee arthroplasty (TKA) by comparing the outcomes and cost-effectiveness of different protocols implemented at a large, urban, academic medical centre. Patients and Methods Between September 2013 and September 2015, we used a series of modifications to our standard regimen for the management of pain after TKA. In May 2014, there was a department-wide transition from protocols focused on femoral nerve blocks (FNB) to periarticular injections of liposomal bupivacaine. In February 2015, patient-controlled analgesia (PCA) was removed from the protocol while continuing liposomal bupivacaine injections. Quality measures and hospital costs were compared between the three protocols. Results The cohort being treated with PCA-less liposomal bupivacaine injections had a significantly higher percentage of patients who were discharged to their home (p = 0.010) and a significantly shorter length of stay (p < 0.001). Patient-reported Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores relating to pain being "well-controlled" and "overall pain management" also favoured this cohort (p = 0.214 and p = 0.463, respectively), in which cost was significantly lower compared with the other two cohorts (p = 0.005). Conclusion The replacement of FNBs injections and the removal of PCAs, both of which are known to be associated with high rates of adverse outcomes, and the addition of liposomal bupivacaine periarticular injections to a multimodal pain regimen, led to improvements in many quality measures, HCAHPS pain scores, and cost-effectiveness.
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0 |
Do associations with hand OA vary by knee osteoarthritis phenotype? Cross-sectional data from the Multicenter Osteoarthritis Study
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AMP (Acute Meniscal Pathology)
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Objective: Osteoarthritis (OA) is highly heterogeneous and has both biomechanical and systemic components that may not have the same etiology. We therefore aimed to identify specific knee OA phenotypes that may be more strongly associated with hand OA to refine the criteria used to define multi-joint OA. Design: We assessed data from the Multicenter Osteoarthritis Study (MOST). We ascertained hand OA from bilateral hand photographs; scores for each joint row were summed to yield an aggregate hand OA score. Knee OA was ascertained from bilateral posteroanterior knee radiographs read for Kellgren-Lawrence grade and individual radiographic features. We tested associations between hand and knee OA with phenotypes including symptomatic OA, hyper- and atrophic knee OA, and one excluding post-traumatic OA. Associations between hand and knee OA were assessed with logistic regression, adjusted for age. Results: We studied 2493 participants with hand and knee OA measures. Median age was 63 years with 57% women. 55% had an aggregate hand OA score =2; frequency of knee OA phenotypes ranged from 8% to 34%. The age-adjusted odds ratio (OR) was 1.14 (95% confidence interval (CI) ?= ?1.04–1.26) for knee OA per standard deviation of the hand OA aggregate score. Hand OA associations with symptomatic knee OA and knee OA excluding post-traumatic knee OA were OR ?= ?1.16 (95% CI ?= ?1.03–1.31) and OR ?= ?1.21 (95% CI ?= ?1.08–1.35), respectively. No other knee OA phenotype reached statistical significance. Conclusions: Age-adjusted associations between hand and knee OA were modest and were largely similar across knee OA phenotypes.
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1 |
Osteochondral Biopsy Analysis Demonstrates That BST-CarGel Treatment Improves Structural and Cellular Characteristics of Cartilage Repair Tissue Compared With Microfracture
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Osteochondritis Dissecans 2020 Review
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OBJECTIVE: The efficacy and safety of BST-CarGel, a chitosan-based medical device for cartilage repair, was compared with microfracture alone at 1 year during a multicenter randomized controlled trial (RCT) in the knee. The quality of repair tissue of osteochondral biopsies collected from a subset of patients was compared using blinded histological assessments. METHODS: The international RCT evaluated repair tissue quantity and quality by 3-dimensional quantitative magnetic resonance imaging as co-primary endpoints at 12 months. At an average of 13 months posttreatment, 21/41 BST-CarGel and 17/39 microfracture patients underwent elective second look arthroscopies as a tertiary endpoint, during which ICRS (International Cartilage Repair Society) macroscopic scoring was carried out, and osteochondral biopsies were collected. Stained histological sections were evaluated by blinded readers using ICRS I and II histological scoring systems. Collagen organization was evaluated using a polarized light microscopy score. RESULTS: BST-CarGel treatment resulted in significantly better ICRS macroscopic scores (P = 0.0002) compared with microfracture alone, indicating better filling, integration, and tissue appearance. Histologically, BST-CarGel resulted in a significant improvement of structural parameters-Surface Architecture (P = 0.007) and Surface/Superficial Assessment (P = 0.042)-as well as cellular parameters-Cell Viability (P = 0.006) and Cell Distribution (P = 0.032). No histological parameters were significantly better for the microfracture group. BST-CarGel treatment also resulted in a more organized repair tissue with collagen stratification more similar to native hyaline cartilage, as measured by polarized light microscopy scoring (P = 0.0003). CONCLUSION: Multiple and independent analyses in this biopsy substudy demonstrated that BST-CarGel treatment results in improved structural and cellular characteristics of repair tissue at 1 year posttreatment compared with microfracture alone, supporting previously reported results by quantitative magnetic resonance imaging.
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0 |
Management of osteoarthritis during COVID-19 pandemic
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Coronavirus Disease 2019 (COVID-19)
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The pandemic spread of the new COVID-19 coronavirus infection in China first, and all over the world at present, has become a global health emergency due to the rapidly increasing number of affected patients. Currently, a clear relationship between COVID-19 infection incidence and/or complications due to chronic or occasional treatments for other pathologies is still not clear, albeit COVID-19 pandemic may condition the treatment strategy of complex disorders, as osteoarthritis (OA). Importantly, OA is the most common age-related joint disease affecting more than 80% of people older than the age of 55, an age burden also shared with the highest severity in COVID-19 patients. OA patients often show a large array of concomitant pathologies such as diabetes, inflammation and cardiovascular diseases that are again shared with COVID-19 patients and may therefore increase complications. Moreover, different OA treatments such as NSAIDs, paracetamol, corticosteroids, opioids or other molecules have a wide array of iatrogenic effects, potentially increasing COVID-19 secondary infection incidence or complications. In this review we critically analyse the evidences on either negative or positive effect of drugs commonly used to manage OA in this particular scenario. This would provide orthopaedic surgeons at first, and physicians, pharmacologists and clinicians at general, a comprehensive description about the safety of the current pharmacological approaches and a decision making tool to treat their OA patients as the coronavirus pandemic continues.
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0 |
Para-articular osteochondroma
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Diagnosis and Treatment of Osteochondritis Dissecans AUC
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An unusual case of a para-articular osteochondroma in the vicinity of the knee is reported. Typical presentation and differential diagnosis of bone-forming lesions about the knee are discussed. Confirmed diagnosis should combine clinical presentation and appearance, laboratory data, radiographic evaluation, and possible biopsy of the lesion
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Which fractures are associated with low appendicular bone mass in elderly women? The Study of Osteoporotic Fractures Research Group
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Distal Radius Fractures
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OBJECTIVE: To determine which types of fractures have an increased incidence in elderly women with low appendicular bone mass.
DESIGN: Prospective cohort study.
SETTING: Four clinical centers in the United States (Baltimore, Maryland; Minneapolis, Minnesota; Portland, Oregon; Monangehela Valley, Pennsylvania); and one coordinating center in San Francisco, California.
SUBJECTS: Ambulatory, nonblack women (9704) aged 65 years or more who were recruited from population-based listings.
MEASUREMENTS: We measured bone mass at the distal and proximal radius and calcaneus using single-photon absorptiometry. Fractures were verified radiographically. Associations were calculated as age-adjusted hazard ratios (with 95% Cls) per standard deviation decrease in bone mass.
MAIN RESULTS: During a mean follow-up of 2.23 years, 841 nonspinal fractures occurred in 753 women. The risks for fractures of the wrist, foot, humerus, hip, rib, toe, leg, pelvis, hand, and clavicle were significantly related to reduced bone mass (P less than 0.05). These fractures represented 74% of nonspinal fractures. The overall hazard ratio for the occurrence of one or more of these fractures was 1.65 (Cl, 1.49 to 1.82) at the distal radius. In a subsample of the cohort, vertebral fractures were also related to low bone mass. Fractures of the ankle, elbow, finger, and face, however, were not associated with bone mass at any measurement site; the overall hazard ratio for these fractures was 1.12 (Cl, 0.96 to 1.30) at the distal radius.
CONCLUSION: Most types of fractures have an increased incidence in elderly women with low bone mass.
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1 |
One-year follow-up of efficacy and cost of repeated doses versus single larger dose of intra-articular hyaluronic acid for knee osteoarthritis
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OAK 3 - Non-arthroplasty tx of OAK
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Purpose: A recent 3-month randomized, open-label controlled trial found that the intra-articular hyaluronic acid injection (GO-ON®) given as a single dose of 5 mL is as effective and safe as three repeated doses of 2.5 mL in patients with knee osteoarthritis. However, the information on the long-term efficacy and economic implications of the single-dose regimen is still limited. Hence, this follow-up study was designed to compare the effectiveness and costs of the two regimens 12 months following the treatment. Methods: All the 127 patients, who received either three repeated doses (n = 64) or a single dose (n = 63) of GO-ON in the previous trial, were followed up in month 12 following the treatment. The effectiveness of both the regimens was assessed using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and the mean WOMAC scores were compared with those recorded at the baseline and in month 3. Additionally, the total treatment costs of the two regimens, taking account of both direct and indirect costs, were computed and compared. Results: A total of 125 patients (98.4%) completed the assessment. Despite the reduction of the overall mean WOMAC score from 39.24 to 19.93 (p < 0.001) in the first 3 months following the treatment with GO-ON, no further changes were observed up to month 12 (p > 0.95). In the meantime, the two regimens did not differ in the mean WOMAC scores (p = 0.749) and in the subscale scores for pain (p = 0.970), stiffness (p = 0.526), and physical functioning (p = 0.667) in month 12. The cost for single-dose injection was found to be approximately 30% lower compared to the repeated doses. Conclusion: These findings indicate that the single larger dose of GO-ON is as effective as the repeated doses over 12 months, and yet the total treatment cost is lowered.
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0 |
Cabozantinib in progressive medullary thyroid cancer.[Erratum appears in J Clin Oncol. 2014 Jun 10;32(17):1864]
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MSTS 2018 - Femur Mets and MM
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PURPOSE: Cabozantinib, a tyrosine kinase inhibitor (TKI) of hepatocyte growth factor receptor (MET), vascular endothelial growth factor receptor 2, and rearranged during transfection (RET), demonstrated clinical activity in patients with medullary thyroid cancer (MTC) in phase I.
PATIENTS AND METHODS: We conducted a double-blind, phase III trial comparing cabozantinib with placebo in 330 patients with documented radiographic progression of metastatic MTC. Patients were randomly assigned (2:1) to cabozantinib (140 mg per day) or placebo. The primary end point was progression-free survival (PFS). Additional outcome measures included tumor response rate, overall survival, and safety.
RESULTS: The estimated median PFS was 11.2 months for cabozantinib versus 4.0 months for placebo (hazard ratio, 0.28; 95% CI, 0.19 to 0.40; P < .001). Prolonged PFS with cabozantinib was observed across all subgroups including by age, prior TKI treatment, and RET mutation status (hereditary or sporadic). Response rate was 28% for cabozantinib and 0% for placebo; responses were seen regardless of RET mutation status. Kaplan-Meier estimates of patients alive and progression-free at 1 year are 47.3% for cabozantinib and 7.2% for placebo. Common cabozantinib-associated adverse events included diarrhea, palmar-plantar erythrodysesthesia, decreased weight and appetite, nausea, and fatigue and resulted in dose reductions in 79% and holds in 65% of patients. Adverse events led to treatment discontinuation in 16% of cabozantinib-treated patients and in 8% of placebo-treated patients.
CONCLUSION: Cabozantinib (140 mg per day) achieved a statistically significant improvement of PFS in patients with progressive metastatic MTC and represents an important new treatment option for patients with this rare disease. This dose of cabozantinib was associated with significant but manageable toxicity.
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Impact of preadmission anti-inflammatory drug use on the risk of RBC transfusion in elderly hip fracture patients: a Danish nationwide cohort study, 2005â??2016
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AAHKS (2) Corticosteroids
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BACKGROUND: Do prescription drugs with anti-inflammatory properties such as nonsteroidal anti-inflammatory drugs (NSAIDs), corticosteroids, and statins increase the risk of postoperative bleeding measured with RBC transfusion in elderly hip fracture surgery patients?. STUDY DESIGN AND METHODS: Using the Danish Multidisciplinary Hip Fracture Database, 74,791 patients aged 65 years or older with surgery-treated hip fracture were identified during 2005â??2016, and their use of NSAIDs, corticosteroids, and statins was ascertained. For each drug, patients were categorized as nonusers (no prescription â?¤365 days prior to surgery), former users (one prescription 91â??365 days), and current users (one prescription â?¤90 days). Information on surgical treatment, transfusion, other medication and comorbidities were collected using Danish nationwide registries. A log-binomial model was used to estimate relative risks for RBC transfusion within 7 days of surgery and corresponding 95% confidence intervals. Adjustments were made for patient- and surgery-related factors. RESULTS: Former and current users of NSAIDs, corticosteroids, and statins accounted for 22%, 10%, and 24%, respectively. Current users of NSAIDs had an increased adjusted relative risk of transfusion (1.07; confidence interval, 1.04â??1.10) compared to nonusers. There was no association between current users of corticosteroids and statins and risk of transfusion. CONCLUSION: NSAID use within 90 days of a hip fracture surgery was associated with an increased risk of RBC transfusion. Thus, current use of NSAIDs can be associated with an increased risk of postoperative bleeding, but we cannot rule out the influence of confounding.
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Does Patellofemoral Disease Affect Outcomes in Contemporary Medial Fixed-Bearing Unicompartmental Knee Arthroplasty?
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OAK 3 - Non-arthroplasty tx of OAK
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Background: Pre-existing patellofemoral disease has traditionally been a contraindication to unicompartmental knee arthroplasty (UKA), as proposed by Kozinn and Scott. More recently, some propose that patellofemoral disease can be ignored in UKA; however, the supporting research is predominantly in mobile-bearing designs. The study purpose was to evaluate the effect of patellofemoral disease osteoarthritis severity on latest outcomes after fixed-bearing medial UKA. Methods: A retrospective review of 147 consecutive medial fixed-bearing UKAs with minimum 1-year follow-up was performed. The medial and lateral patellofemoral compartments were graded according to the Kellgren & Lawrence grading system, Osteoarthritis Research Society International atlas, and intraoperative assessment performed using the Outerbridge classification. Prospectively collected University of California Los Angeles Activity Level, modern Knee Society pain and function scores, and Likert scale satisfaction were correlated with presence and severity of pre-existing patellofemoral disease. Results: One hundred forty-three medial UKAs were analyzed with mean age, body mass index, and follow-up of 64.1 years, 30.7 kg/m2, and 24.0 months, respectively. No correlations were observed between patellofemoral disease severity and patient-reported outcome measures at latest follow-up or improvement scores for Kellgren & Lawrence grading system or Osteoarthritis Research Society International atlas (P â?¥ .058). Improvement in activity level scores was significantly higher for patients with less patellar and trochlear chondral damage despite not reaching minimal clinically important difference of 2.0 (P â?¤ .028). Regardless of patellofemoral disease severity, 93% of UKAs were satisfied or very satisfied. Conclusion: Clinical outcomes of fixed-bearing medial UKA were not adversely impacted by intraoperatively visualized or radiographically evaluated patellofemoral disease. Furthermore, long-term follow-up is warranted and caution should be used before considering patellofemoral disease as a contraindication for UKA.
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0 |
MRI of bilateral bipartite hamulus: A case report
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Distal Radius Fractures
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Normal skeletal variants are a common occurrence in clinical practice and may lead to misinterpretation. As part of a case control study investigating the carpal tunnel, our asymptomatic and voluntary participant underwent magnetic resonance (MR) imaging of both wrists from the metacarpal bases to the distal radiocarpal joint. The imaging techniques included spin echo (SE), turbo spin echo (TSE) and fast field echo (FFE) sequences using 4 mm-slice thickness. As an incidental finding bipartite hamulus was detected bilaterally. The anomaly was evident in both hamuli with similar MRI characteristics. The congenital origin was further supported by the absence of trauma or surgery to the wrists. in this case report the authors discuss the anatomical variant, bilateral bipartite hook of the hamate, and demonstrate the reliability of contiguous slices of MR axial slices in displaying an anatomical variant of the carpus. This normal variant of the hamate is not commonly encountered in MR imaging of the wrist and can be misinterpreted as fracture or post-traumatic sequelae. Images of the normal hamulus are presented for comparison.
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0 |
S-phase fraction and survival benefit from adjuvant chemotherapy or radiotherapy of breast cancer
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MSTS 2018 - Femur Mets and MM
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Cancer chemotherapy interacts with cell proliferation, but data on the relationship between cancer cell replication and the effect of adjuvant chemotherapy are scarce. We have investigated the S-phase fractions of the primary tumour from premenopausal breast cancer patients who participated in a randomised trial comparing 12 cycles of polychemotherapy (CMF) with post-operative radiotherapy. DNA flow cytometry was performed on frozen tissues from 208 primary breast carcinomas, of which the S-phase fraction was estimated in 176 cases. There was a significantly higher benefit from CMF among patients with a high S-phase fraction (P = 0.0033). The relative risk of distant recurrence or death in the chemotherapy group as compared with the radiotherapy group was 0.19 for patients whose tumours had an S-phase fraction of 10% or over (95% CI 0.07-0.51) and 1.55 (0.88-2.73) for patients whose tumours showed lower S-phase levels. The interaction was still significant in multivariate analysis (P = 0.0057), including lymph node metastases, tumour size and oestrogen receptor content. We conclude that the benefit from adjuvant chemotherapy compared with radiotherapy is largely confined to patients with highly proliferative tumours.
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0 |
Pediatric Vitiligo
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Reconstruction After Skin Cancer
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Vitiligo is a disease of pigment loss. Most investigators currently consider vitiligo to be a disorder that occurs as a result of autoimmune destruction of melanocytes, supported by identification of antimelanocyte antibodies in many patients, and the presence of comorbid autoimmune disease in patients with and family members of individuals with vitiligo. One-half of vitiligo cases are of childhood onset. This article presents a current overview of pediatric vitiligo including comorbidities of general health, psychological factors, therapeutic options, and long-term health considerations. © 2014 Elsevier Inc.
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Turning the tide: benefit finding after cancer surgery
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DoD PRF (Psychosocial RF)
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Post-traumatic growth and benefit finding after adverse life events are emerging topics in stress and coping research. This study examined personal and social resources of cancer patients and their perception of positive life changes as a consequence of illness. In addition, the mediating role of coping strategies (acceptance and social comparison) was investigated. One month after tumor surgery, 105 cancer patients completed measures of social support and self-efficacy. Coping was assessed half a year after surgery, while benefit finding was examined 12 months post-surgery. Correlational and path analyses showed a link between personal resources (self-efficacy) as well as social resources (received social support) and benefit finding. The effect of self-efficacy disappeared when coping was specified as a mediator between the resources and benefit finding. Social support retained a direct effect on benefit finding. The results emphasize the predictive quality of resources for recovery and adjustment after surgery and the mediating role of coping. Findings are discussed with regard to recent developments in the study of post-traumatic growth.
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0 |
Effect of transcutaneous electrical nerve stimulation (TENS) on central nervous system amplification of somatosensory input
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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The effect of transcutaneous electrical nerve stimulation (TENS) on the central nervous system amplification process was investigated focusing on the dorsal column-medial lemniscal pathway, because the dorsal column nucleus was recently shown to receive multiple sources of sensory information, including pain. Short latency somatosensory evoked potentials (SSEPs) were recorded in ten healthy normal volunteers. Amplitude changes in each SSEP component (the N9 brachial plexus potential, the P14 potential that originates from the cervicomedullary junction, spinal N13/P13 generated by the cervical dorsal horn and the cortical N20/P25 potential) were studied at stimulus strenghts ranging from the threshold (40% maximum stimulus) to 2.5 times the threshold (maximum). The findings suggest that sensory amplification begins at the P14 generator source near the cuneate nucleus. There was no statistically significant difference in sensory amplification between P14 and cortical N20/P25, indicating that the cuneate nucleus is the main site of the central amplifying process. When TENS was applied to the palm distal to the median nerve stimulation used for SSEP, cortical N20/P25 amplification disappeared, evidence that TENS suppresses the central amplification phenomenon, most probably at the level of the cuneate nucleus
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0 |
Management of diabetic foot ulcers
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DoD LSA (Limb Salvage vs Amputation)
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Diabetic foot is a serious complication of diabetes which aggravates the patient's condition whilst also having significant socioeconomic impact. The aim of the presentreview is to summarize the causes and pathogenetic mechanisms leading to diabetic foot, and to focus on the management of this important health issue. Increasing physicians' awareness and hence their ability to identify the "foot at risk," along with proper foot care, may prevent diabetic foot ulceration and thus reduce the risk of amputation. © The Author(s) 2012.
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0 |
Traumatic neuropathies of the upper extremity
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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Bodily trauma frequently involves injury to the peripheral nerves. Trauma to the peripheral nerves of the upper extremity can occur through a variety of mechanisms, including avulsion, compression, entrapment and laceration. Injuries that can involve the nerves of the upper extremity include herniation of a intervertebral disc, trauma to the newborn during labor and delivery, accidents, infections, primary and metastatic tumors, and arthritis. These injuries can also present in a variety of forms whose subtle differences are determined by whether injury just affects the sheaths protecting the nerves or involves actual separation or transection of nerve fibers. Neuropathies are diagnosed by evaluating symptoms and obtaining a thorough patient history. Electrophysiologic evaluation with nerve conduction studies and electromyography is helpful for determining the type of injury sustained and improvement in nerve function after treatment
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0 |
Histological analyses of surgically resected synovial tissues in patients with rheumatoid arthritis treated with/without biological agents
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Surgical Management of Osteoarthritis of the Knee CPG
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Background/Purpose: Recent treatment of rheumatoid arthritis (RA) was dramatically improved after introducing biological agents. Although there are several reports with small numbers of cases that analyzed the effect of biological agents from the view point of histopathology, the significance of biological agents on histological changes of joint synovium is remained uncertain. The purpose of this study was to compare the histopathological findings of surgically resected synovium in patients with RA between 2 groups with and without use of the biological agents. Methods: Between January 2006 and December 2010, 59 biopsy specimens of synovium were obtained during joint surgery from 52 cases of RA. The obtained specimens were fixed in 10% neutral buffered formalin and routinely embedded in paraffin. Microscope slides were prepared, stained with hematoxylin and eosin, and reviewed. The histopathological findings of synovium in each specimen were evaluated and scored for detailed findings such as synoviocyte hyperplasia, fibrosis, proliferating blood vessels, perivascular infiltrates of lymphocytes, focal aggregates of lymphocytes, and diffuse infiltrates of lymphocytes using the histological score of the synovium by Rooney et al. The cases were divided into 2 groups. The group with the use of biological agents (Group A) included 25 cases with 32 joint specimens (24 female and 1 male). Seven cases underwent another joint surgery in different surgeries. In Group A, 10 cases (12 joints) used etanercept, 10 cases (12 joints) used infliximab, 3 cases (5 joints) used tocilizumab, and 2 cases (3 joints) used adalimumab at the time of surgery. The variations of surgery were total knee arthroplasty (TKA) in 17 cases, total hip arthroplasty (THA) in 4 cases, total elbow arthroplasty (TEA) in 4 cases, and others in 7 cases. The group without use of biological agents (Group B) included 7 cases with 27 joint specimens (25 female and 2 male). These cases underwent surgery during same study period as Group A. In Group B, the variations of surgery were TKA in 16 cases, THA in 2 cases, TEA in 3 cases, and others in 6 cases. The background data such as age, averaged duration of disease, CRP, DAS-28 score, and mean dose of methotrexate (MTX) and prednisolone (PSL) were not different between 2 groups. Results: Group A showed significantly decreased scores in synovial hyperplasia, perivascular infiltrates of lymphocytes, focal aggregates of lymphocytes, diffuse infiltrates of lymphocytes and also total score than in the Group B. The scores of fibrosis and proliferating blood vessels did not show difference between 2 groups. No correlation between total Rooney's score and age, Larsen's classification, Steinblocker's classification, or the mean dose of MTX or PSL was found in each group. In Group A, no difference of total Rooney's score was found by variety of biologics, additionally, there was no correlation between total Rooney's score and the duration of disease or the duration of administration of biologics. In Group B, there was positive correlation between total Rooney's score and the duration of disease. Conclusion: Based on these results, biological agents for RA clearly showed significant effects on histological findings of joint synovium
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0 |
Remote access perfusion for minimally invasive cardiac surgery: To clamp or to inflate
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DOD - Acute Comp Syndrome CPG
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OBJECTIVES: Endoaortic balloon occlusion (EBO) and aortic transthoracic clamping (TTC) are the dominant methods of remote access perfusion (RAP) in minimally invasive cardiac surgery. The aim of the study was to compare the two methods in terms of feasibility, success and complications. METHODS: From June 2001 to November 2011, 307 (median age; range) (57; 16-77 years) and 460 (62; 11-88 years) patients underwent minimally invasive CABG, ASD and mitral valve surgery using EBO and TTC, respectively. Perioperative procedure feasibility, success and postoperative complications were recorded. RESULTS: Overall 30-day mortality was 0 and 2 (0.43%) for the EBO and TTC groups, respectively (P = 0.52). Overall and RAP-associated conversions were noted in 21 (6.8%) and 4 (1.3%) patients in the EBO and in 9 (2%) and 6 (1.3%) patients in the TTC groups (P < 0.001, P = 1.00, respectively). Incidence of major complications, including aortic dissection, major vessel perforation, injury of intrapericardial structures, limb ischaemia, myocardial infarction and neurologic events, was similar [EBO: 12 (4%); TTC: 11 (2.4%); P = 0.23]. Minor complications such as minor vessel injury, groin bleeding or lymphatic fistula were noted in 31 (10.1%) and 35 (7.6%), respectively (P = 0.23). Successful RAP procedures defined as absence of RAP-associated conversions and major complications were equal [EBO: 295 (96%); TTC: 449 (97.6%); P = 0.23]. Complications detected during follow-up included pain: 30 of 249 (12%) and 13 of 279 (4.7%) (P = 0.002); sensational disturbances: 60 of 249 (24.1%) and 40 of 278 (14.4%) (P = 0.005) and wound-healing complications: 49 of 249 (19.7%) and 42 of 277 (15.2%) (P = 0.172) for EBO and TTC, respectively. CONCLUSIONS: RAP can be successfully and safely implemented in minimally invasive cardiac surgery. EBO and transthoracic clamping of the ascending aorta are performing equally in terms of feasibility and procedural success. © The Author 2013. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.
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Reconstruction of the glenoid using autologous bone-graft and the SMR Axioma TT metal-backed prosthesis: The first 45 sequential cases at a minimum of two yearsâ?? follow-up
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Glenohumeral Joint OA
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Aims We present our experience of using a metal-backed prosthesis and autologous bone graft to treat gross glenoid bone deficiency. Patients and Methods A prospective cohort study of the first 45 shoulder arthroplasties using the SMR Axioma Trabecular Titanium (TT) metal-backed glenoid with autologous bone graft. Between May 2013 and December 2014, 45 shoulder arthroplasties were carried out in 44 patients with a mean age of 64 years (35 to 89). The indications were 23 complex primary arthroplasties, 12 to revise a hemiarthroplasty or resurfacing, five for aseptic loosening of the glenoid, and five for infection. Results Of the 45 patients, 16 had anatomical shoulder arthroplasties (ASA) and 29 had reverse shoulder arthroplasties (RSA). Postoperatively, 43/45 patients had a CT scan. In 41 of 43 patients (95%), the glenoid peg achieved > 50% integration. In 40 of 43 cases (93%), the graft was fully or partially integrated. There were seven revisions (16%) but only four (9%) required a change of baseplate. Four (25%) of the 16 ASAs were revised for instability or cuff failure. At two-year radiological follow-up, five of the 41 cases (11%) showed some evidence of lucent lines. Conclusion The use of a metal baseplate with a trabecular titanium surface in conjunction with autologous bone graft is a reliable method of addressing glenoid bone defects in primary and revision RSA setting in the short term. ASAs have a higher rate of complications with this technique.
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Neuroanatomic substrates of lower extremity somatosensory evoked potentials
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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After stimulation of the lower extremity nerve (tibial nerve), N21 and N23 are recorded from L4 and T12 spine respectively. The far-field potentials of P31 and N35 are registered from Fpz-C5s (fifth cervical spine) or CPi (ipsilateral with respect to the side of stimulation) - ear derivation. Additional far-field potentials of P17 and P24 may be recorded from the scalp when a noncephalic (knee) reference is used. The major positive peak, P40, is registered at the vertex and the CPi. Preceding P40, there is a small negative peak, N37, recorded at the contralateral (CPc) hemisphere. Neuroanatomic substrates of these somatosensory evoked potential (SSEP) components are less well clarified compared with those of upper extremity (median nerve) SSEPs, primarily because clinical application of lower extremity SSEPs is more difficult, and all of the aforementioned potentials but one (P40) are not obligatory components. The concept of 'paradoxical lateralization' complicates the issue further. Accumulating evidence, however, suggests that the far-field potentials of P17 and P31 arise from the distal portion of the sacral plexus and brainstem respectively. These correspond to P9 and P14 of the median nerve SSEPs respectively. The spinal potential of N23 is equivalent to the N13 cervical potential of the median nerve SSEP. N35 recorded from the ipsilateral hemisphere is analogous to N18 of the median nerve. Paradoxically lateralized P40 has been thought to represent the positive end of a dipole field, reflected by the negativity at the mesial surface of the contralateral hemisphere, and has commonly been considered to be equivalent to the first cortical potentials (N20) of the median nerve SSEP. However, more recent evidence suggests that the primary positivity is at the mesial cortical surface, and it more likely corresponds to P26 of the median nerve SSEP. Thus the first cortical potential corresponding to N20 is probably a small and inconsistent N37 recorded on the contralateral hemisphere. These assumptions need to be verified further by more extensive clinical studies applied to various neurologic disorders
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0 |
The immune response to oral infections
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Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures
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This article summarizes some of the important interactions between the immune system and inflammatory process, with the primary focus on the host response to infection. A subsequent brief review of the pathogenesis of periodontal disease serves to illustrate the relevance of these interactions to our understanding of disease
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0 |
Intra-articular osteoid osteoma in the proximal tibia and its imaging characteristics
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PJI DX Updated Search
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Due to mostly non-specific clinical symptoms and variable appearance on magnetic resonance imaging (MRI), the diagnosis of an intra-articular osteoid osteoma (iaOO) is often delayed. We report the case of a 26-year-old male with an atypical clinical manifestation of an iaOO in the proximal tibia and its MRI specific characteristics of tumor progression. The patient presented to our clinic after receiving multiple unsuccessful conservative and surgical interventions due to anterior knee pain, which persisted for 12months. Prior to the correct diagnosis of iaOO manifestation, the patient was subjected to multiple steroid infiltrations and two arthroscopies including partial meniscal resection. Due to increasing complaints, meniscal transplantation, bone decompression and/or ACL reconstruction were recommended. Subsequent computer tomography (CT) scanning and successful test medication with salicylates (ASS) confirmed iaOO presentation. Only after arthroscopic tumor resection was the patient symptom free at three months of follow-up. The present description of MRI specific characteristics of iaOO progression has the potential to accelerate correct tumor detection in the future
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Arthroscopic Repair of Humeral Avulsion of Glenohumeral Ligament Lesions: Outcomes at 2-Year Follow-up
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AMP (Acute Meniscal Pathology)
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Background: Humeral avulsion of the glenohumeral ligament (HAGL) is an uncommon condition but a major contributor to shoulder instability and functional decline. Purpose: To describe the pre- and postoperative HAGL lesion presentations of instability, pain, and functionality and the return-to-sports activities in patients managed arthroscopically for anterior and posterior HAGL lesions. Study Design: Case series; Level of evidence, 4. Methods: Data on patients with HAGL lesions treated with arthroscopic repair between 2009 and 2018 were retrospectively retrieved from medical charts, and the patients were interviewed to assess their level of postoperative functionality. The Rowe; Constant; University of California, Los Angeles; Oxford; and pain visual analog scale (VAS) scores were obtained for both pre- and postoperative status. Return-to-sports activities and level of activities after surgery were compared with the preinjury state, and complications, reoperations, and recurrent instability were recorded and evaluated. Results: There were 23 study patients (12 females and 11 males; mean age, 24 years). The mean follow-up duration was 24.4 months (range, 7-99 months; median, 17 months). In 7 (30.4%) of the patients, HAGL lesions were diagnosed only intraoperatively. A significant improvement was seen in all examined postoperative functional scores and VAS. At the last follow-up visit, 2 patients (8.7%) reported residual instability with no improvement in pain levels and declined any further treatment, and 3 others (13.0%) required revision surgeries for additional shoulder pathologies (reoperations were performed 18-36 months after the index procedure). The remaining 18 patients (78.3%) were free of pain and symptoms. There was a mean of 0.65 coexisting pathologies per patient, mostly superior labral anterior-posterior, Bankart, and rotator cuff lesions. Conclusion: HAGL lesions are often missed during routine workup in patients with symptoms of instability, and a high level of suspicion is essential during history acquisition, clinical examination, magnetic resonance imaging arthrogram interpretation, and arthroscopic evaluation. Arthroscopic repair yields good pain and stability results; however, some high-level athletes may not return to their preinjury level of activity.
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0 |
Morphometric Analysis of the Umbilicus According to Age
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Panniculectomy & Abdominoplasty CPG
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Background: Morphometric and anatomical analyses of the shape and position of the umbilicus have been conducted in adults, but umbilicoplasty in children remains challenging because growth is still occurring. Objectives: The main objective of this study was to evaluate the difference in the position and shape of the umbilicus between childhood and adulthood. The secondary objective was to improve the surgical management of umbilicoplasty in children. Methods: This prospective single-center study focused on the morphometric analysis of the umbilicus in 200 adults and children. All data, including standardized measures and pictures, were determined by one single operator. Results: Despite a variation of approximately 2% in the xiphoid-pubis distance, the location of the umbilicus remains stable during the entire growth period. In a supine individual, the location is at one half to two thirds of the xiphoid-pubis distance (slightly lower in children), with a mean ratio of 0.57 for the xiphoid-umbilicus distance to the xiphoid-pubis distance. In the general population, the most common shapes are round and vertical oval. T-shaped umbilici were only observed in adults. Round and protruding shapes were twice as frequent in children under 18 as in adults. The horizontal oval shape was twice as frequent in adults. Conclusions: Abdominal growth and changes in the repartition of subcutaneous adipose tissues with age are responsible for the vertical orientation and deepening of the umbilicus as well as its horizontal orientation. To promote final cosmetic outcomes, secondary umbilicoplasty must place the umbilicus between one half and two thirds of the xiphoid-pubis distance.
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Long-term follow-up of fresh tibial osteochondral allografts for failed tibial plateau fractures
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Diagnosis and Treatment of Osteochondritis Dissecans AUC
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BACKGROUND: The management of large posttraumatic full-thickness osteochondral defects in the proximal part of the tibia remains a challenge. The goal of treatment is a pain-free range of motion of the knee that provides enduring function and enables a young patient to participate in a wide range of activities. The use of fresh osteochondral allograft transplantation for tibial plateau lesions has been well documented. The purpose of the present study was to assess the survivorship and the long-term functional outcome following fresh osteochondral transplantation for unipolar posttraumatic tibial plateau defects in young, high-demand patients. METHODS: A cohort study was carried out to assess outcome in patients who had undergone fresh tibial osteochondral grafting for the treatment of a posttraumatic defect that measured at least 3 cm in diameter and 1 cm in depth. Sixty-five (97%) of sixty-seven patients were identified and were evaluated clinically and radiographically. A modified Hospital for Special Surgery (HSS) score was calculated for each patient. Radiographic examination was directed toward the identification of graft union, resorption, or collapse. Degeneration of the joint and alignment of the limb (on standing radiographs) was assessed. The end points that defined survivorship were an HSS score of <70 points, a patient's decision to undergo knee arthroplasty, or revision of the graft for any reason. RESULTS: At a mean of twelve years, forty-four patients had an intact graft and twenty-one had had conversion to a total knee arthroplasty. The mean modified HSS Score for the patients with an intact graft was 85 points. Radiographs, reviewed for thirty-five of the forty-four patients with an intact graft, revealed union of the graft to host bone in all cases and an 8.6% prevalence of graft collapse in excess of 3 mm. Forty percent of these thirty-five patients demonstrated moderate to severe degenerative changes. Kaplan-Meier survivorship analysis showed that the survival rate was 95% at five years, 80% at ten years, 65% at fifteen years, and 46% at twenty years. A trend toward increased survivorship (p = 0.08) was seen among patients who had undergone meniscal transplantation in conjunction with osteochondral grafting. CONCLUSIONS: Fresh osteochondral allografts for large traumatic defects of the tibial plateau have provided a long-lasting and reliable reconstructive solution for a high-demand population. Meniscal allografts should be used when clinically warranted. In the present study, all grafts were protected with a coincident realignment osteotomy when preoperative radiographs suggested that the allograft would be placed under increased load. Conversion to knee arthroplasty was required for approximately one-third of the patients at an average of ten years
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1 |
Return to duty following combat-related multi-ligamentous knee injury
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DoD LSA (Limb Salvage vs Amputation)
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Introduction This retrospective cohort study characterized injury patterns, treatment practices, and identified the return to duty (RTD) rate following combat-related multi-ligament knee injuries (MLKI). Patients and methods We evaluated injury characteristics and treatment methods of 46 military service members who had sustained a MLKI during combat activity. The primary clinical outcome measure was ability to return to active military duty. Secondary outcomes included subjective pain score, knee motion, knee instability, and use of ambulatory assistive device. Results The RTD rate was 41% (19/46). High-energy mechanism, neurovascular injury, compartment syndrome, traumatic knee arthrotomy, and intra-articular femur fracture (Orthopedic Trauma Association Classification (OTA) 33-B/C) were all more prevalent in subjects who were unable to return to duty (p < 0.05). Acute external fixator application and poor knee range of motion (ROM) were also associated with military separation (p = 0.041 and p = 0.016, respectively). The most common ligament injury pattern (n = 9; 20%) was combined disruption of the anterior cruciate ligament (ACL), posterior cruciate ligament (PCL), posterolateral corner (PLC), and medial collateral ligament (MCL). However, number of ligaments injured was not associated with RTD status. Conclusion MLKIs sustained in a combat setting have a high incidence of associated lower extremity injuries. Certain associated injuries, such as intra-articular femur fracture, knee arthrotomy, neurovascular injury, and compartment syndrome may be more important than the severity of the knee ligamentous injury in determining RTD outcome.
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0 |
Tear gap and severity of osteoarthritis are associated with meniscal extrusion in degenerative medial meniscus posterior root tears
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OAK 3 - Non-arthroplasty tx of OAK
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Introduction: Meniscal extrusion is a typical finding of medial meniscus posterior root tear, and it causes loss of the chondroprotective function of the meniscus as well as progression of osteoarthritis; it is therefore associated with poor clinical outcomes. The purpose of this study was to investigate factors associated with meniscal extrusion in degenerative medial meniscus posterior root tear. It was hypothesized that larger displacement from the posterior root insertion was associated with larger meniscal extrusion. Materials and methods: One hundred and nine knees with degenerative medial meniscus posterior root tears were retrospectively reviewed. Multiple regression analysis was used to determine whether factors such as age, weight, body mass index, chondral wear at surgery, Kellgren-Lawrence (KL) grade, alignment, tibial slope, and tear gap on performing magnetic resonance imaging (MRI) were associated with meniscal extrusion. Subjects were divided based on the amount of displacement (displaced group: tear gap � 1 mm, non-displaced group: tear gap < 1 mm) to compare meniscal extrusion, chondral wear, and severity of arthritis. Results: The mean age of the patients was 58.14 ± 9.64 years, the mean absolute extrusion was 4.02 ± 1.22 mm, the mean relative percentage of extrusion was 44.53 ± 13.09%, and the mean tear gap was 2.39 ± 2.42 mm. Multiple regression analysis showed that absolute extrusion was only associated with tear gap on MRI (B = 0.242, p = 0.001) and that the relative percentage of extrusion was associated with tear gap (B = 1.894, p = 0.001) and the K-L grade (B = 4.492, p = 0.024). Absolute extrusion was significantly higher in the displaced group than in the non-displaced group (4.29 ± 1.04 mm vs. 3.01 ± 1.35 mm, p = 0.001). Relative percentage of extrusion was also significantly higher in the displaced group than in the non-displaced group (47.70 ± 11.44% vs. 36.17 ± 13.65%, p = 0.001). The proportion of chondral wear (Outerbridge grade III and IV) on the medial femoral condyle and K-L grade III and IV were significantly greater in the displaced group than in the non-displaced group (76% vs. 53.3%, p = 0.023 and 13.9% vs. 0%, p = 0.001, respectively). Discussion: Greater tear gap is significantly associated with increasing meniscal extrusion in medial meniscus posterior root tear. Additionally, severity of arthritis is significantly associated with increasing relative percentage of extrusion. Chondral wear and severity of arthritis tended to be significantly worse in the displaced group than in the non-displaced group. Level of evidence: III, comparative retrospective study.
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1 |
Role of magnetic resonance imaging in the evaluation of the anterior knee pain
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AMP (Acute Meniscal Pathology)
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Background: To review the most common causes of Anterior knee pain (AKP), with an emphasis on their MRI findings; 70 patients were included (24 males and 46 females). Their age range is 10–53 years with a mean ± SD of 28.8 ± 9.06 years. All patients performed MRI of the affected knee. Results: Eleven disease entities were encompassed in this study; the patellar causes were dominating, where the chondromalacia patella being found in 43% of cases (n = 30), patellar instability was found in 19% (n = 13), transient patellar dislocation was found in 7% (n = 5), patellar tendinopathy was found in 4% (n = 3), and bipartite patella was found in 1% (n = 1). Hoffa’s disease was found in 14% (n = 10); the anterior meniscal tear was found in 13% (n = 9). Quadriceps tendinopathy was found in 3% (n = 2), and quadriceps tear was found in 4% (n = 3). Cartilage disease was found in 6% (n = 4); Osgood–Schlatter disease was found in 4% (n = 3); the coexistence of more than an entity was found in 13 cases (18.5%). Conclusions: MRI provided a safe and accurate modality in the diagnosis of different causes of AKP with a high specification in detecting the grades and the types of some diseases.
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0 |
Increased operating room time in patients with obesity during primary total knee arthroplasty: conflicts for scheduling
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OAK 3 - Non-arthroplasty tx of OAK
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Obesity is associated with increased complications related to total knee arthroplasty (TKA), but the relationship between body mass index (BMI) and operating room time during TKA is unknown. A total of 454 unilateral primary TKAs (2005-2009) were reviewed and categorized by BMI (normal weight, 18.5-25 kg/m(2); overweight, 25-30 kg/m(2); obese class I, 30-<35 kg/m(2); class II, 35-40 kg/m(2); class III, >40 kg/m(2)). Intraoperative time measurements (total room time, anesthesia induction time, tourniquet time, closing time, surgery time) were compared across the BMI groups. Comparing normal weight to obese class III, time differences were significant in total room time (24 minutes, P < .01), surgery time (16 minutes, P < .01), tourniquet time (7.5 minutes, P < .01), and closure time (8 minutes, P < .01). Armed with this information, BMI can be used to better allocate operating room time for TKA.
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1 |
Amputees in a hospital of the International Committee of the Red Cross
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DoD LSA (Limb Salvage vs Amputation)
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The object of this study is to describe the treatment of patients with an amputation in terms of causes and distribution of injuries, mortality and drain on surgical resources. A group of patients with war injuries, who did not undergo an amputation (1796) and a group of war-injured patients with an amputation (245) were analysed retrospectively. All these patients were treated in the hospital for Afghan war wounded of the International Committee of the Red Cross. The most common amputation was below-knee amputation (BKA). In more than 90 per cent of the patients a BKA was the result of a mine explosion. About 80 per cent of amputations of the lower limb were caused by antipersonnel mines. The upper limb amputations were mainly caused by mines or by fragments. War-injured patients with an amputation face more serious problems than non-amputated patients. Their mortality is higher, they stay longer in the hospital, the risk of infection is higher, they need more blood and they undergo more surgical interventions. The high percentage of non-combatants stresses the need to give civilians better protection against the indiscriminate use of mines.
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Implementation and Analysis of a Lean Six Sigma Program in Microsurgery to Improve Operative Throughput in Perforator Flap Breast Reconstruction
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Reduction Mammoplasty for Female Breast Hypertrophy
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PURPOSE: Perforator flaps have become a preferred method of breast reconstruction but can consume considerable resources. We examined the impact of a Six Sigma program on microsurgical breast reconstruction at an academic medical center.
METHODS: Using methods developed by Motorola and General Electric, we applied critical pathway planning, workflow analysis, lean manufacturing, continuous quality improvement, and defect reduction to microsurgical breast reconstruction. Primary goals were to decrease preoperative-to-cut time and total operative time, through reduced variability and improved efficiency. Secondary goals were to reduce length of stay, complications, and reoperation. The project was divided into 3 phases: (1) Pre-Six Sigma (24 months), (2) Six Sigma (10 months), (3) and Post-Six Sigma (24 months). These periods (baseline, intervention, control) were compared by Student t test and chi analysis.
RESULTS: Over a 5-year period, 112 patients underwent 168 perforator flaps for breast reconstructions, by experienced microsurgeons. Total operative time decreased from 714 to 607 minutes (P < 0.01), across the study period, with the greatest drop occurring in unilateral cases, from 672 to 498 minutes (P < 0.01). Length of stay decreased from 6.3 to 5.2 days (P = 0.01). Overall complication rates (35.9% vs 30%, not significant) and take-back rates (20.5% vs 23.9%, not significant) remained similar over the 5-year period. Physician revenue/minute increased from US $6.28 to US $7.59, whereas hospital revenue/minute increased from US $21.84 to US $25.11.
CONCLUSIONS: A Six Sigma program in microsurgical breast reconstruction was associated with better operational and financial outcomes. These incremental gains were maintained over the course of the study, suggesting that these benefits were due, in part, to process improvements. However, continued reductions in total operative time and length of stay, well after the intervention period, support the possibility that "learning curve" phenomenon may have contributed to the improvement in these outcomes.
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1 |
Comparative Matched-Pair Analysis of Keyhole Bone-Plug Technique Versus Arthroscopic-Assisted Pullout Suture Technique for Lateral Meniscal Allograft Transplantation
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AMP (Acute Meniscal Pathology)
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PURPOSE: To compare the clinical outcomes and meniscal extrusion measured by magnetic resonance imaging (MRI) between the keyhole bone-plug technique and arthroscopic-assisted pullout suture technique in lateral meniscal allograft transplantation (MAT).
METHODS: Between October 2009 and February 2015, patients who underwent lateral MAT were retrospectively reviewed. The inclusion criteria were patients with symptomatic knees that had undergone total or subtotal meniscectomy who were treated with lateral MAT with a minimum follow-up period of 2 years. We excluded 13 patients with anterior cruciate ligament injury to the ipsilateral knee and 6 patients with combined cartilage procedures. In addition, we excluded 19 patients because they did not undergo follow-up MRI and 13 patients who did not undergo more than 2 years of follow-up. Thirty-seven patients who underwent lateral MAT with the keyhole bone-plug technique were identified and assigned to group A. Forty-five patients who underwent lateral MAT with the arthroscopic-assisted pullout suture technique (group B) were then matched by age, body mass index, and time from previous meniscectomy to lateral MAT. Clinical outcome assessments included preoperative and postoperative subjective International Knee Documentation Committee (IKDC), Tegner, and Lysholm scores and the visual analog scale (VAS) score for pain evaluation. MRI was used to assess meniscal extrusion.
RESULTS: The mean follow-up period was 35.8 +/- 6.5 months (range, 24-65 months) in group A and 34.6 +/- 6.2 months (range, 24-55 months) in group B. Significant improvements in the VAS pain score, subjective IKDC score, Tegner score, and Lysholm score after lateral MAT were found (P < .001), and there were no significant differences between the 2 groups at final follow-up (VAS score, 1.4 +/- 0.8 in group A and 1.2 +/- 1.0 in group B [P = .164]; subjective IKDC score, 72.9 +/- 8.1 in group A and 74.2 +/- 7.3 in group B [P = .427]; Tegner activity score, 4.0 +/- 0.9 in group A and 4.1 +/- 0.8 in group B [P = .374]; and Lysholm score, 75.5 +/- 10.6 in group A and 76.2 +/- 11.8 in group B [P = .786]). On MRI, the meniscal extrusion extent was 3.1 +/- 0.9 mm in group A and 2.9 +/- 0.8 mm in group B (P = .223), and the relative percentages of extrusion were 27.0% +/- 3.9% and 26.1% +/- 4.2%, respectively (P = .273).
CONCLUSIONS: Compared with the keyhole bone-plug technique, the arthroscopic-assisted pullout suture technique in lateral MAT showed comparable clinical and MRI results at short-term follow-up.
LEVEL OF EVIDENCE: Level IV, case series with intragroup comparisons.
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Continuous iliac compartment block of lumbar plexus combined with continuous femoral block in severe trauma of the lower limb. Case report
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Surgical Management of Osteoarthritis of the Knee CPG
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Background and Objectives - Regional anesthesia with local anesthetics, alone or associated to opioids, provides safe and effective analgesia during surgery and may also provide analgesia in the immediate postoperative period. This report aimed at presenting a case of a patient with a severe knee open fracture associated to popliteal artery injury, in whom an association of left continuous lumbar plexus block and right continuous femoral nerve block was performed. Case Report - The patient was a 27-year-old man, 67 kg, with gastric contents, presenting left knee open fracture and popliteal artery injury. He was thirsty, sweating and pale; BP = 110/65 mmHg, HR = 83 bpm, with cold and ischemic left foot. Lumbar plexus block was performed via left iliac compartment and femoral nerve was blocked with a catheter in the peri-femoral sheath of the right inguinal region to remove the saphenous vein for a possible graft. Forty ml of 0.25% bupivacaine with epinephrine (1:200.000) were used for lumbar plexus block and 14 ml of the same solution for femoral block. Continuous lumbar plexus block was maintained for 12 days for postoperative analgesia. Conclusions - The association of lumbar plexus block via left lilac compartment and right femoral nerve block was effective for the proposed procedures. Continuous lumbar plexus block provided prolonged postoperative analgesia, even allowing the manipulation of the operated site to replace dressings
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Determining the outcomes of post-mastectomy radiation therapy delivered to the definitive implant in patients undergoing one- and two-stage implant-based breast reconstruction: A systematic review and meta-analysis
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Reduction Mammoplasty for Female Breast Hypertrophy
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BACKGROUND: Post-mastectomy radiation therapy (PMRT) is known to increase the complication rate and implant loss in implant-based breast reconstruction. The purpose of this study was to systematically review the literature regarding the outcome of PMRT delivered to the permanent/definitive implant.
METHODS: Systematic review and meta-analysis of studies involving immediate implant-based reconstruction and PMRT when delivered to the permanent implant.
RESULTS: Seven studies included 2921 patients (520 PMRT, 2401 control). PMRT was associated with significant increase in capsular contracture (7 studies, 2529 patients, 494 PMRT, 2035 control, OR 10.21, 95% CI 3.74 to 27.89, p < 0.00001). In addition, PMRT was associated with a significant increase in revisional surgery (7 studies, 2921 patients, 520 PMRT, 2401 control, OR 2.18, 95% CI 1.33 to 3.57, p = 0.002) and reconstructive failure (6 studies, 2814 patients, 496 PMRT, 2318 control, OR 2.52, 95% CI 1.48 to 4.29, p+0.0007). Moreover, it was associated with a significant reduction in patient satisfaction (4 studies, 468 patients, 138 PMRT, 294 control, OR 0.29, 95% CI 0.15 to 0.57, p = 0.0003) and cosmetic outcome (4 studies, 1317 patients, 238 PMRT, 1009 control, OR 28, 95% CI. 0.11 to 0.67, p = 0.005).
CONCLUSIONS: This meta-analysis demonstrates that within the first 5 years, post implant-based reconstruction for those patients who receive PMRT, the rates of adverse events are increased, and there is a significant reduction in patient satisfaction and cosmetic outcome.
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Clinical and ultrasonographic predictors of joint replacement for knee osteoarthritis: Results from a large, 3-year, prospective EULAR study
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PJI DX Updated Search
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Objectives: To determine clinical and ultrasonographic predictors of joint replacement surgery across Europe in primary osteoarthritis (OA) of the knee. Methods: This was a 3-year prospective study of a painful OA knee cohort (from a EULAR-sponsored, multicentre study). All subjects had clinical evaluation, radiographs and ultrasonography (US) at study entry. The rate of knee replacement surgery over the 3-year follow-up period was determined using Kaplan-Meier survival data analyses. Predictive factors for joint replacement were identified by univariate log-rank test then multivariate analysis using a Cox proportional-hazards regression model. Potential baseline predictors included demographic, clinical, radiographic and US features. Results: Of the 600 original patients, 531 (88.5%), mean age 67ñ10 years, mean disease duration 6.1ñ6.9 years, had follow-up data and were analysed. During follow-up (median 3 years; range 0-4 years), knee replacement was done or required for 94 patients (estimated event rate of 17.7%). In the multivariate analysis, predictors of joint replacement were as follows: Kellgren and Lawrence radiographic grade (grade ââ°Â¥III vs <III, hazards ratio (HR) = 4.08 (95% CI 2.34 to 7.12), p<0.0001); ultrasonographic knee effusion (ââ°Â¥4 mm vs <4 mm) (HR = 2.63 (95% CI 1.70 to 4.06), p<0.0001); knee pain intensity on a 0-100 mm visual analogue scale (ââ°Â¥60 vs <60) (HR = 1.81 (95% CI 1.15 to 2.83), p=0.01) and disease duration (ââ°Â¥5 years vs <5 years) (HR=1.63 (95% CI 1.08 to 2.47), p=0.02). Clinically detected effusion and US synovitis were not associated with joint replacement in the univariate analysis. Conclusion: Longitudinal evaluation of this OA cohort demonstrated significant progression to joint replacement. In addition to severity of radiographic damage and pain, US-detected effusion was a predictor of subsequent joint replacement
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1 |
The von Rosen splint compared with the Frejka pillow. A study of 408 neonatally unstable hips
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Developmental Dysplasia of the Hip CPG
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101 children in Tromso, Norway, treated with the Frejka pillow for 4.5 months because of neonatal hip instability (NHI) were compared with 307 children in Malmo, Sweden, treated with the von Rosen splint for 3 months. The pelvic radiographs, taken when the treatment was terminated, were assessed by the acetabular index (AI) and the cases of failure were evaluated. The AI showed no difference between the two groups. The Frejka group had 4 patients who received further treatment because of remaining acetabular dysplasia and/or subluxation while the von Rosen group had none. The difference in risk of failure might partly be explained by different criteria for failure
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Avascular necrosis as a complication of the treatment of dislocation of the hip in children with cerebral palsy
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Developmental Dysplasia of the Hip 2020 Review
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We investigated the incidence and risk factors for the development of avascular necrosis (AVN) of the femoral head in the course of treatment of children with cerebral palsy (CP) and dislocation of the hip. All underwent open reduction, proximal femoral and Dega pelvic osteotomy. The inclusion criteria were: a predominantly spastic form of CP, dislocation of the hip (migration percentage, MP > 80%), Gross Motor Function Classification System, (GMFCS) grade IV to V, a primary surgical procedure and follow-up of > one year. There were 81 consecutive children (40 girls and 41 boys) in the study. Their mean age was nine years (3.5 to 13.8) and mean follow-up was 5.5 years (1.6 to 15.1). Radiological evaluation included measurement of the MP, the acetabular index (AI), the epiphyseal shaft angle (ESA) and the pelvic femoral angle (PFA). The presence and grade of AVN were assessed radiologically according to the Kruczynski classification. Signs of AVN (grades I to V) were seen in 79 hips (68.7%). A total of 23 hips (18%) were classified between grades III and V. Although open reduction of the hip combined with femoral and Dega osteotomy is an effective form of treatment for children with CP and dislocation of the hip, there were signs of avascular necrosis in about two-thirds of the children. There was a strong correlation between post-operative pain and the severity of the grade of AVN.
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The results of a multicenter Italian study on the use of the Gamma nail for the treatment of pertrochanteric and subtrochanteric fractures: a review of 1181 cases
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Management of Hip Fractures in the Elderly
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A total of 1147 pertrochanteric and subtrochanteric fractures, 10 delays in consolidation and non-union, 24 pathologic fractures and osteolysis with the risk of fracture, treated with a gamma nail in 17 Italian departments of traumatology, were collected. In 70% of the patients weight-bearing was allowed during the first week postsurgery; 77% of the patients followed-up recovered the same ability to walk that had preceded trauma. Complications included intraoperative (1.8%) and postoperative (1.1%) diaphyseal fractures, cephalic screw cut out (2.2%), and breakage of the nail (0.4%). There were two cases of infection (0.3%). Most of the complications were related to errors in technique. The safest procedure is constituted by the choice of a nail with a thinner caliber, 2 mm diaphyseal over-reaming, insertion of the nail without the use of a hammer, and distal locking; the cephalic screw must always be inserted in the lower portion of the femoral head
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One-year mortality after a hip fracture: prospective study of a cohort of patients aged over 75 years old
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Hip Fx in the Elderly 2019
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Hip fracture (HF) is a serious complication of the elderly who have suffered a fall. Studies focused on patients over 75 years old without excluding the most vulnerable are not frequent. Before we can think about the creation of an orthogeriatric unit, we evaluated the mortality rate one year after a HF only of patients over 75 years old and we identified associated factors with mortality, functional status and living.
METHODS: Prospective observational study of 75 years and older hospitalized for a HF in a conventional orthopaedic unit. Surgical and geriatric data collected was: instrumental activities of daily life ADL (IADL), comorbidity (cumulative illness rating scale-geriatric (CIRS-G)), mini nutritional assessment (MNA), severity, preoperative delay. A phone assessment one year after HF was about: vital and functional status, living place.
RESULTS: The mean age of 113 patients included was 87 years (76-100). The mortality rate was 35%. It was associated with low IADL day -15 (p< 0.01), elevated CIRS-G (p< 0.01), severity (p=0.05) and malnutrition (p=0.05). Preoperative delay average was 70.7 h (+/- 59) and 48.6% had surgery within 48 hours. Among survivors and from the data available, 45% had a functional decline one year after the HF and 11% were admitted in a nursing home.
CONCLUSION: Without any exclusion of frailty patients, the one-year mortality rate of HF of people aged 75 years and older was 35%. HF is a public health challenge due to its high prevalence, poor prognosis with considerable expense. The associated factors help to explain why geriatricians are required and support the project of creating an orthogeriatric unit. Nevertheless, geriatric care will not likely change prognosis of the most vulnerable patients but could improve the level of care.
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1 |
Outcome of surgical management of bony metastases to the humerus and shoulder girdle: a retrospective analysis of 93 patients
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MSTS 2022 - Metastatic Disease of the Humerus
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BACKGROUND: Metastatic disease to the shoulder girdle is a challenging problem because of the potential for pain, pathologic fracture and loss of function of that limb. Management of the bone disease centers around palliation, prevention of further complications and the preservation of residual function. A variety of surgical options exist for managing metastatic disease to the shoulder girdle and our experience with over 90 patients is reported. We focus on a preferred technique of combining rigid intramedullary nailing with cementation.
METHODS: Patients with metastatic disease to the shoulder girdle were accrued over a 9 year period from 1996 to 2004. 93 patients were identified with 96 operations being performed. The median age was 63 years (range 33 - 89) and 54% were female. The commonest primary tumor to metastasize was breast, and the proximal and midshaft humerus was involved in 84% of cases. The median survival time was 8 months and at last review 82% of patients had died of their disease
RESULTS: Operations performed were intramedullary nailing (n = 51), resection with or without prosthetic reconstruction (n = 34) or plate osteosynthesis (n = 9). The site of the metastasis was a guide to the most appropriate operation. Amputations (n = 2) were not done as the primary procedure. Median post operative hospitalization ranged from 3 to 6 days depending on the type of operation performed. Our preferred technique for diaphyseal lesions (intramedullary nailing plus cementation) achieved excellent results in terms of pain relief, functional restoration and minimal complications. Functional restriction was most notable for proximal humeral prostheses (35% of patients).
CONCLUSION: Surgical treatment of metastases to the shoulder girdle can be successful, allowing prompt relief of pain and return to prehospital level of care. Proximal and midshaft humeral metastases are easily amenable to resection and reconstruction or intramedullary nailing with cementation. Relief of pain and preservation of function occurs for the majority of patients.
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1 |
Efficacy and Safety of Tranexamic Acid in Intertrochanteric Fractures: A Single-Blind Randomized Controlled Trial
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Hip Fx in the Elderly 2019
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OBJECTIVE: To investigate the efficacy and safety of tranexamic acid (TXA) in the reduction of bleeding and the need for transfusion in elderly intertrochanteric fracture patients.
METHODS: A total of 100 patients with intertrochanteric fractures undergoing surgery were enrolled and randomly allocated to the TXA group in which patients (75.10 +/- 8.27 years old) were treated with 1 g of TXA, or the control group (77.82 +/- 6.42 years old) treated with a placebo. Surgery was performed by two senior orthopaedic surgeons from two institutions. The proximal femoral nail antirotation (PFNA) was conducted using the standard procedure. Three outcome measures, including blood loss, transfusion, and complications, were recorded. Blood loss and transfusion were investigated to assess TXA's effectiveness, while complications were investigated to assess TXA's safety. Statistical indicators for blood loss included total, intraoperative, postoperative, and hidden blood loss volumes, calculated by hemoglobin levels, hematocrit levels, and drainage volume. The number and amount of blood transfusions were recorded. Complications associated with surgery, including deep vein thrombosis, pulmonary embolism, wound hematoma, wound infection, cardiovascular and cerebrovascular accidents, and respiratory infections, were also recorded.
RESULTS: All patients were followed up for 1 month after surgery. There were no significant differences in demographic and clinical characteristics between the two groups. The TXA group suffered significantly less total blood loss (563.37 +/- 197.51 vs 819.25 +/- 273.96 mL, 95% CI: -349.49 to -162.27, P < 0.01), intraoperative blood loss (140.3 +/- 80.64 vs 230.5 +/- 130.56 mL, 95% CI -132.74 to -47.66, P < 0.01), and hidden blood loss (410.42 +/- 178.23 vs 571.19 +/- 218.13 mL, 95% CI: -238.85 to -82.69, P < 0.01) than the control group. However, postoperative total blood loss was not significantly different (97.5 +/- 20.93 vs 94.7 +/- 35.78 mL; P = 0.63). A total of 5 patients from the TXA group and 27 from the control group received packed RBC for postoperative transfusion, but the mean number of transfusion units was not significantly different between groups. Complications including deep vein thrombosis, pulmonary embolism, myocardial infarction, ischemic cerebral infarction, hematoma, and infection were observed in both groups, but no significant differences were found.
CONCLUSIONS: In intertrochanteric fracture surgery performed using PFNA, intravenous administration of TXA significantly reduced the risk of intraoperative, total and hidden blood loss, in addition to the need for allogeneic transfusion, without increasing the rate of complications.
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0 |
Comparison of three methods for identifying the heelstrike transient during walking gait
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OAK 3 - Non-arthroplasty tx of OAK
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Impulsive, or high rate, loading contributes to cartilage degradation and is commonly identified via the heelstrike transient (HST) in the vertical ground reaction force (vGRF) during gait. Investigation of the HST may improve our understanding of knee osteoarthritis mechanical pathogenesis. However, the most appropriate method for objectively identifying the HST is unclear. Twenty-eight healthy subjects walked at a self-selected pace while vGRF data were captured. The efficacies of three HST identification methods (Radin, Hunt, and Modified Hunt) were evaluated using vGRF data lowpass filtered at three frequencies (raw/unfiltered, 75Hz, and 50Hz). Both the HST identification method and lowpass filter frequency influenced whether a HST was identified and whether a subject was classified as an "impulsive loader" (i.e. HST identified in 3 of 5 trials). The methods identified different phenomena in the vGRF, with the Radin and Modified Hunt methods identifying the HST 11-16ms following ground contact and the Hunt method identifying the HST 83-122ms following ground contact. Lowpass filtering the vGRF at 75Hz and implementing the Radin method was the most effective approach for identifying the HST. Future longitudinal observations are necessary to determine if specific HST criteria are indicative of knee osteoarthritis development and progression.
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Triple arthrodesis in rheumatoid arthritis
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DoD SSI (Surgical Site Infections)
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Fifty-five patients with rheumatoid arthritis were treated with 65 triple arthrodeses of the hindfoot from March 1975 through July 1985. Twelve patients (12 procedures) have died, and follow-up evaluation could not be completed on three patients (four procedures), leaving 40 patients (49 procedures) available for clinical and roentgenographic evaluation. There were 32 women and eight men, with an average age at the time of surgery of 50 years. The follow-up period averaged five years. Standard operative technique involved medial and lateral incisions with staple fixation and local bone grafting. Correction of deformity was performed with closing wedge osteotomies. All patients had moderate to severe pain preoperatively and difficulty with ambulation. Postoperatively, 94% of the patients had significant pain relief and 83% had complete pain relief. Ambulatory status was improved in 80% of the patients. Ninety percent were at least community ambulators at the time of review, whereas more than half the patients were limited to household ambulation preoperatively. Complications included four superficial wound infections, all of which responded to local care. One patient required revision surgery for pseudarthrosis, and three patients had progression of ankle disease and required pantalar arthrodeses. There was no significant progression of fore-foot or knee symptoms, however, and there was no progression of ankle symptoms in patients whose hindfeet were corrected to 0 degrees-10 degrees valgus. Triple arthrodesis in the rheumatoid population has a high union rate. Pain relief and ambulation improvement can be expected.
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A long-term follow-up study of children with supracondylar fractures of the humerus
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The Treatment of Pediatric Supracondylar Humerus Fractures AUC
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A retrospective study to assess the long-term results of the treatment of supracondylar fractures of the humerus was undertaken to provide guidance on the management of these troublesome injuries. In our experience as long as there was less than 25% displacement on an anteroposterior (A/P) or lateral x-ray, and less than 10 degrees angulation on an A/P or lateral x-ray, it is not essential to achieve an anatomical reduction, and good elbow function could be expected. Although children do not appear to correct for valgus or varus deformity there was no functional deficit from this deformity in this series. It was found that major displacements were more likely to have a worse result than undisplaced or minimally displaced fractures. These results would support a conservative approach to the management of these fractures--closed reduction followed by three weeks in a collar and cuff. If the position proved unstable, closed reduction was re-attempted or internal fixation performed. Conservative treatment was safe and effective, and the results comparable with other series that advocate internal fixation
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[Postoperative analgesia for total knee arthroplasty: a comparative study]
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Surgical Management of Osteoarthritis of the Knee CPG
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Introduction: Total knee arthroplasty is associated with an intense postoperative pain. A number of techniques are being used to ease it. Objective: To compare the effectiveness and safety of three analgesic techniques to control post-surgical knee total arhroplasty pain. Methods: A double-blinded randomized clinical trial was conducted with three groups of fifteen patients each. Group A received intra venous analgesia; group B, epidural analgesia and group C, regional blockade. The intensity of pain was measured when the patient was motionless and when doing active movements at 12 and 24 hours; also, the adverse effects were registered. The statistical analysis included mean comparisons and Student T test. Results: Mean of age was 49.8 years, 57.8% were women. Group A, AVS 12 hours 1.5, active movement 2.6, 24 hours 1.8 and 3. Group B, 1.4 motionless, 1.9 when moving; at 24 hours, 1.8 motionless and 2.4 when moving. Group 3 AVS, motionless 0.1 and when moving 1.9; at 24-hour, motionless 0.2 and 3.0 when moving. There were not statistically significant differences among groups (p>0.05). Adverse effects: group A reported 13.3%; group B 6.7% and group C did not report adverse effects (p< 0.001). Conclusion: These three techniques are effective and safe to control postoperative pain after total knee arthroplasty. Copyright © 2011 Elsevier B. V., Amsterdam. All Rights Reserved
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YKL-40 as a novel factor associated with inflammation and catabolic mechanisms in osteoarthritic joints
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OAK 3 - Non-arthroplasty tx of OAK
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YKL-40 is associated with tissue injury and inflammation, and consequently to diseases in which these mechanisms lead to tissue degradation, for example, asthma and rheumatoid arthritis. The purpose of the present study was to investigate if YKL-40 is also a significant factor in osteoarthritis (OA) by assessing associations of YKL-40 with mediators related to the pathogenesis of OA: cartilage destructing matrix metalloproteinases (MMPs) and proinflammatory cytokines interleukin-6 (IL-6) and interleukin-17 (IL-17). Cartilage, synovial fluid (SF), and plasma samples were obtained from 100 OA patients undergoing total knee replacement surgery. SF levels of YKL-40 (1027.9 +/- 78.3 ng/mL) were considerably higher than plasma levels (67.2 +/- 4.5 ng/mL) and correlated with YKL-40 released from cartilage samples obtained from the same patients (r = 0.37, P = 0.010), indicating that YKL-40 is produced by OA cartilage. Interestingly, YKL-40 concentrations in OA SF correlated positively with MMP-1 (r = 0.36, P = 0.014), MMP-3 (r = 0.46, P = 0.001), IL-6 (r = 0.57, P < 0.001), and IL-17 (r = 0.52, P = 0.010) levels. Moreover, IL-6 and IL-17 enhanced YKL-40 production in human primary chondrocyte cultures. The present study introduces YKL-40 as a cartilage-derived factor associated with mediators of inflammation and cartilage destruction involved in the pathogenesis of OA.
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Oucome of management of non-gonococcal septic arethritis at National Orthopaedic Hospital, Enugu, Nigeria
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Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures
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BACKGROUND: Septic arthritis is an accute bacterial infection of a synovial joint. It is an orthopaedic emergency that can lead to morbidity or mortality if not properly treated. the fundamental issues in the management of septic arthritis include the duration of antibiotic therapy, the mode of joint drainage and the role of physiotherapy. There is a paucity of local data on septic arthritis in Nigeria. The study wa carried out at the National Orthopoedic Hospital, Enugu; a regional trauma and orthopaedic center with wide catchments area covering at least three geopolitical zones of Nigeria. The objective of the study is to describe the pattern and distribution of non-gonococcal septic arthritis, the causative organisms, and the outcome of management of this condition at Enugu, Nigeria and make recommendations on the antibiotic therapy. METHOD: A retrospective study of all the patients that presented at the National Orthopaedic Hospital Enugu with Non-gonococcal septic arthritis between January 1997 and December, 2006 was done. The patient's case notes were retrieved from the Medical Record Department. Information extracted and analyzed included demographic data, joints affected, cultured organisms, antibiotic sensitivity pattern, duration of parenteral and oral antibiotics therapy, complications and follow-up period. Patients with incomplete records, immune-compromised patients and those with subjacent osteomyelitis were excluded from the study. RESULT: Forty-three patients were seen within the period and 40 had analyzable data. The age range was 1 month to 39 years, with a mean age of 10.2 years. Twenty-one patients (52.5%) were males and 19 (47.5%) were females. The hip joint was the most commonly affected (47.5%). Staphylococcus aureus was the most common organism (50%), followed by Coliformn (42.5%). Most patients (75%) had parenteral antibiotics for 3-5 days, while 77.5% of patients received oral antibiotics for 2-4 weeks. All the patients had arthrotomy and joint irrigation within 48 hours of admission. Complicatins were recorded in 11 patients (27.5%). Fixed flexion deformity was the commonest complication (17.5%). No mortality was recorded. CONCLUSION: Septic arthritis is an orthopaedic emergency. Early diagnosis and prompt treatment with appropriate ontibiiotics and surgical drainage are the keys to a successful outcome. In our environment (Enugu), the coliforms ore competing favourably with stophylococcus oaureus as causative agents of septic arthritis. Short term parenteral antibiotics of 3-5 days seems to be as effective as the 1-2 weeks therapy in the non-immune compromised patients and in cases not complicated by juxtarticular osteomyehlitis or presence of prosthetic implants
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Association of postoperative delirium with markers of neurodegeneration and brain amyloidosis: a pilot study
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Hip Fx in the Elderly 2019
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The aim of the study was to investigate the association between postoperative delirium (POD) and in vivo markers of Alzheimer's disease pathology in nondemented hip fracture surgery patients. POD was assessed with the Confusion Assessment Method. Amyloid load was quantified on <sup>18</sup>F-Flutemetamol positron emission tomography images as standardized uptake value ratio. Secondary outcome measures were gray matter volumes, white matter integrity, and functional connectivity at rest. All the patients with POD (POD+, N = 5) were amyloid negative (standardized uptake value ratio <0.59), whereas 6 out of 11 patients without POD (POD-) showed brain amyloid positivity. POD+ compared to POD- displayed: lower gray matter volumes in the amygdala (p = 0.003), in the middle temporal gyrus and in the anterior cingulate cortex (p < 0.001), increased diffusivity in the genu of the corpus callosum and in the anterior corona radiata (p < 0.05), and higher functional connectivity within the default mode network (p < 0.001). POD patients showed altered gray and white matter integrity in the fronto-limbic regions in absence of brain amyloidosis. Based on this preliminary investigation, delirium pathophysiology might be independent of Alzheimer's disease. Future studies on larger samples are needed to confirm this hypothesis.
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The James A. Rand Young Investigator's Award: Large Opioid Prescriptions Are Unnecessary After Total Joint Arthroplasty: A Randomized Controlled Trial
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AAHKS (8) Anesthetic Infiltration
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Background: The purpose of this randomized controlled trial is to determine whether the quantity of opioid pills prescribed at discharge is associated with the number of opioid pills consumed or unused by patients after primary hip and knee arthroplasty within 30 days after discharge. Methods: A total of 304 opioid-naïve patients were randomized to receive either 30 or 90 5-mg oxycodone immediate-release (OxyIR) pills at discharge. Daily opioid consumption, number of unused pills, and pain scores were calculated for 30 days with a patient-completed medication diary. Statistical analysis involved t-test, rank-sum, chi-squared tests, and multiple linear regression with alpha = 0.05. Results: Of the 304 patients randomized, 161 patients were randomized to receive 30 pills and 143 to receive 90. In the first 30 days after discharge, the median number of unused pills was 15 in the 30 group vs 73 in the 90 group (P < .001). Within 90 days of discharge, 26.7% of the 30 group and 10.5% of the 90 group requested a refill (P < .001), leading to a mean of 777.1 ± 414.2 morphine equivalents vs 1089.7 ± 536.4 prescribed (P < .0001). There was no difference between groups in mean morphine equivalents consumed. Regression analysis demonstrated that being prescribed 90 OxyIR pills was independently associated with taking more OxyIR pills (P = .028). There was no difference in pain scores within the first 30 days and in patient-reported outcome scores at 6 weeks postoperatively. Conclusion: Prescribing fewer OxyIR pills is associated with a significant reduction in unused opioid pills and decreased opioid consumption with no increase in pain scores and no difference in patient-reported outcomes. Level of Evidence: Level I. Randomized controlled trial.
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The pathophysiology of menopausal symptoms
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DoD PRF (Psychosocial RF)
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Increasing life expectancy means that most Western women will experience the menopausal transition. This phase of reproductive life involves a biopsychosocial process where the majority of women experience physiological changes, influenced by a wide range of ethnic, psychological, social and cultural factors. With relatively similar endocrine changes, symptom reporting should be generalized, yet more women in Western cultures report vasomotor symptoms (hot flushes and night sweats) compared to women in Asian cultures. Different approaches to menopause based on biological/medical, psychological or psychosocial premises result in different treatments for women who have troublesome symptoms. Hormone replacement therapy (HRT) is widely used in the management of symptoms associated with oestrogen withdrawal (hot flushes, night sweats, sleep disturbance, vaginal dryness and dyspareunia), but has no known role in the treatment of midlife depression or arthritis. HRT prevents menopausal bone loss and osteoporotic fracture, though long-term use remains controversial because of the increased risk of breast cancer, myocardial infarction and stroke, as reported by the Women's Health Initiative. © 2011 Elsevier Ltd.
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Management of the Difficult Airway in the COVID-19 Pandemic: An Illustrative Complex Head and Neck Case Scenario
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Coronavirus Disease 2019 (COVID-19)
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BACKGROUND: This case highlights challenges in the assessment and management of the "difficult airway" patient in the SARS-CoV-2 (COVID-19) pandemic era. METHODS: A 60-year-old male with history of recent TORS resection, free flap reconstruction and tracheostomy for p16+ squamous cell carcinoma presented with stridor and dyspnea one month after decannulation. Careful planning by a multidisciplinary team allowed for appropriate staffing and personal protective equipment, preparations for emergency airway management, evaluation via nasopharyngolaryngoscopy, and COVID testing. The patient was found to be COVID negative and underwent imaging which revealed new pulmonary nodules and a tracheal lesion. RESULTS: The patient was safely transorally intubated in the operating room. The tracheal lesion was removed endoscopically and tracheostomy was avoided. CONCLUSIONS: This case highlights the importance of careful and collaborative decision making for the management of head and neck cancer and other "difficult airway" patients during the COVID-19 epidemic. This article is protected by copyright. All rights reserved.
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Monitoring of skeletal progression of prostate cancer by GFP imaging, X-ray, and serum OPG and PTHrP
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MSTS 2018 - Femur Mets and MM
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BACKGROUND: Prostate cancers (PCas) produce factors that can serve as biomarkers for tumor metastasis and bone progression. Transduced GFP expression by cancer cells can be imaged to monitor therapy. We exploited both concepts by developing a GFP-expressing PCa cell line that expresses PTHrP and studying it in an animal model of malignancy with methods that assess the skeletal progression of this tumor.
METHODS: We developed a GFP-producing PCa cell line by stable transduction of PC-3 PCa cells. This PC-3 variant was used to study tumor progression in an immunocompromised mouse model. Skeletal progression of the PCa cells and the effects of pamidronate administration were evaluated radiologically, fluorometrically, and by measurement of serum tumor markers.
RESULTS: The PC-3 cells produced extensive bone lesions when injected into the tibia of immunocompromised mice. The skeletal progression of the PC-3 cells could be monitored by GFP optical imaging, X-ray, and by measurements of tumor products in serum, notably PTHrP and OPG. Pamidronate treatment reduced tumor burden as assessed at autopsy by imaging and biomarkers.
CONCLUSIONS: Pamidronate treatment exhibited anti-tumor effects that were reflected by decreases in serum PTHrP, OPG, and by GFP and radiological imaging procedures. Imaging of GFP expression enables real-time monitoring of tumor growth in the bone. PTHrP and OPG may be useful as tumor biomarkers for PCa that has metastasized to bone. This novel human PCa model can be used to study the clinical potential of diagnostic and therapeutic modalities in the skeletal progression of PCas.
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Surgical treatment of femoral neck fractures after 24 hours in patients between the ages of 18 and 49 is associated with poor inpatient outcomes: An analysis of 1361 patients in the National Trauma Data Bank
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DOD - Acute Comp Syndrome CPG
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Objective: To determine (1) the incidence of delayed surgical treatment, (2) risk factors associated with delayed surgical intervention, (3) inpatient adverse events and discharge disposition, and (4) the association of delayed surgery with inpatient adverse events. Design: Retrospective cohort study. Setting: 2011 and 2012 National Trauma Data Bank. Patients/Participants: All adult patients younger than 50 years of age with femoral neck fractures. Intervention: Not applicable. Main Outcome Measures: (1) Time to surgical intervention after inpatient admission, (2) odds ratio (OR) for delayed surgery (later than 24 hours after admission), (3) incidence of inpatient adverse events and discharge disposition, (3) rates of inpatient adverse events and discharge disposition, and (4) OR for occurrence of serious adverse events, minor adverse events, and any adverse events. Results: Of a total of 1361 patients, 67.8% of patients underwent surgery within 24 hours of presentation. In multivariate analysis (controlling for patient and injury characteristics), Charlson comorbidity index of 3+ compared with Charlson comorbidity index of 0 (OR: 3.62), pelvic fracture (OR: 2.01), and treatment at an American College of Surgeons level I trauma center (compared with levels II-IV; OR: 1.56) were associated with delayed surgery. The overall rate of mortality and inpatient adverse events was 0.2% and 12.1%, respectively. Delayed surgery was independently associated with increased occurrence of serious adverse events, minor adverse events, and any adverse events. Conclusions: Although a majority of nonelderly patients with femoral neck fractures underwent surgery within the first 24 hours of admission and had good outcomes in the short-term, certain subpopulations have a higher risk of delayed surgery. As delayed surgery is associated with worse outcomes, and short-term and long-term outcomes, efforts should focus on expediting care of these patients. Level of Evidence: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.
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Treatment of osteoarthritis with continuous versus intermittent celecoxib
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OAK 3 - Non-arthroplasty tx of OAK
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OBJECTIVE: To determine whether "continuous" celecoxib is more efficacious than "intermittent" use in preventing osteoarthritis (OA) flares of the knee and/or hip. METHODS: A doubleâ?blind, randomized, multicenter international study comparing efficacy and safety of continuous (daily) versus intermittent (as required during predefined OA flare) celecoxib 200 mg/day in 858 subjects, aged 18â?80 years. The study consisted of 3 periods: (I) screening/washout visit; (II) openâ?label runâ?in with celecoxib; and (III) 22â?week blinded treatment. Only subjects whose OA flares resolved in Period 2 (without subsequent flare) were randomized. The primary endpoint, number of flares per time of exposure during Period III (number of flares per month), was compared using analysis of variance with treatment as the independent variable. Acetaminophen was available as rescue medication. RESULTS: Of 875 subjects randomized to treatment, 858 subjects received treatment. At randomization > 70% were female; mean age 58.6 years; mean disease duration 6.5 years; total Western Ontario and McMaster Universities Osteoarthritis Index mean score 25.8; ~45% had hypertension; and ~20% were using aspirin (for cardiovascular prophylaxis). Subjects receiving continuous treatment reported 42% fewer OA flares/month than intermittent users (p < 0.0001) or 2.0 fewer OA flares over 22 weeks. Statistical and clinically meaningful benefits in secondary outcomes were also evident with continuous treatment. There were no differences in adverse events (AE) or newâ?onset/aggravated hypertension. CONCLUSION: Continuous treatment with celecoxib 200 mg/day was significantly more efficacious than intermittent use in preventing OA flares of the hip and knee, without an increase in overall AE, including gastrointestinal disorders and hypertension, during 22 weeks of treatment. ClinicalTrials.gov identifier NCT00139776.
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CXCR6/CXCL16 functions as a regulator in metastasis and progression of cancer
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MSTS 2018 - Femur Mets and MM
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Metastasis is considered the obvious mark for most aggressive cancers. However, little is known about the molecular mechanism of the regulation of cancer metastasis. Recent evidence increasingly suggests that the interaction between chemokines and chemokine receptors is pivotal in the process of metastasis. The chemokine receptor CXCR4 and its ligand CXCL12, for example, have been reported to play a vital role in cancer metastasis. Another chemokine and chemokine receptor pair, the CXCL16/CXCR6 axis, has been studied by several independent research groups. Here, we summarize recent advances in our knowledge of the function of CXC chemokine receptor CXCR6 and its ligand CXCL16 in regulating metastasis and invasion of cancer. CXCR6 and CXCL16 are up-regulated in multiple cancer tissue types and cancer cell lines relative to normal tissues and cell lines. In addition, both CXCR6 and CXCL16 levels increase as tumor malignancy increases. Trans-membranous CXCL16 chemokine reduces proliferation while soluble CXCL16 chemokine enhances proliferation and migration. TM-CXCL16 functions as an inducer for lymphocyte build-up around tumor sites. High trans-membranous CXCL16 expression correlates with a good prognosis. Moreover, the Akt/mTOR signal pathway is involved in activating the CXCR6/CXCL16 axis. These findings suggest multiple opportunities for blocking the CXCR6/CXCL16 axis and the Akt/mTOR signal pathway in novel cancer therapies. © 2010 Elsevier B.V.
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Investigation of treatment of algodystrophy by guanethidine blockade
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Distal Radius Fractures
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INTERVENTION: Intravenous regional (Biers) block to the affected arm using either: 1. 30 ml normal saline, or 2. 15 mg guanethidine in 30 ml 0.5% pritocaine CONDITION: Reflex sympathetic dystrophy ; Musculoskeletal Diseases ; Osteopathies and chondropathies PRIMARY OUTCOME: Not provided at time of registration SECONDARY OUTCOME: Not provided at time of registration INCLUSION CRITERIA: Closed, unilateral fracture of the distal radius
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Cemented, cementless or hybrid fixation options in total knee arthroplasty for osteoarthritis and other non-traumatic diseases
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SR for PM on OA of All Extremities
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Background: It is not clear which fixation of total knee arthroplasty obtains the best clinical, functional and radiographic results in people with osteoarthritis and other non-traumatic diseases, such as rheumatoid arthritis.Objectives: To assess the benefits and harms of cemented, cementless and hybrid knee prostheses fixation techniques in participants with primary osteoarthritis (osteoarthritis following trauma was not included) and other non-traumatic diseases, such as rheumatoid arthritis.Search methods: We searched CENTRAL (2011, issue 10), MEDLINE via PubMed, EMBASE, Current Controlled Trials, LILACS, The Cumulative Index to Nursing and Allied Health Literature, SPORTDiscus, Health Technology Assessment Database and the Database of Abstracts of Reviews of Effectiveness, all from implementation to October 2011, along with handsearches of high-yield journals and reference lists of articles. No language restrictions were applied.Selection criteria: Randomized controlled trials (RCTs) evaluating cemented, cementless and hybrid fixation. Participants included patients that were 18 years or older with osteoarthritis and other non-traumatic diseases who were undergoing primary total knee arthroplasty.Data collection and analysis: Three authors independently selected the eligible trials, assessed the trial quality, risk of bias and extracted data. Researchers were contacted to obtain missing information.Main results: Five RCTs and 297 participants were included in this review. Using meta-analysis on roentgen stereophotogrammetric analysis (RSA) we observed that cemented fixation of the tibial components demonstrated smaller displacement in relation to cementless fixation (with and without hydroxyapatite) after a follow-up of two years (maximum total point-motion, N = 167, two RCTs, mean difference (MD) = 0.52 mm, 95% confidence interval (CI) 0.31 to 0.74). However, the risk of future aseptic loosening with uncemented fixation was approximately half that of cemented fixation according to the arthroplasty instability classification (moderate quality as assessed by GRADE) inferred from RSA (N = 216, three RCTs, risk ratio (RR) = 0.47, 95% CI 0.24 to 0.92) with a 16% absolute risk difference between groups. The number needed to treat for an additional beneficial outcome (NNTB) to prevent future aseptic loosening was 7 (95% CI 5 to 44). There was a low risk of bias for RSA among the studies included. It was not possible to perform meta-analysis on patient-important outcomes, such as the survival rate of the implant (any change of a component), patient global assessments, functional measures, pain, health-related quality of life measures and adverse events. Almost all included studies recorded functional measures of Knee Society and Hospital for Special Surgery knee scores, but the authors of each study found no significant difference between the groups.Authors' conclusions: There was a smaller displacement of the cemented tibial component in relation to the cementless fixation in studies with osteoarthritis and rheumatoid arthritis participants who underwent primary total knee prosthesis with a follow-up of two years; however, the cemented fixation presented a greater risk of future aseptic loosening than cementless fixation
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Qualitative Development of a Discrete Choice Experiment for Physical Activity Interventions to Improve Knee Osteoarthritis
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OAK 3 - Non-arthroplasty tx of OAK
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OBJECTIVE: To describe the qualitative process used to develop attributes and attribute levels for inclusion in a discrete choice experiments (DCE) for older adult physical activity interventions.
DESIGN: Five focus groups (n=41) were conducted, grounded in the Health Action Process Approach framework. Discussion emphasized identification and prioritization attributes for a DCE on physical activity. Semi-structured interviews (n=6) investigated attribute levels and lay-language for the DCE. A focus group with physical activity researchers and health care providers was the final stakeholder group used to establish a comprehensive approach for the generation of attributes and levels. A DCE pilot test (n=8) was then conducted with individuals of the target patient population. All transcripts were analyzed using a constant comparative approach.
SETTING: General community and university-based research setting.
PARTICIPANTS: Volunteers (N=55) aged >45 years with knee pain, aches, or stiffness for at least 1 month over the previous 12 months.
INTERVENTIONS: Not applicable.
MAIN OUTCOME MEASURES: Interview guides, attributes, attribute levels, and discrete choice experiment.
RESULTS: The most influential identified attributes for physical activity were time, effort, cost, convenience, enjoyment, and health benefits. Each attribute had 3 levels that were understandable in the pilot test of the DCE.
CONCLUSIONS: The identification of 6 physical activity attributes that are most salient to adults with knee osteoarthritis resulted from a systematic qualitative process, including attribute-ranking exercises. A DCE will provide insight into the relative importance of these attributes for participating in physical activity, which can guide intervention development.
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How valuable is screening for thyroid disease in patients with carpal tunnel syndrome?
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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BACKGROUND: It has been suggested that many patients with carpal tunnel syndrome have associated thyroid or other metabolic diseases. METHODS: 206 patients with clinical features suggestive of carpal tunnel syndrome (CTS), including those with known underlying cause of CTS, were screened for thyroid dysfunction. Nerve conduction studies were compatible with a diagnosis of CTS in 136 patients (CTS group). RESULTS: We diagnosed only 2 new cases of hypothyroidism (1.5% of patients in the CTS group) and none with hyperthyroidism. CONCLUSIONS: Thus routine screening of patients with isolated CTS for thyroid function abnormality does not appear to be worthwhile
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The influence of obesity and volume of resection on success in reduction mammaplasty: An outcomes study
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Reduction Mammoplasty for Female Breast Hypertrophy
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Background: Indications for breast reduction surgery include neck pain, back pain, shoulder pain, and an intertriginous rash. Previous studies have established that bilateral breast reduction surgery is highly effective in relieving these symptoms. Third-party payers may refuse to cover breast reduction surgery for obese patients. In addition, some surgeons turn down obese breast reduction candidates, perhaps fearing that they will not achieve symptom relief or that the complication rate will be prohibitive. It is common for insurers to require an arbitrary minimum volume to be resected in order for them to reimburse for the procedure. This study was conducted to see whether patients with varying levels of obesity had any difference in surgical outcomes compared with nonobese patients with regard to symptom relief and complication rate. The authors also studied the relationship between volume of tissue resected and symptom relief and complication rate. Methods: One hundred eighty-six consecutive patients underwent bilateral breast reduction surgery performed by a single surgeon using the inferior pedicle Wise pattern technique or the free nipple graft technique. Body mass index was calculated for each patient. Results: Significant postoperative symptom relief occurred in 97 percent of patients. Statistical analysis demonstrated no difference among the various body mass index groups in terms of symptom relief or development of complications, nor was there any correlation between volume of tissue resected and relief of symptoms or complications. Conclusions: The authors conclude that there is no justification for discriminating against obese patients in either the performance of breast reduction surgery or the provision of insurance coverage for the same. The authors find no justification for denial of insurance coverage for patients in whom lesser tissue volumes are to be resected.
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Osteoarthritis of the knee in retired, elite Australian Rules footballers
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AMP (Acute Meniscal Pathology)
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OBJECTIVE: To determine the functional and radiological status of knee joints of retired Australian Rules footballers compared with those of active community members.
DESIGN: Retrospective cohort study.
PARTICIPANTS: Fifty retired elite footballers aged 34-85 years (mean, 53.7 years; SD, 11.4) from four AFL clubs and 50 age-matched controls (35-79 years; mean, 55.7 years; SD, 12.4) who had played no contact sport since their teenage years.
MAIN OUTCOME MEASURES: Severity of knee functional osteoarthritis as determined by a questionnaire, and assessment of osteoarthritis by posteroanterior weight-bearing radiographs taken of both knees of each participant in 45-degree flexion.
RESULTS: After adjusting for age, height, weight and body mass index, footballers had a significantly greater prevalence (P < 0.0001) and severity (P < 0.05) of functional and radiological osteoarthritis than controls. Footballers with a history of intraarticular ligamentous and/or meniscal injury (Group 1) had a greater risk of functional osteoarthritis (P = 0.002) and radiological (P = 0.067) osteoarthritis than those with a history of collateral ligament injury or no injury (Group 2). Compared with controls, the odds of developing moderate to severe levels of functional and radiological osteoarthritis were 6.9 times (95% CI, 1.6-29.7; P = 0.01) and 105.0 times (95% CI, 11.8-931.8; P < 0.0001), respectively, those in Group 1 footballers and 3.6 times (95% CI, 0.8-16.2; P = 0.10) and 17.7 times (95% CI, 2.2-146.2; P = 0.0075), respectively, those in Group 2 footballers.
CONCLUSIONS: Elite Australian Rules footballers have a significant risk of both functional and radiological osteoarthritis, and a history of intra-articular ligament or meniscal injury increases this risk.
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0 |
Osteochondritis dissecans of the medial femoral condyle associated with malformation of the menisci
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Diagnosis and Treatment of Osteochondritis Dissecans AUC
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Osteochondritis dissecans is a form of osteochondrosis limited to the articular epiphysis and the relationship of osteochondritis dissecans and discoid lateral meniscus has been clearly identified. This article presents a 10-year-old boy with osteochondritis dissecans of the medial femoral condyle associated with hypoplastic medial and partial deficient lateral menisci. The patient presented with activity-related pain and intermittent swellings of his left knee for 2 months without any evidence of significant knee trauma. Magnetic resonance imaging revealed anomalous medial meniscus mimicking displaced bucket-handle tear and partially deficient lateral meniscus with osteochondritis dissecans at the lateral aspect of medial femoral condyle without any significant bone loss with a non-dislocated fragment. Arthroscopy of the knee revealed an incomplete separated osteochondral flap with partial discontinuity that was unstable on probing on the lateral aspect of the medial femoral condyle. The medial meniscus was hypoplastic without a body and only the meniscal rim could be seen. The lateral meniscus had an anomalous vertical insertion of the posterior horn, normal body, but an absent anterior horn. The anterior cruciate ligament was intact, but looked like a peacock's tail. Arthroscopic fixation of the chondral lesion was performed. At 30-months follow-up, the boy had no limitation in his daily and sports activity. The present case is the first description of congenital anomaly of the both menisci and osteochondritis dissecans together. Meniscal or ligamentous anomalies of the knee may be associated with osteochondritis dissecans
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0 |
Tissue-engineered repair of exercise-induced meniscal injury: International research trends and future
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AMP (Acute Meniscal Pathology)
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BACKGROUND: The depth study of disciplines, such as tissue engineering, genetic engineering, biomechanics and materials science, provides a new approach for the treatment of meniscal injuries. OBJECTIVE: To multivariately analyze the literatures on the tissue-engineered repair of exercise-induced meniscal injury through Scopus database and to summarize the application progress of tissue-engineered repair of exercise-induced meniscal injury. METHODS: A retrieval was performed for the literature of the tissue-engineered repair of exercise-induced meniscal injury, using the key words of "meniscus, sports injuries, tissue engineering, repair" between January 2002 and December 2011 in Scopus database. The retrieval results were analyzed, and the trends were described in words and graphics. RESULTS AND CONCLUSION: A total of 245 literatures on the issue-engineered repair of exercise-induced meniscal injury were retrieved in Scopus database, in which most of paper were published as original articles. Eight articles were identified as classic literatures. The overall number of literature had an upward trend from 2002 to 2011. United States and England published more literature than other countries, which play an important role in the field of tissue-engineered repair of exercise-induced meniscal injury. Most of literatures were published from Rice University, University of Pennsylvania, and Radboud University Nijmegen Medical Centre. Biomaterials published most papers in this field (n=15, 6.12%). This paper provides a valuable reference for researchers to understand the overview and present situation of this field.
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Rejuvenation of the aging neck
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Panniculectomy & Abdominoplasty CPG
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Patients seeking rejuvenation of the face are influenced by youthful faces commonly seen in the media and entertainment world. Although standards of beauty evolve over time, classical facial features such as symmetry, high cheek bones, and an angular jaw-neck line remain as ideals. As the human face ages, a relatively consistent series of anatomic events occurs. Although the rate of change varies from person to person, the process of facial aging is predictable. This process involves a loss of tone of the elastic fibers of the face, resulting in sagging of the skin and soft tissues of the face and neck. Additionally, aging of the lower face often includes ptosis of the soft tissues of the chin and banding or cording of the muscles of the anterior neck. Aesthetic rejuvenation of the face and neck involves repositioning of poorly supported soft tissues. To accurately treat facial aging, an individualized diagnosis and anatomically based problem list is compiled. This should include analysis of the skin quality, bone structure, amount and distribution of subcutaneous fat, and relationship of the superficial muscles to the overlying skin. After a detailed diagnosis is made, a surgical treatment plan is outlined to improve the face and restore a youthful appearance. This article describes the applied anatomy associated with facial aging and explains the author's specific techniques to obtain a natural postoperative appearance. Avoidance of common problems associated with aging face surgery is emphasized.
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Neoadjuvant and adjuvant therapy in patients with oral squamous cell carcinoma Long-term survival in a prospective, non-randomized study
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Reconstruction After Skin Cancer
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PATIENTS AND METHODSWe studied two groups consisting of 74 patients given neoadjuvant treatment and 54 treated surgically. Ninety-nine patients suffered from stage III and IV diseases according to the UICC-criteria. Long-term survival was estimated by the Kaplan-Meier method.RESULTSNeoadjuvant treatment increased the prospect of a long-term survival free of tumour. Kaplan-Meier curves estimated a 5-year tumour-free survival in oral squamous cell carcinoma category T1 as 83% in the neoadjuvant group and 70% in the adjuvant group; the corresponding figures for T2 were 79% and 57%, for T3 68% and 33% and for T4 51% and 30%, respectively. The difference for T1, T2 and T4 tumours were significant. The preoperative radio- and chemotherapy were shown to be effective by the fact that pathohistologically resection specimens were free of tumour in 28 patients in the neoadjuvant group. Four patients died during the preoperative combination treatment. Of the patients, 65% in the adjuvant group and 72% in the neoadjuvant group survived the observation period.CONCLUSIONThe neoadjuvant treatment results in better 5-year-survival rate than adjuvant treatment.INTRODUCTIONRecently new concepts for the treatment of oral squamous cell carcinomas (SCC) have been developed, which include preoperative simultaneous neoadjuvant radiochemotherapy (RCT) and one stage operation with excision of the tumour and reconstruction. When we consider long-term survival, we find substantial evidence that combined treatment based on neoadjuvant radiochemotherapy is superior to adjuvant treatment including operation and postoperative radiation.
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A staged treatment plan for the management of Type II and Type IIIA open calcaneus fractures
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DoD SSI (Surgical Site Infections)
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OBJECTIVE: To assess the results of a standardized staged treatment strategy for displaced open calcaneal fractures with medial wounds.
DESIGN: Retrospective case series.
SETTING: Level I trauma center.
PATIENTS/PARTICIPANTS: Fourteen displaced open Type II or Type IIIA Orthopaedic Trauma Association (OTA) 73 Type B or C calcaneal fractures treated between January 2000 and December 2007 who were managed with a standardized regimen.
INTERVENTION: Patients were treated in a staged fashion with antibiotics, irrigation, debridement, and percutaneous Kirschner wire fixation followed by definitive open reduction and internal fixation when soft tissues were amenable to fixation.
MAIN OUTCOME MEASURES: Data regarding demographics, injury characteristics, time to fixation, interventions, and treatment complications were documented. The complication rate, time to bony union, and additional procedures were determined.
RESULTS: There were four OTA 73B and 10 OTA 73C injuries with open Type II or Type IIIA wounds on the medial side. All patients had debridement, irrigation, and percutaneous fixation within 8 hours of presentation. Definitive fixation was carried out on average 18 days after initial presentation with 10 patients only requiring the initial debridement and stabilization procedure followed by definitive fixation All 14 patients underwent definitive fixation through an extensile lateral approach. A superficial infection developed in one patient and a deep infection in one patient. All patients went on to union at an average follow up of 19 months.
CONCLUSION: Open Type II and IIA wounds associated with displaced OTA Type 73 B or C calcaneal fractures represent high-energy injuries with potential increased risk for wound complications. In our series, a staged treatment strategy consisting of urgent debridement, provisional internal stabilization, and late definitive reconstruction offers a protocol that may reduce infections associated with open calcaneal fractures.
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Optimized perioperative analgesia reduces chronic phantom limb pain intensity, prevalence and frequency: A prospective randomized, clinical trial
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Surgical Management of Osteoarthritis of the Knee CPG
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Background and aims: Persistent pain after amputation manifests as phantom limb pain (PLP), residual (stump) pain, or both, and is frequently a vexing clinical problem that is difficult to manage. PLP is reported by 50% to 80% of patients1;2, can result in depression and sleep disorders and has been associated with serious long term health sequelae, including obesity, joint pain, low back pain and cardiovascular disease3;4. The epidemiology and risk factors for PLP are not fully understood, but pain before limb amputation is associated with development and severity of chronic PLP5;6. Several analgesic regimens, including oral gabapentin7, intravenous morphine, ketamine or lidocaine, nerve blocks and epidural analgesia8;9 have been used to control pain before amputation, in an attempt to prevent phantom pain, but results have been conflicting. This prospective randomized clinical trial (RCT) was conducted to investigatewhether optimized perioperative analgesia aimed at control of pain before, during and/or after lower limb amputation can influence the intensity, prevalence and frequency of PLP at 1 and 6 months after amputation. Methods: Setting This prospective, randomized, double blinded clinical trial was conducted at the University Hospital of Patras in Rion, Greece, between December 2003 and May 2008. The study was approved by the Institution Ethics Committee, and was registered at the trial registry at www.clinicaltrials.gov (Clinical- Trials.gov Identifier: NCT00443404). Written informed consent was obtained from all patients before they enrolled in the study. The study was financially supported by department funds, without any support from outside sources. Patient Selection Inclusion criteria included patients ages 18 - 85 years, scheduled for major (above or below the knee) amputation who had moderate to severe pain before amputation despite routine analgesic therapy. Patients undergoing repeat amputation, emergency amputation, foot or toe amputation, and patients with significant psychiatric disease, chronic pain not related to limb ischemia, history of substance abuse and patients unable to complete a pain questionnaire were excluded. Pain Measurement Pain intensity was evaluated using the Visual Analog Scale (VAS) and the three main measures of the McGill Pain Questionnaire (MPQ): the Pain Rating Index (PRI-R), the Number of Words Chosen (NWC) and Present Pain Intensity (PPI)10. Pain intensity data were collected every 8 hours for 48 hours before the amputation, and at 24 and 48 hours, 4 and 10 days, and 1 and 6 months after amputation. PLP intensity, as measured using the VAS and MPQ-PRIR was designated as primary outcome, whereas all other PLP and residual limb pain measurements were designated as secondary outcomes. Study Design and Interventions Patients who enrolled in the study were randomly assigned to one of five groups. All patients had a lumbar epidural catheter [or subcutaneous catheter in the control group (Group 5) in order to maintain blinding] placed 48 hours before amputation, but use of the epidural catheter differed based on group assignment. Patients in Group 1 (Epi/Epi/Epi group) received epidural analgesia before and after surgery, and epidural anesthesia during surgery; Group 2 (PCA/Epi/Epi group) patients received IV patient-controlled analgesia (PCA) preoperatively, epidural anesthesia intraoperatively and epidural analgesia postoperatively. Group 3 (PCA/Epi/PCA) patients received IV PCA before and after surgery, and epidural anesthesia intraoperatively. Group 4 (PCA/GA/PCA) patients had IV PCA before and after surgery, and general anesthesia intraoperatively. Group 5 (control) patients received conventional analgesia (intramuscular meperidine 50 mg 4-6 times a day as needed, oral codeine/acetaminophen as needed, and IV acetaminophen 650 mg 2-3 times a day) before and after surgery, and general anesthesia intraoperatively. In total, 65 patients participated. All patients had an 'epidural' infusion pump (delivering saline or analgesic depending on group assignment). Similarly, all patients (except for those in the control group) received IV PCA pumps (delivering saline or analgesic depending on group assignment). The epidural analgesic was a solution containing bupivacaine 2 mg/ml and fentanyl 2 mcg/ml administered at 4-8 ml/hour, whereas the IV PCA regimen consisted of fentanyl 25 mcg per dose with 20 minute lockout and no basal infusion. Visual analog scale and McGill Pain Questionnaire pain scores were recorded perioperatively and at 1 and 6 months after the amputation. Statistical analysis Sample size calculation was conducted before starting the study and showed that 10 patients per groups would be adequate, using the following assumptions: ANOVA for 5 groups of patients, VAS pain score at 6 months as the primary outcome, power = 0.8, alpha = 0.05, and mean square standardized effect = 0.6. Subsequently, we decided to increase the sample size to 13 per group, to allow for patient attrition and possible data errors or protocol violations. ANOVA was used to compare differences between groups for normally distributed variables, whereas the Kruskall-Wallis test was used to compare variables that were not normally distributed. P values indicating statistical significance were adjusted for multiple comparisons using the Bonferroni correction method. Data analysis was conducted using 'per protocol' analysis initially; subsequently, analysis was also conducted based on the 'intention-to-treat' principle, and both analyses yielded similar results. Results: Of 107 eligible patients, 42 were excluded before randomization, and 65 patients were randomized. Two patients were excluded from the study after randomization (one patient had a different procedure, and the other patient died before the amputation). The five groups did not differ with regards to age, sex, presence of diabetes or cardiovascular disease and level of amputation. However, patients in the control group had significantly lower median VAS pain scores (70) compared to all four intervention groups (median 80-92) before the analgesic protocol started. Six months after amputation, PLP VAS scores were significantly different between groups (p = 0.001). Post-hoc comparisons between all intervention groups and the control group showed that median (minimummaximum) PLP VAS scores and significance (p value) for the difference between each intervention group vs. control were 20 (0-58) for the control group, 0 (0-20) for the Epi/Epi/Epi group (P = 0.001 vs. control), 0 (0-42) for the PCA/Epi/Epi group (P = 0.014 vs. control), 20 (0-40) for the PCA/ Epi/PCA group (P = 0.532 vs. control) and 0 (0-30) for the PCA/GA/PCA group (P = 0.008 vs. control). Similarly, six months after the amputation MPQ-PRIR scores differed significantly between the intervention groups and the control group (p = 0.001). Post-hoc comparisons showed that, at 6 months, median (minimum-maximum) MPQ-PRIR PLP scores and significance (p value) for the difference between each intervention group vs. controlwere 7 (0-15) in the control group, 0 (0-7) in the Epi/Epi/Epi group (P = 0.001 vs. control), 0 (0-9) in the PCA/Epi/Epi group (P = 0.003 vs. control), 6 (0-11) in the PCA/Epi/PCA group (P = 0.208 vs. control) and 0 (0-9) in the PCA/GA/PCA group (P = 0.003 vs. control). With regards to prevalence, 6 months after the amputation PLP was present in 1 of 13 patients in the Epi/Epi/Epi group, 4 of 13 patients in the PCA/Epi/Epi group, 7 of 13 patients in the PCA/Epi/PCA group and 3 of 13 patients in the PCA/GA/PCA group, compared to 9 of 12 patients in the control group. Overall, the prevalence of PLP at 6 months after amputation was 15 of 52 patients (28.8%) in the intervention group vs. 9 of 12 patients (75%) in the control group, and the observed difference was highly significant (p = 0.004). Interestingly, in contrast to earlier publications, residual limb pain in this study was insignificant in all patients 6 months after the amputation. Conclusions: Phantom Limb Pain remains a significant clinical problem that can adversely affect the health and quality of life of affected individuals 1. The effectiveness of available options for the management of existing phantom pain is limited and not very well documented. 2. Poor pain control before amputation remains the rule, rather than the exception, and pain before limb amputation is associated with phantom limb pain frequency and intensity. 3. Analgesic interventions aimed at optimizing perioperative analgesia for patients undergoing amputation may result in reduced phantom pain frequency and intensity, but published studies have produced conflicting results. 4. Results of this RCT published in 'Anesthesiology' in May 2011 suggest that optimized epidural analgesia or intravenous PCA, starting 48 h preoperatively and continuing for 48 h postoperatively, decreases PLP at 6 months11. However, because this was a small study, more data from larger RCTs are needed to validate these findings
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Carpal tunnel syndrome
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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CTS is a common upper extremity problem that has an increasing incidence and poorly understood causes. Radiographs and electrodiagnostic tests are helpful, but the diagnosis remains based on clinical symptoms and signs. The several sites of median nerve compression must be considered. Splinting and steroid injections are often effective. Carpal tunnel release is indicated in refractory or acute problems, and both open and endoscopic methods remain popular. Each has specific advantages
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Carpal tunnel syndrome in juvenile rheumatoid arthritis
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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The frequency of carpal tunnel syndrome in children is not generally appreciated. Only 11 cases have been published. In some of them the probable diagnosis was juvenile rheumatoid arthritis. A series of 22 operated hands in 14 patients under 15 years is presented. All patients, 9 girls and 5 boys, were suffering from definitely diagnosed juvenile rheumatoid arthritis. The most common symptoms are atrophy of the thenar muscles and tenosynovial masses at the volar side of the wrist. Contrary to adult patients, sensory disturbances are rare and thenar atrophy can be healed. Unilateral cases seem to occur in oligoarticular, slowly progressing type of the disease. Early diagnosis and decompression are emphasized
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EULAR Recommendations 2003: an evidence based approach to the management of knee osteoarthritis: Report of a Task Force of the Standing Committee for International Clinical Studies Including Therapeutic Trials (ESCISIT)
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Surgical Management of Osteoarthritis of the Knee CPG
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OBJECTIVES: To update the EULAR recommendations for management of knee osteoarthritis (OA) by an evidence based medicine and expert opinion approach. METHODS: The literature search and guidelines were restricted to treatments for knee OA pertaining to clinical and/or radiological OA of any compartment of the knee. Papers for combined treatment of knee and other types of OA were excluded. Medline and Embase were searched using a combination of subject headings and key words. Searches for those treatments previously investigated were conducted for January 1999 to February 2002 and for those treatments not previously investigated for 1966 to February 2002. The level of evidence found for each treatment was documented. Quality scores were determined for each paper, an effect size comparing the treatment with placebo was calculated, where possible, and a toxicity profile was determined for each treatment modality. RESULTS: 497 new publications were identified by the search. Of these, 103 were intervention trials and included in the overall analysis, and 33 treatment modalities were identified. Previously identified publications which were not exclusively knee OA in the initial analysis were rejected. In total, 545 publications were included. Based on the results of the literature search and expert opinion, 10 recommendations for the treatment of knee OA were devised using a five stage Delphi technique. Based on expert opinion, a further set of 10 items was identified by a five stage Delphi technique as important for future research. CONCLUSION: The updated recommendations support some of the previous propositions published in 2000 but also include modified statements and new propositions. Although a large number of treatment options for knee OA exist, the evidence based format of the EULAR Recommendations continues to identify key clinical questions that currently are unanswered
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Osteogenic protein-1 in knee arthritis and arthroplasty
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Surgical Management of Osteoarthritis of the Knee CPG
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The use of graft materials to restore bone stock and promote healing and implant stabilization is a crucial part of total knee arthroplasty, especially in revision surgery. Recent research has centered on the use of osteoinductive materials to promote bone formation. Osteogenic proteins are members of a superfamily of proteins called transforming growth factor-beta that, either alone or in combination with other regulatory molecules, induce new bone formation. The cloning and genetic expression of recombinant human osteogenic proteins has led to production of quantities sufficient for their clinical use. Recombinant human osteogenic protein-1 has been combined with bone-derived Type I collagen for delivery to an implant site. Preclinical studies have shown that the osteoinductive capacity of autograft and allograft bone and bone graft substitute materials can be notably improved with the addition of osteogenic protein-1. The use of this protein consistently improved the amount and rate of new bone formation compared with graft alone, resulting in earlier graft incorporation and consolidation. In addition, because osteogenic proteins are chondrogenic, they also may have a role in the treatment of cartilage injury and degeneration. Osteogenic protein-1 has been shown to induce hyalinelike cartilage repair of full thickness osteochondral defects in animal models with no degradation of the tissue with time. Although no detailed clinical studies in knee surgery have been reported with the use of osteogenic protein-1, in anecdotal cases its use alone and with bone graft materials indicate results consistent with those obtained in preclinical studies
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Acupuncture-like stimulation with codetron for rehabilitation of patients with chronic pain syndrome and osteoarthritis
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OAK 3 - Non-arthroplasty tx of OAK
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Acupuncture is one of the oldest healing methods which is used in traditional medicine. In the modern medicine, we are witnessing a renaissance of this ancient treatment applied mainly in the management of chronic pain. A number of modern technological changes are being applied to replace, or modify, the classical needle treatment. Among many modalities used today is the novel addition in Transcutaneous Electrical Nerve Stimulation (TENS) called CODETRON which delivers acupunctureâ?like stimulation in a random order. CODETRON was developed by a Canadian Scientist and had been evaluated in a clinical trial in a multidisciplinary pain clinic on patients who came for acupuncture therapy over a period of two years. Indications, effectiveness and experiences with this form of treatment are presented. In addition, results obtained from a six week doubleâ?blind randomized placebo controlled pilot trial of osteoarthritis of the hip/knee with CODETRON which was conducted later. The results were highly suggestive of the beneficial effect of this nonhabituating mode of therapy and confirmed our initial uncontrolled trial results.
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Periarticular multimodal drug injection improves post-operative pain and functional recovery after total knee arthroplasty
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AAHKS (9/10) Regional Nerve Blocks
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Background This study retrospectively compared the clinical benefits of periarticular multimodal drug injection (PMDI) and continuous femoral nerve block (CFNB) after total knee arthroplasty (TKA). Methods From 2010 to 2012, 520 primary TKAs were performed, and patients were treated with CFNB or PMDI after surgery. Patients who underwent simultaneous bilateral TKA were excluded, leaving 185 and 166 patients in the CFNB and PMDI groups, respectively. Numeric rating scale for pain (NRS) scores and analgesic consumption were evaluated to compare the effectiveness of pain control between the groups. Further, range of motion (ROM), extension lag, the time to recovery of functions, and postoperative C-reactive protein (CRP) levels were monitored. Complications such as deep infection were assessed. Results The PMDI group displayed a significantly smaller NRS score on postoperative day (POD) 1 and lower analgesic consumption on PODs 0 and 1. The times to functional recovery were significantly shorter and the extension lag was smaller in the PMDI group. Furthermore, CRP levels were lower in the PMDI group by POD 7. No obvious deep infections were noted. Conclusion Our results indicate that PMDI induced earlier functional recovery after TKA than CFNB, partially via its analgesic effect.
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St Georg modular knee prosthesis. A two-and-a-half to six-year follow-up
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Surgical Management of Osteoarthritis of the Knee CPG
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The St Georg modular knee replacement has been studied in 59 cases with an observation period ranging from 28 to 73 months. In 47% of the knees both compartments were replaced; five of the six poor results were in this group. These were revised to a hinge arthroplasty or, in one case, to an arthrodesis. Other complications were few and insignificant. There were no infections. We concluded that unicompartmental knee arthroplasty can be recommended when joint involvement is localised to one compartment only. With more generalised joint disease we prefer a semiconstrained total condylar prosthesis
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Hydroxyapatite-coated tibial implants compared with cemented tibial fixation in primary total knee arthroplasty. A randomized trial of outcomes at five years
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Surgical Management of Osteoarthritis of the Knee CPG
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BACKGROUND: Although excellent long-term results have been reported with cemented tibial fixation, cementless fixation as a means to improve the longevity of total knee prostheses continues to be of interest to clinicians. The purpose of this study was to compare outcomes between cementless tibial fixation with hydroxyapatite and cemented tibial fixation in the first five years following primary total knee arthroplasty. METHODS: We performed a prospective, randomized clinical trial that included eighty-one patients with noninflammatory knee arthritis who underwent primary total knee arthroplasty when they were less than seventy years of age. The subjects were randomized at the time of surgery to be treated with either cementless tibial fixation with hydroxyapatite or cemented tibial fixation. Evaluations were performed preoperatively and at six months, one year, and five years postoperatively by a physical therapist who was blinded to group allocation. Self-reported pain and function, the primary outcomes, were measured with the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and the RAND 36-Item Health Survey (RAND-36). Complications and revision rates were determined through a review of hospital records and at each patient evaluation. The Knee Society radiographic score was used to evaluate plain radiographs at each assessment. RESULTS: Seventy subjects (86%) completed the five-year assessment. Slightly more pain was reported in the hydroxyapatite group at six months as measured with both the WOMAC and the RAND-36, a difference that disappeared by one year postoperatively. No differences were seen in function, radiographic findings, or complications. No subject required revision of the tibial prosthesis during the study. CONCLUSIONS: At five years postoperatively, there is no difference between cementless tibial fixation with hydroxyapatite and cemented tibial fixation in terms of self-reported pain, function, health-related quality of life, postoperative complications, or radiographic scores
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Comparative effectiveness of pain management interventions for hip fracture: a systematic review
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Management of Hip Fractures in the Elderly
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BACKGROUND: Pain management is integral to the management of hip fracture. PURPOSE: To review the benefits and harms of pharmacologic and nonpharmacologic interventions for managing pain after hip fracture. DATA SOURCES: 25 electronic databases (January 1990 to December 2010), gray literature, trial registries, and reference lists, with no language restrictions. STUDY SELECTION: Mu ltiple reviewers independently and in duplicate screened 9,357 citations to identify randomized, controlled trials (RCTs); nonrandomized, controlled trials (non-RCTs); and cohort studies of pain management techniques in older adults after acute hip fracture. DATA EXTRACTION: Independent, duplicate data extraction and quality assessment were conducted, with discrepancies resolved by consensus or a third reviewer. Data extracted included study characteristics, inclusion and exclusion criteria, participant characteristics, interventions, and outcomes. DATA SYNTHESIS: 83 unique studies (64 RCTs, 5 non-RCTs, and 14 cohort studies) were included that addressed nerve blockade (n = 32), spinal anesthesia (n = 30), systemic analgesia (n = 3), traction (n = 11), multimodal pain management (n = 2), neurostimulation (n = 2), rehabilitation (n = 1), and complementary and alternative medicine (n = 2). Overall, moderate evidence suggests that nerve blockades are effective for relieving acute pain and reducing delirium. Low-level evidence suggests that preoperative traction does not reduce acute pain. Evidence was insufficient on the benefits and harms of most interventions, including spinal anesthesia, systemic analgesia, multimodal pain management, acupressure, relaxation therapy, transcutaneous electrical neurostimulation, and physical therapy regimens, in managing acute pain. LIMITATIONS: No studies evaluated outcomes of chronic pain or exclusively examined participants from nursing homes or with cognitive impairment. Systemic analgesics (narcotics, nonsteroidal anti-inflammatory drugs) were understudied during the search period. CONCLUSION: Nerve blockade seems to be effective in reducing acute pain after hip fracture. Sparse data preclude firm conclusions about the relative benefits or harms of many other pain management interventions for patients with hip fracture
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Soft tissue disorders in the upper limbs of female garment workers
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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In this cross-sectional investigation of female garment workers the prevalence of soft tissue disorders of the hands and arms was studied. The findings were compared with the prevalence of disorders in a group of female hospital employees not required to use repetitive hand motion. One hundred and eighty-eight garment workers and 76 hospital employees were surveyed by questionnaire and physical examination. The prevalences of persistent shoulder, wrist, and hand pain were significantly greater among the garment workers (rate ratio 2, 4, and 3, respectively). In both groups about 60% of the persistent hand pain was consistent with carpal tunnel syndrome (rate ratio 3). These associations held when the comparisons were stratified by age and by length of employment. Workers whose native language was not English were significantly less likely to report symptoms (rate ratio 0.6). Workers in hand sewing and trimming suffered especially high prevalences of persistent pain in all upper limb sites. Stitchers had elevated rates of pain in the shoulders, wrists, and hands. Workers ironing by hand had a significant elevation in elbow pain rates. Garment assembly tasks appear to be associated with cumulative trauma of the hands and wrists; the biomechanical features of these jobs should be studied in greater detail
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Molecular analyses of bacterial DNA in extirpated heart valves from patients with infective endocarditis
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Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures
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BACKGROUND/AIMS: Infective endocarditis (IE) is caused by a microbial infection of the endothelial surface of the heart. Although blood culture examinations are commonly used to determine the associated bacterial species, molecular techniques, which enable rapid identification of targeted bacterial species, have recently been applied in clinical cases. METHODS: Nine heart valve specimens from IE patients (six subacute cases and three acute cases) were extirpated and collected, then bacterial DNA was extracted. Bacterial species in the specimens were determined by two different molecular methods and the results were compared with those from a conventional blood culture technique. In addition, a comparison between the two molecular methods was carried out using known numbers of six streptococcal species. RESULTS: The conventional blood culture method revealed the bacterial species in eight cases, while one was found to be negative. Multiple species were identified in most of the cases by both molecular methods; however, those specified by one method were not always consistent with those specified by the other. Furthermore, the species determined by the blood culture technique were not always identified by the molecular methods. We also found that the two molecular methods used in the present study were extremely sensitive to detect from 1 to 100 cells of individual oral streptococcal species. CONCLUSION: Our results suggest that species specified by molecular methods may have disseminated incidentally into the bloodstream, so interpretation of such results should be carefully undertaken in clinical situations
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Role of respirators in controlling the spread of Novel Coronavirus (Covid-19) among dental health care providers: a review
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Coronavirus Disease 2019 (COVID-19)
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During the ongoing COVID-19 pandemic, health care professionals are at the forefront of managing the highly infectious corona virus. As the most common route of transmission is via aerosols and droplet inhalation, it is critical for health care workers to have the correct personal protective equipment (PPE) including gowns, masks, and goggles. Surgical masks are not effective in preventing the influenza and SARS, so they are unlikely to be able to resist contaminated aerosols form entering the respiratory system. Therefore, it is vital to use respirators which have been proven to offer better protection against droplets, aerosols and fluid penetration and which form a tight seal around the mouth and nose. Various types of respirators are used in healthcare settings, such as half-mask filtering facepiece respirators (FFRs) and powered air-purifying respirators (PAPRs). The most commonly used FFR is the N95 disposable respirator, which is tight fitting and has a 95% or above particle filtering efficiency for a median particle size of 0.3 micrometer. This review discusses respirators, their purpose, typs, clinical efficiency and proper donning and doffing techniques.
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Effect of antimicrobial mouthrinses on salivary microflora in healthy subjects
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Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures
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The antibacterial effects of chlorhexidine and an oxygen releasing agent on the salivary microflora were evaluated in healthy subjects in two separate experiments: 1) mouthrinsing on a single occasion and 2) mouthrinsing two or four times a day for 1 wk. Both experiments were performed in a cross-over study, and each subject was randomly tested for both rinsing agents and a saline control. The total bacterial number and some selected bacterial genera were followed in saliva samples taken prior to (zero-samples) and on three occasions after the rinsing or rinsing period. The reduction of the total bacterial number by mouthrinsing two or four times a day for 1 wk with chlorhexidine was statistically significant and lasted for over 4 h. After rinsing with chlorhexidine on one single occasion the reduction of the microflora was statistically significant and of the same magnitude as after rinsing two or four times daily for 1 wk. Although statistically significant reduction was obtained, the significant biologic effect of antimicrobial agents may be questioned. The number of Strep. mutans was dramatically reduced with chlorhexidine in some subjects and this reduction lasted for over 1 wk. The oxygen releasing agent did not reduce salivary flora significantly when rinsing took place two or four times daily for 1 wk
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Complications of osteotomies about the knee
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PJI DX Updated Search
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High tibial osteotomy and distal femoral osteotomy are 2 popular techniques for the treatment of monocompartmental osteoarthritis of the knee joint in young patients. Injury to the popliteal neurovascular bundle is still considered to be the most severe complication during an osteotomy procedure even if the rate of occurrence is very low. Loss of correction and hardware failures are more frequent, but not as devastating. Patella baja and modification of tibial slope are associated with high tibial osteotomy. In contrast, complications most commonly associated with distal femoral osteotomy include nonunion and failure of the internal fixation. In general with evolution of techniques and fixation devices, complication rates seem to be reduced. A summary and literature review of complications associated with knee osteotomies will be discussed in this paper. Copyright é 2013 by Lippincott Williams & Wilkins
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