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A comparison of the effects of electroacupuncture vs transcutaneous electrical nerve stimulation for pain control in knee osteoarthritis: A protocol for network meta-analysis of randomized controlled trials
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OAK 3 - Non-arthroplasty tx of OAK
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BACKGROUND: Knee osteoarthritis (KOA), the most common type of osteoarthritis, is a chronic degenerative joint disease accompanied by pain and functional limitation for the elderly. The 2 nonpharmacologic approaches, electroacupuncture (EA) and transcutaneous electrical nerve stimulation (TENS), are considered beneficial in relieving KOA pain, however, the current conclusions are controversial. Furthermore, no direct or indirect meta-analyses between EA and TENS have been reported for the pain relief of KOA patients. METHODS: PubMed, EMBASE, Cochrane library, Web of Science, CNKI, VIP, Wan Fang will be systematically searched their inception to May 2018. Randomized controlled trials that compared the effect of EA and TENS on pain control in knee osteoarthritis will be included. The primary outcome was the knee pain levels, and secondary outcome was the comprehensive indicators. Risk of bias assessment of the included studies will be performed according to the Cochrane risk of bias tool. The pairwise and network meta-analysis will be performed by STATA 14.0 software. RESULTS: This study is ongoing and will be submitted to a peer-reviewed journal for publication. CONCLUSION: This study will provide comprehensive evidence on the effects of EA and TENS for pain control in knee osteoarthritis. PROSPERO REGISTRATION NUMBER: CRD42018091826.
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Microbiology of the infected knee arthroplasty: report from the Swedish Knee Arthroplasty Register on 426 surgically revised cases
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PJI DX Updated Search
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Surgically revised deep infected primary knee arthroplasties reported to the Swedish knee arthroplasty register during the years 1986-2000 were studied with respect to microbiology, antimicrobial susceptibility pattern and changes over time. In early, delayed and late infections, coagulase-negative staphylococci (CoNS) were most prevalent (105/299, 35.1%), and twice as common as Staphylococcus aureus (55/299, 18.4%). In haematogenous infections, S. aureus was the dominating pathogen (67/99, 67.7%), followed by streptococci and Gram-negative bacteria. Methicillin resistance was found in 1/84 tested isolates of S. aureus and 62/100 tested isolates of CoNS. During the study period, methicillin resistance among CoNS increased (p=0.002). Gentamicin resistance was found in 1/28 tested isolates of S. aureus and 19/29 tested CoNS isolates. A relative decrease in infections caused by S. aureus was observed, while enterococci increased. In empiric treatment of infected knee arthroplasty the type of infection should direct the choice of antibiotics. Awareness of the fact that most early infections are caused by CoNS can increase the chances of successful treatment with retained implant. Due to the high rate of gentamicin resistance among CoNS in infected knee arthroplasty, other antibiotics should be used in bone cement at revision
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Management of benign diseases of the breast
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Panniculectomy & Abdominoplasty CPG
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The majority of lesions that occur in the breast are benign. Despite this they are a major cause of concern of anxiety and morbidity to patients. It is important to recognize symptoms and signs, to exclude malignancy and manage appropriately. Breast lumps, nipple discharge, mastalgia, breast infection and gynaecomastia will be reviewed. © 2009 Elsevier Ltd. All rights reserved.
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Impact of intraoperative acetaminophen administration on postoperative opioid consumption in patients undergoing hip or knee replacement
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AAHKS (5) Gabapentinoids
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BACKGROUND: Opioid utilization for acute pain has been associated with numerous adverse events, potentially resulting in longer inpatient stays and increased costs.
OBJECTIVE: To examine the effect of intravenous (IV) acetaminophen administered intraoperatively on postoperative opioid consumption in adult subjects who underwent hip or knee replacement.
METHODS: This retrospective cohort study evaluated postoperative opioid consumption in 176 randomly selected adult subjects who underwent hip or knee replacement at Duke University Hospital (DUH). Eighty-eight subjects received a single, intraoperative, 1 g dose of IV acetaminophen. The other subjects did not receive any IV acetaminophen. This study evaluated mean opioid consumption (in oral morphine equivalents) during the 24-hour postoperative period in the 2 groups. Other endpoints included length of stay in the postanesthesia care unit (PACU), incidence of oversedation, need for acute opioid reversal, and adjunctive analgesic utilization.
RESULTS: Subjects who were given a single dose of intraoperative acetaminophen received an average of 149.3 mg of oral morphine equivalents during the 24 hours following surgery compared to 147.2 mg in participants who were not exposed to IV acetaminophen (P = .904). The difference in average length of PACU stay between the IV acetaminophen group (163 minutes) and those subjects not exposed to IV acetaminophen (169 minutes) was not statistically significant (P = .588). No subjects in the study experienced oversedation or required acute opioid reversal.
CONCLUSION: There was not a statistically significant difference in postoperative opioid consumption between patients receiving and not receiving IV acetaminophen intraoperatively.
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Assessment of condyle and glenoid fossa morphology using CBCT in South-East Asians
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Glenohumeral Joint OA
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INTRODUCTION: Proper imaging allows practitioners to evaluate an asymptomatic tempormandibular joint (TMJ) for potential degenerative changes prior to surgical and orthodontic treatment. The recently developed cone-beam computed tomography (CBCT) allows measurement of TMJ bony structures with high accuracy. A study was undertaken to determine the morphology, and its variations, of the mandibular condyle and glenoid fossa among Malay and Chinese Malaysians.
METHODS: CBCT was used to assess 200 joints in 100 subjects (mean age, 30.5 years). i-CAT CBCT software and The Mimics 16.0 software were employed to measure the volume, metrical size, position of each condyle sample and the thickness of the roof of the glenoid fossa (RGF).
RESULTS: No significant gender differences were noted in thickness of the RGF and condylar length; however condylar volume, width, height and the joint spaces were significantly greater among males. With regards to comparison of both TMJs, the means of condylar volume, width and length of the right TMJ were significantly higher, while the means of the left condylar height and thickness of RGF were higher. When comparing the condylar measurements and the thickness of RGF between the two ethnic groups, we found no significant difference for all measurements with exception of condylar height, which is higher among Chinese.
CONCLUSION: The similarity in measurements for Malays and Chinese may be due to their common origin. This information can be clinically useful in establishing the diagnostic criteria for condylar volume, metrical size, and position in the Malaysian East Asians population.
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1 |
Diagnosis and treatment of common fractures in children: femoral shaft fractures and supracondylar humeral fractures
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The Treatment of Pediatric Supracondylar Humerus Fractures AUC
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Femoral shaft fractures and supracondylar elbow fractures are two of the most common major pediatric injuries managed by the general orthopedic surgeon. Therapeutic choices frequently are influenced by many factors, including associated injuries, fracture type, and the child's age, social situation, and economic issues. Nonsurgical management of femoral shaft fractures has been a preferred and cost-effective treatment for most age groups, but recently the use of surgical techniques has gained popularity with the overall goal of rapid mobilization of the child. Supracondylar elbow fractures are diagnostically challenging and can result in severe acute and long-term complications. An understanding of fracture presentation, anatomic detail, and surgical applications will optimize the chances for successful outcomes
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Pediatric Hodgkin lymphoma survivors at negligible risk for significant bone mineral density deficits
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MSTS 2022 - Metastatic Disease of the Humerus
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BACKGROUND: We hypothesized that pediatric Hodgkin lymphoma (HL) survivors would have bone mineral density (BMD) deficits compared to their peers because of osteotoxic chemotherapy during the time of greatest BMD accretion.
METHODS: We retrospectively reviewed records of HL survivors returning for follow-up between 1990 and 2002. Of the 133 eligible survivors, 109 who underwent quantitative computed tomography (QCT) comprised the study group. QCT-determined BMD Z-scores were correlated with patient characteristics and therapeutic exposures by Wilcoxon rank sum or Chi-square tests. Logistic regression models were used to explore risk factors for diminished BMD.
RESULTS: The study cohort was half male (50.5%) and 85.3% reported their race as white. Participants were representative of all survivors potentially eligible for study, except that more study participants were female, had hypothyroidism, and had received cyclophosphamide. Median age at diagnosis was 15.1 years (range, 3.1-20.7 years); median time between diagnosis and QCT was 7.5 years (range, 5.0-12.4 years). The proportion of HL survivors with BMD below the mean did not significantly differ from the general population (P = 0.503). However, those with BMD -1.5 SD and BMD -2.0 SD or lower (14.7% and 7.3%, respectively) exceeded that in the general population (6.7% and 2.3%, respectively; P < 0.001 for both degrees of severity). Males, diagnosed at 14 years or older, were at 6.5 times higher risk than females (OR 95% CI: 1.24-34.14; P = 0.027) for BMD deficits.
CONCLUSIONS: Overall, pediatric HL survivors had negligible BMD deficits. Male gender was associated with an increased risk of developing BMD deficits.
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1 |
FIM motor scores for classifying community discharge after inpatient rehabilitation for hip fracture
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DoD PRF (Psychosocial RF)
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Objective: To assess the utility of functional status in classifying patients by discharge setting after inpatient rehabilitation for hip fracture. Design: Retrospective cohort study. Setting: A total of 1257 inpatient rehabilitation facilities in the United States. Patients: Medicare beneficiaries (N= 117,168) receiving inpatient rehabilitation for hip fracture from 2007 to 2009. Methods: Receiver operating characteristic curve analyses to assess the overall discriminatory ability of functional status scores (Functional Independence Measure [FIM] total, FIM cognition, and FIM motor) and to identify the functioning threshold that best differentiates patients by discharge setting. Main Outcome Measurements: Discharge setting (community versus institutional). Results: Approximately 68% of patients were discharged to the community after inpatient rehabilitation for hip fracture. Receiver operating characteristic curve analyses indicate that discharge FIM motor ratings (area under the curve: 0.84) alone are as effective as a multivariable model (area under the curve: 0.85), including sociodemographic and clinical factors, in discriminating patients discharged to the community from those discharged to an institution. A discharge FIM motor rating of 58 yielded the best balance in sensitivity and specificity for classifying patients by discharge setting. Conclusions: Discharge FIM motor ratings demonstrated good discriminatory ability for classifying discharge setting. An FIM motor rating of 58 may serve as a clinical tool to guide treatment plans and/or as additional information in complex discharge planning decisions for patients with hip fracture. © 2014 American Academy of Physical Medicine and Rehabilitation.
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Bacteriologic findings in tonsillitis and pericoronitis
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Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures
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Bacteriologic samples from 31 young men were cultured quantitatively for aerobes and anaerobes; these samples included 31 specimens of tonsils (16 infected and 15 healthy), 16 specimens from pericoronal pockets of lower third molars (11 infected and 5 symptom-free), and 6 postoperative specimens from lower-third-molar extraction sockets. Anaerobes were isolated more often from infected third molars than from infected tonsils (14.5 isolates vs. 8.4 isolates, respectively; P < .001). Infected tonsil samples contained significantly more anaerobic species if an adjacent partly erupted lower third molar was present rather than absent (10.3 isolates vs. 6.9 isolates, respectively; P < .05). Eubacterium aerofaciens, Clostridium species, Peptostreptococcus micros, and Prevotella oris were frequently isolated. Streptococcus salivarius was found more frequently in tonsillar specimens, whereas Corynebacterium species, Prevotella denticola, Capnocytophaga species, Peptostreptococcus anaerobius, and Lactobacillus species were more common in pericoronal pocket samples. Thus, partial eruption of lower third molars increases the number of anaerobic bacterial species on tonsils and many species can be isolated simultaneously from both tonsils and lower third molars
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Comparison of Osteochondral Autografts and Allografts for Treatment of Recurrent or Large Talar Osteochondral Lesions
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DoD SSI (Surgical Site Infections)
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BACKGROUND: The purpose of this study was to prospectively evaluate and compare the long-term clinical and radiographic outcomes of using osteochondral autograft and allograft to manage either recurrent or large osteochondral lesions of the talar dome (OLT) in a single surgeon's practice.
METHODS: Between January 2008 and January 2014, a total of 40 patients presented with either a recurrent OLT that failed initial arthroscopic treatment (ie, excision, curettage, debridement, and micro-fracture) or a primary OLT greater than 1.5 cm2 that had undergone no prior surgery. Before surgery, 20 patients were randomized to receive osteochondral autograft plugs (Arthrex, Naples, FL) from the ipsilateral superolateral distal femoral condyle whereas the remaining 20 were randomized to receive osteochondral allograft plugs from a fresh size-matched donor talus (Joint Restoration Foundation, Centennial, CO, and Arthrex, Naples, FL), but 4 of these were excluded that received a hemi-talus allograft with internal fixation. Preoperative and postoperative function and pain was graded using the Foot and Ankle Ability Measures (FAAM) scoring system and a Visual Analog Scale (VAS) of pain, respectively. Radiographs were assessed for osteochondral graft healing, joint congruency, and degenerative changes. Data regarding postoperative complications and revision surgeries were also recorded.
RESULTS: Of the 20 patients who received osteochondral autograft, the mean FAAM score increased from 54.4 preoperatively to 85.5 at the time of final follow-up. The mean VAS pain score decreased from 7.9 of 10 preoperatively to 2.2 of 10 at final follow-up. Two patients (10%) that received osteochondral autograft, 1 for a recurrent OLT of 1.3 cm2 and 1 for a primary OLT of 2.0 cm2, developed a symptomatic nonunion at the entire graft site. Both of these patients had their autograft converted to talar allograft plugs and achieved full osteochondral healing. At the time of final follow-up, no patients who received osteochondral autograft developed ankle degenerative changes or knee complications. The mean FAAM score of the 16 patients who received osteochondral allograft plugs increased from 55.2 preoperatively to 80.7 at the time of final follow-up. This postoperative score was lower than that of the osteochondral autograft group, but not to a statistically significant degree (P = .25). The mean VAS pain score decreased from 7.8 of 10 preoperatively to 2.7 of 10 at final follow-up. This postoperative score was higher than that of the osteochondral autograft group but not to a statistically significant degree (P = .15). Three patients (18.8%) that received osteochondral talar allograft, 2 for recurrent OLTs less than 1.5 cm2 and 1 for a primary OLT of 2.2 cm2, developed a symptomatic nonunion at the entire graft site. Two of these 3 patients had their allograft converted to osteochondral autograft plugs harvested from the ipsilateral superolateral distal femoral condyle and achieved full osteochondral healing. At the time of final follow-up, 1 of these 16 (6.3%) patients who received talar allograft as OLT treatment had developed asymptomatic anterior ankle arthritis upon radiographs.
CONCLUSION: Using fresh talar osteochondral allograft provided results that were comparable to the use of distal femoral osteochondral autograft for treating recurrent or large OLTs. Although the use of allograft avoided the risk of knee complications when harvesting autograft from the distal femur, fresh talar allograft may have lower healing rates than osteochondral autograft.
LEVEL OF EVIDENCE: Level II, comparative case series.
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A psychological profile of children with hemangiomas and their families
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DoD PRF (Psychosocial RF)
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OBJECTIVE: To assess the psychosocial impact of hemangiomas and their treatment on children with the disease and their families.
DESIGN: Thirty-nine children who were treated for hemangiomas were examined by a questionnaire that addressed the emotional attitudes of the parent and child toward the disease and the related treatment.
SETTING: Two private ambulatory surgery centers (in Latham and Charleston).
RESULTS: Overall, the survey found a negative effect on the child's family, with considerable fear caused in part by adverse public commentary or attitudes--which was ameliorated by education from the primary care provider and specialist. However, the family's perception was that the child was not deeply affected by his or her condition and that treatment (laser, intralesional corticosteroids, oral corticosteroids, surgery, or a combination) did not change the child's emotional response to the disease. However, most parents observed that their child was too young to appreciate his or her malady.
CONCLUSION: Given earlier intervention for children with late-involuting hemangiomas and the advent of more effective therapies, our survey did not seem to indicate that the children experienced significant emotional trauma from their condition; nevertheless, their families experienced appreciable emotional and psychological distress.
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Heparinless partial cardiopulmonary bypass for the repair of aortic trauma
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DoD LSA (Limb Salvage vs Amputation)
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OBJECTIVE: We hypothesized that partial cardiopulmonary bypass with a heparin-bonded system would be a technically simple, effective adjunct for reducing paraplegia during repair of traumatic aortic rupture. It avoids the risk of heparin, but, unlike left atrial-arterial bypass, it can heat, cool, oxygenate, and rapidly infuse volume if needed. METHODS: A retrospective review was conducted of patients admitted for aortic trauma from July 1994 to December 1999. Bypass consisted of femoral venous (right atrial) cannulation, a centrifugal pump, and an oxygenator-heater/cooler. Arterial return was to the femoral artery or distal aorta. The entire system was heparin-bonded and no systemic heparin was given. RESULTS: Heparin-bonded partial bypass was established in 50 patients (mean age 43 +/- 17 years). Crossclamp time was 32 +/- 11 minutes (range 14-70 minutes), mean flow 3.0 +/- 0.8 L/min, and bypass time 64 +/- 43 minutes. During repair, 58% of patients received volume through the system (mean 1.1 +/- 1.9 L). Core temperature rose slightly (35.9 degrees C +/- 0.7 degrees C to 36.3 degrees C +/- 0.8 degrees C). Three of the 15 patients who underwent percutaneous femoral arterial and venous cannulation concomitant with their angiograms had vessel injury, with one limb loss, and this procedure was discontinued. Thirty-five patients underwent percutaneous femoral vein and direct distal aortic cannulation without event. The mortality rate for patients supported by bypass was 10%, and all deaths were due to other injuries. There were no new cases of paraplegia and no worsening of intracranial or pulmonary injuries. CONCLUSIONS: Heparin-bonded bypass is technically simple to use and avoids the risk of anticoagulation. Paraplegia was avoided. The ability to correct hypothermia, oxygenate, and rapidly infuse volume may simplify management and improve outcomes.
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Effects of a 12-week rehabilitation program with music & exercise groups on range of motion in young children with severe burns
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The Treatment of Pediatric Supracondylar Humerus Fractures AUC
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Previous studies indicate that rehabilitation programs supplemented with a strength and endurance-based exercise program improve lean body mass, pulmonary function, endurance, strength, and functional outcomes in severely burned children over the age of 7-years when compared with standard of care (SOC). To date, supplemental exercise programming for severely burned children under the age of 7-years has not yet been explored. The purpose of this study was to determine if a 12-week rehabilitation program supplemented with music & exercise, was more effective in improving functional outcomes than the SOC alone. This is a descriptive study that measured elbow and knee range of motion (ROM) in 24 severely burned children between ages 2 and 6 years. Groups were compared for demographics as well as active and passive ROM to bilateral elbows and knees. A total of 15 patients completed the rehabilitation with supplemental music and exercise, and data was compared with 9 patients who received SOC. Patients receiving the 12-week program significantly improved ROM in all joints assessed except for one. Patients receiving SOC showed a significant improvement in only one of the joints assessed. Providing a structured supplemental music and exercise program in conjunction with occupational and physical therapy seems to improve both passive and active ROM to a greater extent than the SOC alone
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Five-year experience with the 'Sheba' model of comprehensive orthogeriatric care for elderly hip fracture patients
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Management of Hip Fractures in the Elderly
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BACKGROUND AND PURPOSE: The Sheba model of orthogerioatric medicine is a unique model of in-hospital care for elderly hip fractured patients, based upon the concept that a hip fracture represents a geriatric, rather than an orthopedic disease. The nature and feasibility of such a comprehensive orthogeriatric unit, taking care of all surgical, medical and rehabilitation needs, in a single geriatric-based setting (rather than orthopedic-based), were questioned. The aim of the study is to describe the results of its operation during a five-year period. METHOD: A retrospective charts analysis of consecutive older patients with hip fractures, admitted from the emergency unit directly to the orthogeriatric unit of a department of geriatric medicine. RESULTS: A total number of 592 patients were admitted. Mean age of patients was 83.2 years, mostly women. A total of 538 (91%) were treated surgically. Delay to surgery was 3.6 +/- 2.9 days. A total of 65.6% were suitable for rehabilitation, and had a mean Functional Independence Measure (FIM) gain of 22.3 +/- 7.9. Mean total hospital length of stay was 29.9 days and 68.7% of patients returned to their previous living residence. Rates of major complications (4.1%) and in-hospital mortality (3.2%, equivalent to 30 days mortality) were low. CONCLUSIONS: Treatment within this unit was associated with low rates of major morbidity and mortality, short stay and acceptable functional outcomes. The data provide clinical evidence supporting the implementation of this model of comprehensive orthogeriatric care, being a practical, applicable and feasible service for elderly hip fractured patients, and covering the various needs of these patients. The present model of organization could also help in skillful use of economic resources, facilitating effective treatment strategies
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Total knee arthroplasty after complete patellectomy: A review
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PJI DX Updated Search
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The absence or dysfunction of the knee extensor mechanism accelerates degenerative joint disease and complicates knee arthroplasty. Various treatment strategies have been suggested to improve outcomes in total knee arthroplasties after patellectomy (semi- or constrained components, autograft, allograft, prosthetic reconstruction), but the optimal management of this condition is not known. The purpose of this report is to review the relevant basic biology and biomechanics of the patella and the extensor mechanism, and to review the current literature on the management of complete patellectomy during total knee arthroplasty. Tissue engineered heart valves, BMMSCs, oscillatory shear stress, nicotine, F-actin filaments, cell differentiation, endothelial cells
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Anxiety in predicting suicide-related symptom of typhoon disaster victims: a one-year follow-up study in southern Taiwan
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DoD PRF (Psychosocial RF)
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The aim of this study was to screen those at high risk of psychological distress in areas affected by typhoon Morakot, which hit Taiwan on August 7th, 2009. Screening was conducted a year later to assess the changes in psychiatric symptoms and investigate the factors which may be predictive of psychological distress and suicide ideation. One-hundred and fifty-two participants were collected at the first screening and 125 a year later. The five-item Brief Symptom Rating Scale was used to measure the level of psychological distress. Our results showed the prevalence of psychological distress immediately post-disaster was 2.4% and increased to 4.0% the next year. The level of anxiety post-disaster could predict continuous psychological distress and the development of suicidal ideation a year later. Traumatic events prior to the typhoon were not associated with the level of psychological distress a year after the disaster. Difference was found in the level of hostility immediately post-disaster and a year later. Our follow-up study found anxiety was the only indicator which predicted psychological distress a year later, and hostility was a transient state which was lower a year after the disaster. Policy-makers and future programs should focus on high anxiety cases post-disaster to prevent mental symptom and suicide ideation development.
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Treatment of Slipped Capital Femoral Epiphysis with the Modified Dunn Procedure: A Multicenter Study
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Pediatric Diaphyseal Femur Fractures 2020 Review
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Introduction: Treatment of moderate to severe slipped capital femoral epiphysis (SCFE) is controversial. Over the last years, 3 institutions in Argentina adopted the modified Dunn procedure for capital realignment in selected cases of SCFE. Our aim in this study was to evaluate the clinical outcome and the rate of complications of patients who had undergone surgical hip dislocation and capital realignment. Methods: A multicenter retrospective cohort study of patients who received the modified Dunn procedure from January 2009 to 2013 was performed. Data concerning clinical features, surgical technique, intraoperative findings, and postoperative complications were obtained from all available medical records. The operative results were evaluated on clinical and radiographic criteria. Results: Twenty patients (21 hips) with a mean of 40.4 months (range, 12 to 84 mo) of follow-up were evaluated. The average Harris Hip score was 76.3 points (range, 40 to 100 points). Seven patients had excellent results, 6 good, 2 fair, and 5 poor. Mean slip angle improved from a preoperative value of 59.1±11.2 degrees to 5.4±2.5 degrees (P=0.001). The mean postoperative alpha angle and neck-shaft angle were 40.8±2 degrees and 131±9.9 degrees, respectively. One patient had a superficial infection that was resolved with oral antibiotics. Six patients had complete osteonecrosis with severe involvement and 4 partial femoral head necrosis with minimal deformity. No patients developed chondrolysis, infection, deep venous thrombosis, heterotopic ossification, nonunion, or nerve palsies. Discussion: Modified Dunn procedure for treating hip SCFE is a technically demanding surgery with wide variations in the reported outcomes. Although in this series 65% of patients had good or excellent functional results, a high rate of complications was observed. This may be related, among other factors, to the learning curve of the procedure. Level of Evidence: Level IV - therapeutic study.
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Ceramic-on-ceramic cementless total hip arthroplasty in patients aged 40 years or under: Do preoperative conditions affect long-term results?
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Hip Fx in the Elderly 2019
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INTRODUCTION: Underlying diseases, bone deformities and polyethylene wear affect outcome in young patients undergoing total hip arthroplasty (THA). These issues are not widely confirmed for ceramic - on-ceramic THA, particularly regarding cup fixation. Therefore, we did a retrospective long-term investigation on a large population of cementless ceramic-on-ceramic THA in patients aged 40 years or younger aiming to analyze: 1) the complication rate; 2) clinical results; and 3) survival for cup loosening with regard to their preoperative conditions.
HYPOTHESIS: Cup loosening could be related to preoperative diagnosis in young patients with a cementless ceramic-on-ceramic THA.
PATIENTS AND METHODS: Two hundred and seven hips in 171 patients (97 men and 74 women) underwent a cementless ceramic-on-ceramic THA at a mean age of 31.6+/-6.8 years. The most frequent diagnoses were avascular necrosis (AVN) of the femoral head (74 hips), pediatric hip diseases (35 hips), severe congenital hip dysplasia (CHD) (31 hips), juvenile rheumatoid arthritis (30 hips) and mild CHD (26 hips). The prosthesis included a press-fit metal backed cup with a hydroxyapatite coating and a macrotexture surface on either the equatorial region (93 cups) or the entire surface of the shell (114 cups). Ceramics were made of pure alumina and had a femoral head size of 28 (60 hips) or 32mm (147 hips). In all cases same the straight cementless tapered stem was inserted.
RESULTS: There were three early dislocations, one requiring cup revision No hip was revised due to infection, ceramic fracture, or femoral component loosening. Eight cups were revised for aseptic loosening (3,8%). The mean preoperative Harris Hip score was 52.8+/-6.2 and 93.4+/-6.9 at the end of follow-up. It was better in AVN (95.7+/-2.3) and worst in severe CHD (88.8+/-11.8) (p=0.001). If the end-point was cup aseptic loosening, the survival rate at 17 years was 95.1% (95% CI: 91.3-98.9), 100% for AVN and post-traumatic arthritis, and 86.8% (95% CI: 74.9-98.7) for severe CHD.
CONCLUSIONS: Despite diagnoses frequently causing technical difficulties at the surgery, outcome of cementless ceramic-on-ceramic THA in patients under the age of 40 years is satisfactory over ten years of follow up. Cup aseptic loosening was the main cause of failure and appears more related to the initial hip diseases than the age of the patient.
LEVEL OF EVIDENCE: III; retrospective comparative study.
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Osteoporosis diagnosis and fracture
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Management of Hip Fractures in the Elderly
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PURPOSE: The purpose of this study was to examine correlates for osteoporosis diagnosis and hip fracture among a national sample of women. DESIGN: Data were extracted from the Third National Health and Nutrition Examination Survey (NHANES III). This large-scale data set was collected by the National Center for Health Statistics. SAMPLE: The sample for this study included 2,336 women aged 50 years and older who resided in household interviewed for NHANES III. METHODS: Predictors for examination included age, race, heredity, body mass index, physical activity, smoking status, alcohol use, and dairy product use. Analyses were conducted using SAS procedures. FINDINGS: Correlates for screening and diagnosis of osteoporosis included age and race. Risk factors predicting hip fracture included age, race, low body mass index, and inactivity. IMPLICATIONS FOR NURSING PRACTICE: Recommendations emphasize screening of high-risk women, achieving and maintaining healthy body weights for underweight women, and obtaining moderate physical activity
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Scapular-focused exercise treatment protocol for shoulder impingement symptoms: Three-dimensional scapular kinematics analysis
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Trial Systematic Review Project
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Background The present study aimed to describe the effects of a periscapular strengthening and neuromuscular training protocol in three-dimensional scapular kinematics and resting positioning in participants with shoulder impingement symptoms. Self-reported function was also evaluated. Method The study group comprised 50 subjects with shoulder impingement syndrome (control group, n = 25; treatment group, n = 25). The treatment group underwent 8 weeks of neuromuscular training and periscapular strengthening. Scapular kinematics was measured using an electromagnetic tracking device, and the Brazilian version of the Shoulder Pain and Disability Index (SPADI-Br) questionnaire was carried out before and after the treatment. Findings In the resting position, treated subjects had lower (p < 0.01) internal rotation of the scapula compared to the control group, with a large effect size (2.4). On the coronal plane, the treated group had less scapular upward rotation (p < 0.01) and less internal rotation (p < 0.05), with a medium effect size. On the sagittal plane, the treated group had less internal rotation (p < 0.01), less upward rotation (p < 0.05), and less scapular anterior tilt (p < 0.01), with a medium effect size. On the scapular plane, a reduction in upward rotation (p < 0.01) after the intervention was observed, with a large effect size. Moreover, a reduction in the total SPADI-Br score was found, with a mean difference of 32.4 [24.4; 40.4] points (p < 0.01) after the implementation of the protocol and a large effect size (2.0). Interpretation The results provide biomechanical support for the clinical rationale for indicating therapeutic exercises focused on the periscapular muscles to improve scapular dynamics.
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Large fixed-size metal-on-metal total hip arthroplasty: higher serum metal ion levels in patients with pain
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Hip Fx in the Elderly 2019
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Purpose: Recently, concerns have arisen about metal-on-metal (MoM) total hip arthroplasty (THA). Therefore, the purpose of this cross-sectional cohort study was to describe the incidence of pain, pseudotumours, revisions and the relation between elevated metal ion levels, functional outcome and quality of life after MoM THA.Methods: In 351 patients, 377 MoM THA with a fixed-size 38-mm head were evaluated with a mean follow-up of 30 months (range 11â??58). Evaluation included pain, serum metal ions, patient-reported questionnaires (Short Form-36 [SF-36], Hip disability and Osteoarthritis Outcome Score [HOOS] and the Oxford Hip Score [OHS]) and radiological imaging. Sixteen patients did not participate in the screening.Results: One hundred and eighteen (35 %) patients reported pain and showed significantly higher cobalt and chromium levels compared to patients without pain. Median serum cobalt levels were 4.4 μg/l (interquartile range [IQR] 6.6) and chromium levels were 3.6 μg/l (IQR 4.8). Patients with cobalt levels of â?¤5 μg/l reported significantly better outcome on the SF-36 and HOOS. Fifty-seven pseudotumours were identified in 227 THAs. A revision rate of 19 % was observed.Conclusions: In conclusion, 35 % of the patients experienced pain after MoM THA. These patients showed significantly higher serum metal ion levels. The patient-reported questionnaires indicated significantly better outcome in patients with cobalt levels â?¤5 μg/l.
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Lateral femoral condyle insufficiency fractures: imaging findings, demographics, and analysis of outcomes
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Osteochondritis Dissecans 2020 Review
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Objective: To describe imaging characteristics and demographics of lateral femoral condyle insufficiency fractures (LFCIFs) and identify characteristics associated with progression to epiphyseal collapse. Materials and methods: A retrospective review of 105 consecutive patients with LFCIF was performed (mean age 58.1 years) after excluding post-traumatic and pathological fractures. Lesion size and location, presence of bone marrow edema–like signal, soft tissue edema, chondrosis grade, and meniscus pathology were documented. Demographics were recorded from the electronic patient record. Follow-up MRI and/or radiographs were evaluated for healing/stability or progression to epiphyseal collapse. Bone mineral density was assessed from dual-energy x-ray absorptiometry (DEXA) scans and/or radiographs. Results: Fifty-six female and 49 male subjects were included. Female subjects were older at presentation (60.5 versus 56.3 years, p =.02). A total of 61.7% of the subjects with available DEXA and/or radiographs had osteopenia/osteoporosis. The central weight-bearing (61%) and outer condyle (54.3%) were most involved. High-grade chondrosis was present in = 1 compartment in 70.5% including 42% in the lateral compartment. A total of 67.6% had = 1 meniscus tear with similar frequency of medial and lateral tears (47.6% versus 41%). Bone marrow edema–like signal was present in all cases; soft tissue edema was present in 83.8%. Fifty-three subjects had available follow-up MRI (n = 24) and/or radiographs (n = 29). Increased age, fracture dimensions, presence of medial meniscus tears, and high-grade patellofemoral chondrosis were associated with progression (p =.05). Conclusion: LFCIFs are associated with meniscus tears, high-grade chondrosis, and osteopenia/osteoporosis with more global knee pathology present when compared with medial femoral condyle insufficiency fracture. Increased age, medial meniscus tears, fracture dimensions, and high-grade patellofemoral chondrosis were associated with progression.
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0 |
Effect of SKI 306X, a new herbal anti-arthritic agent, in patients with osteoarthritis of the knee: a double-blind placebo controlled study
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OAK 3 - Non-arthroplasty tx of OAK
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SKI 306X is a purified extract from a mixture of three oriental herbal medicines (Clematis mandshurica, Trichosanthes kirilowii and Prunella vulgaris) that have been widely used for the treatment of inflammatory diseases such as lymphadenitis and arthritis in far East Asia. A doubleâ?blind, controlled study was performed to evaluate the efficacy and safety of SKI 306X with placebo in 96 patients with classical osteoarthritis of the knee. Patients were randomized to four treatment groups: placebo, 200 mg, 400 mg and 600 mg of SKI 306X t.i.d.. Clinical efficacy and safety were evaluated for 4 weeks continuous treatment. SKI 306X demonstrated its clinical efficacy, as assessed by 100 mm visual analogue scale (VAS), Lequesne index and patients' and investigators opinion of the therapeutic effect compared with placebo (p<0.01). No significant adverse events were observed in patients treated with SKI 306X. This study demonstrated that SKI 306X, a new herbal antiâ?arthritic agent provided clinical efficacy in patients with osteoarthritis.
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0 |
Patella denervation in primary total knee arthroplasty - a randomized controlled trial with 2 years of follow-up
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OAK 3 - Non-arthroplasty tx of OAK
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We randomized 126 consecutive patients undergoing primary total knee arthroplasty into group 1: patella denervation (n = 63) and group 2: no patella denervation (n = 63). Assessment was performed preoperatively and at 3, 12 and 24 months post-operatively. Average follow-up of patients was 26.5 months for denervation group and 26.3 months for no denervation group (P = 0.84). Pain scores for anterior knee pain were significantly better in the denervation group at 3 months but not at 12 and 24 months. Patient satisfaction was higher in the denervation group. Flexion range was higher in the denervation group at 3, 12 and 24 months review (P < 0.01). There were, however, no statistically significant differences with other validated knee scores.
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0 |
Magnetic Resonance Imaging of the Pediatric Shoulder
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The Treatment of Pediatric Supracondylar Humerus Fractures AUC
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Magnetic resonance (MR) imaging is a modality widely used to assess shoulder abnormalities in children. A thorough understanding of the development of the shoulder and adequate MR techniques are crucial in the radiologic evaluation. The immature skeleton is particularly vulnerable to insults such as trauma, infection, and inflammation, and responds in unique ways. The pediatric shoulder can also be affected by complex congenital deformities such as brachial plexus injuries. In addition, certain neoplasms can be seen specifically in the young patient. MR imaging plays a critical role in the initial diagnostic evaluation and in assessing posttreatment responses. (copyright) 2012 Elsevier Inc
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0 |
Multilineage cells from adipose tissue as gene delivery vehicles
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Panniculectomy & Abdominoplasty CPG
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We have characterized a population of mesenchymal progenitor cells from adipose tissue, termed processed lipoaspirate (PLA) cells, which have multilineage potential similar to bone marrow-derived mesenchymal stem cells and are also easily expanded in culture. The primary benefit of using adipose tissue as a source of multilineage progenitor cells is its relative abundance and ease of procurement. We examined the infection of PLA cells with adenoviral, oncoretroviral, and lentiviral vectors. We demonstrate that PLA cells can be transduced with lentiviral vectors at high efficiency. PLA cells maintain transgene expression after differentiation into adipogenic and osteogenic lineages after lentiviral transduction. Therefore, PLA cells and lentiviral vectors may be an efficient combination for use as a therapeutic gene delivery vehicle.
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0 |
Are We Still Prescribing Opioids for Osteoarthritis?
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OAK 3 - Non-arthroplasty tx of OAK
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BACKGROUND: The United States is in the midst of an opioid epidemic. These medications continue to be used to manage pain associated with osteoarthritis, despite mounting evidence questioning the benefits. The rate at which opioids are prescribed for osteoarthritis is largely unknown. We sought to identify rates of opioid prescriptions for osteoarthritis and identify factors associated with higher rates of prescribing.
METHODS: We queried the Humana, Inc. administrative claims database from 2007 to 2014. Patients with osteoarthritis were identified using International Classification of Diseases 9th Revision codes and classified as having hip, knee, or any joint osteoarthritis. Claims data were reviewed to identify opioid prescriptions associated with a diagnosis of osteoarthritis. Rates of prescribing were trended over time and stratified by sex, age, and geographic region.
RESULTS: From 2007 to 2014, 17.0% of patients with any joint osteoarthritis, 13.4% of patients with hip osteoarthritis, and 15.9% with knee osteoarthritis were prescribed an opioid for their condition. Yearly rates of prescription were fairly stable over this period. Patients in the South had the highest odds of opioid prescription, while those in the Northeast had the lowest. Patients <=49 years old were more likely to receive a prescription than those >=50 years old.
CONCLUSION: This study provides important epidemiologic data about the use of opioids for osteoarthritis. Despite increasing evidence calling proposed benefits into question and increasing awareness of risks of opioids, prescribing rates remained stable between 2007 and 2014. This provides important baseline data as we work to combat excessive and inappropriate opioid use within the United States.
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0 |
Trends in lower extremity amputations in people with and without diabetes in England, 1996-2005
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DoD LSA (Limb Salvage vs Amputation)
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AIMS: To examine trends in non-traumatic lower extremity amputations over a 10-year-period in people with and without diabetes (DM) in England. METHODS: All individuals admitted to NHS hospitals for non-traumatic amputations between 1996 and 2005 in England were identified using hospital activity data. Postoperative and 1-year mortality were examined between 2000 and 2004. RESULTS: There was a reduction in minor and major amputations during the study period. The number of type 1 DM- and non-DM-related minor amputations decreased by 11.4% and 32.4%, respectively, while the number of type 2 DM-related minor amputations almost doubled. The incidence of type 1- and non-DM-related minor amputations decreased from 1.5 to 1.2 and from 8.1 to 5.1/100,000 population, respectively, while type 2 DM-related amputations increased from 2.4 to 4.1/100,000 population. The number of type 1- and non-DM-related major amputations declined by 41% and 22%, respectively, whereas type 2 DM-related amputations increased by 43%. The incidence of type 2 DM-related amputations increased from 2.0 to 2.7/100,000 population. Overall perioperative and 1-year mortality did not significantly change between 2000 and 2004. CONCLUSIONS: While several factors may explain the increase in type 2 DM-related LEAs, these findings highlight the importance of diabetes prevention strategies and controlling risk factors for LEAs in people with diabetes.
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Wound microenvironment sequesters adipose-derived stem cells in a murine model of reconstructive surgery in the setting of concurrent distant malignancy
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Acellular Dermal Matrix
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BACKGROUND: It is unclear whether mesenchymal stem cells that are applied to regenerate wound tissues can migrate to existing tumors and enhance their growth. The authors investigated whether adipose-derived stem cells had any effect on the growth and progression of distant tumors when applied to a skin wound. METHODS: The authors subcutaneously injected murine 4T1 breast cancer cells into all BALB/c-nu/nu mice. After tumor injection, mice were randomized to five groups (five mice per group) based on the means of co-introduction of green fluorescent protein-labeled adipose-derived stem cells, if any. In group 1, adipose-derived stem cells were combined and co-injected subcutaneously. In group 2, they were injected subcutaneously at a distant anatomical site. In group 3, they were injected intravenously. In group 4, they were delivered via a human acellular dermal matrix to a distant skin wound. In group 5, no adipose-derived stem cells were introduced. RESULTS: After 2 weeks, tumor volume increased in group 1 (356.5 ± 44.4 mm(3)), followed by group 3 (256.6 ± 47.1 mm(3)) and then group 2 (201.6 ± 28.6 mm(3)). In group 4, in which adipose-derived stem cells carried on acellular dermal matrix were applied to a wound distant to the primary tumor, the tumor volume was 143.8 ± 50.9 mm(3), which was similar to that observed in the control group (group 5; 167.8 ± 29.9 mm(3)). CONCLUSIONS: The authors' findings suggest that the wound microenvironment can retain adipose-derived stem cells, preventing their homing and stromal contribution to a distant neoplastic focus. These findings are an important first step in establishing the feasibility and safety of utilizing adipose-derived stem cell therapy for reconstructive surgery in the setting of malignancy.
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0 |
Blunt popliteal artery injuries
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DoD LSA (Limb Salvage vs Amputation)
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AIMS: To survey the recent results of vascular damage resulting from knee injuries at Middlemore Hospital. METHOD: A group of sixteen patients treated between 1980-92 were retrospectively analysed. RESULTS: One patient failed a grafting procedure and required a below knee amputation. Another patient lost two muscle compartments with its associated disability, as a result of pressure necrosis from the acute compartment syndrome. The remaining patients were successfully revascularised. CONCLUSION: Unless revascularisation is quickly achieved popliteal artery damage associated with knee injuries will lead to frequent leg amputation.
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Is dual mobility associated with an increased risk of revision for infection? Matched cohort of 231 cases of dual-mobility cups and 231 fixed cups
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Developmental Dysplasia of the Hip 2020 Review
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INTRODUCTION: We used a matched cohort of 231 cases of revision of primary dual-mobility cups (DMC) total hip arthroplasty (THA) and 231 cases of fixed cups (FC) THA, to determine whether (i) revision for infection was more frequent when using DMC-THA than FC-THA; (ii) Causes for revision were significantly different. METHODS: The French Society of Orthopaedics and Traumatology carried out a prospective multicentre study from 2010 to 2011. The inclusion criterion was an exhaustive collection of 1(st) revision THA (at least 1 component revised, re-revision excluded). 2,044 1(st) revision cases were prospectively collected; 251 (13.5%) were revision of DMC-THA and 1,793 were revision of FC-THA (87.7%). We defined a matching process (1:1) between the 2 cohorts. 231 DMC-THAs were eligible for comparison with 231 FC-THAs. RESULTS: 47 (20.3%) FC-THAs were revised for infection and 54 (23.3%) DMC-THAs. There was no statistical difference (p = 0.43). 41 (17.7%) FC-THAs were revised for dislocation, compared to 11 (4.7%) DMC-THAs (p<0.001). DISCUSSION: The main finding of our study was that DMC was not associated with an increased risk of revision for infection compared to standard THA. THA revision for infection was not correlated to the type of cup used. It is mandatory to report on comparable types of patients when comparing outcomes. For similar patient profiles (i) DMC-THAs were not revised more often for infection than FC-THA (ii) FC-THAs were revised 4 times more for dislocation than DMC-THA.
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1 |
Efficacy of different fixation devices in maintaining an initial reduction for surgically managed distal radius fractures
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Distal Radius Fractures
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BACKGROUND: Fracture of the distal radius is a common injury. Many treatment options exist for the surgical management of extra-articular and intra-articular distal radius fractures. The best method of treatment for these fractures remains controversial. We sought to examine radiographic outcomes of patients treated with non-spanning external fixator (NSEF), open reduction and internal fixation (ORIF) with locking plates and screws or closed reduction and percutaneous pinning (CRPP) and compare their ability to maintain radiographic parameters over the initial 6-week postoperative period.
METHODS: We performed a retrospective review of radiographs showing 211 distal radius fractures treated with NSEF, ORIF or CRPP. We examined the images for a variety of radiological parameters. Measurements were taken immediately postoperatively and at 6-week follow-up to determine whether there was any loss of reduction.
RESULTS: Of the 211 fractures, 104 (49.3%) were type-A fractures, 12 (5.7%) were type-B fractures and 95 (45.0%) were type-C fractures. The 3 treatments maintained the reduction obtained at surgery until healing. The CRPP and ORIF treatments failed to maintain correction in ulnar variance for the 6-week period; however, only ORIF actually changed the ulnar variance from presurgical values.
CONCLUSION: Treatment with ORIF for comminuted, intra-articular distal radius fractures produces good radiographic results with maintenance of surgical radiographic parameters, whereas NSEFand CRPP of less complex fractures also provide good results. This suggests that fracture-specific fixation with CRPP or NSEF are sufficient for certain distal radius fractures.
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Kinematic analysis of knee varus and rotation movements at the initial stance phase with severe osteoarthritis of the knee
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OAK 3 - Non-arthroplasty tx of OAK
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Background: The purposes of this study were to understand the kinematics changes in the frontal and horizontal planes with severe medial knee OA at the stance phase and to examine the relationship between varus and rotational movements. Methods: The OA group comprised 18 knees in 12 subjects (five men, seven women) with a Kellgren-Lawrence grade of three or four in at least one knee. From the results of gait analysis, we calculated Spearman rank-correlation coefficients for the following items: varus angle at initial contact (IC); varus angle at loading response (LR); amount of varus thrust from IC to LR; rotational angle at IC; rotational angle at LR and amount of rotational angle change from IC to LR. Results: The results indicated that, as the external rotation angle at IC and internal rotational movement from IC to LR increased, the maximum varus angle to LR showed a tendency to become large. In addition, varus thrust showed a tendency to become larger as the external rotation angles increased at IC and LR. The subjects with severe knee OA showed a strong correlation between the knee varus angle at IC and at LR. Furthermore, an increase in movement to internal rotation of the knee during the initial stance phase increased the knee varus angle at LR. Conclusions: The control of the rotational movement according to the extent of varus thrust during the initial stance phase may have possible effects to decrease the load on the medial compartment of the knee.
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Partial medial meniscectomy leads to altered walking mechanics two years after anterior cruciate ligament reconstruction: Meniscal repair does not
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AMP (Acute Meniscal Pathology)
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BACKGROUND: Partial meniscectomy dramatically increases the risk for post-traumatic, tibiofemoral osteoarthritis after anterior cruciate ligament reconstruction (ACLR). Concomitant medial meniscus surgery influences walking biomechanics (e.g., medial tibiofemoral joint loading) early after ACLR; whether medial meniscus surgery continues to influence walking biomechanics two years after ACLR is unknown.
RESEARCH QUESTION: Does medial meniscus treatment at the time of ACLR influence walking biomechanics two years after surgery?
METHODS: This is a secondary analysis of prospectively collected data from a clinical trial (NCT01773317). Fifty-six athletes (age 24+/-8 years) with operative reports, two-year biomechanical analyses, and no second injury prior to two-year testing participated after primary ACLR. Participants were classified by concomitant medial meniscal status: no medial meniscus involvement (n=36), partial medial meniscectomy (n=9), and medial meniscus repair (n=11). Participants underwent biomechanical analyses during over-ground walking including surface electromyography; a validated musculoskeletal model estimated medial compartment tibiofemoral contact forces. Gait variables were analyzed using 3x2 ANOVAs with group (medial meniscus treatment) and limb (involved versus uninvolved) comparisons.
RESULTS: There was a main effect of group (p=.039) for peak knee flexion angle (PKFA). Participants after partial medial meniscectomy walked with clinically meaningfully smaller PKFAs in both the involved and uninvolved limbs compared to the no medial meniscus involvement group (group mean difference [95%CI]; involved: -4.9degree[-8.7degree, -1.0degree], p=.015; uninvolved: -3.9degree[-7.6degree, -0.3degree], p=.035) and medial meniscus repair group (involved: -5.2degree[-9.9degree, -0.6degree], p=.029; uninvolved: -4.7degree[-9.0degree, -0.3degree], p=.038). The partial medial meniscectomy group walked with higher involved versus uninvolved limb medial tibiofemoral contact forces (0.45 body weights, 95% CI: -0.01, 0.91 BW, p=0.053) and truncated sagittal plane knee excursions, which were not present in the other two groups.
SIGNIFICANCE: Aberrant gait biomechanics may concentrate high forces in the antero-medial tibiofemoral cartilage among patients two years after ACLR plus partial medial meniscectomy, perhaps explaining the higher osteoarthritis rates and offering an opportunity for targeted interventions.
LEVEL OF EVIDENCE: Level III.
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0 |
Patient-related risk factors for early revision of total hip replacements. A population register-based case-control study of 674 revised hips
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Management of Hip Fractures in the Elderly
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In this population register-based, matched case control study, we assessed patient-related factors and early risk of revision after total hip replacement (THR). Information was obtained via a mail survey among patients reported to the Norwegian Arthroplasty Register during the period 1987-1993. The study included 674 revised hips, as cases, and 1343 hips with a primary operation only, as controls. Completed questionnaires were received from 81% of the 2017 individual cases and controls. We identified a set of patient-related factors associated with poor THR prognosis. Increasing weight was a risk factor among male patients older than 67 years who were more than 1.77 m tall (p = 0.01). Smoking had no overall effect, but former heavy smokers had an increased risk of 2.6 compared to never-smokers. Alcohol intake was associated with an increased risk of dislocation. Revision due to infection was commoner among patients taking antidiabetic drugs (OR = 14) than among patients taking no medication. An increased overall revision risk was found among patients using systemic steroids (OR = 2.8) or local pulmonary steroids (OR = 6.0). The risk also increased in male patients performing regular exercise before the primary operation (OR = 2.6), and in female patients of working-age doing heavy work (OR = 1.9)
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0 |
Loading of the knee joint during activities of daily living measured in vivo in five subjects
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Surgical Management of Osteoarthritis of the Knee CPG
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Detailed knowledge about loading of the knee joint is essential for preclinical testing of implants, validation of musculoskeletal models and biomechanical understanding of the knee joint. The contact forces and moments acting on the tibial component were therefore measured in 5 subjects in vivo by an instrumented knee implant during various activities of daily living.Average peak resultant forces, in percent of body weight, were highest during stair descending (346% BW), followed by stair ascending (316% BW), level walking (261% BW), one legged stance (259% BW), knee bending (253% BW), standing up (246% BW), sitting down (225% BW) and two legged stance (107% BW). Peak shear forces were about 10-20 times smaller than the axial force. Resultant forces acted almost vertically on the tibial plateau even during high flexion. Highest moments acted in the frontal plane with a typical peak to peak range -2.91% BWm (adduction moment) to 1.61% BWm (abduction moment) throughout all activities. Peak flexion/extension moments ranged between -0.44% BWm (extension moment) and 3.16% BWm (flexion moment). Peak external/internal torques lay between -1.1% BWm (internal torque) and 0.53% BWm (external torque).The knee joint is highly loaded during daily life. In general, resultant contact forces during dynamic activities were lower than the ones predicted by many mathematical models, but lay in a similar range as measured in vivo by others. Some of the observed load components were much higher than those currently applied when testing knee implants. (copyright) 2010 Elsevier Ltd
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Fentanyl prolongs lidocaine spinal anesthesia without prolonging recovery
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Surgical Management of Osteoarthritis of the Knee CPG
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Lidocaine spinal anesthesia is a popular anesthetic for short procedures due to its brief duration. The addition of fentanyl may improve the quality and duration of lidocaine spinal anesthesia. Eight volunteers received plain lidocaine 5% in dextrose (50 mg) both with and without 20 micrograms of fentanyl in a randomized, double-blind, cross-over fashion. Sensory analgesia was assessed with pinprick, cold, touch, transcutaneous electrical stimulation equivalent to surgical incision, and duration of tolerance of pneumatic thigh tourniquet. Motor block was assessed with isometric force dynamometry. Regression of pinprick, touch, and cold was prolonged with fentanyl. Duration of tolerance of electrical stimulation at the umbilicus, hip, knee, and ankle was increased with fentanyl (181% increase from plain lidocaine on average; P < 0.01). Duration of tolerance of tourniquet-induced pain was increased by an average of 48% with addition of fentanyl (P = 0.02). Neither motor block nor time to void was prolonged with fentanyl. Pruritus occurred in all subjects receiving fentanyl but was treated easily and were well tolerated. We recommend the addition of 20 micrograms of fentanyl to lidocaine spinal anesthesia as a means to improve duration of sensory anesthesia without prolonging recovery of motor function or time to micturition
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Predictors of appointment adherence following operative treatment of pediatric supracondylar humerus fractures: which patients are not following up?
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Pediatric Supracondylar Humerus Fracture 2020 Review
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This study aims to identify characteristics associated with poor appointment adherence after surgical stabilization of supracondylar humerus fractures (SCHFX) in children. A retrospective review of 560 consecutive, surgically managed patients with SCHFX from 2010 to 2015 was performed. One missed follow-up appointment was classified as 'low adherence', whereas missing two or more appointments was classified as 'very low adherence'. Demographics, insurance status, estimated family income and distance from clinic were analyzed to identify differences in variables between adherent and low-adherent groups. Of 560, 121 (21.8%) missed one follow-up visit and 39/560 (7.1%) missed more than two visits. Age, gender, distance traveled, insurance status and primary language were nonpredictive. Estimated income <$50 000 was associated with a >200% increase in low adherence vs patients with estimated income >$50 000 (9.3 vs 3.8%; P = 0.012). African American patients had significantly lower adherence vs patients of other races (47.5 vs 19.6%; P < 0.0001). Ethnicity remained the only significant factor correlated to adherence after multivariate analysis. African Americans were three times more likely demonstrate low adherence (P = 0.0014). Ethnicity and estimated income <$50 000 were predictors of missing two or more visits. African American patients were four times more likely to miss two or more visits [odds ratio (OR), 4.17; P = 0.0026] than others; estimated income <$50 000 was associated with a two-fold increase in missing two or more visits (OR, 2.33; P = 0.035). By identifying at-risk patient populations, healthcare systems can adopt strategies to remove barriers of accessing follow-up care.
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Anterior Clinoid Metastasis Removed Extradurally: First Case Report
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Reduction Mammoplasty for Female Breast Hypertrophy
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Background We report a case of isolated metastasis on the anterior clinoid process (ACP) mimicking meningioma. Clinical Presentation A 58-year-old male presented with headaches, right-sided visual disturbances, and blurred and double vision. The cause of double vision was partial weakness of the right III nerve, resulting from compression of the nerve by "hypertrophied" tumor-involved right anterior clinoid. Medical history revealed two primary malignant tumors-male breast cancer and prostate cancer (diagnosed 6 and 18 months prior, respectively). The patient was treated with chemotherapy and showed no signs of active disease, recurrence, or metastasis. Postcontrast head magnetic resonance imaging (MRI) showed extra-axial well-bordered enhancing mass measuring 1.6 x 1.1 x 1 x 1 cm (anteroposterior, transverse, and craniocaudal dimensions) on the ACP, resembling a clinoidal meningioma. Extradural clinoidectomy with tumor resection was performed via right orbitozygomatic pretemporal skull base approach. Visual symptoms improved. Follow-up MRI showed no signs of tumor residual or recurrence. Conclusion This is the first case report of a metastasis of any kind on ACP. Metastasis should be included as a part of the differential diagnosis of lesions of the anterior clinoid. Extradural clinoidectomy is a safe and effective method in the treatment of these tumors.
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Aesthetic surgery of the thoracoabdominal area combining abdominoplasty and circumferential lipoplasty: 7 Years' experience
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Panniculectomy & Abdominoplasty CPG
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Background: Aesthetic surgery of the thoracoabdominal area combining abdominoplasty and circumferential lipoplasty during the same surgical procedure is not a very common surgical procedure, but its use has increased during recent years. The authors present their surgical technique combining abdominoplasty and circumferential liposuction to improve body shape, emphasizing how complications can be prevented. Methods: The authors present a 7-year experience combining abdominoplasty and circumferential liposuction. The authors operated on 310 female patients between 26 and 64 years of age (mean, 38 years), weighing between 51 and 113 kg (mean, 76 kg); 86 percent of them were overweight. During the surgical procedure, the authors performed abdominoplasty combined with posterior, lateral, and anterolateral suction-assisted lipoplasty. The abdominoplasty was performed with minimal superior undermining, performing only that necessary to permit muscle plication, preserving maximal blood supply to the distal flap. Results: One thousand five hundred to 8200 ml of fat was obtained with liposuction (mean, 3700 ml) and 380 to 5100 g was eliminated on the abdominal flap (mean, 870 g). Sixty-three patients (20.3 percent) had minor complications and four patients (1.3 percent) had major complications. Conclusions: The combination of abdominoplasty and circumferential liposuction permits excellent body contouring in a single surgical procedure with minimal complications.
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A randomized trial of epidural analgesia followed by continuous femoral analgesia compared with oral opioid analgesia on short- and long-term functional recovery after total knee replacement
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AAHKS (8) Anesthetic Infiltration
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OBJECTIVE: The purpose of this study was to compare continuous femoral nerve analgesia to oral opioid analgesics after discontinuation of epidural analgesia following total knee replacement.
DESIGN: Randomized prospective controlled parallel group trial. Setting. Large tertiary university teaching hospital in a major Midwestern city. Subjects. Sixty-two subjects were randomized to receive neuraxial anesthesia followed by either oral analgesics (N = 31) or continuous femoral nerve analgesia (N = 31).
INTERVENTIONS: After discontinuation of epidural anesthesia on the morning after surgery, continuous femoral nerve analgesia (CFA), ropivacaine 25 mg bolus and 5 mg/h infusion was initiated. Catheters were removed 24 hours later. All subjects received oral opioid analgesics as needed.
OUTCOME MEASURES: The primary outcome measure was knee flexion at 1 month. Physical therapy assessments, pain scores, opioid consumption, and patient satisfaction were assessed during hospitalization. Knee flexion, pain scores, and opioid consumption were collected at 1, 6, and 12 months, and health-related quality of life was collected at 6 and 12 months. RESULTS; The median difference (95% CI) in the change in knee flexion from baseline was 7.5 (0 to 15) degrees greater after CFA (P = 0.04) at 1 month. CFA subjects had greater compliance with physical therapy, reduced pain scores, and opioid requirements during hospitalization. Thromboembolic events occurred in 0/31 CFA vs 4/31 non-CFA subjects (P = 0.04).
CONCLUSIONS: CFA for 24 hours following discontinuation of epidural analgesia was associated with lower pain scores, greater compliance with physical therapy, increased range of motion, reduced opioid analgesia use, and greater patient satisfaction during hospitalization. The increased flexion of the operated joint was still evident at 1 month postoperatively.
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Extracorporeal shock waves down-regulate the expression of interleukin-10 and tumor necrosis factor-alpha in osteoarthritic chondrocytes
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Surgical Management of Osteoarthritis of the Knee CPG
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BACKGROUND: The purpose of this study was to investigate the effects of extra corporeal shock waves (ESW) therapy on the metabolism of healthy and osteoarthritic human chondrocytes, and particularly on the expression of IL-10, TNF-alpha and beta1 integrin. METHODS: Human adult articular cartilage was obtained from 9 patients (6 male and 3 females), with primary knee osteoarthritis (OA), undergoing total joint replacement and from 3 young healthy donors (HD) (2 males, 1 female) with joint traumatic fracture. After isolation, chondrocytes underwent ESW treatment (electromagnetic generator system, MINILITH SL1, STORZ MEDICAL) at different parameters of impulses, energy levels and energy flux density. After that, chondrocytes were cultured in 24-well plate in DMEM supplemented with 10% FCS for 48 hours and then beta1 integrin surface expression and intracellular IL-10 and TNF-alpha levels were evaluated by flow-cytometry. RESULTS: At baseline, osteoarthritic chondrocytes expressed significantly lower levels of beta1 integrin and higher levels and IL-10 and TNF-alpha levels. Following ESW application, while beta1 integrin expression remain unchanged, a significant decrease of IL-10 and TNF-alpha intracellular levels was observed both in osteoarthritic and healthy chondrocytes. IL-10 levels decreased at any impulses and energy levels, while a significant reduction of TNF-alpha was mainly found at middle energies. CONCLUSION: Our study confirmed that osteoarthritic chondrocytes express low beta1 integrin and high TNF-alpha and IL-10 levels. Nonetheless, ESW treatment application down-regulate the intracellular levels of TNF-alpha and IL-10 by chondrocytes, suggesting that ESW might restore TNF-alpha and IL-10 production by osteoarthritic chondrocytes at normal levels. However, further in vivo and in vitro studies are necessary to establish if ESW can represent a viable option in the treatment of OA
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0 |
Association between joint stiffness and health-related quality of life in community-dwelling older adults
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OAK 3 - Non-arthroplasty tx of OAK
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Objective This study aimed to examine the association between joint stiffness and health-related quality of life (HRQOL) in community-dwelling older adults. Methods Participants in this cross-sectional study were 530 Japanese community-dwelling older adults (mean age, 73.9 years; women, 64.3%). Joint stiffness was assessed at the neck, low back, shoulder, elbow, hand or wrist, hip, knee, and ankle or feet; the duration of joint stiffness was also evaluated. We assessed HRQOL using the Short Form-12 (SF-12) and EuroQOL-5 Dimension (EQ-5D) questionnaires. We calculated the physical component summary scores (PCS) and mental component summary scores (MCS) from SF-12 and the EQ-5D index from EQ-5D. Results The prevalence of joint stiffness was 54.0%. Joint stiffness at two or more sites and at each site had a meaningful impact on PCS. Joint stiffness that lasted for 30 min or more was meaningfully associated with low PCS and EQ-5D scores (PCS, 30â??60 min: beta = â??6.122, P < 0.05; >60 min: beta = â??5.962, P < 0.01; EQ-5D index, 30â??60 min: beta = â??0.068, P < 0.01; >60 min: beta = â??0.070, P < 0.01). Further, joint stiffness that lasted over 60 min extended over MCS (MCS, >60 min: beta = â??3.212, P < 0.05). Conclusions Joint stiffness is associated with HRQOL. Assessing joint stiffness and intervention could be beneficial for HRQOL.
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1 |
COVID-19 Response in the Global Epicenter: Converting a New York City Level 1 Orthopedic Trauma Service into a Hybrid Orthopedic and Medicine COVID-19 Management Team
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Coronavirus Disease 2019 (COVID-19)
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The SARS-COV-2 (COVID-19) pandemic has placed unprecedented challenges on the health care system in the United States with New York City at its epicenter. By the end of the 8 week (4/23/2020) since the virus's emergence in New York City, there have been 142,432 confirmed COVID-19 cases and 10,977 deaths attributed to complications from COVID-19-related illnesses. Secondary to policies enacted by the New York State government to limit spread of the virus, Orthopedic Surgery departments at hospitals around the area have witnessed an abrupt change in clinical demands. At a local level one trauma hospital in Queens, New York, Orthopedic Surgery elective cases have been cancelled, trauma consult volume has experienced a sharp decline, and both residents and attendings have been repurposed to meet the new clinical demands of this medical crisis. Our own orthopedic surgery service has adopted care for patients normally admitted to an internal medicine service in a novel Ortho-Medical COVID-19 management team. We prepared this primer to make our experience with caring for COVID-19 patents available as a reference for other surgical subspecialty services preparing to adjust the clinical focus of their hospital teams during this or future pandemics. LEVEL OF EVIDENCE:: Level V.
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Inflammatory bowel disease has a small effect on bone mineral density and risk for osteoporosis
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Management of Hip Fractures in the Elderly
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Background & Aims: A high prevalence of osteoporosis has been reported among individuals with inflammatory bowel disease (IBD). We performed a population-based analysis to determine whether IBD is itself a risk factor for low bone mineral density (BMD) or whether low BMD results from other factors associated with IBD. Methods: We identified 1230 subjects with IBD in the Manitoba BMD Database, which contains results of BMD tests performed on all Manitobans since 1997 (n = 45,714). BMD was assessed at the lumbar spine (mean value, L1-L4), hip (total), femoral neck, and trochanter. Multivariate linear and logistic regression analyses were performed to determine the independent effects of IBD, Crohn's disease (CD), or ulcerative colitis (UC) on T score and the presence of osteoporosis (a low T score was equal to or less than -2.5) at any site; we controlled for age, sex, body mass index, hormone replacement therapy, osteoprotective medications, and corticosteroid use. We also performed regression analysis within the IBD population to determine the effect of IBD-specific factors on T score and osteoporosis. Results: IBD was associated with a statistically significant but small effect on T score; IBD did not increase the risk for osteoporosis at any site measured. CD was associated with an increased risk of osteoporosis at the lumbar spine and trochanter, but UC was not associated with an increased risk of osteoporosis or low T score. No IBD-specific variables were associated with increased risk of osteoporosis or low T score. Conclusions: IBD has a small effect on BMD; CD poses a greater risk than UC. The risk of osteoporosis in patients with IBD appears to be related to other known osteoporosis risk factors. (copyright) 2013 AGA Institute
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Total knee replacement following repeated cycles of intra-articular sodium hyaluronate (500-730 Kda) in failed conservative treatment of knee osteoarthritis: a 54-month follow-up
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Surgical Management of Osteoarthritis of the Knee CPG
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BACKGROUND: Treatment with repeated cycles of Intra-Articular Sodium Hyaluronate (IA-HA), from previous study, can improve symptoms and delay surgical interventions in knee osteoarthritis patients who failed conservative treatment within minimum 2-years follow-up. This is a continued study to follow-up responded patients in the mentioned study whether continuing treatment with IA-HA could prolong time to surgery until the end of follow-up. OBJECTIVE: To evaluate the incidence of total knee replacement (TKR) in patients receiving repeated cycles of IA-HA during a 54-month follow-up period. MATERIAL AND METHOD: This was a prospective cohort study with 54-month follow-up period. All patients received at least a single course of 3-weekly injections of IA-HA (500-730 Kilodalton, Hyalgan). Patients who well responded to the treatment were recommended to repeat the administration of a 3-weekly injections every 6-12 months based on their symptoms. The incidence of TKR and time was recorded. Time to event analysis using Kaplan-Meier survival analysis was performed. RESULTS: 183 patients were recruited during March 2001 and March 2004 and followed-up until October 2008. Patients were classified into three groups according to Ahlback radiological grading system. 46 patients were in group 1 (Ahlback grade I-II), 70 patients were in group 2 (Ahlback grade III-IV) and 67 patients were in group 3 (Ahlback grade V). The incidence of TKR was 28.4% with a mean time to TKR of 15.4 months (0.7-51.7 months). For the rest of patients who had no TKR during study period (80.4%, 64.3% and 73.1% for group 1, 2, and 3 respectively), their mean follow-up time was 45.6 months (19.0-53.1 months). Mean survival time was 42.1 months (95% CI = 39.4-44.9 months). CONCLUSION: The repeated cycles of intra-articular sodium hyaluronate treatment in delay time to TKR in patients with knee osteoarthritis which failed conservative treatment was found efficacious during a 54-month follow-up period
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Principles of anti-infective therapy
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Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures
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Antimicrobial drugs, along with competent surgical procedures, provide an effective means for restoration of oral health. In dentistry, antibiotics are indicated for either treatment of acute infections or for prophylactic coverage of patients at risk for developing bacterial endocarditis or other infections as the result of bacteremia caused by dental procedures. Whenever possible, a bactericidal agent is preferred because of greater effectiveness and less reliance on host defense mechanisms. For maximal effectiveness of antibiotic therapy of orodental infections, several factors must be evaluated in choosing an antibiotic: (1) antibacterial spectrum and specificity of the agent; (2) degree of bacterial resistance reported for the antibiotic; (3) concentrations achieved at various sites; (4) age, type, and extent of infection; and (5) various host factors
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Cochrane corner: local corticosteroid injection for carpal tunnel syndrome
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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BACKGROUND: Carpal tunnel syndrome is a clinical syndrome manifested by signs and symptoms of irritation of the median nerve at the carpal tunnel in the wrist. Local corticosteroid injection for carpal tunnel syndrome has been studied but its effectiveness is unknown. OBJECTIVES: To evaluate the effectiveness of local corticosteroid injection for carpal tunnel syndrome versus placebo injection or other non-surgical interventions. Search methods: We searched the Cochrane Neuromuscular Disease Group Trials register (searched May 2006), MEDLINE (searched January 1966 to May 2006), EMBASE (searched January 1980 to May 2006) and CINAHL (searched January 1982 to May 2006). SELECTION CRITERIA: Randomized or quasi-randomized studies. DATA COLLECTION AND ANALYSIS: Three authors independently selected the trials and rated their overall quality. Relative risks and 95% confidence intervals were calculated for each trial and summary relative risks and 95% confidence intervals were also calculated
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Older men with low serum IGF-1 have an increased risk of incident fractures: The MrOS Sweden study
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Management of Hip Fractures in the Elderly
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Osteoporosis-related fractures constitute a major health concern not only in women but also in men. Insulin-like growth factor 1 (IGF-1) is a key determinant of bone mass, but the association between serum IGF-1 and incident fractures in men remains unclear. To determine the predictive value of serum IGF-1 for fracture risk in men, older men (n=2902, mean age of 75 years) participating in the prospective, population-based Osteoporotic Fractures in Men (MrOS) Sweden study were followed for a mean of 3.3 years. Serum IGF-1 was measured at baseline by radioimmunoassay. Fractures occurring after the baseline visit were validated. In age-adjusted hazards regression analyses, serum IGF-1 associated inversely with risk of all fractures [hazard ratio (HR) per SD decrease=1.23, 95% confidence interval (CI) 1.07-1.41], hip fractures (HR per SD decrease=1.45, 95% CI 1.07-1.97), and clinical vertebral fractures (HR per SD decrease=1.40, 95% CI 1.10-1-78). The predictive role of serum IGF-1 for fracture risk was unaffected by adjustment for height, weight, prevalent fractures, falls, and major prevalent diseases. Further adjustment for bone mineral density (BMD) resulted in an attenuated but still significant association between serum IGF-1 and fracture risk. Serum IGF-1 below but not above the median was inversely related to fracture incidence. The population-attributable risk proportion was 7.5% for all fractures and 22.9% for hip fractures. Taken together, older men with low serum IGF-1 have an increased fracture risk, especially for the two most important fracture types, hip and vertebral fractures. The association between serum IGF-1 and fracture risk is partly mediated via BMD. Copyright (copyright) 2011 American Society for Bone and Mineral Research
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Salvage of Combat Hindfoot Fractures in 2003-2014 UK Military
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DoD SSI (Surgical Site Infections)
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BACKGROUND: Hindfoot fractures pose a considerable challenge to military orthopaedic surgeons, as combat injuries are typically the result of energy transfers not seen in civilian practice. This study aimed to characterize the pattern of hindfoot injuries sustained by UK military casualties in recent conflicts, define the early amputation and infection rate, and identify factors associated with poor early outcomes.
METHODS: The UK Joint Theatre Trauma Registry was searched for British military casualties sustaining a hindfoot fracture from Iraq and Afghanistan between 2003 and 2014. Data on the injury pattern and management were obtained along with 18-month follow-up data. Statistical analysis was performed with the chi-square test and binomial logistic regression analysis. The threshold for significance was set at P < .05. One hundred fourteen patients sustained 134 hindfoot injuries. Eighteen-month follow-up was available for 92 patients (81%) and 114 hindfeet (85%).
RESULTS: The calcaneus was fractured in 116 cases (87%): 54 (47%) were managed conservatively, 32 (28%) underwent K-wire fixation, and 30 (26%) underwent internal fixation. Nineteen patients (17%) required transtibial amputation during this time. A deep infection requiring operative treatment occurred in 13 cases (11%) with Staphylococcus aureus, the most common infectious organism (46%). A deep infection was strongly associated with operative fracture management ( P = .0016). When controlling for multiple variables, the presence of a deep infection was significantly associated with a requirement for amputation at 18 months ( P = .023). There was no association between open fractures and a requirement for amputation at 18 months ( P = .640), nor was conservative management associated with a requirement for amputation ( P = .999). Thirty-six fractures (32%) required unplanned revision surgery within the first 18 months following salvage, of which 19 (53%) involved amputation.
CONCLUSION: A deep infection was the sole variable significantly associated with a requirement for amputation by 18 months. These results suggest that attempts at salvaging these injuries are at the limits of orthopaedic technical feasibility.
LEVEL OF EVIDENCE: Level III, comparative series.
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Modified auricular cartilage sling for paralytic ectropion
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Upper Eyelid and Brow Surgery
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OBJECTIVE: To evaluate the outcomes of a modified auricular cartilage sling for paralytic ectropion. METHODS: We treated 17 eyelids of 17 patients (average 67 years old) with an auricular cartilage sling between 2004 and 2012. All patients had paralytic ectropion with lower eyelid ptosis. Cartilage was harvested via an incision just inside the anterior rim of the helix. Skin incisions were made at the subciliary, medial and lateral canthal regions. The auricular cartilage graft was sutured to the medial canthal tendon medially, lateral orbital rim laterally, inferior tarsus superiorly, and lower eyelid retractors inferiorly. Average follow-up period was 40 months (range 16-60 months). RESULTS: The median L-MRD (mm) was improved from 8.4 preoperatively (interquartile range 7.5-8.9) to 5.2 postoperatively (4.8-5.3). The median lagophthalmos (mm) was improved from 5.8 preoperatively (4.7-7.0) to 2.2 postoperatively (1.6-2.6). 16 patients had corneal exposure preoperatively and this resolved completely in 12 patients. All patients experienced good anatomical and functional results with relief of their preoperative pain/discomfort symptoms without complications. No patients required reoperation and none experienced infection, exposure of the cartilage graft, or recurrence of lower eyelid malpositions. Postoperatively, all lower eyelids moved downward with down-gaze. The auricular scar left no significant cosmetic deformity. CONCLUSIONS: The modified auricular cartilage sling with 4 point fixation for paralytic ectropion appears to maintain normal eyelid mobility with down-gaze and avoids the problem of lower eyelid fixation.
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Cost and effectiveness of hip protectors among the elderly
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Management of Hip Fractures in the Elderly
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OBJECTIVE: To characterize the net cost and quality of life effects associated with hip protector use among the elderly relative to no intervention. METHODS: We developed two deterministic hypothetical cohorts of 500,000 65-year-old women or men and followed them over the remainder of their lifetimes. Data inputs were collected from secondary sources. Net costs are expressed in 1999 U.S. dollars, whereas net effectiveness is expressed in lives saved and in quality-adjusted life-years (QALYs) gained. RESULTS: Hip protector use results in net cost savings for both elderly women and men. Women over age 65 and men over age 85 also gain QALYs through hip protector use. CONCLUSION: Using the estimates available in the literature, our analysis indicates that use of hip protectors among women is associated with large cost savings and QALY gains even when accounting for the inconvenience of using the protectors. Among men, hip protectors are also associated with cost savings (although of smaller magnitude), but there are net losses of QALYs because of the inconveniences associated with the protectors
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Thigh muscle cross-sectional areas and strength in knees with early vs knees without radiographic knee osteoarthritis: a between-knee, within-person comparison
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OAK 3 - Non-arthroplasty tx of OAK
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OBJECTIVE: To compare cross-sectional and longitudinal side-differences in thigh muscle anatomical cross-sectional areas (ACSAs), muscle strength, and specific strength (strength/ACSA), between knees with early radiographic change vs knees without radiographic knee osteoarthritis (RKOA), in the same person.
DESIGN: 55 (of 4796) Osteoarthritis Initiative (OAI) participants fulfilled the inclusion criteria of early RKOA in one limb (definite tibiofemoral osteophytes; no radiographic joint space narrowing [JSN]) vs no RKOA (no osteophyte; no JSN) in the contralateral limb. ACSAs of the thigh muscles and quadriceps heads were determined using axial MRIs at 33%/30% femoral length (distal to proximal). Isometric extensor and flexor muscle strength were measured (Good Strength Chair). Baseline quadriceps ACSA and extensor (specific) strength represented the primary analytic focus, and 2-year changes of quadriceps ACSAs the secondary focus.
RESULTS: No statistically significant side-differences in quadriceps (or other thigh muscle) ACSAs, muscle strength, or specific strength were observed between early RKOA vs contralateral limbs without RKOA (P >= 0.44), neither in men nor in women. The 2-year reduction in quadriceps ACSA in limbs with early RKOA was -0.9 +/- 6% (mean +/- standard deviation) vs -0.5 +/- 6% in limbs without RKOA (statistical difference P = 0.85).
CONCLUSION: Our results do not provide evidence that early unilateral radiographic changes, i.e., presence of osteophytes, are associated with cross-sectional or longitudinal differences in quadriceps muscle status compared with contralateral knees without RKOA. At the stage of early unilateral RKOA there thus appears to be no clinical need for countervailing a potential dys-balance in quadriceps ACSAs and strength between both knees.
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Good mid-term clinical results of a cemented dual mobility cup: a single-centre experience
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Hip Fx in the Elderly 2019
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INTRODUCTION AND METHODS: From January 2004 to December 2008, 188 total hip arthroplasties were performed using a cemented dual mobility cup. 174 patients were available for final analysis. Their mean age was 76.8 (range 54-98 years). The mean follow-up was 7.7 years (range 5-10 years).
RESULTS: There were no dislocations. Survivorship rates of the femoral and acetabular components were 100% at a minimum of 5 years. At the latest follow-up, the mean Harris Hip Score significantly increased from 31.6 (only arthritic patients) points preoperatively to 84.5 points. No patients had progressive osteolysis, component migration, or loosening on radiographs. 2 patients presented with periprosthetic fractures treated conservatively. 2 patients presented with infection treated without implant removal and 1 patient presented with transient femoral palsy.
CONCLUSIONS: The results of this consecutive series confirmed the good performance of the cemented dual mobility cup at mean 7.7 years follow-up with no revision and no dislocations.
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Early preoperative thromboprophylaxis with Klexane (R) in hip fracture surgery: A placebo-controlled study
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Management of Hip Fractures in the Elderly
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The aim of this study was to evaluate any possible benefits of early thromboprophylactic treatment in the prevention of deep vein thrombosis (DVT) in high-risk hip fracture patients. Within 30 months, 239 patients were included in a double-blind placebo-controlled study. With the diagnosis of hip fracture confirmed, patients received either 40-mg Enoxaparin s.c. or placebo once daily until operation. Postoperatively, all patients received 40-mg Enoxaparin s.c. once daily until phlebography. Phlebography was first performed on the operated leg, and with no thrombosis detected, the other leg was investigated as well. The two groups did not differ demographically. Eighty-five patients were excluded. Eight patients died during the study period. The remaining 146 patients had ascending phlebography performed and 24 patients (16.4%) developed DVT. Nine (12%) of 75 patients in the Klexane (R) and 15 (21%) of 72 patients in the placebo group developed DVT. The risk ratio was 0.58 (95% confidence limits 0.27-1.25) and p = .15 (chi2 test). There was no difference in perioperative bleeding or transfusion requirements. We conclude that Klexane (R) is an effective and safe thromboprophylactic agent in hip fracture patients. Copyright © 2011 Elsevier B. V., Amsterdam. All Rights Reserved
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Osteoarthritis after sports knee injuries
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AMP (Acute Meniscal Pathology)
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Recent advances in the knowledge of tissue homeostasis, including the tissue homeostasis theory and the envelope of function theory as proposed by Dye, have greatly increased our knowledge of the pathophysiology of osteoarthrosis after sports knee injuries. The development of these two theories has not only advanced our understanding of the treatment and prevention of osteoarthrosis after acute injuries to the knee, but has also given us guidance as to directions for future research. © 2004 Elsevier Inc. All rights reserved.
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Effects of platelet-rich plasma on lateral epicondylitis of the elbow: prospective randomized controlled trial
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PRPs for Lateral Epicondylitis/Elbow Tendinopathies
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OBJECTIVE: To evaluate the effects of platelet-rich plasma (PRP) infiltration in patients with lateral epicondylitis of the elbow, through analysis of the Disabilities of the Arm, Shoulder and Hand (DASH) and Patient-Rated Tennis Elbow Evaluation (PRTEE) questionnaires.
METHODS: Sixty patients with lateral epicondylitis of the elbow were prospectively randomized and evaluated after receiving infiltration of three milliliters of PRP, or 0.5% neocaine, or dexamethasone. For the scoring process, the patients were asked to fill out the DASH and PRTEE questionnaires on three occasions: on the day of infiltration and 90 and 180 days afterwards.
RESULTS: Around 81.7% of the patients who underwent the treatment presented some improvement of the symptoms. The statistical tests showed that there was evidence that the cure rate was unrelated to the substance applied (p = 0.62). There was also intersection between the confidence intervals of each group, thus demonstrating that the proportions of patients whose symptoms improved were similar in all the groups.
CONCLUSION: At a significance level of 5%, there was no evidence that one treatment was more effective than another, when assessed using the DASH and PRTEE questionnaires.
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Assessment of needle arthroscopy, standard arthroscopy, physical examination, and magnetic resonance imaging in knee pain: a pilot study
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AMP (Acute Meniscal Pathology)
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Nine patients with mechanical or osteoarthritic knee pain present for more than 6 weeks were evaluated by clinical examination, needle arthroscopy, and standard arthroscopy. Each knee was assessed for patellofemoral cartilage disruption, cartilage abnormalities in the tibiofemoral joints, meniscal tears, and synovitis. Needle arthroscopy was performed immediately before standard arthroscopy in the operating room under local anesthesia. Six of the nine patients had magnetic resonance imaging (MRI) scans before the arthroscopic procedures. The clinical examination was 100% sensitive for the detection of patellofemoral disease, 62% sensitive for medial meniscal tears, and 14% sensitive for lateral meniscal tears. Visualization of the femoral-tibial joint was significantly better with standard arthroscopy than with needle arthroscopy (p = 0.002). Percent visualization with the needle arthroscope was higher for the patellofemoral and the medical tibiofemoral cartilage compared to the lateral tibiofemoral cartilage and menisci (p < 0.05). The needle arthroscope and MRI scan were equivalent to the standard arthroscope in the detection of patellofemoral cartilage disruption of any depth and in the detection of meniscal tears. However, the standard arthroscope was better in detecting cartilage abnormalities in the medial and lateral joint spaces (p < 0.05 and p < 0.01, respectively). The costs for diagnostic standard arthroscopy, needle arthroscopy, and MRI of the knee in an academic center are $3900, $1650, and $900, respectively. These data suggest that the majority of reversible causes of knee pain are diagnosed by physical examination. Therefore, after a complete history and physical examination, if the physician thinks that the patient has an internal derangement of the knee and that surgical intervention is needed, we suggest that the patient go directly to standard arthroscopy, which offers both confirmation and therapy. The MRI scan or needle arthroscopy should be considered only if, after a history and physical examination, the diagnosis of the knee pain is unclear.
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Rheological study of viscosupplements and synovial fluid in patients with osteoarthritis
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Surgical Management of Osteoarthritis of the Knee CPG
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A detailed rheological characterization of synovial fluid from 22 patients undergoing total knee arthroplasty and three commercially available viscosupplements is performed. The results show that synovial fluid in osteoarthritis (OA) patients exhibits non-Newtonian shear thinning behavior and viscoelastic properties. Synovial fluid of the knees aspirated from one individual show very different viscosities and viscoelasticities. Moreover, rheopectic behavior is observed in OA synovial fluid at 37(degrees)C. All three viscosupplements exhibit non-Newtonian shear thinning behavior. The viscosupplement with cross-linked hyaluronic acid has a higher viscosity than that of with non-cross-linked hyaluronic acid. Moreover, high-molecular-weight viscosupplements have greater viscoelasticity than that of low-molecular-weight viscosupplements
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Enhancing screw stability in osteosynthesis with hydroxyapatite granules
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Management of Hip Fractures in the Elderly
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We employed hydroxyapatite (HA) granules to enhance screw fixation in revision surgery of failed osteosynthesis with a compression hip screw system in an 83-year-old woman. After reduction of the fracture, the fracture site with a large bone defect was filled with HA granules, and osteosynthesis was accomplished with a double cannulated lag screw and plate system. We feel that this HA granule augmentation method may also be suitable for osteosynthesis in other osteoporotic fractures
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The relationship between radiological severity and functional status in patients with knee osteoarthritis
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OAK 3 - Non-arthroplasty tx of OAK
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In this study, we aimed to explore the relationship between radiological findings and functional status in patients with knee osteoarthritis (OA). In this study, 117 female patients diagnosed with knee osteoarthritis according to the ACR criteria were included. Antero-posterior knee radiographs of the patients were graded according to Kellgren-Lawrence, and functional capacity was evaluated with WOMAC and Lequesne indexes. Quadriceps and hamstring muscle strengths were also concentrically measured using an isokinetic dynamometer, five repetitions at 90degree/s and 20 repetitions at 180degree/s. In this study, a significant relationship was determined between the age, weight, praying period, and pain period of the patients with the radiological findings. No significant relationship was determined between the functional capacity of knee and muscle strength and the radiological findings. However, left hamstring functioning capacity was found as lower in the group with the radiological findings. The radiological findings in knee OA are not associated with decrease in knee muscle strength and functional capacity. Clinical symptoms such as pain, decrease in range of motion, etc. in knee OA may be responsible for decrease in knee muscle strength and functional capacity.
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Collarless polished tapered impaction grafting of the femur during revision total hip arthroplasty: pitfalls of the surgical technique and follow-up in 31 cases
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Management of Hip Fractures in the Elderly
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Impacting morcellized allograft bone into the femur during revision total hip arthroplasty is a simple concept with the goal of rebuilding femoral bone stock and providing secure fixation to the femoral stem. Using the collarless polished tapered (CPT, Zimmer, Warsaw, IN) stem impaction grafting system, we became concerned about the discrepancy between the straightforward concept and precise execution of the technique. In this study, we examined 31 consecutive procedures to determine intraoperative difficulties and report on the clinical outcome of 30 cases at an average follow-up of 31 months. Modified Harris Hip Scores averaged 41 points preoperatively and improved to 86 points at follow-up. Nineteen cases were performed on intact femora, whereas 12 cases had disrupted femoral integrity, either extended trochanteric osteotomy or periprosthetic fracture. Successful outcome was seen in all cases with an intact femur, and restoration of femoral integrity was key to successful outcome in cases with compromised femoral integrity. Among cases with disrupted femoral integrity, 3 distal fractures occurred as a result of the rigid CPT cement plug, and 2 complete femoral fractures occurred as a result of bone impaction, for a technique-related fracture rate of 16%. Difficulty packing bone distally occurred in 94% of cases and was associated with varus and valgus stem alignment and medial and lateral stem displacement. Complete cement mantles were seen in 77% of cases. No stem subsidence was seen in 15 of 30 cases (50%). Stem subsidence of <5 mm was seen in 10 of 30, stem subsidence of 6 to 8 mm was seen in 4 of 30, and stem subsidence of >10 mm was seen in 1 patient (4%). Of the patients, 87% thought the procedure improved their function, and 97% would recommend it to a friend with a failed femoral component. Although we hope that the instruments for this procedure can improve, we endorse the concept of impaction grafting with the CPT stem as a successful way of dealing with revision femoral surgery
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Gender differences in osteoporosis: A single- center observational study
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Hip Fx in the Elderly 2019
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Purpose: Osteoporosis affects more than 200 million people worldwide: its prevalence increases with age and is actually growing due to the constant population aging. Women are at greater risk than men, but in recent years it has become increasingly evident that osteoporosis represents a significantly important problem also for men. However, osteoporosis in men is still poorly studied, underdiagnosed and inadequately treated. Materials and Methods: We conducted an observational study to identify any gender disparities in osteoporosis screening. For this purpose we observed people consecutively admitted at our Outpatient Service for the Diagnosis of Osteoporosis during the last 3 years. Patients underwent clinical and laboratory assessment and bone mineral density (BMD) measurements by dual-energy X-ray absorptiometry. Bone turnover serum markers have been evaluated and stratified according to gender. Results: Out of 3,752 patients, 2,376 subjects who met the inclusion criteria were identified. As expected, the great majority (94.5%) of the screened subjects were women and only 5.4% were men. Women exhibited lower BMD compared to men (Tscore values: -2.33±1.14 vs. -1.31±1.55; p<0.001), whereas the prevalence of fractures in osteoporotic men was significantly higher (50% vs. 31%; p<0.001). Women had lower vitamin D and higher bone remodeling markers compared to men. Secondary osteoporosis was more frequent in men (66.67%) than in women (20.83%) and the calculated risk for hip fractures was higher in osteoporotic men compared to women (11.47±10.62 vs. 6.87±7.73; p<0.001). Conclusions: Here we highlighted that men are under-screened for osteoporosis and exhibit secondary osteoporosis more frequently than women.
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CXC chemokine receptor 7 expression in cervical intraepithelial neoplasia
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MSTS 2018 - Femur Mets and MM
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Cervical intraepithelial neoplasia (CIN), also known as transformation and dysplasia of cervical intraepithelial cells, is the precancerous lesion of squamous cell carcinoma. CXC chemokine receptor 7 (CXCR7) has been indicated in tumor development and metastasis of multiple malignancies or precancerous lesion. However, the protein expression and function of CXCR7 in different stages of human CIN remains unclear. The present study examined CXCR7 protein expression in cervical tissue samples from 34 patients, including 7 patients with normal cervical tissues (negative control), 10 patients with stage I of CIN (CIN I), 8 patients with CIN II and 9 patients with CIN III. Receiver operating characteristic curves (ROC) were established to evaluate the prognostic value of CXCR7 in differentiating various stages of CIN. Immunohistochemical staining showed that protein expression of CXCR7 was higher in CIN tissues compared with the normal cervical epithelium (P<0.05). High-grade CIN tissues expressed a higher level of CXCR7 compared to low-grade samples. The ROC curve of integral optical density analysis showed that CXCR7 could discriminate CIN I-III from normal cervical epithelium with 88.9% sensitivity and 71.4% specificity, and CIN II-III from the negative control and CIN I with 92.7% sensitivity and 50.0% specificity. ROC curve of area analysis also showed that CXCR7 could discriminate CIN I-III from normal cervical epithelium with 70.4% sensitivity and 100.0% specificity, and CIN II-III from the negative control and CIN I with 50.0% sensitivity and 90.0% specificity. An increase in CXCR7 expression may represent a novel predictor of CIN. The wide expression of CXCR7 in CIN also supports the assumption that CXCR7 plays a role in precancerous lesion progression, as well as proliferation, migration and angiogenesis.
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Outcomes of total knee arthroplasty in degenerative osteoarthritic knee with genu recurvatum
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OAK 3 - Non-arthroplasty tx of OAK
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Background: This study aimed to assess the incidence of genu recurvatum without neuromuscular disorders in knees that underwent navigation-assisted total knee arthroplasty (TKA), to evaluate short-term radiologic and clinical results of navigation-assisted TKA in genu recurvatum, and to evaluate differences in results according to the degree of pre-operative hyperextension and type of implant and insert. Methods: This study retrospectively reviewed 510 knees that underwent navigation-assisted TKA from January 2005 to December 2011. The incidence of knees that showed hyperextension of â?¥ 5° (genu recurvatum) on navigation, and the accompanying alignment were evaluated. It assessed radiologic, intraoperative, and clinical results in recurvatum and control groups by using propensity score matching. Results: A total of 465 knees underwent navigation-assisted TKA for degenerative osteoarthritis. Genu recurvatum was observed in 55 knees (11.8%). Of these, 41 knees (74.5%) had degree of hyperextension between five degrees and 10°, and 47 (85.4%) had varus alignment. The thickness of the resected distal femur in the recurvatum group (7.6 ± 1.6 mm) was less than that in the control group (8.4 ± 1.4 mm, P = 0.001). The thickness of the insert in the recurvatum group (12.5 ± 2.3 mm) was greater than in the control group (10.8 ± 1.5 mm, P < 0.001). The sagittal alignment at the final follow-up was 1.3 ± 3.4° in the control group and â?? 0.1 ± 0.7° in the recurvatum group (P = 0.003). Subgroup analyses in the recurvatum group showed no significant difference in sagittal alignment and patient-related outcomes by degree of pre-operative hyperextension and implant/insert type (P > 0.05 for all parameters). Conclusions: Genu recurvatum was not uncommon among patients undergoing primary TKA. This review obtained satisfactory short-term clinical and radiologic results, with a smaller distal femoral resection and thicker insert.
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A comparative analysis between fixed bearing total knee arthroplasty (PFC Sigma) and rotating platform total knee arthroplasty (PFC-RP) with minimum 3-year follow-up
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PJI DX Updated Search
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Background Since the introduction of mobile bearing total knee designs nearly 30 years back, many studies have been done to evaluate its long-term result. Comparison with fixed bearing designs has been done in the past, but the studies were confounded by variables such as disease, surgeon, bone quality, pain tolerance, etc. We attempt to eliminate these variables in this study. Methods A total of 50 patients who had bilateral arthritis of the knee with similar deformity and pre-operative range of motion on both sides agreed to have one knee replaced with mobile bearing total knee design (PFC-RP) and the other with a fixed bearing design (PFC Sigma) were prospectively evaluated. Comparative analysis of both the designs was done at a mean follow-up of 40 months, minimizing patient, surgeon and observer related bias. Clinical and radiographic outcome, survival and complication rates were compared. Results At a mean follow-up of 40 months (range 36-47 months), no benefit of mobile bearing (PFC-RP) over fixed bearing design (PFC Sigma) could be demonstrated with respect to Knee Society scores, pain scores, range of flexion, subject preference or patello-femoral complication rates. Radiographs showed no difference in prosthetic alignment. No patient required a revision surgery till last follow-up. Conclusions Our study demonstrated no advantage of the mobile-bearing arthroplasty over fixed bearing arthroplasty with regard to clinical results at short-term follow-up. However, longer follow-up is necessary to confirm whether these results are sustained. é Springer-Verlag 2012
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Different regional healing rates with the outside-in technique for meniscal repair
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Anterior Cruciate Ligament Injuries CPG
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Fifty-one patients with meniscal repair using the outside-in technique were reassessed with second-look arthroscopic procedures (N = 15), arthrographic examination (N = 41), magnetic resonance imaging (N = 36), or a combination of these techniques. Forty-one medial and 10 lateral menisci were repaired. The average clinical follow-up was 15 months (range, 3 to 80). Forty-five of 51 patients had tears that were located in or extended into the posterior horn of the medial or lateral meniscus. Complete healing occurred in 23 menisci (45%), partial healing was observed in 16 (15 medial, 1 lateral) (32%), and no healing occurred in 12 (24%). Remarkably, in all 15 patients who had tears extending from the posterior to the middle third of the medial meniscus that were partially healed, it was always the posterior third that had not fully healed. This finding is statistically significant. In addition, the middle third of these menisci had not fully healed in five patients. No healing occurred in the two patients with tears in the posterior third of the medial meniscus. Poor healing with the outside-in technique was observed in patients with tears into the posterior horn of the medial meniscus. For tears in the middle and anterior portion of the medial meniscus, as well as all lateral meniscus tears, the outside-in technique is our current method of choice
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Sublingual sufentanil tablet system Zalviso® for postoperative analgesia after knee replacement in fast track surgery: a pilot observational study
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AAHKS (2) Corticosteroids
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Background: Currently many TKA protocols rely on multimodal analgesic protocols with patient-controlled analgesia systems that administer opioids through a patient controlled IV infusion pump, in addition to concomitant peripheral nerve blocks and local anesthetics. Although effective, PCA IV opioids do not provide optimal results with fast track rehabilitation protocols. Methods: The present is a retrospective study comparing the novel sublingual sufentanil PCA system (SSTS) to our standard of care foreseeing continuous femoral nerve block (cFNB) within a multimodal analgesic in a TKA fast-track protocol. The study evaluated 95 patients on SSTS (SSTS group) and 87 on cFNB (cFNB/control group) and collected data on numeric rating scores for pain from day 1â??3 after surgery (T1, T2, T3), both at rest (NRS) and during movement (mNRS), patientâ??s ability to walk, need for supplementary analgesia (rescue dose), occurrence of adverse effects, length of hospital stay, and usability rating for SSTS by both patients and hospital staff. Results: NRS at rest was lower in the cFNB than in the SSTS group for all 3 days after surgery, whereas mNRS scores were lower in the SSTS group at all time points measured. Adverse effects were significantly fewer among patients of the SSTS group (6% patients) than those of the cFNB (74% patients) (p < 0.001). Rescue doses were needed by 5% of SSTS patients vs 60% of cFNB. The fewer adverse events and lower pain scores for the SSTS group were associated to a notably better ability to ambulate, with all patients (100%) of the SSTS group being able to stand and walk for 10 m from T1 on; patients in the cFNB group showed a slower recovery with only 40% being able to stand and walk on T1, 70% on T2 and 85% on T3. All patients of the SSTS group had a length of stay of 4 days (day of surgery plus 3 after) as foreseen by the fast track protocol, in comparison only 36% of cFNB. Lastly, patient and nursing staff judged SSTS easy to use. Conclusion: Our experience suggests that SSTS is a valuable strategy for routine postoperative analgesia following TKA in the context of a multimodal analgesic approach within the fast-track setting.
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Effect of carpal tunnel syndrome on grip force coordination on hand tools
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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This study investigated coordination of the grip force on and force applied with a hand tool using a precision pinch grip. A simulated hand tool was developed to measure grip force exerted on the tool as a function of the force transmitted from the tool to an external object in a dynamic force matching paradigm. Grip force coordination measures reflected subjects' abilities to modulate grip force in parallel with the tool application force and their abilities to minimize excessive grip force. These measures were calculated for seven subjects with a diagnosis of carpal tunnel syndrome (CTS) and seven age- and gender-matched controls. The absolute magnitude of excessive grip force (safety margin) was unreliable because of the high intrasubject variability in coefficient of friction measurements. Linear regression equations predicting coefficient of friction from pinch force magnitude had low r2 coefficients of determination and were generally not statistically significant (p > 0.05). Relative comparisons of grip force control showed that individuals with CTS exhibited a statistically significant (p < 0.05) increase in ratio of grip force to application force (54% higher than controls) and a significant (p < 0.05) decrease in modulation of pinch force with application force (12% lower than controls). These results suggest that individuals with CTS lose some ability to coordinate efficiently grip force on hand tools and exert higher grip forces on tools, at equivalent application forces, than controls. This is believed to be a result of tactile sensibility deficits associated with CTS. As a result, workers with CTS may be at increased risk of accelerating the progression of their musculoskeletal disorder
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Efficacy Analysis of Separation Surgery Combined with SBRT for Spinal Metastases—A Long-Term Follow-Up Study Based on Patients with Spinal Metastatic Tumor in a Single-Center
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MSTS 2022 - Metastatic Disease of the Humerus
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Objective: Follow-up data of patients with spinal metastatic tumors were analyzed to investigate the effect of separation surgery combined with SBRT on clinical outcomes. Methods: The clinical data of 52 patients with spinal metastatic tumors admitted to our hospital from January 2015 to December 2018 were retrospectively analyzed. There were 24 males and 28 females, aged 25–77 years, with an average of 56.7 ± 7.4 years. The separation surgery of all patients was successfully completed and followed up. Frankel neurological function grading, Karnofsky performance scores, VAS scores, Epidural spinal cord compression (ESCC) grading and muscle strength grading were used to assess the patients’ condition. Kaplan-Meier analysis and the Log?rank test were used to calculate the hazard ratio (HR) and the 95% feasible interval for patients with different ages, genders, and treatments. The multivariate Cox regression model was used to calculate the risk value HR and the 95% feasible interval in patients undergoing only separation surgery or separation surgery combined with SBRT. Results: After separation surgery, 46 patients had pain relief (88.5%), and the average VAS score decreased to 2.17 ± 0.52 points, which was significantly improved compared with preoperative score (P < 0.01). Muscle strength grading decreased in seven cases, showed no change in two cases, and recovered in 19 cases. Postoperative Frankel neurological function grading and Karnofsky performance scores were also significantly improved compared with preoperative scores (P < 0.01). The patients who accepted separation surgery were followed up for 9–47 months (26.3 ± 18.1 months), and 15 patients died due to the deterioration of the primary tumor. Thirteen patients received SBRT after surgery, including 12 cases of pain relief. The average VAS score of these 13 patients decreased to 1.64±0.41 points, which was significantly improved compared with preoperative and postoperative (P < 0.01), and muscle strength recovered in eight cases. Frankel neurological function grading and Karnofsky performance scores of these patients were also significantly improved compared with preoperative and postoperative Frankel neurological function grading and Karnofsky performance scores (P < 0.01). The patients who accepted separation surgery combined with SBRT were followed up for 11–38 months (mean 22.5 ± 10.2 months), and five cases died of primary tumor. Univariate and multivariate analysis showed that separation surgery combined with SBRT was an independent predictor of overall survival rate (OS). Conclusions: Separation surgery combined with SBRT is an effective way to treat spinal metastatic tumors as it not only has smaller surgical trauma, but can also significantly relieve pain, improve nerve function, and relieve spinal cord compression.
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0 |
Skeletal metastasis: the effect on the immature skeleton
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The Treatment of Pediatric Supracondylar Humerus Fractures AUC
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The unique opportunity to study the entire appendicular skeleton of a child who died from metastatic angiosarcoma allowed detailed assessment of radiographically evident involvement. Virtually every portion of the appendicular skeleton had evidence of metastatic disease. However, the extent of involvement was extremely variable, especially when contralateral regions were assessed. The most likely region of metastasis, the metaphysis, is normally a fenestrated cortex of woven bone in the young child, rather than a well demarcated cortex formed by osteon (lamellar) bone, as it is in the adult. The pattern of destruction is such that less extensive areas may be involved before becoming radiographically evident, and trabecular bone involvement may be evident even without cortical damage. The metaphyseal metastatic spread supports the concept of arterial hematogenous dissemination, comparable to osteomyelitis in the child. Pathologic metaphyseal fractures involved both proximal humeri; the fracture also extended along a portion of the metaphyseal-physeal interface in one humerus. In one distal femur the physis readily separated from the metaphysis; this was a non-displaced type 1 growth mechanism injury
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1 |
Efficacy of neonatal hip examination
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Developmental Dysplasia of the Hip CPG
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An examination of the ongoing neonatal hip screening program at the Vancouver General and Grace Hospitals in Vancouver, British Columbia, over a 9 1/2 year period revealed that of the 32,480 newborns examined, 321 (9.8 per 1,000 live births) had unstable hips. Treated immediately with abduction splintage, five of these children came to percutaneous adductor tenotomy and hip spica casts. There was one false-negative screening, and there were five children with unidentified acetabular dysplasia who presented within the first year of life. No child came to open reduction of the hip or innominate or femoral osteotomy. A standardized neonatal hip screening program would seem to significantly alter the natural history of the classic congenital dislocation of the hip but also seems unable to effectively screen out acetabular dysplasia
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A prospective population-based study of the predictors of undergoing total joint arthroplasty
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Surgical Management of Osteoarthritis of the Knee CPG
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OBJECTIVE: To examine prospectively the predictors of time to total joint arthroplasty (TJA). METHODS: This was a prospective cohort study with a median followup time of 6.1 years. We included participants from an existing population-based cohort of 2,128 individuals, ages 55 years and older with disabling hip and/or knee arthritis and no prior TJA, from 2 regions of Ontario, Canada, 1 urban with low TJA rates and 1 rural with high rates. The main outcome measure was the occurrence of a TJA based on procedure codes in the hospital discharge abstract database. RESULTS: At baseline, the mean age of the patients was 71.5 years, 67.9% had a high school education or higher, 73.4% were women, the mean arthritis severity (Western Ontario and McMaster Universities Osteoarthritis Index [WOMAC]) score was 41.1 (maximum possible score 100), and 20.0% were willing to consider TJA. Greater probability of undergoing TJA was associated with higher (worse) baseline WOMAC scores (hazard ratio [HR] 1.22 per 10-unit increase, P < 0.001), age (compared with age <or=62 years, the HR increased to 1.57 for 63-68 years, 1.46 for 69-74 years, and 1.51 for 75-81 years, and fell to 0.44 for >or=82 years; P < 0.05 for all), better health (HR 1.14 per 10-unit increase in Short Form 36 general health survey score, P < 0.001), and willingness to consider TJA (HR 4.92, P < 0.001). When willingness was excluded from the model, education level, but not sex or income, became a significant predictor of TJA receipt. CONCLUSION: Willingness to consider TJA was the strongest predictor of the time to first TJA. Given that previous research indicates that willingness is largely explained by perceptions of the indications for and risks associated with TJA and not disease severity, this finding supports the need for population education about arthritis treatments, including TJA
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1 |
Degree of tendon degeneration and stage of rotator cuff disease
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Trial Systematic Review Project
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PURPOSE: While tendon degeneration has been known to be an important cause of rotator cuff disease, few studies have objectively proven the association of tendon degeneration and rotator cuff disease. The purpose of this study was to investigate changes of tendon degeneration with respect to the stage of rotator cuff disease.
METHODS: A total of 48 patients were included in the study: 12 with tendinopathy, 12 with a partial-thickness tear (pRCT), 12 with a full-thickness tear (fRCT), and 12 as the control. A full-thickness supraspinatus tendon sample was harvested en bloc from the middle portion between the lateral edge and the musculotendinous junction of the tendon using a biopsy punch with a diameter of 3 mm. Harvested samples were evaluated using a semi-quantitative grading scale with 7 parameters after haematoxylin and eosin staining.
RESULTS: There was no significant difference in age, gender, symptom duration, and Kellgren-Lawrence grade between the groups except for the global fatty degeneration index. All of the seven parameters were significantly different between the groups and could be categorized as follows: early responders (fibre structure and arrangement), gradual responder (rounding of the nuclei), after-tear responders (cellularity, vascularity, and stainability), and late responder (hyalinization). The total degeneration scores were not significantly different between the control (6.08 +/- 1.16) and tendinopathy (6.67 +/- 1.83) (n.s.). However, the score of pRCT group (10.42 +/- 1.31) was greater than that of tendinopathy (P < 0.001), and so was the score of fRCT (12.33 +/- 1.15) than that of pRCT (p = 0.009).
CONCLUSION: This study showed that the degeneration of supraspinatus tendon increases as the stage of rotator cuff disease progresses from tendinopathy to pRCT, and then to fRCT. The degree of degeneration of tendinopathy was not different from that of normal but aged tendons, and significant tendon degeneration began from the stage of pRCT. The clinical relevance of the study is that strategies and goals of the treatment for rotator cuff disease should be specific to its stage, in order to prevent disease progression for tendinopathy and pRCT, as well to restore the structural integrity for fRCT.
LEVEL OF EVIDENCE: Diagnostic, Level I.
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0 |
Outcome of Dimon-Hughston osteotomy in unstable intertrochantric fractures
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Hip Fx in the Elderly 2019
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Objective: To Evaluate effectiveness of Dimon-Hughston osteotomy using a dynamic hip screw in unstable intertrochanteric fractures in term of union. Study Design: Descriptive case series Study Place and Duration: This was a multicenteric study conducted at Lahore General Hospital, Surriya Azeem Hospital Lahore and Civil Hospital Quetta for the period of 36 months (Between January 2012-December 2014). Methods and Materials: Through non-probability purposive sampling, 50 cases of unstable intertrochanteric fractures were included. All fifty patients were managed by Dimon Hughston osteotomy with a 135° dynamic hip screw. During the course of follow up radiographically data for union, nonunion and implant position and clinically data regarding infection was recorded. Data was analyzed by SPSS version 20. Results: The mean age of all patients was 59.76 years (range 38-80years). There were 28(56%) male and 22(44%) female patients. All patients included in study were AO type A2 fractures. Union occurred in 34 patients 68%, mean union time was 19.88 weeks (Range 18-26 weeks) nonunion and pulling out of plate occurred in 16 patients 32% during course of follow-up. Only 2(4%) patients developed superficial infection later on which settled down with antibiotics.. Conclusion: Dimon-Hughston osteotomy for unstable pertrochanteric fractures may provided immediate stability for early weight-bearing in some patients, but has got high failure rate.
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1 |
Condylocephalic nails versus extramedullary implants for extracapsular hip fractures
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Management of Hip Fractures in the Elderly
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BACKGROUND: Two types of implants used for the surgical fixation of extracapsular hip fractures are condylocephalic nails (intramedullary nails that are inserted up through the femoral canal from above the knee and across the fracture) and extramedullary implants. OBJECTIVES: To compare condylocephalic nails (e.g. Ender and Harris nails) with extramedullary implants (e.g. fixed nail plates and sliding hip screws) for the treatment of extracapsular (trochanteric and subtrochanteric) hip fracture in adults. SEARCH STRATEGY: We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (September 2004), the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 3, 2004), MEDLINE (1966 to September week 1 2004), EMBASE, the UK National Research Register, orthopaedic journals, conference proceedings and reference lists of articles. SELECTION CRITERIA: Randomised or quasi-randomised trials comparing condylocephalic nails with extramedullary implants. DATA COLLECTION AND ANALYSIS: We independently assessed trial quality and extracted data. Ender nails and Harris nail data were presented separately. Results from fixed nail plates and sliding hip screws were subgrouped. MAIN RESULTS: Eleven trials involving 1667 people with predominantly trochanteric fractures were included. Ten compared Ender nails with either a fixed nail plate or a sliding hip screw. One compared the Harris condylocephalic nail with a sliding hip screw.The only advantages of condylocephalic nails were a reduced deep wound sepsis rate (0.9% versus 4.2%; relative risk 0.28, 95% confidence interval 0.11 to 0.62), length of surgery and operative blood loss. However, there was an increased risk of reoperation (20.9% versus 5.5%; relative risk 3.72, 95% confidence interval 2.54 to 5.44) and later fracture of the femur when compared with extramedullary implants. There was an increased risk of cut-out of the implant from the femoral head for Ender nails compared with the sliding hip screw, but not for fixed nail plates. Backing out of the nail was a frequent complication (30%) of Ender nails and often resulted in revision surgery.Ender nails had an increased risk of shortening of the leg and external rotation deformity and potentially a poorer return to previous walking ability. An increase in residual pain, predominantly knee pain, was also evident in patients undergoing condylocephalic nailing. There was no apparent difference in mortality between the condylocephalic nail and extramedullary implant groups. AUTHORS' CONCLUSIONS: Any advantages in intra-operative outcomes of condylocephalic nails are outweighed by the increase in fracture healing complications, reoperation rate, residual pain and limb deformity when compared with an extramedullary implant, particularly a sliding hip screw. The use of condylocephalic nails (in particular Ender nails), for trochanteric fracture is no longer appropriate. CONDYLOCEPHALIC NAILS VERSUS EXTRAMEDULLARY IMPLANTS FOR EXTRACAPSULAR HIP FRACTURES: A hip fracture is a break near the top of the thigh bone (femur). Those located further away from the hip joint are termed extracapsular. Such fractures may be surgically fixed using metal implants. Two types of implant are compared here. Condylocephalic nails, such as Ender nails, are inserted near the knee, and pushed up through the bone marrow of the femur and across the fracture site. Extramedullary implants consist of a screw or rod, inserted in the upper part of the femur to bridge the fracture, connected to a plate secured to the femur. This review found that, despite quicker surgery, Ender nails were associated with an increased risk of complications and reoperation when compared with extramedullary implants in common use
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An Analysis of the Most Commonly Tested Topics and Their Taxonomy From Recent Self-Assessment Examinations
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Pediatric Supracondylar Humerus Fracture 2020 Review
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Objective: The purpose of this study is to determine the most commonly tested topics and the question taxonomy of the American Academy of Orthopaedic Surgeons Self-Assessment Examinations (SAE) from 2009 through 2014. Design: All SAEs were analyzed from 2009 through 2014. The SAEs were separated by subject and the questions of each SAE were analyzed for topic, taxonomic classification, and question type. Results: A total of 2107 questions were reviewed from 10 different subjects. In all, 6 of the 9 subjects had roughly 1/3 of their questions composed of the 3 most commonly tested topics. Each subject had at least 1 trauma-related question within its top 5 most commonly tested topics. Almost half (47%) of all questions were of taxonomy 1 classification and 29% were taxonomy 3. The Basic Science SAEs had the greatest percentage of taxonomy 1 questions of any subject (83%) whereas Trauma contained the highest percentage of taxonomy 3 questions (47%). Conclusions: Certain topics within each subject are consistently tested more often than other topics. In general, the 3 most commonly tested topics comprise about one-third of total questions and orthopedic surgeons should be very familiar with these topics in order to best prepare for standardized examinations.
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1 |
Time-course of PTSD symptoms in the Australian Defence Force: a retrospective cohort study
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DoD PRF (Psychosocial RF)
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AIMS: Understanding the time-course of post-traumatic stress disorder (PTSD), and the underlying events, may help to identify those most at risk, and anticipate the number of individuals likely to be diagnosed after exposure to traumatic events.
METHOD: Data from two health surveys were combined to create a cohort of 1119 Australian military personnel who deployed to the Middle East between 2000 and 2009. Changes in PTSD Checklist Civilian Version (PCL-C) scores and the reporting of stressful events between the two self-reported surveys were assessed. Logistic regression was used to examine the association between the number of stressful events reported and PTSD symptoms, and assess whether those who reported new stressful events between the two surveys, were also more likely to report older events. We also assessed, using linear regression, whether higher scores on the Kessler Psychological Distress Scale or the Alcohol Use Disorder Identification Test were associated with subsequent increases in the PCL-C in those who had experienced a stressful event, but who initially had few PTSD symptoms.
RESULTS: Overall, the mean PCL-C scores in the two surveys were similar, and 78% of responders stayed in the same PCL-C category. Only a small percentage moved from having few symptoms of PTSD (PCL-C < 30) in Survey 1 to meeting the criteria for PTSD (PCL-C >= 50) at Survey 2 (1% of all responders, 16% of those with PCL-C >= 50 at Survey 2). Personnel who reported more stressful lifetime events were more likely to score higher on the PCL-C. Only 51% reported the same stressful event on both surveys. People who reported events occurring between the two surveys were more likely to record events from before the first survey which they had not previously mentioned (OR 1.48, 95% CI (1.17, 1.88), p < 0.001), than those who did not. In people who initially had few PTSD symptoms, a higher level of psychological distress, was significantly associated with higher PCL-C scores a few years later.
CONCLUSIONS: The reporting of stressful events varied over time indicating that while the impact of some stressors endure, others may increase or decline in importance. When screening for PTSD, it is important to consider both traumatic experiences on deployment and other stressful life events, as well as other mental health problems among military personnel, even if individuals do not exhibit symptoms of PTSD on an initial assessment.
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Elbow biomechanics during sports: 21st Century research
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The Treatment of Pediatric Supracondylar Humerus Fractures AUC
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Injuries to the elbow joint are becoming more and more prominent in today's sporting society. This is largely because of the biomechanical demands during popular sports such as baseball, softball, and tennis; wherein the majority of elbow injuries occur. Implications for injuries in these sports range from overuse to incorrect mechanics, which cause increased loads at the elbow joint. This can be seen in the overhead throwing motion where a large varus torque leads to tensile injuries in the medial elbow and compressive injuries in the lateral elbow. The tennis serve produces large varus torque like in baseball pitching, but significantly less elbow extension velocity and elbow flexion torque. In cricket, elbow biomechanics play a very important role, as the rules prohibit elbow flexion during the arm acceleration of bowling. Windmill softball pitchers were once thought to not be at high risk for injury because of their style of throw. However, studies of windmill pitching reveal rapid kinematics and high kinetic loads that are leading to increased amounts of injuries. To improve on surgical treatment, physical therapy, and even prevention of elbow injuries, one must have a good understanding of the biomechanics of the elbow during these activities. This article presents recent advances in understanding elbow biomechanics during sports, based on studies published since the year 2000. (copyright) 2006 Lippincott Williams & Wilkins, Inc
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1 |
Evaluation of sympathetic vasomotor fibres in carpal tunnel syndrome using continuous wave Doppler ultrasonography
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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Sympathetic vasomotor fibres carried by the median nerve and ulnar nerve innervate their respective sensory territories. The sympathetic vasomotor fibres of the median nerve were evaluated in patients with carpal tunnel syndrome and in healthy volunteers using continuous wave Doppler ultrasonography. The pulsatility index of the radialis indicis artery and the radial palmar digital artery of the little finger were measured at baseline and after stimulation. The maximal increase in the pulsatility index of each artery was measured. This was significantly lower for the radialis indicis artery in the CTS group than in the healthy controls. However, there was no significant difference in the maximal increase in pulsatility index of the radial palmar digital artery of the little finger between both groups. Sympathetic vasomotor fibres of the median nerve are affected in carpal tunnel syndrome. Continuous wave Doppler ultrasonography is easy to use and should be investigated further as a possible diagnostic tool for the confirmation of carpal tunnel syndrome
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0 |
Single Nucleotide Polymorphism in the COL11A2 Gene Associated with Heat Pain Sensitivity in Knee Osteoarthritis
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OAK 3 - Non-arthroplasty tx of OAK
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Abstract: Pain is one of the most prominent symptoms of osteoarthritis. However, there is often discordance between the pain experienced by individuals with osteoarthritis and the degree of articular pathology. This suggests that individual differences, including genetic variability in the central processing of nociceptive stimuli, may impact the presentation of osteoarthritis. Here, we show that the single nucleotide polymorphism rs16868943 in the collagen gene COL11A2 is significantly associated with lowered heat pain tolerance on the arm in participants with knee osteoarthritis (P = 1.21 x 10-6, P = 0.0053 after Bonferroni correction, beta = -3.42). A total of 161 knee osteoarthritis participants were included and evaluated for heat, punctate and pressure pain sensitivity of the affected knee and the ipsilateral arm. Each participant was genotyped for 4392 single nucleotide polymorphisms in genes implicated in pain perception, inflammation and mood and tested for association with pain sensitivity. The minor A allele of single nucleotide polymorphism rs16868943 was significantly associated with lower arm heat pain tolerance after correction for age, gender, race, and study site. This single nucleotide polymorphism was also nominally associated with other measures of heat pain sensitivity, including lowered knee heat pain tolerance (P = 1.14 x 10-5, P = 0.05 after Bonferroni correction), lowered arm heat pain threshold (P = 0.0039, uncorrected) and lowered knee heat pain threshold (P = 0.003, uncorrected). Addition of genotypes from 91 participants without knee pain produced a significant interaction between knee osteoarthritis status and the rs16868943 single nucleotide polymorphism in heat pain tolerance (P = 1.71 x 10-5), such that rs16868943 was not associated with heat pain tolerance in participants without knee pain (P = 0.12, beta = 1.3). This is the first study to show genetic association with heat pain tolerance in individuals with osteoarthritis. The association is specific to participants who have already developed knee osteoarthritis, suggesting that the COL11A2 gene, which has previously been associated with familial osteoarthritis, may play a role in pain sensitization after the development of osteoarthritis.
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1 |
Social Causation Versus Social Erosion: Comparisons of Causal Models for Relations Between Support and PTSD Symptoms
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DoD PRF (Psychosocial RF)
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Social support is a robust correlate of posttraumatic stress disorder (PTSD) symptoms and of general psychological distress (Ozer, Best, Lipsey, & Weiss, 2003). The nature of the causal relationship between support and PTSD remains the subject of debate, with 2 models, social erosion and social causation, often used to explain findings. Despite extensive research using these models, no studies of which we are aware have included tests of both models within the same series of analyses, across more than 2 time points, in veterans. These competing models were tested in a sample of National Guard soldiers (N = 521) who completed measures of perceived social support and the PTSD Checklist-Military version (Weathers, Litz, Herman, Huska, & Keane, 1993) at 3 months, 15 months, and 27 months following a combat deployment to Iraq. Analyses were run separately for overall PTSD symptoms and the PTSD components of intrusion, trauma-avoidance, dysphoria, and hyperarousal. Both the social erosion (betas ranging from -.10 to -.19) and social causation (betas ranging from -.08 to -.13) hypotheses were supported. Results suggested PTSD-specific symptom dimensions may both erode and be influenced by social support, whereas general psychological distress erodes social support. Implications for clinical intervention and research are discussed.
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0 |
Low skeletal muscle mass is associated with poor structural parameters of bone and impaired balance in elderly men--the MINOS study
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Management of Hip Fractures in the Elderly
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In 796 men, 50-85 years of age, decreased relative skeletal muscle mass index was associated with narrower bones, thinner cortices, and a consequent decreased bending strength (lower section modulus), as well as with impaired balance and an increased risk of falls. INTRODUCTION: In men, appendicular skeletal muscle mass (ASM) is correlated positively with BMC and areal BMD (aBMD). In elderly men, low muscle mass and strength (sarcopenia) is associated with difficulties in daily living activities. The aim of this study was to evaluate if ASM is correlated with bone size, mechanical properties of bones, balance, and risk of falls in elderly men. MATERIALS AND METHODS: This study used 796 men, 50-85 years of age, belonging to the MINOS cohort. Lifestyle factors were evaluated by standardized questionnaires. Estimates of mechanical bone properties were derived from aBMD measured by DXA. ASM was estimated by DXA. The relative skeletal muscle mass index (RASM) was calculated as ASM/(body height)(2.3). RESULTS: After adjustment for age, body size, tobacco smoking, professional physical activity, and 17beta-estradiol concentration, RASM was correlated positively with BMC, aBMD, external diameter, and cortical thickness (r = 0.17-0.34, p < 0.0001) but not with volumetric BMD. Consequently, RASM was correlated with section modulus (r = 0.29-0.39, p < 0.0001). Men in the lowest quartile of RASM had section modulus of femoral neck and distal radius lower by 12-18% in comparison with men in the highest quartile of RASM. In contrast, bone width was not correlated with fat mass, reflecting the load of body weight (except for L(3)), which suggests that the muscular strain may exert a direct stimulatory effect on periosteal apposition. After adjustment for confounding variables, a decrease in RASM was associated with increased risk of falls and of inability to accomplish clinical tests of muscle strength, static balance, and dynamic balance (odds ratio per 1 SD decrease in RASM, 1.31-2.23; p < 0.05-0.001). CONCLUSIONS: In elderly men, decreased RASM is associated with narrower bones and thinner cortices, which results in a lower bending strength. Low RASM is associated with impaired balance and with an increased risk of falls in elderly men. It remains to be studied whether low RASM is associated with decreased periosteal apposition and with increased fracture risk in elderly men, and whether the difference in skeletal muscle mass between men and women contributes to the between-sex difference in fracture incidence
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0 |
Post-traumatic osteoarthritis: From mouse models to clinical trials
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OAK 3 - Non-arthroplasty tx of OAK
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Osteoarthritis (OA), the most common of all arthropathies, is a leading cause of disability and has a large (and growing) worldwide socioeconomic cost. Despite its burgeoning importance, translation of disease-modifying OA therapies from the laboratory into clinical practice has slowed. Differences between the OA models studied preclinically and the disease evaluated in human clinical trials contribute to this failure. Most animal models of OA induce disease through surgical or mechanical disruption of joint biomechanics in young individuals rather than the spontaneous development of age-associated disease. This instability-induced joint disease in animals best models the arthritis that develops in humans after an injurious event, known as post-traumatic OA (PTOA). Studies in genetically modified mice suggest that PTOA has a distinct molecular pathophysiology compared with that of spontaneous OA, which might explain the poor translation from preclinical to clinical OA therapeutic trials. This Review summarizes the latest data on potential molecular targets for PTOA prevention and modification derived from studies in genetically modified mice, and describes their validation in preclinical therapeutic trials. This article focuses on how these findings might best be translated to humans, and identifies the potential challenges to successful implementation of clinical trials of disease-modifying drugs for PTOA. © 2013 Macmillan Publishers Limited. All rights reserved.
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MRI and bone scintigraphy in operated high risk femoral neck fractures
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Management of Hip Fractures in the Elderly
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Fifteen patients who had been operated on for high risk femoral neck fractures with titanium screws were examined with 1.0 Tesla MRI and scintimetry at 1 and 6 weeks after operation. Radiological and clinical follow-up was performed up to two years after surgery. Three patients underwent a third 1.5 Tesla MRI examination. Six patients had normal radiographic findings. Early redisplacement (R) was found in 5/15 patients and non-union (NU) in 2/15 patients. Two patients developed late segmental collapse (LSC). Scintigraphy correlated well with normal radiographic findings, but seemed less reliable in detecting R, NU and LSC. MRI seemed reliable but revealed pathological changes in 2/6 patients with an uneventful recovery. Three of 5 patients with R had moderate to severe pathological findings on MRI. In 2 cases with NU moderate or severe pathologic changes were seen, and 2 patients with LSC had clear pathological MRI findings. We conclude that MRI seems to be the method of choice to detect osteonecrotic areas early, even with T weighted images only, if performed more than 6 weeks after the operation
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0 |
New radiographic standards for age at appearance of the ossification center of the femoral head in Japanese: Appearance at â?¤12 months of age is normal in Japanese infants
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Developmental Dysplasia of the Hip 2020 Review
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BACKGROUND: The ossification center of the femoral head reportedly appears at 7-8 months in 95% infants in the radiographs, but its appearance often delays in Japanese normal infants. The purpose of this study was to survey the age at appearance of the femoral head in the radiographs, evaluate the normal standards of its appearance in Japanese infants, and determine whether the acetabular state affects the time of its appearance. MATERIALS AND METHODS: The patients comprised 436 infants consulted with our institution because of a limitation of abduction in flexion (LA), acetabular dysplasia, or suspected developmental dysplasia of the hip (DDH). Among these patients, 111 infants (222 hips) without radiographic appearance of the femoral head at the first visit were reviewed. The 222 hips were classified into three groups: α angle �30° (DDH + group), <30° with LA (DDH-/LA + group), or < 30° without LA (DDH-/LA-group). The age at appearance of the femoral head was investigated in the radiograph in each group. RESULTS: The 50th percentile of the age at appearance of the femoral head was 6 months in the DDH-/LA- and DDH-/LA + groups and 8 months in the DDH + group. The femoral head significantly appeared earlier in the DDH-/LA- and DDH-/LA + groups than in the DDH + group (P < 0.01). The 95th percentile was 12 months in all groups. CONCLUSIONS: Radiographic appearance of the ossification center of the femoral head by 12 months of age is normal in Japanese infants. When the α angle is � 30°, the age at appearance of the femoral head is sometimes delayed.
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Peripheral dystonia
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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We studied four patients with distal, action-induced involuntary postures of the hand that could be considered focal dystonia. All four patients had electro-physiologic findings consistent with peripheral nervous system lesions (pronator teres syndrome, radial nerve palsy, lower brachial plexus lesion, or median nerve lesion). With varying success, patients were treated with carbamazepine, trihexyphenidyl, methocarbamol, and wrist splinting. We wish to emphasize that peripheral entrapment and brachial plexopathy should be added to the causes of secondary dystonias
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Greater first year effectiveness drives favorable cost-effectiveness of brand risedronate versus generic or brand alendronate: modeled Canadian analysis
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HipFx Supplemental Cost Analysis
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The RisedronatE and ALendronate (REAL) study provided a unique opportunity to conduct cost-effectiveness analyses based on effectiveness data from real-world clinical practice. Using a published osteoporosis model, the researchers found risedronate to be cost-effective compared to generic or brand alendronate for the treatment of Canadian postmenopausal osteoporosis in patients aged 65 years or older. INTRODUCTION: The REAL study provides robust data on the real-world performance of risedronate and alendronate. The study used these data to assess the cost-effectiveness of brand risedronate versus generic or brand alendronate for treatment of Canadian postmenopausal osteoporosis patients aged 65 years or older. METHODS: A previously published osteoporosis model was populated with Canadian cost and epidemiological data, and the estimated fracture risk was validated. Effectiveness data were derived from REAL and utility data from published sources. The incremental cost per quality-adjusted life-year (QALY) gained was estimated from a Canadian public payer perspective, and comprehensive sensitivity analyses were conducted. RESULTS: The base case analysis found fewer fractures and more QALYs in the risedronate cohort, providing an incremental cost per QALY gained of $3,877 for risedronate compared to generic alendronate. The results were most sensitive to treatment duration and effectiveness. CONCLUSIONS: The REAL study provided a unique opportunity to conduct cost-effectiveness analyses based on effectiveness data taken from real-world clinical practice. The analysis supports the cost-effectiveness of risedronate compared to generic or brand alendronate and the use of risedronate for the treatment of osteoporotic Canadian women aged 65 years or older with a BMD T-score < or =-2.5
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[Reconstruction of chest wall after resection]
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Acellular Dermal Matrix
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OBJECTIVE: To evaluate the results of chest wall reconstruction (CWR) in patients who underwent chest wall tumor resection accompanying huge chest wall defect. METHODS: From Jan. 1998 to Mar. 2003, 31 patients underwent CWR. Among them, 20 were male and 11 female. The age ranged from 8 to 72 years. The indications for resection were primary chest wall tumor in 21 patients, lung cancer with invasion of chest wall 6, recurrence of breast cancer 2, radiation necrosis 1 and skin cancer 1. The number of rib resected was 2-7 ribs (3.6 in average). The defect was 20-220 cm2 (97.1 cm2 in average). Concomitant resection was done in 13 patients, including lobectomy or wedge resection of lung 10, partial resection of diaphragm 2, and partial sternotomy 1. Seven patients underwent soft tissue reconstruction alone (latissimus dorsi+greater omentum, latissimus dorsi myocutaneous flap, latissimus dorsi muscle flap), 5 patients bony reconstruction alone (Prolene web), and simultaneous BR and STR were performed in 19 patients (latissimus dorsi, pectoralis major, latissimus dorsi+fascia lata, and Prolene web). RESULTS: Three patients (9.7%) developed postoperative complications. Postoperative survival period was 6-57 months with a median of 22 months. CONCLUSION: A favorable clinical outcome can be achieved by CWR for the patients with huge chest wall defects that result from resection of chest wall tumors.
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1 |
Upper-Arm Anthropometry: An Alternative Indicator of Nutritional Health to Body Mass Index in Unilateral Lower-Extremity Amputees?
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DoD LSA (Limb Salvage vs Amputation)
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Miller M, Wong WK, Wu J, Cavenett S, Daniels L, Crotty M. Upper-arm anthropometry: an alternative indicator of nutritional health to body mass index in unilateral lower-extremity amputees? Objective: To evaluate the utility of body mass index (BMI) and corrected-arm-muscle area (CAMA) as measures of nutritional health for lower-limb amputees attending prosthetics clinics. Design: Cross-sectional study. Setting: Prosthetics clinic in Australia. Participants: Unilateral lower-extremity amputees (N=58; age range, 21-91y; 37 transtibial, 21 transfemoral) attending a regional prosthetics clinic between May and November 2003. Interventions: Not applicable. Main Outcome Measures: Weight (without prosthesis), corrected and uncorrected for the amputated limb was used with height estimated from knee height to calculate corrected BMI (cBMI) and uncorrected BMI (uBMI). CAMA was calculated using the mean of triplicate mid-upper-arm circumference (MUAC) and triceps skinfold thickness (TST) measurements. The Mini Nutritional Assessment (MNA) and Assessment of Quality of Life were administered according to recommended protocols. The Pearson correlation was used to determine the strength and significance of associations between variables, and bivariate regression analyses were performed to determine whether an association existed between the nutritional variables (BMI, CAMA, MNA) and quality of life (QOL). Results: There were no statistically significant differences in the measures of nutritional health according to site (transtibial, transfemoral) of amputation. MUAC, TST, and CAMA all showed moderate to high positive correlations (r range, .541-.782) with both cBMI and uBMI. The strength of the relationship between the MNA and cBMI/uBMI was weaker (r=.383, r=.380, respectively) but remained positive and statistically significant (P=.003). QOL was not associated with cBMI or uBMI but was related to CAMA (β=-.132; P=.030) and MNA (β=-.561; P=.017). Conclusions: For persons with unilateral lower-extremity amputation, measurement of upper-arm anthropometry may be a more useful indicator of nutritional health and its consequences than BMI. © 2008 American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation.
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Facet joint menisci of the cervical spine: Correlative MR imaging and cryomicrotomy study
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AMP (Acute Meniscal Pathology)
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An analysis of the cervical facet joint menisci was done in which cryomicrotomy sections were correlated with magnetic resonance (MR) images. In parasagittal anatomic sections in ten candavers, 10-69 years of age at death, four types of meniscus were defined. Type 1 was a thin washer of dense connective tissue covering 50% or more of the joint space. Type 2 in sagittal section appeared as a wedge of connective tissue containing collagen in the tapering free edge and fat in the peripheral portion attached to the joint capsule. Type 3 had no meniscuslike connective tissue extending into the joint. Type 4 had irregular, thick masses of collagen, fat, and cartilage in the periphery of the joint space. Menisci in the child were predominantly type 1. In adults type 2 menisci predominated at C1-2 and type 3 in the lower cervical facet joints. The few type 4 menisci found were in association with facet joint degeneration. Types 2 and 4 menisci could be demonstrated with MR imaging. In MR images the collagenous portion of the menisci were of low signal intensity, and the fat was of higher signal intensity. Few menisci conform to the traditional anatomic description.
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1 |
Association of patella alta with worsening of patellofemoral osteoarthritis-related structural damage: data from the Osteoarthritis Initiative
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OAK 3 - Non-arthroplasty tx of OAK
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Objectives: To determine the association between Insall-Salvati ratio (ISR), a measure of patella alta, and worsening of Magnetic Resonance Imaging (MRI)-based osteoarthritis (OA)-related patellofemoral joint structural damages over 24-month in participants of the Osteoarthritis Initiative (OAI). Design: Using weighted random sampling method, we selected a sample of 500 knees (from 1,677 knees with available baseline and 24-months MRI OA Knee Score (MOAKS) measurements), which is OAI-representative regarding knee OA-related factors (i.e., baseline age, sex, body mass index (BMI), and radiographic Kellgrenâ??Lawrence grading). The ISR was measured in all enrolled knees using baseline sagittal 3T-MRI plane by three radiologists. Baseline and 24-month MOAKS variables for patellofemoral bone marrow lesions (BMLs), cartilage damages, and osteophytes were extracted, and the associations between ISR and 24-month worsening of these 3T-MRI features were evaluated using multivariable regression models. After computing receiver operating characteristic curves, the optimal cutoff point of ISR for indicating worsening of patellofemoral OA was determined. P-values were adjusted for multiple comparisons and false discovery rate (FDR) adjusted P-values were reported. Results: In this longitudinal analysis, 24-month worsening of BML (odds ratio [OR] (95% confidence interval [95% CI]):11.18 (3.35â??39.6), adjusted-p-value:<0.001) and cartilage scores (OR:7.39 (1.62â??34.71), adjusted-p-value:0.042) in lateral patella was associated with higher baseline ISR. However, higher ISR was not statistically associated with medial patellar or medial and lateral trochlear BML or cartilage scores worsening. We determined the optimal cutoff point of ISRâ?¥1.14 (95% CI: 1.083â??1.284) for predicting lateral patellofemoral OA-related structural damages worsening over 24-months (sensitivity:73.73%; specificity: 66.67%). Conclusions: Given the uncertainly surrounding the results, our overall findings suggest that ISR could be considered as a predictor of lateral patellofemoral OA-related structural damages worsening with the optimal cutoff point of â?¥1.14 using knee sagittal MRI measurements.
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SIRT1, a class III histone deacetylase, regulates TNF-alpha-induced inflammation in human chondrocytes
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OAK 3 - Non-arthroplasty tx of OAK
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OBJECTIVE: The present study was performed to elucidate the possible role of SIRT1 signaling in joint inflammation in human articular chondrocytes.
DESIGN: Real-time quantitative reverse transcription polymerase chain reaction (qRT-PCR) and Western blotting were performed to detect gene products and proteins involved in tumor necrosis factor alpha (TNF-alpha)-induced inflammation and cartilage degradation in human primary chondrocytes. Matrix metalloproteinase (MMP)-2 and MMP-9 activity was evaluated by gelatin zymography. Overexpression and knockdown of SIRT1 were also performed to investigate whether SIRT1 is associated with the anti-inflammatory activity of resveratrol in chondrocytes.
RESULTS: Resveratrol dose-dependently inhibited TNF-alpha-induced cyclooxygenase-2 (COX-2), MMP-1, MMP-3, MMP-13 and PGE(2) production in human chondrocytes. Moreover, MMP-2 and MMP-9 activity was increased by treatment with TNF-alpha; however, SIRT1 activation decreased the proinflammatory effects induced by TNF-alpha. In addition, treatment of SIRT1 activator and overexpression of SIRT1 inhibited the expression and activation of the main proinflammatory regulator NF-kappaB, which was increased by TNF-alpha. When SIRT1 was overexpressed in chondrocytes, the anti-inflammatory action of SIRT1 was similar to that exerted by resveratrol.
CONCLUSIONS: SIRT1 activation deacetylates and inactivates NF-kappaB, and thereby, exerts an anti-inflammatory effect on chondrocytes, suggesting that SIRT1 activators could be explored as potential treatments for arthritis.
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Open Talus Fractures: Early Infection and Its Epidemiological Characteristics
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DoD SSI (Surgical Site Infections)
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Open talus fractures are relatively rare and severe open injuries with a high risk of severe infection. To better understand the epidemiological characteristics of this kind of injury, a monocentric case review was conducted among open talus fracture patients admitted in West China Hospital of Sichuan University between January 2010 and December 2014. Fifty-one (N=51) patients were recruited to the study, including 44 (86.3%) males and 7 (13.7%) females. Fifty-two cases of open talus fractures were diagnosed among the patients (1 patient had bilateral fractures). The primary cause of open talus fracture was a fall from a height. The rate of concurrent injuries associated with open talus fracture was 84.3%. The overall infection rate was 41.2%, rising with the increase of injury severity classified by Gustilo-Anderson classification and the existence of peritalar dislocation. Therefore, it can be concluded that open talus fractures are at high risk of concurrent complications and early infection. It is necessary to perform a complete physical examination to search for possible concurrent injuries. When evaluating the risk of infection, in addition to the severity of open talus fracture, the existence and severity of peritalar dislocation should also be taken into consideration.
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Lateral trunk lean and medializing the knee as gait strategies for knee osteoarthritis
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OAK 3 - Non-arthroplasty tx of OAK
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OBJECTIVE: To determine (1) if Medial Thrust or Trunk Lean reduces the knee adduction moment (EKAM) the most during gait in patients with medial knee osteoarthritis, (2) if the best overall strategy is the most effective for each patient and (3) if these strategies affect ankle and hip kinetics.
DESIGN: Thirty patients with symptomatic medial knee osteoarthritis underwent 3-dimensional gait analysis. Participants received verbal instructions on two gait strategies (Trunk Lean and Medial Thrust) in randomized order after comfortable walking was recorded. The peaks and impulse of the EKAM and strategy-specific kinematic and kinetic variables were calculated for all conditions.
RESULTS: Early stance EKAM peak was significantly reduced during Medial Thrust (-29%). During Trunk Lean, early and late stance EKAM peak and EKAM impulse reduced significantly (38%, 21% and -25%, respectively). In 79% of the subjects, the Trunk Lean condition was significantly more effective in reducing EKAM peak than Medial Thrust. Peak ankle dorsi and plantar flexion, knee flexion and hip extension and adduction moments were not significantly increased.
CONCLUSIONS: Medial Thrust and Trunk Lean reduced the EKAM during gait in patients with knee osteoarthritis. Individual selection of the most effective gait modification strategy seems vital to optimally reduce dynamic knee loading during gait. No detrimental effects on external ankle and hip moments or knee flexion moments were found for these conditions.
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Aging-related inflammation in osteoarthritis
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AMP (Acute Meniscal Pathology)
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It is well accepted that aging is an important contributing factor to the development of osteoarthritis (OA). The mechanisms responsible appear to be multifactorial and may include an age-related pro-inflammatory state that has been termed "inflamm-aging." Age-related inflammation can be both systemic and local. Systemic inflammation can be promoted by aging changes in adipose tissue that result in increased production of cytokines such as interleukin (IL)-6 and tumor necrosis factor-a (TNFa). Numerous studies have shown an age-related increase in blood levels of IL-6 that has been associated with decreased physical function and frailty. Importantly, higher levels of IL-6 have been associated with an increased risk of knee OA progression. However, knockout of IL-6 in male mice resulted in worse age-related OA rather than less OA. Joint tissue cells, including chondrocytes and meniscal cells, as well as the neighboring infrapatellar fat in the knee joint, can be a local source of inflammatory mediators that increase with age and contribute to OA. An increased production of pro-inflammatory mediators that include cytokines and chemokines, as well as matrix-degrading enzymes important in joint tissue destruction, can be the result of cell senescence and the development of the senescence-associated secretory phenotype (SASP). Further studies are needed to better understand the basis for inflamm-aging and its role in OA with the hope that this work will lead to new interventions targeting inflammation to reduce not only joint tissue destruction but also pain and disability in older adults with OA.
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Impending or completed pathologic femur fractures treated with intramedullary hip screws
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Hip Fx in the Elderly 2019
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This study examined the use of the long intramedullary hip screw in 13 consecutive patients with metastatic disease of the femur with impending or completed fractures. There were 6 impending and 7 completed fractures. Eleven of 13 patients had unreamed rods placed with an average operative time of 100 minutes and blood loss of 280 cc. Eleven of 12 patients who were able to ambulate preoperatively regained that status postoperatively. Postoperative complications included death (1), myocardial infarction (1), and urinary tract infection (2). These results indicate the long intramedullary hip screw is a safe and effective surgical device for treating metastatic disease of the femur.
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The Reconstruction of Periprosthetic Pelvic Discontinuity
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Hip Fx Time to Surgery
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The surgical techniques and outcomes of acetabular reconstruction for periprosthetic pelvic discontinuity cases are reported. The mean time to surgery for 9 patients with acute pelvic discontinuity was 16.3 days, with 8 patients (88%) having posterior column plating and a porous metal acetabular cup. No cases required revision surgery, with a mean follow-up of 34 months (range, 24-67 months). Of the 62 chronic pelvic discontinuity cases, 20 had an ilioischial cage, with a revision rate of 29%. There were 42 cup-cage reconstructions with an 8-year survivorship of 86.3%, with a mean follow-up of 35 months (range, 24-93 months). Stable reconstruction of chronic pelvic discontinuity was achievable by distraction using a cup-cage acetabular reconstruction; however, satisfactory stability of acute pelvic discontinuity was achieved with compression of the posterior column using screw augmentation of the acetabular shell supplemented by posterior column plating. © 2012 Elsevier Inc.
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A case of severe hydroxychloroquine-induced retinal toxicity in a patient with recent onset of renal impairment: a review of the literature on the use of hydroxychloroquine in renal impairment
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Upper Eyelid and Brow Surgery
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We present a case of a 67-year-old female who presented with a twelve-month history of progressive blurred vision in both eyes. The patient was on hydroxychloroquine 200 mg twice a day for eight years for the treatment of scarring alopecia. Two years prior to presenting, the patient was found to have chronic kidney disease stage 3 secondary to hypertension. Examination revealed bilateral reduced visual acuities with attenuated arterioles and pigmentary changes on retinal assessment. Goldmann visual fields showed grossly constricted fields in both eyes. The patient was diagnosed with retinal toxicity secondary to hydroxychloroquine probably potentiated by renal impairment. Risk factors for retinal toxicity secondary to hydroxychloroquine can be broadly divided into dose-related and patient-related factors. Our patient developed severe retinal toxicity despite being on the recommended daily dose (400 mg per day). Although retinal toxicity at this dose has been documented, the development of renal impairment without dose adjustment or close monitoring of visual function is likely to have potentiated retinal toxicity. This case highlights the need to monitor renal function in patients on hydroxychloroquine. Should renal impairment develop, either the drug should be stopped or the dose reduced with close monitoring of visual function by an ophthalmologist.
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Unilateral total knee arthroplasty: Comparison among subcutaneous drainage, articular cavity drainage, and no drainage
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PJI DX Updated Search
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BACKGROUND: Drainage placement and pattern during total knee arthroplasty (TKA) remain controversial. OBJECTIVE: To explore the effect of subcutaneous drainage after unilateral TKA with or without drainage. METHODS: A randomized prospective study was performed. The 101 patients were divided into 3 groups: subcutaneous drainage (n=35), articular cavity drainage (n=32), no drainage (n=34). The blood loss, blood transfusion and hemoglobin reduction among groups were compared. The recovery after surgery and the correlative complications were analyzed. RESULTS AND CONCLUSION: Subcutaneous ecchymosis area (11-30 cm<sup>2</sup>, > 30 cm<sup>2</sup>) and knee joint diameter increase rate 3 days post surgery were significantly lower in subcutaneous drainage group compared with other groups (P < 0.05); blood transfusion amount, drainage amount 24 hours post replacement, hemoglobin reduction were lower in subcutaneous drainage group compared with articular cavity drainage group (P < 0.05). The pain scores, flexion degree, infection rate during 1-year follow-up were similar among the groups (P > 0.05). Results show that subcutaneous drainage has advantages after unilateral TKA compared with articular cavity drainage or no drainage
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