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Anaesthesia for major surgery in a patient with a transplanted heart
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AAHKS (8) Anesthetic Infiltration
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A 29 yr old male presented for elective hip replacement surgery 26 mth after cardiac transplantation. The principles involved in the anesthetic management of this patient include sterile management of the airway, maintenance of an adequate intravascular volume, and immediate detection and treatment of hypotension and arrhythmia should they occur. The patient made a good recovery from both anesthesia and operation.
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How do visual, spectroscopic and biomechanical changes of cartilage correlate in osteoarthritic knee joints?
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Surgical Management of Osteoarthritis of the Knee CPG
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BACKGROUND: Characteristic changes in cartilage of human knee joints with different degrees of osteoarthritis (OA) have been investigated by visual, biophotonical and biomechanical examination. Knowledge about the cartilage composition and changes during the development of OA is important for diagnostic decisions and understanding the pathogenesis of OA. METHODS: Thirty two patients with severe knee OA received endoprosthetic replacement. During surgical intervention cartilage specimen were harvested from defined surface areas of the joints. The degree of cartilage defects was classified visually (ICRS Grade: International Cartilage Repair Society), biophotonically (NIRS: near infrared spectroscopy) and biomechanically (Young's Modulus). To characterise links between the investigated parameters the Spearman's rank correlation coefficient was used. FINDINGS: Significant negative correlations were found between visual macroscopic degree of degeneration (ICRS Grade) and biophotonic characteristics (NIRS) (rho=-0.467) or cartilage stiffness (Young's Modulus) (rho=-0.501). Between NIRS and Young's Modulus significant positive correlation of rho=0.535 was detected. INTERPRETATION: Visual, biophotonic and biomechanical properties of cartilage reveal strong correlations in all degrees of cartilage defects in patients with severe OA. According to these results, we indicate that an objective, non-invasive and non-destructive measurement of cartilage properties during open and arthroscopic knee surgery is possible by NIRS and provide a novel tool to evaluate disease intervention and treatment
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Compartment syndrome in open tibial fractures
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DOD - Acute Comp Syndrome CPG
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A retrospective review of the cases of 180 patients who had 198 acute open fractures of the tibial shaft and were admitted to a multiple-trauma referral center over a three-year period revealed an incidence of accompanying compartment syndrome of 9.1 per cent (eighteen fractures in sixteen patients). Each of the eighteen compartment syndromes was documented by measurements of intracompartmental pressure that were obtained by the saline-injection technique, and all were treated by four-compartment fasciotomy. The incidence of compartment syndrome was found to be directly proportional to the degree of injury to soft tissue and bone; this complication occurred most often in association with a comminuted, grade-III open injury to a pedestrian. The physician must maintain a high index of suspicion to detect a compartment syndrome in the patient who has multiple trauma, as its clinical signs and symptoms may be masked by a closed injury of the head or the need for ventilatory support or prolonged anesthesia for other surgical procedures.
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Uncovering the Hidden Penis: A Novel Nomenclature and Classification System
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Panniculectomy & Abdominoplasty CPG
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INTRODUCTION: A hidden penis can interfere with normal hygiene, prevent effective voiding, restrict sexual activity, and cause great embarrassment to the patient. The terms "hidden," "buried," and "trapped" penis are used interchangeably. To date, there is no classification system that adequately characterizes the spectrum of this condition. In this study, we propose a simplified nomenclature and classification system for adult-acquired hidden penis. METHODS: We performed a retrospective review of all adult patients treated surgically for hidden penis by the senior author from 2009 to 2019. Patients were classified into either "buried" or "trapped" categories. A "buried" penis was defined as a hidden penis concealed by suprapubic fat without fibrous tethering. These patients were managed with panniculectomy, monsplasty, or both. In contrast, those with a "trapped" penis presented with scarred or fibrous tissue, which required surgical lysis, phalloplasty, and penile skin resurfacing. RESULTS: Thirteen patients met the inclusion criteria. The cohort was aged 53 ± 15.7 years with a mean body mass index of 37.4 ± 4.3 kg/m. Two patients required repeat operations, yielding a total of 15 operative encounters. Six were defined as buried, and 9 as trapped. Inability to achieve erection was the most common preoperative complaint in those with buried penis (67%), whereas difficulties in voiding were most common with trapped penis (78%). Patients with trapped penises had a significantly larger body habitus than those with a buried penis (39.8 vs 34.2 kg/m, P = 0.0088). Operative duration and length of hospital stay were comparable between the trapped and buried penis groups (206 vs 161 minutes, P = 0.3664) (5 vs 1 day, P = 0.0836). One third experienced wound complications, but this was not significantly different between buried and trapped penises (17% vs 44%, P = 0.5804). Postoperatively, 5 patients experienced spontaneous erections, and 7 were able to void while standing. CONCLUSIONS: Patients with a trapped penis present with a different preoperative symptom profile and body type than those with a buried penis. Our nomenclature and classification system offer a simple and clear algorithm for the management of hidden penis. Large cohort studies are warranted to assess differences in clinical outcomes between trapped and buried penises.
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Lateral fixation of open AO type-B2 ankle fractures: the Knowles pin versus plate
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DoD SSI (Surgical Site Infections)
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Forty-seven patients with open lateral malleolar (AO type-B2) fractures treated with copious irrigation and radical debridement, reduction, and immediate fixation by Knowles pins or lateral plates were retrospectively reviewed with an average follow-up period of 29 months. The 47 patients were divided into two groups, based on the method of treatment. The Knowles pin group included 25 patients. The plate group included 22 patients. There was no difference between the Knowles pinning and lateral plating with respect to the rate of good reduction (96% vs. 95.5%, p = 1). Both of the groups were similar in good and excellent results (92% vs. 86.4%, p = 0.65). However, Knowles pinning had significantly shorter operation time, smaller wound size, less symptomatic hardware, and lower complication rate than lateral plating (all p values <0.04). In conclusion, lateral fixation of open AO type-B2 ankle fractures by the Knowles pin is recommended due to its efficacy, simplicity, and low complication rate.
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Femoral malrotation after surgical treatment of femoral shaft fractures in children: a retrospective CT-based analysis
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Pediatric Diaphyseal Femur Fractures 2020 Review
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BACKGROUND: Rotational malalignment is an important and not always avoidable complication after surgical treatment of femoral shaft fractures. The purpose of this study was to determine the incidence of rotational malalignment in children after surgical treatment of femoral shaft fractures and to identify potential patient- and treatment-related risk factors based on data obtained from CT scans. METHODS: We conducted a retrospective analysis of all patients aged less than 15 years with femoral shaft fractures admitted to our level 1 trauma centre between January 2004 and July 2014. Patients having obtained postoperative CT scans were included for the determination of rotational malalignment. A difference of greater than 15° in femoral torsion between both legs was considered as clinically relevant. Additionally, demographic data and clinical information such as fracture type, treatment method, fluoroscopy time and operating time were reviewed. RESULTS: A total of 24 patients were enrolled in this study. Clinically relevant femoral malrotation was identified in 10 patients (41.6%). Surgical revision was performed in 7 patients (29.2%). There was no association between the type of surgical procedure, age and the incidence and/or amount of femoral malrotation. CONCLUSIONS: The data suggest that relevant femoral malrotation is an evident problem after surgical treatment of femoral shaft fractures in children that requires critical postoperative assessment. LEVEL OF EVIDENCE: Level III, retrospective study.
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Sports activities after lower limb osteotomy
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SR for PM on OA of All Extremities
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INTRODUCTION: Active sports participation can be important in some patients with degenerative joint disease in the lower limb. We investigated whether this is possible after an osteotomy for osteoarthritis of the hip, knee and ankle joints. SOURCES OF DATA: We performed a literature search using Medline, Cochrane, CINAHL and Google Scholar with no restriction to time period or language using the keywords: 'osteotomy and sports'. Eleven studies (all level IV evidence) satisfied our inclusion and exclusion criteria. Nine reported on high tibial osteotomies, one on periacetabular osteotomies and one on distal tibial osteotomies. The Coleman Methodology Score to assess the quality of studies showed much heterogeneity in terms of study design, patient characteristics, management methods and outcome assessment. AREAS OF AGREEMENT: Participation in recreational sports is possible in most patients who were active in sports before lower limb osteotomy. In no study were patients able to participate in competitive sports. AREAS OF CONTROVERSY: Intensive participation in sports after osteotomy may adversely affect outcome and lead to failures requiring re-operation. GROWING POINTS: Patients may be able to remain active in selected sports activities after a lower limb osteotomy for osteoarthritis. More rapid progression of arthritis is however a possibility. AREAS TIMELY FOR DEVELOPING RESEARCH: Prospective comparative studies investigating activities and sports participation in age-matched patients undergoing osteotomy or joint replacement could lead to useful conclusions. Increased activity and active sports participation may lead to progression of arthritis and earlier failure requiring additional surgery
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Acetylcholinesterase Inhibitors Are Associated with Reduced Fracture Risk among Older Veterans with Dementia
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Hip Fx in the Elderly 2019
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Acetylcholinesterase inhibitors (AChEIs) have been noted to increase bone density and quality in mice. Human studies are limited but suggest an association with improved bone healing after hip fracture. We examined the relationship between AChEI use and fracture risk in a national cohort of 360,015 male veterans aged 65 to 99 years with dementia but without prior fracture using Veterans Affairs (VA) hospital, Medicare, and pharmacy records from 2000 to 2010. Diagnosis of dementia, any clinical fracture (excluding facial and digital), comorbidities, and medications were identified using ICD-9 and drug class codes. Cox proportional hazard models considering AChEI use as a time-varying covariate and adjusting for fall and fracture risk factors compared the time-to-fracture in AChEI users versus non-AChEI users. Potential confounders included demographics (age, race, body mass index), comorbidities associated with fracture or falls (diabetes, lung disease, stroke, Parkinson's, seizures, etc.) and medications associated with fracture or falls (bisphosphonates, glucocorticoids, androgen deprivation therapy [ADT], proton pump inhibitors [PPIs], selective serotonin receptor inhibitors [SSRIs], etc.). Competing mortality risk was considered using the methods of Fine and Gray. To account for persistent effects on bone density or quality that might confer protection after stopping the medication, we completed a secondary analysis using the medication possession ratio (MPR) as a continuous variable in logistic regression models and also compared MPR increments of 10% to minimal/no use (MPR 0 to <0.10). Among older veterans with diagnosis of dementia, 20.1% suffered a fracture over an average of 4.6 years of follow-up. Overall, 42.3% of the cohort were prescribed AChEIs during the study period. The hazard of any fracture among AChEI users compared with those on other/no dementia medications was significantly lower in fully adjusted models (hazard ratio [HR] = 0.81; 95% confidence interval [CI] 0.75-0.88). After considering competing mortality risk, fracture risk remained 18% lower in veterans using AChEIs (HR = 0.82; 95% CI 0.76-0.89). © 2019 American Society for Bone and Mineral Research. Published 2019. This article is a U.S. Government work and is in the public domain in the USA.
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Variable expressivity in a family with an aggrecanopathy
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Osteochondritis Dissecans 2020 Review
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BACKGROUND: Osteochondritis dissecans is a condition wherein there is a subchondral bone lesion that causes pain, inflammation, and cartilage damage. Dominant Familial Osteochondritis Dissecans is a rare and severe form of osteochondritis dissecans (OCD). It is caused by heterozygous pathogenic variants in the gene encoding Aggrecan; ACAN. Aggrecan, a proteoglycan, is an essential component of the articular and growth plate cartilage. METHODS: Herein, we report three individuals from one family; the proband who presented with short stature, a lower limb bone exostosis, and bilateral knee and elbow OCD at the age of 13 years old. His twin brother presented with isolated short stature and his father with short stature and lumbar disc herniation. RESULTS: Next-generation sequencing of the ACAN gene in the proband identified a frameshift variant which is also present in the brother and father with short stature. The proband was treated surgically with bilateral elbow microfracture, after the failure of conservative therapy. CONCLUSION: To the best of our knowledge, this is the first patient with an aggrecanopathy who presents with osteochondritis dissecans due to a frameshift variant. This family presents with variable expressivity which might be attributed to modifier genes.
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Risk factors and predictors of mortality for proximal humeral fractures
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MSTS 2022 - Metastatic Disease of the Humerus
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BACKGROUND: Risk factors for mortality after proximal humeral fracture, including socioeconomic status, are poorly defined. This retrospective review of prospectively collected data defines the epidemiology and predictors of mortality in association with proximal humeral fractures.
METHODS: Patients who sustained proximal humeral fractures were identified from fragility fracture and trauma databases between May 2001 and September 2012.
RESULTS: In total, 1880 patients with a mean age of 69 years and a male to female ratio of 2 : 3 were identified. Socioeconomic distribution is skewed towards the lowest and highest quintiles. Low-energy mechanisms caused 88% of fractures. Men sustain fractures when they are aged 10 years younger and via higher-energy mechanisms. In total, 536 patients (29%) died within the study period with a 1-year mortality of 9.8%, rising to 28.2% at 5 years. Female gender, increasing age, pathological fracture and increased number of co-morbidities were independent variables for increased mortality.
CONCLUSIONS: The present study, which was conducted over an 11-year period, is the first to combine the epidemiology and risk factors for mortality with socioeconomic rank. One-year mortality risk is twice that of the background matched population. Patient counselling with respect to increased mortality should be considered, especially in higher-risk elderly females with multiple co-morbidities.
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Migraine Care in the Era of COVID-19: Clinical Pearls and Plea to Insurers
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Coronavirus Disease 2019 (COVID-19)
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OBJECTIVE: To outline strategies for the treatment of migraine which do not require in-person visits to clinic or the emergency department, and to describe ways that health insurance companies can remove barriers to quality care for migraine. BACKGROUND: COVID-19 is a global pandemic causing widespread infections and death. To control the spread of infection we are called to observe "social distancing" and we have been asked to postpone any procedures which are not essential. Since procedural therapies are a mainstay of headache care, the inability to do procedures could negatively affect our patients with migraine. In this manuscript we review alternative therapies, with particular attention to those which may be contra-indicated in the setting of COVID-19 infection. DESIGN/RESULTS: The manuscript reviews the use of telemedicine visits and acute, bridge, and preventive therapies for migraine. We focus on evidence-based treatment where possible, but also describe "real world" strategies which may be tried. In each section we call out areas where changes to rules from commercial health insurance companies would facilitate better migraine care. CONCLUSIONS: Our common goal as health care providers is to maximize the health and safety of our patients. Successful management of migraine with avoidance of in-person clinic and emergency department visits further benefits the current urgent societal goal of maintaining social distance to contain the COVID-19 pandemic.
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The lateral decubitus approach for complex proximal femur fractures: Anatomic reduction and locking plate neutralization: A technical trick
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Management of Hip Fractures in the Elderly
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Unstable intertrochanteric or subtrochanteric fractures with significant proximal or distal extension or comminution are often a challenge for achieving stable fixation. In recent years, locked proximal femoral plates have been developed that aid fixation of these complex fractures often permitting the biological advantages of minimal contact or minimally invasive application. Although previously described with success using a standard lateral approach in the supine position, we describe a lateral decubitus position for the locked plating of proximal femur fractures. We have found that lateral positioning neutralizes the gravitational forces acting on the bone and soft tissues, facilitating reduction and exposure while continuing to be compatible with intraoperative image intensification. We present lateral positioning as a technical trick for anatomic and stable reduction of complex proximal femur fractures with proximal femoral locking plates and present a series of 10 cases that were treated with this combination of approach and internal fixation. (copyright) 2012 Lippincott Williams & Wilkins, Inc
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Variables Associated with Self-Prediction of Psychopharmacological Treatment Adherence in Acute and Chronic Pain Patients
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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Objectives: The objectives of this article were the following: (1) determine risk for self-predicted future psychopharmacological nonadherence in rehabilitation acute pain patients (APPs) and rehabilitation chronic pain patients (CPPs) vs. pain-free community controls and community patients, and (2) determine which variables predict nonadherence.Design: The Battery for Health Improvement 2 was developed utilizing a healthy (pain-free) community sample (N = 1,478), a community patient sample (N = 158), and a rehabilitation patient sample (N = 777) of which 326 were APPs, 341 were CPPs, and 110 were patients without pain. These groups predicted their future psychopharmacological treatment adherence. Risk for nonadherence was calculated for each group utilizing the healthy community sample as the reference group. Nonadherent and adherent APPs and CPPs were compared statistically on variables of interest. Significant variables (P (less-than or equal to) 0.01) were utilized in APPs' and CPPs' logistic regression models to predict nonadherence.Setting: The participants in this article were from a variety of settings.Results: Of APPs and CPPs, 10.74% and 10.85%, respectively, predicted that they would be nonadherent. Risk for nonadherence was greater in both groups vs. healthy nonpain community subjects and nonhealthy community patients. The predictors for APPs' nonadherence were general resistance to using medications and a tendency to forget physicians' suggestions. For CPPs, the predictors were general resistance to using medications, fear of dependence on prescription medications, and fighting with loved ones. The models classified 90% and 89% of APPs and CPPs (respectively) correctly. However, these were no better than the base rate.Conclusions: APPs and CPPs are at greater risk for self-predicted psychopharmacological nonadherence than healthy community subjects and community patients. We cannot as yet predict self-predicted psychopharmacological nonadherence at greater than the base rate. However, the identified variables could be clinically useful. (copyright) 2010 The Authors. Pain Practice (copyright) 2010 World Institute of Pain
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Analysis of factors related to long bone fracture and hip-knee joint replacement accompanied with fat embolism syndrome
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AAHKS (2) Corticosteroids
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Background: Fat embolism syndrome is a commonly seen severe complication in the field of opthopaedics in clinic. It frequently occurs after long bone fracture and hip-knee joint replacement. However, its etiological factors and pathogenesis are not identified. Objective: To sum up the onset influencing factors, pathogenesis and therapeutic methods of long bone fracture and hip-knee joint replacement accompanied with fat embolism syndrome. Retrieve strategy: Using the terms "fat embolism syndrome, pathogenesis, treatment, prevention, diagnosis", we retrieved PubMed database to identify studies published in the English language. Fifty-five literatures were searched. Meanwhile, we searched the medical information network of Shanghai Jiao Tong University with the same terms in the Chinese language. Inclusive criteria: studies, which can reflect the diagnosis and treatment as well as pathogenesis of fat embolism syndrome. Exclusive criteria: repetitive studies. Literature evaluation: The involved 38 literatures are all about the diagnosis and treatment as well as pathogenesis of fat embolism syndrome, among which, 6 were review and the others were clinical or basic studies. Data synthesis: 1 The influencing factors of fat embolism syndrome included trauma factor, operation factor and other factors. 2 The pathogenesis of fat embolism syndrome involved mechanical obstruction theory, biochemical theory, condensation theory and inflammatory reaction theory. 3 The treatments of fat embolism syndrome include respiration supporting, glucocorticoid application, protecting brain function, drug treatment, heat shock treatment and so on. Conclusion: Study on bone fracture and joint replacement accompanied with fat embolism syndrome can provide evidence for the diagnosis and treatment of this syndrome.
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Uncertainties surrounding the choice of surgical treatment for 'bone on bone' medial compartment osteoarthritis of the knee
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OAK 3 - Non-arthroplasty tx of OAK
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A number of different surgical interventions can be used for treating antero-medial osteoarthritis (AMOA) of the knee and this choice can present challenges for patient's decision-making. Patients with AMOA can undergo Total Knee Replacement (TKR), Unicompartmental Knee Replacement (UKR) or High Tibial Osteotomy (HTO) for the same pathology. However many uncertainties still exist as to deciding which operation is best for individual patients and the Orthopaedic community has failed to systematically compare treatment options. The relative lack of scientifically based evidence has impacted on the ability to provide clear guidelines on treatment choice, patient suitability and direct patient preference for treatment. This paper, using available evidence, discusses the issue and offers some suggestions for future development.
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An exploration of modifiable risk factors for depression after spinal cord injury: which factors should we target?
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DoD PRF (Psychosocial RF)
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OBJECTIVE: To identify modifiable risk factors for depression in people with spinal cord injury (SCI).
DESIGN: Cross-sectional survey.
SETTING: Outpatient and community settings.
PARTICIPANTS: Community-residing people with SCI (N=244; 77% men, 61% white; mean age, 43.1y; 43% with tetraplegia) who were at least 1 month postinjury.
INTERVENTIONS: Not applicable.
MAIN OUTCOME MEASURES: Depression severity (Patient Health Questionnaire-9 [PHQ-9]), physical activity (International Physical Activity Questionnaire [IPAQ]), pleasant and rewarding activities (Environment Rewards Observation Scale [EROS]), and self-efficacy to manage the effects of SCI (Modified Lorig Chronic Disease Self-Management Scale).
RESULTS: Greater depression severity was associated with being 20 to 29 years of age, not completing high school, not working or attending school, and being <=4 years post-SCI. After controlling for demographic and injury characteristics (adjusted R(2)=.13), lower EROS scores (change in adjusted R(2)=.34) and lower self-efficacy (change in R(2)=.13) were independent predictors of higher PHQ-9 scores. Contrary to predictions, physical activity as measured by the IPAQ did not predict depression severity.
CONCLUSIONS: Our findings suggest that having fewer rewarding activities, and to a lesser extent, having less confidence in one's ability to manage the effects of SCI are independent predictors of greater depression severity after SCI. Interventions such as behavior activation, designed to increase rewarding activities, may represent an especially promising approach to treating depression in this population.
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Primary vs secondary wound reconstruction in Gustilo type III open tibial shaft fractures: follow-up study of 35 cases
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DoD LSA (Limb Salvage vs Amputation)
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AIM: To compare primary and secondary wound reconstruction as a treatment method for Gustilo type III open tibial fractures. METHODS: Thirty-five consecutive patients with a Gustilo type III open tibial shaft fracture were treated and followed up for 3 years. The patients were divided into two groups depending on the treatment protocol and timing of wound reconstruction: primary wound reconstruction (n=15) and secondary wound reconstruction (n=20). After determining median value, the variability was expressed with the 25th and 75th percentiles. RESULTS: In the primary wound reconstruction group, healing was achieved in 13 out of 15 patients. The median time to recovery was 68 (25th-75th percentile=32-86) weeks, median number of operations was 4 (25th-75th percentile=3-5), and median Johner and Wruhs score was 4 (25th-75th percentile=3-5). There were 9 cases with a bone defect and 2 tibial amputations were performed. In the secondary wound reconstruction group, complete recovery was achieved in 18 out of 20 patients. The median time to recovery was 115.5 (25th-75th percentile=70.0-128.5) weeks, median number of operations 7.5 (25th-75th percentile=6.5-8.5), and median score according to Johner and Wruhs' criteria 3 (25th-75th percentile=2-4). There were 19 cases with a bone defect and 1 tibial amputation was performed. Chronic osteomyelitis persisted only in a single patient. Median time to recovery and number of operations were significantly smaller in patients undergoing primary wound reconstruction. CONCLUSION: Primary wound reconstruction required smaller number of operations and shorter time to recovery than secondary wound reconstruction, mostly due to a significantly smaller proportion of cases with a bone defect.
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Braces and orthoses for treating osteoarthritis of the knee
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Management of Hip Fractures in the Elderly
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BACKGROUND: Patients with osteoarthritis of the knee can be treated with a brace or orthosis (insole). The main purpose of these aids is to reduce pain, improve physical function and, possibly, to slow disease progression. This review was originally published in Issue 1, 2005. OBJECTIVES: To assess the effectiveness of a brace or orthosis in the treatment of osteoarthritis of the knee. SEARCH STRATEGY: Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE (Current contents, Health STAR) up to October 2002 in the original review and in this update until May 2007. Reference lists of identified trials were screened. SELECTION CRITERIA: Randomised and controlled clinical trials investigating all types of braces and orthoses for osteoarthritis of the knee. DATA COLLECTION AND ANALYSIS: Three reviewers independently selected trials, extracted data and assessed trial quality. Due to the heterogeneity of the studies, pooling of outcomes was not possible. MAIN RESULTS: Five studies (n=589) were included: two knee brace and three orthoses studies. In the longer follow-up studies (1 to 2 years) many patients stopped their brace or insole treatment.The pain and function scores of a brace and a neoprene sleeve group showed greater improvement at six months compared with a control group. In a second brace study, the pain and function scores were improved in the brace group compared with the controls, but only the walking distance was significantly longer. In one study there was a significantly less intake of NSAIDs and significantly better compliance in a lateral wedge group compared with a neutral wedge group, but there were no significant differences in function scores at 6 and 24 months.In another insole study at 6 months follow up, the pain score was significantly improved in the strapped insole group compared with the traditional lateral wedge group (relative percentage difference (RPD=29%). The femorotibial angle was significantly improved in the strapped insole group at 6 and 24 months (RPDs at both timepoints= -1.1%). The pain and function scores were not significantly different at 24 months. AUTHORS' CONCLUSIONS: Based on two brace and three insole studies, we conclude that there is 'silver' level evidence (www.cochranemsk.org) that a brace and a lateral wedge insole have small beneficial effect. There is 'silver' level evidence that strapped insoles correct leg alignment. However, long-term adherence to brace and insole treatment is low. There is no evidence whether a brace is more effective than an insole. BRACES AND ORTHOSES FOR OSTEOARTHRITIS: This summary of a Cochrane review presents what we know from research about the effect of braces and orthoses for osteoarthritis (OA) of the knee.The review shows that in people with OA of the knee :wearing a knee brace compared to no brace:increases the distance you are able to walk. may not lead to any difference in pain, knee function, or quality of life.wearing a laterally wedged orthosis compared to wearing a neutral wedge:may not lead to any difference in pain, knee function or overall well-being.wearing an elastically strapped insole compared to wearing a traditional lateral wedge after 6 months:may improve pain and function.We often do not have precise information about side effects and complications. Possible side effects may include pain in the back of the knee, low back pain, foot sole pain, skin irritation and poor fit.An assessment of any changes in the x-rays of the joints over the long term was not measured in these studies.What is osteoarthritis and what are braces and orthoses? Osteoarthritis (OA) is the most common form of arthritis that can affect the hands, hips, shoulders and knees. In OA, the cartilage that protects the ends of the bones breaks down and causes pain and swelling. OA can occur in different areas of the knee or the whole knee. Depending on the area, OA can change the alignment of joints. Braces and orthoses are devices that you wear to support your knee joint. Orthoses are insoles that fit comfortably inside your shoes. Braces are made of combinations of metal, foam, plastic, elastic material and straps. A knee brace can be fitted especially for the person wearing it.Best estimate of what happens to people with OA who use a knee brace:Walking distance: People were able to walk 1.8 km longer after wearing a knee brace for one year. These results are based on high quality evidence.Best estimate of what happens to people with OA who wear foot or ankle orthoses:Pain: People's pain was reduced by 14 more points on a scale of 0 to 100 after wearing an orthoses for 6 months. These results are based on low quality evidence.The numbers given are our best estimate. When possible, we have also presented a range because there is a 95 percent chance that the true effect of the treatment lies somewhere between that range
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Late ophthalmological manifestations in patients with subarachnoid hemorrhage and coiling of cerebral aneurysm
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Upper Eyelid and Brow Surgery
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Late ocular manifestations of aneurysmal subarachnoid hemorrhage (SAH) have not been previously investigated except for one study which demonstrated that one half of patients subjected to aneurysm clipping suffer from symptoms of visual pathway impairment. We assessed ophthalmological status of patients after 1-4.5 years from SAH and aneurysm embolization to identify predictors of damage to the visual pathways. Complete ophthalmological examination, static perimetry, and visual evoked potentials (VEPs) were performed in 74 patients (26 men, 48 women, aged 19-76 years), who constituted a consecutive sample of 129 patients treated with aneurysm embolization in the years 2008-2010. The following independent variables: sex, age, time from SAH to embolization, size and site of aneurysm, score in Glasgow Coma Scale, Glasgow Outcome Scale, Hunt-Hess and Fisher scales were subject to univariate and multivariate statistical analyses to study their influence on the ocular outcome. 40 patients (54%) demonstrated visual field defects appearing as multiple peripheral foci and constricted field, affecting both eyes. Among these subjects, 12 patients had severe defects in the visual field, 20 had deterioration in VEPs, and 9 had decreased visual acuity. Older age and high score in Hunt-Hess and Fisher scales were identified as predictors for visual field defects and disturbances in VEPs. More than half of the survivors of SAH and aneurysm embolization suffer from a permanent defect in visual function. Damage of visual pathway correlates with severity of SAH and older age of patients.
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Carpal tunnel syndrome in patients undergoing maintenance hemodialysis
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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Five of 62 maintenance hemodialysis patients were found to have carpal tunnel syndrome, and another five had prolonged distal motor latencies. Contrary to previous reports, there was no relation between carpal tunnel syndrome and the site of vascular access. Synovial biopsy specimens from flexor tendons demonstrated edema without inflammation, suggesting that extracellular fluid volume excess in the presence of flexion and immobility during dialysis may be pathogenetically important
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The long-term risks of infection and amputation with limb salvage surgery using endoprostheses
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Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures
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Endoprostheses are now an established technique to reconstruct defects following bone tumour resection. The long-term durability of the reconstruction is excellent, with limb salvage being maintained in the long term in 91% of patients at 20 years from surgery. The main reasons for secondary amputation were locally recurrent disease and deep periprosthetic infection. Infection remains one of the biggest threats to early failure of reconstructions with endoprostheses. Most series of reconstructions show a periprosthetic infection rate of approximately 10%. Infection most frequently occurs within 12 months from the last surgical procedure; however, the risk of infection is life-long. The commonest pathogenic organism is coagulase-negative Staphylococcus. The most effective treatment for deep infection is two-stage revision, with local treatments having little chance of curing deep infection. Research is on-going into surface treatments with silver and other materials to help to reduce the infection rates. (copyright) 2009 Springer Berlin Heidelberg
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Surgical Treatment for Extracapsular Condylar Fractures of the Mandible
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Hip Fx in the Elderly 2019
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BACKGROUND: Condylar fractures are considered the most controversial mandibular fractures, regarding both the diagnosis and the treatment. With the increase in surgical indications for handling this type of fracture, it is important to discuss about the advantages and disadvantages of the several surgical approaches available. This article describes the surgical details and postoperative results of the mini-retromandibular transparotid approach for treating extracapsular condylar fractures of the mandible.
METHODS: In a 1-year period, 16 patients affected by extracapsular condylar fractures with surgical indication were treated with the mini-retromandibular transparotid approach. All the surgeries were executed by the same surgeon. Preoperative and postoperative details of each patient were analyzed.
RESULTS: In the postoperatory, only 2 patients had purulent drainage in the associated fractures area and only 1 patient had paresis of the buccal branch of the facial nerve. No scar issues concerning the surgical wound were observed and reintervention was not necessary in any of the patients.
CONCLUSION: The mini-retromandibular transparotid approach offers advantages and should be included as an option for the open treatment of extracapsular condylar fractures of the mandible.
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Factors associated with the decision of operative procedure for proximal femoral bone metastasis: Questionnaire survey to institutions participating the Bone and Soft Tissue Tumor Study Group of the Japan Clinical Oncology Group
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MSTS 2018 - Femur Mets and MM
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Background Pathological fracture of the proximal femur is a main cause of cancer patients losing their ability to walk. Although both osteosynthetic devices (predominantly intramedullary nails) and prosthetic replacement have been widely performed for treatment, controversies exist regarding which procedure should be used for the various conditions. In order to decide the eligibility criteria of a planned randomized prospective study about the treatment of pathological fractures of the proximal femur, we assessed the factors affecting the selection of operative procedures using questionnaires sent to the members of the Bone and Soft Tissue Tumor Study Group (BSTTSG) of the Japan Clinical Oncology Group (JCOG). Methods Questionnaire surveys to evaluate (1) the priority levels of the factors, (2) the equipoise range of each factor in situations where either procedure could be applied, (3) risk and benefit of each procedure, and (4) the degree of bone destruction affecting the selection of operative procedures, were sent to 26 institutions. Results Over 80% of the institutions answered. Orthopaedic surgeons of BSTTSG decided on the procedure according to the following factors in descending order: life expectancy, performance status before fracture, the degree of bone destruction, walking ability before fracture, general complications, the number of bone metastases in other sites, and the visceral metastasis status. With regard to bone destruction, (1) the involvement of the head, neck, calcar, and intertrochanteric region, (2) transverse destruction >1/2, and (3) soft-tissue tumor extension, were the factors that led to the choice of prosthesis treatment. Conclusions Using these identified factors, the inclusion criteria for the prospective randomized study of the surgical treatment of metastatic bone tumors of the proximal femur were optimized. The evaluation system about the bone destruction of metastases needs to be refined through the following prospective randomized study.
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0 |
Infections associated with body modification
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Panniculectomy & Abdominoplasty CPG
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Although exact statistics are lacking, body modifications for cosmetic purposes are performed in many countries. The commonest forms include tattooing, body piercing, and breast and facial augmentation using implants or injectable fillers. Liposuction and, to a lesser extent, mesotherapy are also practiced in many countries. Infective complications of these procedures include local infections, transmission of bloodborne pathogens (viral hepatitis and human immunodeficiency virus), and distant infections such as infective endocarditis. Presence of foreign bodies, long healing time of piercing wounds, and poor compliance with infection control practices of some practitioners all predispose the recipients to infections. Apart from the endogenous microbial flora of the skin and mucosae, atypical mycobacteria, especially the rapid growers, have emerged as some of the most important pathogens in such settings. Outbreaks of infection are commonly reported. We hereby review the current knowledge of the topic with specific focus on infections associated with tattooing, body piercing, breast augmentation, mesotherapy, liposuction, and tissue filler injections. Greater awareness among consumers and health-care professionals, as well as more stringent regulations by the health authorities, is essential to minimize the health risks arising from these procedures. © 2012 .
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Morbidity and mortality associated with dental extraction before cardiac operation
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Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures
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BACKGROUND: Dental extraction of abscessed or infected teeth before cardiac operation is often performed to decrease perioperative infection and late endocarditis. Literature to support dental extraction before cardiac operation is limited. The goal of this study was to evaluate the risk of major adverse outcomes in patients undergoing dental extraction before cardiovascular surgical procedures. METHODS: A retrospective review was performed to identify patients who underwent dental extraction before planned cardiac operation. Major adverse outcomes within 30 days after dental extraction or until time of cardiac operation were recorded and defined as death, acute coronary syndrome, stroke, renal failure requiring dialysis, and need for postoperative mechanical ventilation. RESULTS: Two hundred five patients underwent 208 dental extractions before 206 planned cardiac operations. Major adverse outcomes occurred in 16 of 205 patients (8%). Twelve patients (6%) died within 30 days after dental extraction, of which 6 (3%) occurred before cardiac operation, and 6 (3%) occurred after cardiac operation. CONCLUSIONS: Patients with planned dental extraction before cardiac operation are at risk for major adverse outcomes, including a 3% risk of death before cardiac operation and an 8% risk of a major adverse outcome. The prevalence of major adverse outcomes should advise physicians to evaluate individualized risk of anesthesia and surgical procedures in this patient population
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Distribution of periacetabular osteolytic lesions varies according to component design
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Management of Hip Fractures in the Elderly
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Using computed tomography, the volume, location, and number of osteolytic lesions were determined adjacent to 38 Harris-Galante 1 (HG-1) acetabular components fixed with screws and 19 porous-coated anatomic (PCA) acetabular components press-fitted without screws. The median implantation times were 16 and 15 years, respectively. The mean total lesion volumes were similar: 11.1 cm(3) (range, 0.7-49 cm(3)) and 9.8 cm(3) (range, 0.4-52 cm(3)), respectively, for hips with HG-1 and PCA components (P = .32). There was a significant difference in the proportion of rim-related, screw or screw hole-related, and combined lesions between the 2 component designs (P < .0001). HG-1 components had more screw and screw hole-related lesions, and PCA components had more rim-related lesions. Although there are concerns regarding screw and screw hole-associated osteolysis, these findings suggest that peripheral fixation may be well maintained in the long term with the use of multiple-hole acetabular components with screw fixation. (copyright) 2010 Elsevier Inc
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Treatment satisfaction with pharmaceutical interventions in Japanese adults with osteoarthritis and chronic knee pain: An analysis of a web-based survey
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OAK 3 - Non-arthroplasty tx of OAK
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Purpose: Patient satisfaction is an important outcome in successful osteoarthritis (OA) treatment. The aim of this study was to evaluate treatment satisfaction for medication (TSM) in people with knee OA (KOA), identify the factors predictive of treatment satisfaction, and describe the burden of illness. Patients and methods: This cross-sectional, patient-reported study used an Internet-based survey and analyzed responses of respondents with KOA (N=400) on characteristics including pain sites and levels (including pain ratings using the Numerical Rating Scale and Short-Form McGill Pain Questionnaire), treatment satisfaction (Global, Effectiveness, and Convenience scores) based on the Treatment Satisfaction Questionnaire for Medication (TSQM-9), and quality of life (QoL; based on the Arthritis Impact Measurement Scale 2-Short Form). Respondents with only KOA (n=237) were compared with those having KOA and additional painful sites (KOA+; n=163). Factors predicting TSM were identified using multivariable linear regression analyses. Results: Respondents with KOA were more likely to report intermittent pain for 3 months or more compared with those with KOA+ (58.6% vs 48.5%, respectively; P=0.044), while those with KOA+ were more likely to report consistent pain for 3 months or more (P=0.022). Respondents with KOA+ also had more difficulty due to their knee pain while sleeping (P=0.022) and resting (P=0.015). Reported TSM did not differ significantly across KOA vs KOA+ groups, with both groups reporting low satisfaction; all domains of QoL were worse for those with KOA+. Knee pain reduction by medication predicted higher satisfaction across domains, while lower pre-medication pain and post-medication pain matching expectations predicted higher TSQM-9 Global and Effectiveness scores. Conclusion: Medication treatment satisfaction rates were low among Japanese respondents with KOA. Given that lower pain, greater pain reduction post-medication, and meeting pain management expectations were predictive of higher satisfaction, treatment strategies that can better address pain may prove beneficial for overall patient satisfaction.
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Acute nontraumatic clavicle fracture associated with long-term bisphosphonate therapy
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Pediatric Supracondylar Humerus Fracture 2020 Review
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Cases of osteonecrosis of the jaw, insufficiency fractures and atypical low energy or atraumatic fractures of pelvis, femur (subtrochanteric/mid-shaft/distal-third), tibia, fibula, metatarsal, humerus, and ulna related to long-term bisphosphonate therapy have been reported in the literature. We present the case of an acute nontraumatic clavicle fracture, associated with long-term bisphosphonate therapy, which to our knowledge has not been reported previously. This case highlights the need of critical evaluation of patients with atypical fractures during long-term bisphosphonate therapy.
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Evaluation of residual instability after arthroscopic meniscectomy in anterior cruciate deficient knees
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AMP (Acute Meniscal Pathology)
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Forty-five patients who underwent a partial meniscectomy in an anterior cruciate deficient knee were followed from 2 to 9 years. The average age at the time of the meniscectomy was 28.6 years. The majority of the patients were injured in recreational athletics. The subjects were evaluated preoperatively by a questionnaire and clinical examination, both of which were repeated at followup. The efficacy of the postsurgical rehabilitation was monitored with measurement of quadriceps and hamstring strength on the Cybex Dynamometer. All of the patients had a KT-1000 knee ligament arthrometer test at followup that was compared with the clinical examination. Sixty-five percent of the subjects (13 of 20) with a Lachman and pivot shift of +1 returned to their previous activity level without limitation. Of the patients with a KT-1000 compliance index of 1 mm, 70% (11 of 17) returned to the same athletic level. However, only 20% (2 of 11) of the patients with a clinical instability greater than +1 or a compliance index of 2 mm were able to perform without limitation. The location of the meniscal tear did not correlate with the functional outcome. Six patients required ACL reconstruction.
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Safety and Efficacy of Subcutaneous Parenteral Nutrition in Older Patients: A Prospective Randomized Multicenter Clinical Trial
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Hip Fx in the Elderly 2019
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Background: Many patients who cannot tolerate adequate enteral nutrition could benefit from parenteral nutrition support but fail to receive it due to difficult intravenous (IV) access. The objective of this study was to compare the safety and efficacy of subcutaneous (SC) administration of parenteral nutrition with the peripheral IV route. Materials and Methods: This was a prospective randomized multicenter study of 121 older hospitalized patients. The primary outcome was the composite end point of major local side effects, defined as local edema, blistering, erythema, phlebitis, cellulitis, unbearable pain, or route failure requiring a switch in route. Secondary outcomes were nutrition parameters, biochemical parameters, clinical outcomes, and safety. Results: The SC route (n = 59) was noninferior to the IV route (n = 61) for major local side effects. Major local side effects trended higher in the IV group (P =.059). Local edema was more common in the SC group (P <.05), while route failure was more common in the IV group (P <.001). Nutrition and biochemical parameters, safety, and clinical outcomes were similar between groups. Conclusions: The SC route of nutrient administration was better tolerated than the peripheral IV route. SC administration of parenteral nutrition represents a safe alternative to IV nutrition.
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Cartilage oligomeric matrix protein in serum and synovial fluid of rheumatoid arthritis: Potential use as a marker for joint cartilage damage
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AAHKS (2) Corticosteroids
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This study examined the serum and synovial fluid concentrations of cartilage oligomeric matrix protein (COMP) in relation to the evolution of joint cartilage damage and the requirement for surgery in 125 patients with rheumatoid arthritis (RA). We compared the erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) level, and matrix metalloproteinase-3 (MMP-3) levels with COMP levels determined by specific enzyme-linked immunosorbent assay (ELISA). Patients were divided into three groups: (1) patients with least erosive disease (LES); (2) patients with more erosive disease (MES); and (3) patients with mutilating disease (MUD). In addition, synovial fluid samples were collected from patients undergoing arthroscopic synovectomy of the knee joint (ASS) and total knee arthroplasty (TKA). Serum COMP levels correlated with the ESR (P< 0.0001, r = 0.374, n = 125) and the CRP level (P = 0.0014, r = 0.281, n = 125). COMP levels did not correlate with the MMP-3 level (P = 0.182, r = 0.114, n = 125). The COMP levels of the LES group were significantly lower than those of the MES or MUD groups. Lastly, synovial fluid COMP levels in the TKA group were higher than in the ASS group. Therefore, these findings suggest that serum and synovial fluid COMP levels in patients with RA may reflect cartilage destruction and are correlated with the ESR and the CRP level, which are indicators of the acute-phase response. © Japan College of Rheumatology and Springer-Verlag Tokyo 2004.
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Influence of fracture type and surgeon experience on the emission of radiation in distal radius fractures
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Distal Radius Fractures
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INTRODUCTION: Ionising radiation is a potential risk for potentially exposed personnel. Only a few studies have examined the factors contributing to the emission of radiation in orthopaedic trauma procedures. We hypothesize that the experience of the surgeon and the fracture type influence the emission of radiation intraoperatively.
METHODS: In a retrospective analysis, we examined 100 consecutive distal radius fractures receiving a volar plate osteosynthesis. The following parameters were documented: demographic data, plate system, fracture type, duration of the surgical procedure and duration of the emission of radiation, the experience level of the surgeon and the first assisting surgeon.
RESULTS: Of all included patients (74 female), 48 had a type A, 7 a type B and 45 a type C fracture. The duration of radiation was longer for type C fractures [1.04 min (min)] in comparison to type A fractures (0.88 min) (P = 0.8152). In the type C subgroup, the highest amount of radiation was required for type C3 fractures (1.6 min), which was significantly more in comparison to type A (P = 0.0460) and type C1 fractures (P = 0.0089). The intraoperative emission of radiation (P = 0.00141) and the procedure time (P = 0.0006) depended on the experience of the surgical team.
CONCLUSION: The emission of radiation during this procedure depends on the fracture type and the experience of the surgical team. Operating theatre personnel should be aware of the higher emission rates during the treatment of type C fractures and in teaching hospitals with inexperienced team members.
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Dual mobility cup reduces dislocation rate after arthroplasty for femoral neck fracture
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HipFx Supplemental Cost Analysis
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Background. Hip dislocation after arthroplasty for femoral neck fractures remains a serious complication. The aim of our study was to investigate the dislocation rate in acute femoral neck fracture patients operated with a posterior approach with cemented conventional or dual articulation acetabular components. Methods. We compared the dislocation rate in 56 consecutive patients operated with conventional (single mobility) cemented acetabular components to that in 42 consecutive patients operated with dual articulation acetabular components. All the patients were operated via posterior approach and were followed up to one year postoperatively. Results. There were 8 dislocations in the 56 patients having conventional components as compared to no dislocations in those 42 having dual articulation components (p = 0.01). The groups were similar with respect to age and gender distribution. Conclusions. We conclude that the use of a cemented dual articulation acetabular component significantly reduces the dislocation rates in femoral neck fracture patients operated via posterior approach. (copyright) 2010 Tarasevicius et al; licensee BioMed Central Ltd
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A Study Comparing the Effectiveness and Safety of Varying Dose Strengths (100, 200, 300 and 400 mg) of Extended-release Tramadol HCl With Placebo for the Treatment of Osteoarthritis(OA) of the Knee and/or Hip
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OAK 3 - Non-arthroplasty tx of OAK
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Immediate release (IR) tramadol has demonstrated efficacy in several pain conditions including: obstetrical, gynecological, orthopedic, abdominal, and oral surgery. The short elimination halfâ?life of tramadol IR necessitates every 4â?6 hour dosing to maintain optimal levels of analgesia in chronic pain. The study medication in this study is a onceâ?daily, extendedâ?release tramadol formulation. This is a 12â?week multiâ?center, doubleâ?blind, randomized, doseâ?ranging, parallelâ?group, fixedâ?dose, placeboâ?controlled study. Patients with OA Functional Class Iâ?III of the knee or hip (index joint) are eligible for participation, if appropriate criteria are met. During a 2â?7 day washout period, the use of all analgesic medications will be discontinued. Eligible patients experiencing moderate to severe pain (<=40 mm on a 100 mm visual analog scale) in the index joint to be evaluated and who meet all other study criteria will enter in a 2â?week,doubleâ?blind titration period. During this period, patients will be randomly assigned to receive treatment with tramadol HCl ER 100 mg, 200 mg, 300 mg, 400 mg or placebo, once a day. Patients will be titrated to their assigned dose between study days 1 â? 15 and will continue at that dose for the remainder of the study (Week 12). Efficacy and safety evaluations will be collected at study visits occurring at Weeks 1, 2, 3, 6, 9 and 12 or at early termination. Study medication will be discontinued at Week 12 and patients will return after 1 week for a postâ?treatment visit (Week 13). Patients with unmanageable pain or with unacceptable side effects will be discontinued from the study and alternate analgesic therapy initiated, as appropriate.
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Traumatic and Degenerative Meniscus Tears Have Different Gene Expression Signatures
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AMP (Acute Meniscal Pathology)
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BACKGROUND: Meniscus tears are classified as traumatic or degenerative based on the tear pattern. There is little evidence demonstrating biological differences between the 2 tear types.
HYPOTHESIS: Gene expression signatures in the injured meniscus are different between traumatic (vertical) and degenerative (complex, horizontal, or flap) tears.
STUDY DESIGN: Controlled laboratory study.
METHODS: Samples of the torn meniscus from the white-white zone were removed at the time of clinically indicated partial meniscectomy from 48 patients (37 with degenerative tears and 11 with traumatic tears). mRNA expression in the injured menisci was measured by quantitative real-time polymerase chain reaction for selected molecular markers of osteoarthritis, inflammation, and cartilage homeostasis (eg, cytokines/chemokines, aggrecanases/metalloproteinases, transcription factors, cartilage matrix genes, and adipokines). The tear pattern (traumatic or degenerative) and location (medial or lateral) were recorded for each patient. Gene expression differences between degenerative and traumatic tears were computed after adjusting for patients' age, sex, and body mass index and for location of the resected meniscus (medial/lateral).
RESULTS: Gene expression in meniscus tears varied by pattern. Chemokines ( IL8 [ P < .001] and CXCL6 [ P < .001]) and matrix metalloproteinases ( MMP1 [ P = .011] and MMP3 [ P = .016]) were expressed at a significantly higher level in traumatic tears compared with degenerative tears. In contrast, COL1A1 was expressed at a lower level in traumatic tears compared with degenerative tears ( P = .058). None of the genes tested demonstrated significant differences between medial and lateral meniscus tears.
CONCLUSION: Traumatic meniscus tears overall exhibited a higher inflammatory/catabolic response as evidenced by higher levels of chemokine and matrix metalloproteinase expression than degenerative tears. These findings suggest that there is a (molecular) biological distinction between traumatic and degenerative tears.
CLINICAL RELEVANCE: The catabolic/inflammatory differences between traumatic and degenerative tears may be relevant to treatment decisions regarding the meniscus as well as advance our understanding of how meniscus tears relate to the development of knee osteoarthritis.
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The operative treatment of intraarticular fractures of the distal radius
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Distal Radius Fractures
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Surgical management of 13 complex intraarticular (pilon) fractures of the distal radius was remarkably effective. Most of the fractures were the result of high-energy impact, with associated soft-tissue trauma in seven cases. The preoperative planning, fracture classification, surgical tactics, and results are presented in detail. Only three patients had any residual functional problems. Follow-up motion showed wrist dorsiflexion/palmar flexion to be 74% of the opposite side, and grip strength was 76% of the opposite side. Twelve of the 13 patients showed no roentgenographic evidence of posttraumatic arthritis at an average follow-up period of 2.5 years. [References: 41]
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Does high-resolution computed tomography image analysis of the distal radius provide information independent of bone mass?
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Management of Hip Fractures in the Elderly
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This study aimed to investigate the usefulness of computed tomography (CT) image analysis of the distal radius for comparing two groups of postmenopausal women matched for age and bone mineral density at both the lumbar spine and femoral neck. The first one consisted of 16 women with at least one vertebral fracture and the second consisted also of 16 women without disease affecting bone mass or bone metabolism. Eight slices were selected in each patient: four consecutive coronal slices and four consecutive axial slices. Bone texture analysis was performed using structural methods leading to the measurement of 24 features. Most of the structural variables derived from histomorphometric parameters and were measured after segmentation from a binary or a skeletonized image. Nine variables were significantly different between the two groups on axial slices: valley number, valley surface area, apparent bone volume/tissue volume (BV/TV), apparent trabecular separation, apparent trabecular number, trabecular bone pattern factor, trabecular skeletal length, node count, and node-to-node strut count. Also four variables were significantly different between osteoporotic women and controls on coronal slices: apparent BV/TV, trabecular partition, node-to-node strut count, and terminus-to-terminus strut count. In conclusion this study suggests that bone texture analysis could yield additional data on bone mass for explaining bone strength and therefore could be used for improving the prediction of fracture risk
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Midvastus Versus Medial Parapatellar Approach for Minimally Invasive Total Knee Arthroplasty
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OAK 3 - Non-arthroplasty tx of OAK
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The purpose of this study is to compare two different surgical approaches for total knee replacement surgery. The miniâ?midvastus approach involves cutting less of the thigh muscle (quadriceps) tendon than the classic approach (median parapatellar) in order to implant the knee components. Both will have the same skin incision.
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Relation of wrist angles to median nerve conduction studies
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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OBJECTIVES: To measure the changes in median nerve conduction parameters at various angles of wrist flexion and extension. DESIGN: We studied 8 patients with carpal tunnel syndrome (CTS) and 4 subjects (5 hands) without the condition (controls). Conduction parameters were measured with the wrist in neutral position and at different wrist angles. RESULTS: Onset motor latency increased in both groups with wrist extension and decreased with wrist flexion. Sensory onset latency decreased in both groups with wrist flexion. Compound Muscle Action Potential (CMAP) amplitude increased with wrist flexion for both groups. Wrist extension resulted in reduction of the CMAP amplitude in controls; however, for the CTS group it increased for the first 30 degrees and then decreased. Sensory Nerve Action Potential (SNAP) amplitude increased with wrist flexion and decreased with wrist extension in both groups. CONCLUSION: Median nerve conduction parameters improve with wrist flexion and generally worsen with extension
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Pathological fractures secondary to metastatic cancer
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MSTS 2018 - Femur Mets and MM
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An analysis is presented of 96 fractures of long bones resulting from metastatic cancer. The breast was the commonest source of the primary lesion. In many patients, the development of the pathologic fracture was not a terminal event and treatment was worthwhile. Subcapital and transcervical femoral fractures were best treated by primary replacement arthroplasty; intertrochanteric, subtrochanteric and shaft femoral fractures by internal fixation. Fractures of the humeral shaft were probably best treated by internal fixation but in fractures of the proximal and distal humerus, distal femur and proximal tibia, external immobilisation is required. All lesions should be irradiated and, if indicated, hormones or chemotherapy given. In large lytic metastases without fracture, internal fixation should be carried out before irradiation is begun.
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Accessory Axillary Breast Excision with Liposuction Using Minimal Incision: A Preliminary Report
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Panniculectomy & Abdominoplasty CPG
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BACKGROUND: Accessory breasts have received little attention in the surgical fields, although the condition is quite common in the female population, with 2-6% of women suffering from it. Its convexity and cyclic pain make women feel embarrassed and uncomfortable, so patients often desire surgical excision to improve their appearances and to remove the pain. METHODS: A total of 967 patients who had been treated by an excision of accessory breast tissue with liposuction using minimal incision from September 2013 to Dec 2015 at the Damsoyu Hospital were analyzed for clinical factors retrospectively. RESULTS: All 967 patients were female. There were 514 (53.2%) unmarried patients and 453 (46.8%) married patients. The major clinical manifestation was the problem in the appearance with cyclic pain in both unmarried and married groups (82.7 vs. 87.9%). Three types of accessory breasts were observed: 779 (80.6%) breast tissue only in axillae, 182 (18.8%) breast tissue with accessory nipple, and 6 (0.6%) breast tissue with accessory nipple-areolar complex. The mean operation time was 58 min. All cyclic axillar pain in our cases was resolved after the operation. Postoperative complications developed in 160 patients (16.55%). Among them, seroma after operation was the most common (11.27%). In our study, 95.65% of the patients were satisfied with the cosmetic outcomes. CONCLUSIONS: The surgical excision of accessory breasts with liposuction through the minimal incision is a safe and effective method to make women feel comfortable in clinical manifestations and be satisfied with their cosmetic axillar line. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
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Involvement of WNT Signaling in the Regulation of Gestational Age-Dependent Umbilical Cord-Derived Mesenchymal Stem Cell Proliferation
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TO: WNT2 Pathway Modulator
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Mesenchymal stem cells (MSCs) are a heterogeneous cell population that is isolated initially from the bone marrow (BM) and subsequently almost all tissues including umbilical cord (UC). UC-derived MSCs (UC-MSCs) have attracted an increasing attention as a source for cell therapy against various degenerative diseases due to their vigorous proliferation and differentiation. Although the cell proliferation and differentiation of BM-derived MSCs is known to decline with age, the functional difference between preterm and term UC-MSCs is poorly characterized. In the present study, we isolated UC-MSCs from 23 infants delivered at 22-40 weeks of gestation and analyzed their gene expression and cell proliferation. Microarray analysis revealed that global gene expression in preterm UC-MSCs was distinct from term UC-MSCs. WNT signaling impacts on a variety of tissue stem cell proliferation and differentiation, and its pathway genes were enriched in differentially expressed genes between preterm and term UC-MSCs. Cell proliferation of preterm UC-MSCs was significantly enhanced compared to term UC-MSCs and counteracted by WNT signaling inhibitor XAV939. Furthermore, WNT2B expression in UC-MSCs showed a significant negative correlation with gestational age (GA). These results suggest that WNT signaling is involved in the regulation of GA-dependent UC-MSC proliferation.
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Osteocondritis dissecans lesions of the knee restored by bone marrow aspirate concentrate. Clinical and imaging results in 18 patients
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Osteochondritis Dissecans 2020 Review
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BACKGROUND: Osteochondritis dissecans (OCD) is a common cartilage disorder that specifically affects the knees of skeletally immature and young adult patients. There have been a few treatments that have been proposed: fixation of the fragment, drilling, microfractures. The aim of this study was to analyze retrospectively clinical and imaging results obtained by treating it with one-step bone marrow-derived cells Transplantation (BMDCT) technique. METHODS: From 2007 to 2014, 18 patients (mean-age 19.1?±?5.0 years) affected by OCD were treated with one-step BMDC transplantation. In our observational study, clinical evaluation was performed at a scheduled follow-up through IKDC, Tegner, KOOS and EQ-VAS. X-rays and MRI were conducted preoperatively and at 12 months. At final follow-up, MRI MOCART Score was evaluated. RESULTS: IKDC and KOOS clinical scores showed a progressive increase. Tegner Score at final follow-up (5.3?±?2.7) was significantly lower compared to the pre-injury level (6.5?±?2.1); however, these results showed a statistically significant improvement that remained over time. EQ-VAS showed a significant improvement in every follow-up measure. MRI Mocart Score showed a complete or almost complete filling of the lesion in 13 patients. CONCLUSIONS: "One-step" technique allows articular surface restoration with viable physiologic osteochondral tissue with a high clinical efficacy and imaging results. The number of cases is still limited, and further studies with larger sample sizes and greater follow-up evaluations are required to confirm our results. Nevertheless, we believe that BMDCT may represent a suitable option to treat OCD lesion in young adults.
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Risk, causes, and outcomes of visual impairment after loss of vision in the non-amblyopic eye: a population-based study
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Upper Eyelid and Brow Surgery
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BACKGROUND: Screening for amblyopia in early childhood is done in many countries to ensure that affected children are detected and treated within the critical period, and achieve a level of vision in their amblyopic eye that would be useful should they lose vision in their non-amblyopic eye later in life. We aimed to investigate the risk, causes, and outcomes of visual impairment attributable to loss of vision in the non-amblyopic eye. METHODS: For 24 months from July, 1997, national surveillance was done to identify all individuals in the UK with unilateral amblyopia (acuity worse than 6/12) who had newly acquired vision loss in the non-amblyopic eye, resulting in acuity of worse than 6/12 or visual-field restriction precluding driving. Information about participants was obtained at presentation and 1 year later. Participants were categorised as having socially significant visual impairment, or visual impairment, severe visual impairment, or blindness, in accordance with WHO taxonomy. FINDINGS: Of 370 eligible individuals, at presentation 104 (28%) had socially significant visual impairment, 180 (49%) visual impairment, and 86 (23%) severe visual impairment or blindness. The minimum risk of permanent visual impairment by age 95 years was 32.9 (95% CI 29.1-36.9) per 100,000 total population. The projected lifetime risk of vision loss for an individual with amblyopia was at least 1.2% (95% CI 1.1-1.4). Only 36 (35%) of 102 people previously in paid employment were able to continue. INTERPRETATION: In the UK, where screening for amblyopia is under review, risk of serious vision loss affecting the non-amblyopic eye and its results are greater than that previously assumed. Thus, in addition to the benefits of improved vision in the amblyopic eye, treatment of amblyopia during childhood is a potentially valuable strategy to prevent incapacitating vision loss later in life.
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Hypobaric versus isobaric spinal levobupivacaine for total hip arthroplasty
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AAHKS (8) Anesthetic Infiltration
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BACKGROUND: Spinal anesthesia (SA) in the lateral decubitus position is often used to perform total hip arthroplasty (THA). Hypobaric local anesthetic ensures enhanced and prolonged sensory and motor block in the involved side. The aim of this study was to compare the intraoperative anesthetic efficacy of hypobaric with isobaric levobupivacaine solutions for THA.
METHODS: Forty patients scheduled to elective THA were allocated into two groups: isobaric levobupivacaine group (IL group) and hypobaric levobupivacaine group (HL group). All the patients were placed with the operative side uppermost on the surgical table and spinal anesthesia was performed with 4 mL (12.5 mg) of selected solution. The evolution of sensory and block on nondependent (operative) and dependent sides were checked.
RESULTS: Regarding the nondependent side the onset times for maximal sensory block level in the in HL group was 17.8+/-1.1 minutes vs. 24.2+/-4.1 minutes in IL group. In HL group the onset time for motor block was 9.2+/-3.5 minutes vs. 15.6+/-5.4 minutes in IL group. The sensory regression time to L2 was significantly prolonged in HL group (192+/-30.3 minutes vs. 111+/-13.4 min). After surgery in HL group the residual motor block degree was 2.4+/-0.9 vs. 0.2+/-0.4 in IL group.
CONCLUSIONS: In patients undergoing THA under spinal anesthesia 12.5 mg of hypobaric levobupivacaine, compared with the same dose of isobaric levobupivacaine, allow shorter onset time for sensory block and delayed regression of sensory and motor block in the nondependent side.
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A new and simple scoring system to predict overall survival after irradiation for metastatic spinal cord compression
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MSTS 2022 - Metastatic Disease of the Humerus
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PURPOSE: To develop a model that predicts survival in patients irradiated for metastatic spinal cord compression (MSCC), hence assisting in the decision between a short and a long-course radiotherapy (RT) regimen.
METHODS: 138 patients diagnosed with MSCC and treated with RT alone were included. Based on a multivariate analysis, a scoring system was developed. It included four prognostic variables: age, number of vertebrae, ECOG and histology. Total scores ranged between 14 and 24 points and patients were divided into two groups.
RESULTS: The 6-month survival rate was 22% for patients with a score of 14-18 points; and 69% for patients with a score of 19-24 points (P < 0.001). The system exhibits a high specificity and positive predictive value and an appropriate discriminative ability.
CONCLUSIONS: Patients with scores between 19 and 24 points were found to survive longer, thus a long-course RT appears to be more appropriate.
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1 |
Seroma Formation in Pre-pectoral Implant-Based ADM Assisted Breast Reconstruction: A Comprehensive Review of Current Literature
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Acellular Dermal Matrix
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In the field of implant-based breast reconstruction (IBBR), the most recent and successful progress has been the evolution of the prepectoral approach through the use of acellular dermal matrix (ADM). ADM-assisted breast reconstruction is now gaining a foothold as standard practice, but its advantages are often clouded due to discouraging studies reporting increased seroma formation. The origin of the serum accumulation still remains unclear, but it has always been the most frequent early complication in breast reconstruction, thus proving to be crucial to address since it can lead to further complications. Using a standardized approach to obtain high-quality scientific evidence, the aim of this review is therefore to investigate the occurrence of seroma in breast implant-based reconstructive surgery and its possible relation with matrices. We conducted the review investigating only pre-pectoral implant positioning and one specific ADM (BraxonÃÂî) which is the one who has the highest number of cases in literature. nterestingly, ADM does not appear to be causative of seroma formation, but a surgery-related origin is discussed. In this setting, a series of rigorous guidelines have therefore been identified and analyzed to allow not only the treatment, but also the prevention of seroma, thus leading to a reduction in the incidence of this frequent problem.
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Acute arthroscopy
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AMP (Acute Meniscal Pathology)
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The role and significance of acute arthroscopy have been evaluated in the treatment of knee joint injuries on the basis of findings during 59 arthroscopic operations which were conducted within two weeks after the accident. The injuries developed isolated in more than half of the cases (65%) whereas they appeared in a combination of two or more in 26% and in 9%, respectively. Injuries requiring operation were found in 91.5%, most of which were ruptures of the ACL (33 cases) and menisci (23 cases). In the case of ACL rupture, in the acute phase on sportsmen and physical workers primary arthroscopically assisted transligamental replacement was performed with patellar graft while in the case of proximal rupture of the ACL reinsertion and augmentation were carried out with semitendinosus tendon. The ruptures of dislocated eminentia were refixed in each case. In the case of the rupture of meniscus the refixation of the meniscus of resection of the ruptured part was attempted. By means of acute arthroscopy the lesion of the intraarticular structures or that of their combinations can be exactly diagnosed. Depending on the findings of arthroscopy the injuries can be treated immediately or operated on at a later time, thus preventing the joint from further deterioration.
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A multicenter, retrospective epidemiologic survey of the clinical features and management of bone metastatic disease in China
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MSTS 2018 - Femur Mets and MM
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BACKGROUND: Bone metastases are common in patients with advanced cancer. Bisphosphonates (BPs) could prevent or delay the development of skeleton-related events (SREs). The present study aimed to identify the clinical features of and treatment strategies for Chinese patients with bone metastases.
METHODS: Consecutive cancer patients who had bone metastases and received BP treatment were enrolled. A questionnaire was developed to collect the patients' clinical data, as well as information on the diagnosis and management of bone metastases. Physicians' awareness of the guidelines and knowledge of the application of BP were also assessed.
RESULTS: A total of 3223 patients with lung cancer (36.5%), breast cancer (30.9%), prostate cancer (8.5%), and gastrointestinal cancer (5.7%) were included in this study. The sites of bone metastases were the thoracic spine (56.0 %), lumbar spine (47.1%), ribs (32.6%), and pelvis (23.2%). The SRE frequency was the highest in patients with multiple myeloma (36.6%), followed by those with lung cancer (25.9%), breast cancer (20.2%), prostate cancer (18.2%), and gastrointestinal cancer (17.3%). Irradiation to the bone was the most frequent SRE (58% in lung cancer patients, 45% in breast cancer patients, and 48% in prostate cancer patients). Our survey also showed that 45.5% of patients received BP within 3 months after their diagnosis of bone metastases, whereas the remaining 54.5% of patients did not receive BP treatment until at least 3 months after their diagnosis of bone metastases. The SRE frequency in the former group was significantly lower than that in the latter group (4.0% vs. 42.3%, P < 0.05). In patients with more than 6 months of continuous BP treatment, the mean time to the first SRE was significantly longer than that in patients with less than 6 months of continuous BP treatment (7.2 vs. 3.4 months, P < 0.05). In addition, 12.2% of the physicians were not aware of the efficacy of BP in preventing and delaying SRE. Only half (52.3%) of the physicians agreed that the BP treatment should persist for at least 6 months unless it was intolerable.
CONCLUSIONS: Our study suggested that prompt and persistent BP treatment was associated with a reduced risk of SREs. However, our survey also revealed that the proper application of BP was not as common as expected in China.
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Chronic postoperative pain: Recent findings in understanding and management
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AAHKS (4) Acetaminophen
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Chronic postoperative pain is a poorly recognized potential outcome from surgery. It affects millions of patients every year, with pain lasting for months to years, resulting in patient suffering and ensuing economic consequences. The operations with the highest incidence of chronic postoperative pain are amputations, thoracotomies, cardiac surgery, and breast surgery. Other risk factors include preoperative pain, psychological factors, demographics, and the intensity of acute postoperative pain. Attempts to prevent chronic postoperative pain have often led to debatable results. This article presents data from recently published studies examining the incidence, risk factors, mechanisms, treatment options, and preventive strategies for chronic postoperative pain in adults. In summary, many of the previously identified risk factors for chronic postoperative pain have been confirmed and some novel ones discovered, such as the importance of the trajectory of acute pain and the fact that catastrophizing may not always be predictive. The incidence of chronic postoperative pain hasn't changed over time, and there is limited new information regarding an effective preventive therapy. For example, pregabalin may actually cause more harm in certain surgeries. Further research is needed to demonstrate whether multimodal analgesic techniques have the best chance of significantly reducing the incidence of chronic postoperative pain and to determine which combination of agents is best for given surgical types and different patient populations.
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Epidemiology of lumbar osteoporosis and osteoarthritis and their causal relationship-is osteoarthritis a predictor for osteoporosis or vice versa?: The miyama study
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Management of Hip Fractures in the Elderly
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Summary: In a 10-year follow-up of a population-based cohort of Japanese subjects, incidences of and causal relationships between osteoporosis (OP) and osteoarthritis (OA) at the lumbar spine were clarified. OP might reduce the risk of subsequent OA at the spine in women, but not in men. Introduction: The aim of this study is to clarify the contribution of osteoarthritis (OA) to osteoporosis (OP) and vice versa. Methods: A population-based, epidemiological study was conducted in a Japanese rural community. From 1,543 participants aged 40-79 years, 200 men and 200 women were selected and followed up for 10 years. Bone mineral density measurements were repeated after 3, 7, and 10 years, and X-rays were repeated after 10 years. Results: The incidence of lumbar OP per 10,000 person-years for persons in their 40s, 50s, 60s, and 70s was 0, 0, 109.5, and 151.1 for men and 124.2, 384.0, 227.3, and 239.5 for women, respectively. The cumulative incidence of lumbar OA over 10 years aged 40-79 years was 25.8% in men and 45.2% in women. Cox's proportional hazards model showed no significant relationship between the presence of lumbar OA at the baseline and incidence of lumbar and femoral neck OP in both genders. A significant relationship was demonstrated between the presence of lumbar OP, not femoral neck OP, at the baseline and cumulative incidence of lumbar OA in women (odds ratio, 0.20; 95% confidence interval, 0.05-0.80; P(element of)=(element of)0.02). Conclusion: OP in women appears to reduce the future incidence of OA at the lumbar spine. (copyright) 2008 International Osteoporosis Foundation and National Osteoporosis Foundation
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A methodological guide to performing a cost-utility study comparing surgical techniques
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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BACKGROUND: When recommending the adoption of a new surgical intervention as opposed to maintaining an old one, surgeons need to consider the opportunity cost, which is the value of the forgone benefits. To inform these decisions, surgeons can use economic analyses of surgical practices. Unfortunately, economic analyses conducted alongside randomized controlled trials in surgery are rare. OBJECTIVES: The objective of the present study was to use data from a small randomized controlled trial to illustrate the methodology for a cost-utility analysis comparing two techniques of carpal tunnel release: open release without ('usual' technique) and with ('novel' technique) ligament reconstruction. METHODS: Eighteen eligible patients were entered into this prospective study. Fifteen were followed to six weeks postoperatively. One day preoperatively, and five days, three weeks and six weeks postoperatively, patients completed a self-administered Health Utilities Index Mark 2-3 questionnaire (utilities) and a case report form from which resource utilization (cost) was collected. Utilities were expressed as quality-adjusted life weeks, a fraction of quality-adjusted life years. RESULTS: The mean total cost of the usual technique was lower than the novel technique, and the mean quality-adjusted life week was higher, favouring the usual technique. Indirect costs were four to nine times higher than direct costs in both techniques. CONCLUSION: The novel technique was more costly and less effective, and fell in the 'lose-lose' quadrant of the cost-effectiveness plane; it was rejected in favour of the usual technique. This methodology should be applied when deciding whether to adopt novel surgical techniques in plastic surgery to optimize scarce health care resources
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Arthroplasty infection rates in fractured neck of femur: single vs dual antibiotic cement
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Hip Fx in the Elderly 2019
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INTRODUCTION: Mortality rates following hip arthroplasty range between 10% and 40% after 12 months. A higher rate is attributed to postoperative complications, of which surgical site infection is one of the most significant. In an effort to reduce surgical site infection following arthroplasty, antibiotics can be added to the cement used. The primary aim of this study was to determine whether dual antibiotic impregnated cement can reduce the rate of deep surgical site infection in patients following cemented arthroplasty for fractured neck of femur compared with single antibiotic impregnated cement. The secondary aim was to compare the rate of superficial surgical site infection in single compared with dual antibiotic cement.
MATERIALS AND METHODS: A total of 206 patients were included. Group 1 included 108 retrospective patients who underwent arthroplasty for neck of femur fracture over a 12-month period using single antibiotic impregnated cement. Group 2 included 98 prospective patients who underwent arthroplasty for neck of femur fracture over a 12-month period using dual antibiotic impregnated cement. The rates of deep and superficial surgical site infection were investigated.
RESULTS: Group 1 had a deep surgical site infection rate of 2.9% (n = 3), Group 2 had a deep surgical site infection rate of 0% (n = 0). Group 1 had a superficial surgical site infection rate of 3.7% (n = 4), Group 2 had a superficial surgical site infection rate of 5.1% (n = 5).
CONCLUSION: Dual antibiotic cement reduced the rate of deep surgical site infection compared with conventional single antibiotic cement in arthroplasty for fractured neck of femur. Only a marginal difference in superficial surgical site infection was observed.
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Treatment of graf type IIa hip dysplasia: A cut-off value for decision making
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Developmental Dysplasia of the Hip 2020 Review
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Background: The rate of spontaneous normalization in type IIa hips is reported to be high, whereas dysplsia persists or worsens in 5%-10% of cases. Aims: To evaluate the natural course of type IIa hips using Grafâ??s own perspective of physiological immaturity and maturational deficit. Study Design: A single center, retrospective cohort study. Methods: This was an institutional review board-approved retrospective review of all patients diagnosed with type IIa hip dysplasia at a single institution from 2012 to 2014. All patients included in the study had hip ultrasonography at about 6 weeks and 3 months of age. To assess reliability in α and β angles, ultrasonography measurements were carried out on the same image individually by all observers. The α and β angles were used as the main outcome measurements to evaluate hip maturation at the last follow-up. A receiver operating characteristics curve was drawn at the 3 month ultrasonography to evaluate the cut-off values for α and β angles for persistent dysplasia. Results: Sixty-four patients and 88 affected hips (63% unilateral and 37% bilateral) were included. The mean age at diagnosis was 6.4±2.7 weeks. Fifty-four hips were type IIa(+) (physiologically immature) and 34 hips were type IIa(-) (maturational deficit) at the initial ultrasonography evaluation. Improvement to type I was seen in 52 type IIa(+) and 17 type IIa(-) hips. Receiver operating characteristic analyses showed that patients do well if the α angle was >55° (area under the curve: 0.86; p<0.001 for the left hip and area under the curve: 0.72; p=0.008 for the right hip). Conclusion: The cut-off α angle value of 55° on initial ultrasonography should be considered to prevent future dysplasia. An α angle <55° on the initial ultrasonography was an independent predictor of worsening sonographic findings.
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Experimental generation of carcinoma-associated fibroblasts (CAFs) from human mammary fibroblasts
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Reduction Mammoplasty for Female Breast Hypertrophy
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Carcinomas are complex tissues comprised of neoplastic cells and a non-cancerous compartment referred to as the 'stroma'. The stroma consists of extracellular matrix (ECM) and a variety of mesenchymal cells, including fibroblasts, myofibroblasts, endothelial cells, pericytes and leukocytes (1-3). The tumour-associated stroma is responsive to substantial paracrine signals released by neighbouring carcinoma cells. During the disease process, the stroma often becomes populated by carcinoma-associated fibroblasts (CAFs) including large numbers of myofibroblasts. These cells have previously been extracted from many different types of human carcinomas for their in vitro culture. A subpopulation of CAFs is distinguishable through their up-regulation of alpha-smooth muscle actin (alpha-SMA) expression(4,5). These cells are a hallmark of 'activated fibroblasts' that share similar properties with myofibroblasts commonly observed in injured and fibrotic tissues (6). The presence of this myofibroblastic CAF subset is highly related to high-grade malignancies and associated with poor prognoses in patients. Many laboratories, including our own, have shown that CAFs, when injected with carcinoma cells into immunodeficient mice, are capable of substantially promoting tumourigenesis (7-10). CAFs prepared from carcinoma patients, however, frequently undergo senescence during propagation in culture limiting the extensiveness of their use throughout ongoing experimentation. To overcome this difficulty, we developed a novel technique to experimentally generate immortalised human mammary CAF cell lines (exp-CAFs) from human mammary fibroblasts, using a coimplantation breast tumour xenograft model. In order to generate exp-CAFs, parental human mammary fibroblasts, obtained from the reduction mammoplasty tissue, were first immortalised with hTERT, the catalytic subunit of the telomerase holoenzyme, and engineered to express GFP and a puromycin resistance gene. These cells were coimplanted with MCF-7 human breast carcinoma cells expressing an activated ras oncogene (MCF-7-ras cells) into a mouse xenograft. After a period of incubation in vivo, the initially injected human mammary fibroblasts were extracted from the tumour xenografts on the basis of their puromycin resistance (11). We observed that the resident human mammary fibroblasts have differentiated, adopting a myofibroblastic phenotype and acquired tumour-promoting properties during the course of tumour progression. Importantly, these cells, defined as exp-CAFs, closely mimic the tumour-promoting myofibroblastic phenotype of CAFs isolated from breast carcinomas dissected from patients. Our tumour xenograft-derived exp-CAFs therefore provide an effective model to study the biology of CAFs in human breast carcinomas. The described protocol may also be extended for generating and characterising various CAF populations derived from other types of human carcinomas.
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Open knee joint injuries: An evidence-based approach to management
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DoD LSA (Limb Salvage vs Amputation)
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Open knee joint injuries are potentially devastating injuries if not properly diagnosed and treated. Current diagnostic techniques, such as the saline load test (SLT), are based on outdated literature. Diagnosis of traumatic arthrotomies via the presence of intra-articular air on computed tomography (CT) scan has recently been shown to be 100% sensitive and specific to detect these injuries. Additionally, open knee joint injuries have a high rate of associated periarticular fractures (51%). The workhorse open surgical approach to the knee is the medial parapatellar approach; however, arthroscopic irrigation and debridement (I&D) should be considered in the setting of small puncture wounds (e.g., gunshot wounds). Antibiotic therapy following I&D of an open knee joint injury includes 24 to 48 hours of intravenous antibiotics. Oral antibiotic therapy can be administered afterwards for 3 to 5 days if the original injury was grossly contaminated. Ultimately, a unified management algorithm for open knee joint injuries based on current literature should be followed to ensure appropriate diagnosis and treatment of this potentially devastating injury.
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Distal radial fractures heal by direct woven bone formation
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Distal Radius Fractures
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BACKGROUND: Descriptions of fracture healing almost exclusively deal with shaft fractures and they often emphasize endochondral bone formation. In reality, most fractures occur in metaphyseal cancellous bone. Apart from a study of vertebral fractures, we have not found any histological description of cancellous bone healing in humans.
PATIENTS AND METHODS: We studied histological biopsies from the central part of 12 distal radial fractures obtained during surgery 6-28 days after the injury, using routine hematoxylin and eosin staining.
RESULTS: New bone formation was seen in 6 cases. It was always in the form of fetal-like, disorganized woven bone. It seldom had contact with old trabeculae and appeared to have formed directly in the marrow. Cartilage was scarce or absent. The samples without bone formation showed only necrosis, scar, or old cancellous bone.
INTERPRETATION: The histology suggests that cells in the midst of the marrow respond to the trauma by direct formation of bone, independently of trabecular surfaces.
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A study to assess the use and effectiveness of GEMOS2 in achieving early bone formation and healing of distal radius fractures
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Distal Radius Fractures
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INTERVENTION: GEM OS2 is applied to the bone void(s) and is contained within the fracture void(s) it physically fills bone defects providing a biocompatible, osteoconductive scaffold for new bone formation and promoting cellular ingrowth into the osseous defect. This device is composed of two components: a beta tricalcium phosphate (Ã?â?TCP) / collagen matrix, and becaplermin, which is a highly purified recombinant human plateletâ?derived growth factor (rhPDGFâ?BB).â?derived growth factor (rhPDGFâ?BB). The GEM OS2 device is supplied as a single use kit, with sterile individual components of Ã?â? TCP/collagen matrix and a separate syringe containing a solution of rhPDGFâ?BB (becaplermin). At the time of surgery, the clinician fully saturates the Ã?â?TCP/collagen matrix with the rhPDGF BB solution. After mixing, the hydrated graft will have a putty consistency which may be injected percutaneously, or manually packed into the osseous defect dependent on the method of fixation. As this device is surgically implanted it will remain and be taken up by the body as the fracture heals. The GEM OS2 device is supplied as a two component kit. Each kit consists of: one (1) â??brickâ? containing 3 cc of bâ?TCP/ collagen; and, one (1) syringe containing 3 mL solution of 0.3 mg/ml rhPDGFâ?BB (becaplermin) in sodium acetate buffer. When combined there is a total of 0.9 mg rhPDGFâ?BB in the 3 mL that may be implanted at the fracture site. It has been estimated that each patient will receive approximately 1mL at minimum and no more than 3 mL at maximum which equates to 0.3mg rhPDGFâ?BB at minimum and no more than 0.9mg rhPDGFâ?BB at maximum. CONDITION: distal radius fractures PRIMARY OUTCOME: Radiographic assessment of time to fracture healing evaluated by an independent radiologist. SECONDARY OUTCOME: Function Subscale Score will be assessed by using the Patientâ?Rated Wrist Evaluation (PRWE) Grip strength will be assessed with three measures averaged using a Jamar ; Dynamometer (Bechtol et al, 1954). The grip strength score will be the ratio of the grip strength of the injured side to that of the uninjured side. Healing rate compared to control as assessed by radiographic outcomes evaluated by a qualified radiographer. Pain Subscale Score: will be evaluated using the Patientâ?Rated Wrist Evaluation: (PRWE) subscale score. Range of Motion: Measurement: ; Movement of the wrist (flexion/extension, pronation/supination, radial/ulnar ; deviation) will be measured using a goniometer. ; Determinations of both active and passive range of motion will be made. Movement of the unaffected wrist will be taken as the normal range for each subject. Time to removal of external fixation device or cast as determined by clinical healing ; assessment: ; o Radiographic evidence of healing ; o Pain upon fracture site palpation INCLUSION CRITERIA: Subjects who meet the following criteria may be included in the study if they present with all of the following: 1) The subject has signed the Independent Ethics Committee (IEC) approved Informed Consent Form specific to this study prior to enrollment 2) The subject has an unstable unilateral, extraarticular distal radius fracture classified as unstable with the following radiographic findings: wide displacement requiring reduction defined as >10° or 20° volar tilt or instability defined as 20° dorsal tilt; or an intraarticular fracture that is amenable to externalâ?fixation or closed fracture reduction. Avulsed ulnar styloid tip is allowed 3) The subjectâ??s fracture is able to be manually reduced in a single attempt up to 2 weeks post injury 4) The subject is independent, ambulatory, and can comply with all postâ?treatment evaluations and visits 5) The subject is skeletally mature and =18 years of age 6) The dist
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Unicompartmental knee replacement
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Surgical Management of Osteoarthritis of the Knee CPG
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The results of unicompartmental knee replacement in a series of 83 knees were reviewed for the period of 1970 to 1978; 30.1 percent achieved good or excellent results; 48.2 percent fair or poor results; 21.7 percent were failures. The vast majority of failures and poor results were due to technical errors. Only 9.6 percent of the nonoperated contralateral compartments required further surgery
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The press-fit condylar modular total knee system with a posterior cruciate-substituting design. A concise follow-up of a previous report
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Dental Implant Infection
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The purpose of the present study was to determine the long-term results of a series of 150 consecutive primary posterior stabilized modular knee arthroplasties that had been performed in 118 patients with use of a circumferential tibial insert capture as described in a previous report, published in 1997. The patients were evaluated with use of a patient-administered questionnaire; Knee Society clinical, functional, and radiographic scoring systems; and Kaplan-Meier survivorship analysis. A good to excellent result was confirmed in seventy-six (90%) of the eighty-four patients (105 knees) with a mean duration of follow-up of twelve years (range, ten to thirteen years). At twelve years, the survival rate was 94.6% +/- 4.0% with failure for any reason as the end point and 98.3% +/- 2.4% with mechanical failure as the end point. Revision surgery was performed in five knees because of infection (two knees), dislocation (one knee), and substantial polyethylene wear with femoral osteolysis (two knees). We concluded that, while fixation failure is rare, polyethylene wear and osteolysis are emerging as important causes of failure.
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Clinical and radiographic results of arthroscopic partial lateral meniscectomies in stable knees with a minimum follow up of 20 years
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OAK 3 - Non-arthroplasty tx of OAK
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PURPOSE: The purpose of this retrospective multicentric study was to evaluate the long-term effects of lateral meniscectomy and to identify those patients who are at the most risk of developing osteoarthritis (OA).
METHODS: Eighty-nine arthroscopic partial lateral meniscectomies in stable knees with a mean follow-up of 22 +/- 3 years were included. The following influencing factors were analyzed: age, sex, body mass index (BMI), physical activity, alignment, the types of meniscal lesions, the extent of meniscal resections and the initially associated cartilage lesions. An independent examiner reviewed all patients, using subjective (KOOS and IKDC scores) and objective clinical and radiological evaluations (IKDC score). The contralateral knee was used as a reference to calculate the prevalence and the incidence of OA.
RESULTS: The mean age at the time of surgery was 35 +/- 13 years. The main location of the lesions was the mid-section of the lateral meniscus (79% of the cases). At the latest follow-up, 48% of the patients had an active lifestyle with as many as 48% of the patients enjoying moderate to intense physical activity 22 years after the procedure (vs. 71% before surgery). The KOOS score evolved from 82 to 69% during the same period. The prevalence of OA was 56% in the affected knee and the difference of prevalence between the operated and healthy knees was 44%. In those patients presenting with an OA of the operated knee and a normal contralateral knee, the incidence of OA was 53%. Predictors of OA were an age superior to 38 years at the time of surgery, obesity (BMI >30), and valgus malalignment as well as the presence of cartilage and degenerative meniscal lesions at the time of surgery.
CONCLUSION: In the long term, arthroscopic partial lateral meniscectomy in stable knees without initial cartilage lesions might yield good to excellent results in young patients. Patients are at higher risk to develop symptomatic OA if they are over 40, having a high BMI, valgus malalignment and cartilage lesions at the time of surgery. This study provides precise guidelines for the surgical treatment of lateral meniscus tears.
Level of evidence: Iv.
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The Effects of the COVID-19/SARS-CoV-2 Pandemic Outbreak on Otolaryngology Activity in Italy
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Coronavirus Disease 2019 (COVID-19)
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The coronavirus disease 2019 (COVID-19) pandemic during the first months of 2020 is causing profound changes in worldwide health care systems, resulting in a major reduction of surgical interventions and routine non-urgent outpatient diagnostic procedures. The lockdown due to the COVID-19 pandemic in Italy, one of the most affected countries in Europe, is having severe effects on the otolaryngology medical and surgical activities. The main changes are represented by the postponement of outpatient visits and scheduled surgery, while the only guaranteed service is reserved to diagnostics and surgery for oncology and urgent patients. In these cases, given the sites of action typical of the otolaryngology practice, physicians and nurses are exposed to a high risk of contagion through virus aerosol transmission. Furthermore, as the current measures of lockdown continue, it will be difficult to perform scheduled and new diagnostic assessments, medical treatments and surgical procedures in a timely manner favoring the risk of diagnostic and therapeutic delays with severe impact on patients' health.
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Condrosulf vs Celebrex vs Placebo in the Treatment of Knee OA
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OAK 3 - Non-arthroplasty tx of OAK
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The purpose of this study is to confirm the efficacy and safety of 800 mg Chondroitin 4&6 sulfate (Condrosulf) vs placebo once a day for 6 months in the symptomatic treatment of knee osteoarthritis. A third group, Celecoxib 200 mg (Celebrex) once a day, will be used as active comparator.
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Sport after total knee arthroplasty - Does dynamic stability matter?
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Surgical Management of Osteoarthritis of the Knee CPG
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Purpose: After big joints arthroplasty some patients wish not only to have general functions restored, but also the opportunity to return to high levels of activity. Generally, low-impact sports such as cycling, swimming, golf and hiking are recommended. Some authors have even recommended tennis or skiing. High-impact sports such as jogging or jumping can cause increased polyethylene wear, which can lead to implant failure. Incongruity between the surfaces of the patellar and the prostheses surfaces remains a most distressing complication following total knee arthroplasty. Our aim was to find risks for and negative influences on the prostheses during intense sporting activity. Methods: An analysis of 21 patients (mean age 68y), 6,0 years after surgery, who regularly practice sport branch 2-3 times a week was conducted. Patient Tegner activity score was 4 or higher. In group were 8 men (6,3 years after surgery) and 13 women (5,8 years after surgery). These patients consisted of 12 cyclists, 2 swimmers, 2 skiers, 2 runners, hiker, tennis player and golfer. Results: No subjective disability of the movement of the operated extremity. No deficiency of extension, flexion not less 100 degrees. Good stability of the collateral ligaments. In test of the dynamic joint control were 7 patients with dynamic instability (3 men, 4 women). Sport complications of this group was skier with distension of the collateral ligament due to fall, runner with anterior knee pain because of patellar osteofytes and lateralization, and tennis player with knee endoprosthesis loosening 8 years after implantation. Every patient with injuries and complications were without correction of dynamic control of the knee in our test on air balance board. Conclusions: We can see strong dependence with total knee arthroplasty complications and result of the dynamic joint stability control test. Through one loosening is difficult to give practical expression to long-term survivorship of arthroplasty caused by small group of patients and relatively short-term follow up. But correct dynamic joint stability optimizing joint loading and reduce risk of the ligament injury. After big joint replacement, patients may improve aerobic capacity through sport, but for long term survivorship low-impact sport is more acceptable. Rehabilitation neuromuscular training programs must be necessary to practice sport after knee replacement. Cycling is considered as low-impact sport, but there is real risk of injury through falling. Sports with risk of fallen should be recommended individually according abilities, age and skills of the patients. Regularly follow up of the arthroplasty is necessary. There are healthy reasons to practice sports on a regular basis, but patient activity must be conformed according to the arthroplasty
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Bone disease in multiple myeloma: pathophysiology and management
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MSTS 2018 - Femur Mets and MM
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Myeloma bone disease (MBD) is a devastating complication of multiple myeloma (MM). More than 80% of MM patients suffer from destructive bony lesions, leading to pain, fractures, mobility issues, and neurological deficits. MBD is not only a main cause of disability and morbidity in MM patients but also increases the cost of management. Bone destruction and lack of bone formation are main factors in the development of MBD. Some novel factors are found to be involved in the pathogenesis of MBD, eg, receptor activator of nuclear factor kappa-B ligand (RANKL), osteoprotegerin (OPG) system (RANKL/OPG), Wingless (Wnt), dickkopf-1 (Wnt/DKK1) pathway. The addition of novel agents in the treatment of MM, use of bisphosphonates and other supportive modalities such as radiotherapy, vertebroplasty/kyphoplasty, and surgical interventions, all have significant roles in the treatment of MBD. This review provides an overview on the pathophysiology and management of MBD.
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An innovative technique of rear entry creation for retrograde humeral nailing: how to avoid iatrogenic comminution
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Pediatric Supracondylar Humerus Fracture 2020 Review
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BACKGROUND: Antegrade and retrograde nails are widely used for intramedullary fixation of humeral shaft fractures. Creating the rear entry is the crucial step for retrograde nailing. The common manual technique is associated with considerable risks of additional iatrogenic comminution of the distal humerus. DESCRIPTION OF THE TECHNIQUE: A specific device for the creation of a rear entry hole has been developed as part of the instruments for humeral shaft nailing (Targon H) and made commercially available (BBraun Aesculap, Germany). After standard triceps-splitting approach, a guide instrument is firmly applied to the distal humerus with one screw. The screw hole is later used for distal interlocking. The oval rear entry hole is then performed by frontal cutter along the guide. PATIENTS AND METHODS: We have been performing a retrospective evaluation of all unreamed humeral nailings (Targon H) since 2000. Operation time, use of the guide instrument and intra-operative problems were analysed. X-rays were checked for iatrogenic humeral comminution directly after the operation and after physiotherapy. Cases of infection and nonunion were noted. RESULTS: We identified 87 cases of intramedullary fracture fixation with an interlocking nail (46 antegrade, 41 retrograde). In all retrograde cases a guide instrument and an access reamer were used for the creation of an entry hole. No iatrogenic comminutions were observed during the operation or on postoperative X-rays. Active postoperative exercises were generally allowed in every patient. Mean operative time was shorter for retrograde than for antegrade nailing (90 min vs. 108 min; p = 0.012). We saw two nonunions (2%) and no infections. CONCLUSIONS: Use of access reamer and guide instrument is a safe and reproducible way of creating a rear entry hole for retrograde humeral nailing. The risk of additional comminution seems to be eliminated.
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Candida albicans and denture stomatitis: evaluation of its presence in the lesion, prosthesis, and blood
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Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures
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Denture stomatitis is a primarily oral disease that affects denture wearers. The presence of Candida albicans in the palatal mucosa, on the internal surface of the maxillary denture, and in the blood of patients with denture stomatitis was evaluated. Although the results did not show C albicans in the bloodstream of patients, a strong relationship between denture stomatitis and Candida sp was confirmed for both the palatal mucosa and maxillary denture
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Prospective study on complications following a lower body lift after massive weight loss
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Panniculectomy & Abdominoplasty CPG
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BACKGROUND: Lower body lift procedures are in high demand following the increase of massive weight loss patients. As surgical complication rates in this patient group are generally high, patients need to be prepared for risk factors and complications in lower body lift surgery. The aim of this study was to identify the complications and possible risk factors of a lower body lift as concrete data for this procedure are limited. METHODS: A prospective study on 50 consecutive patients who underwent a lower body lift procedure was performed. Measures included co-morbidities and complications. Risk factors assessed included patient age, gender, highest lifetime body mass index (BMI) (BMI max), current BMI, excess weight loss (EWL), type of weight loss and nicotine consumption. RESULTS: There were 50 patients (44 females, six males) with a mean age of 41+/-10.8 years and a mean EWL of 86.4+/-15.6%. Mean BMI max was 49.5+/-10.5 kg m(-2), current BMI was 27.8+/-4.0 kg m(-2). A total of 35 (70%) patients developed at least one complication. Five patients (10%) suffered a major complication that necessitated surgical revision. Wound dehiscence occurred in 30 patients (60%), followed by seroma in 17 patients (34%). A surgical complication was directly related to BMI max (p=0.02) and age of the patient at the time of surgery (p=0.03). CONCLUSIONS: The overall complication rate following a lower body lift was 70%, which is comparable with that known for high-risk patient groups. The most important risk factors are BMI max and age of the patient (Clinical trial registration number (ISRCTN): NCT01551862).
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1 |
Correlation of radiographic and arthroscopic findings with rotator cuff tears and degenerative joint disease
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Glenohumeral Joint OA
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The purpose of this study was to identify early signs of rotator cuff tear and glenohumeral articular cartilage degeneration by using conventional radiography. A non-weighted anteroposterior oblique and a weighted active abduction view were evaluated for superior humeral migration and matching degenerative changes at the inferolateral acromion and superior aspect of the greater tuberosity in 40 patients who underwent shoulder arthroscopy. Measurements of the glenohumeral distance were performed. Surgical reports were reviewed to determine rotator cuff and glenohumeral articular cartilage status. Matching degenerative changes correlate with complete rotator cuff tear (P =.04); superior migration does not. Severe glenohumeral cartilage loss correlates with narrowing of the superior joint space on the anteroposterior oblique radiograph (P =.02) and with narrowing of the mid joint space on the active abduction view (P =.05). Both glenohumeral articular cartilage degenerative change and rotator cuff injury, before formation of typical sequelae of chronic rotator cuff tear, can be detected with the use of conventional radiography.
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0 |
Infection After Orthopaedic Trauma: Prevention and Treatment
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DoD SSI (Surgical Site Infections)
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Trauma to the extremities is disproportionately represented in casualties of recent conflicts, accounting for >50% of injuries sustained during operations in Iraq and Afghanistan. Infectious complications have been reported in >25% of those evacuated for trauma, and 50% of such patients were treated in the intensive care unit (ICU). Osteomyelitis has been reported in 9% (14% of intensive care unit patients), and deep-wound infection in 27% of type III open-tibia fractures. Infections complicating extremity trauma are frequently caused by multidrug-resistant bacteria and have been demonstrated to lead to failure of limb salvage, unplanned operative take-backs, late amputations, and decreased likelihood of returning to duty. Invasive fungal infections of extremities have also presented a unique challenge in combat-injured patients, particularly in those with blast injuries with massive transfusion requirements and high injury severity scores. Infection prevention should begin at the time of injury and, although context-specific depending on the level of care, includes appropriate irrigation, surgical debridement, wound care and coverage, fracture fixation, and antibiotic prophylaxis, in addition to basic infection prevention measures. Clinical practice guidelines to address infection prevention after combat trauma (including extremity infection) were developed in 2007 and revised in 2011, with endorsement from the Surgical Infection Society and the Infectious Disease Society of America. Nevertheless, significant challenges remain, including austere environments of care, multiple transitions of care, and lack of coordinated efforts in prevention. Treatment of established infections is optimally multidisciplinary, particularly when deep wounds, bone, and joints are involved. Surgical debridement of overtly infected or necrotic tissue is necessary, with particularly aggressive margins if invasive fungal infection is suspected. Infected nonunion frequently requires the use of prosthetic materials for fixation, potentiating biofilm formation, and complicating medical therapy. Antibiotic therapy should be targeted at results of deep wound and bone cultures. However, this is complicated by frequent contamination of wounds, requiring differentiation between potential pathogens in terms of their virulence and decreased culture recovery in patient who have frequently received previous antibiotics. Lessons learned in infection prevention and treatment of orthopaedic trauma from combat can serve to inform the care of patients injured in natural disasters and noncombat trauma.
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A multicenter study of the association of aromatase and estrogen receptor genes with hip and knee osteoarthritis
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Surgical Management of Osteoarthritis of the Knee CPG
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Purpose: Several lines of evidence suggest that estrogens influence the development of osteoarthritis (OA). The aim of this study was to explore the genetic and functional association of two common polymorphisms from within the aromatase (CYP19A1) and estrogen receptor (alpha) (ESR1) genes with severe OA of the lower limbs. Methods: The rs1062033 (CYP19A1) and rs2234693 (ESR1) single nucleotide polymorphisms (SNPs) were genotyped in 5,479 individuals (3,098 patients with hip or knee OA ascertained by the need for joint replacement surgery due to severe primary OA, and 2,381 controls) from three centres in Spain and one centre in the UK. Expression of CYP19A1 and ESR1 was measured in femoral bone RNA samples from a group of patients by real-time quantitative PCR and was subsequently stratified by donor genotype at rs1062033 and rs2234693. Results: In the global analysis, both polymorphisms were associated with OA, but there was a significant sex interaction. The GG genotype at rs1062033 (a C/G transversion SNP) was associated with an increased risk of knee OA in women (OR 1.23; p=0.04). The CC genotype at rs2234693 (a C/T transition SNP) tended to be associated with reduced OA risk in women (OR 0.76, p=0.028, for knee OA; OR=0.84, p=0.076 for hip OA), but with increased risk of hip OA in men (OR 1.28; p=0.029). Women carrying two copies of the rs1062033 G-allele and no copies of the rs2234693 C-allele were at particular risk for knee OA, with an OR of 1.61 (p=0.006). The rs1062033 GG genotype associated with increased OA risk was also associated with reduced expression of CYP19A1 in bone (p=0.036). Conclusions: Common genetic variations of the aromatase and estrogen receptor (alpha) genes CYP19A1 and ESR1 are associated with the risk of severe OA of the large joints of the lower limb in a sex-specific manner. These results are consistent with the hypothesis that estrogen activity influences the development of large-joint OA. The CYP19A1 SNP rs1062033, or a SNP in linkage disequilibrium with it, may mediate its effect on OA susceptibility by regulating the expression of CYP19A1
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Attentional bias and symptoms of posttraumatic stress disorder one year after burn injury
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DoD PRF (Psychosocial RF)
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Trauma-related attentional bias is suggested to play a role in maintaining posttraumatic stress disorder (PTSD). Although being burn injured is a traumatic event for many patients, there are no prospective studies investigating attentional bias. The aims were to assess burn-specific attentional bias 1 year after burn, and its associations with risk factors for PTSD and symptoms of PTSD. A total of 38 adult patients with burns were assessed with a structured clinical interview and a Swedish version of the Impact of Event Scale-Revised up to 1-year after burn. The Emotional Stroop Task was used to assess attentional bias 1 year after burn. In total 29 participants displayed burn-specific attentional bias. This group had more previous life events, perceived life threat, larger burns, and higher PTSD symptom severity. In conclusion, the majority of the patients had burn-specific attentional bias 1 year after burn and this was related to symptoms of PTSD. (PsycINFO Database Record (c) 2016 APA, all rights reserved)
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Antibacterial activity of joint fluid in cemented total-knee arthroplasty: an in vivo comparative study of polymethylmethacrylate with and without antibiotic loading
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Dental Implant Infection
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The objective of this study was to evaluate the antibacterial activities of joint fluids of patients undergoing total-knee arthroplasty (TKA). Thirty patients who were scheduled for primary cemented TKA were enrolled in the study. The patients were grouped on the basis of whether the cement was without antibiotic loading (control group) or loaded with oxacillin (oxacillin group) or vancomycin (vancomycin group). Cefazolin was administered to every patient as the perioperative prophylactic antibiotic. Samples of joint fluids were collected from the knee joints at 8, 16, 24, 32, 40, and 48 h after prosthesis implantation. We assessed the bioactivities of the joint fluids against methicillin-susceptible Staphylococcus aureus (MSSA) and methicillin-resistant S. aureus (MRSA). The antibiotic contents of the joint fluid samples were further evaluated by using high-performance liquid chromatography. Against MSSA, all joint fluid samples exhibited at least 24 h of bacterial inhibition activity. The oxacillin (43.2 h +/- 2 h) and vancomycin (40.8 h +/- 1.8 h) groups exhibited significantly longer durations of antibacterial activities than the control group (28 h +/- 1.3 h; P < 0.05). However, antibacterial activity against MRSA was observed only in the vancomycin group. In conclusion, cefazolin, which was administered as a prophylactic antibiotic in TKA, exhibited good ability for knee joint penetration and was sufficient to inhibit MSSA during its administration. The use of antibiotic-loaded cement can prolong the antibacterial activity of joint fluid in TKA. Further, vancomycin-loaded cement had antibacterial activity against MRSA superior to that of cement loaded with oxacillin or without antibiotic loading.
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Application of 3D-printed and patient-specific cast for the treatment of distal radius fractures: initial experience
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Distal Radius Fractures
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Background: Distal radius fracture is common in the general population. Fracture management includes a plaster cast, splint and synthetic material cast to immobilise the injured arm. Casting complications are common in those conventional casting technologies. 3D printing technology is a rapidly increasing application in rehabilitation. However, there is no clinical study investigating the application of a 3D-printed orthopaedic cast for the treatment of bone fractures. We have developed a patient-specific casting technology fabricated by 3D printing. This pioneering study aims to use 3D-printed casts we developed for the treatment of distal radius fractures, to provide the foundation for conducting additional clinical trials, and to perform clinical assessments.
Method: Ten patients with ages between 5 and 78 years are involved in the clinical trial. Patients are applied 3D-printed casts we developed. Orthopaedic surgeons carried out a six-week follow-up to examine clinical outcomes. Two questionnaires were developed for the assessment of clinical efficacy and patients' satisfaction. These questionnaires are completed by physicians and participating patients.
Results: A 3D-printed cast creates a custom-fitted design to maintain the fractured bone alignment. No loss of reduction is found in all patients. Compartment syndrome and pressure sores are not present. Patient comfort gets positive scores on the questionnaire. All (100%) of the patients opt for the 3D-printed cast instead of the conventional plaster cast.
Discussion: A patient-specific, 3D-printed cast offers a proper fit to immobilise an injured arm and holds the fracture reduction appropriately. A custom-fitted structure reduces the risk of pressure-related complications due to the high and concentrated local stress. The ventilated and lightweight design minimises interference with a patient's daily activities and reduces the risk of cutaneous complications. Patients express a strong preference for using a 3D-printed cast instead of a plaster cast. Limitations of the novel cast include a slight odour after heavy sweating and the relatively high cost due to the limitations of current 3D printing technologies.
Conclusions: This pioneering study is the first clinical trial on the application of a 3D-printed cast for the treatment of forearm fractures. The novel casting technology heals the fracture effectively without casting complications. The 3D-printed cast is patient-specific and ventilated as well as lightweight, and it features both increased patient comfort and satisfaction.
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Postoperative discomfort due to residual peripheral nerve blocks in outpatients operated from for carpal tunnel release
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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Background and Goal of Study: For hand surgery, peripheral nerve blocks (PNBs) can be performed at the wrist or more proximally at the brachial level. No data are available concerning the potential discomfort due to the residual block in the early postoperative period. The aim of our study was to assess the discomfort due to residual distal and proximal blocks in outpatients operated from carpal tunnel release. Materials and Methods: Cohort of outpatients undergoing open carpal tunnel release under PNBs. Median and ulnar nerves were always blocked with mepivacaine 1.5%. Musculocutaneous nerve block and PNB choice depended on the attending anaesthesiologist routine. Five anaesthesiologists performed distal PNBs (at the wrist, with nerve stimulation). Two anaesthesiologists performed proximal PNBs : at the brachial canal with nerve stimulation, or at the axillary crease with ultrasound guidance. Patients went home 2-3 hours after surgery. They were phoned 3 days later for our routine follow up, and were invited to graduate the discomfort due to the residual block after hospital discharge on a verbal scale (absence, minor, mild, quite important and very important). This was our primary end point. Both groups were compared with Fisher exact tests and student t tests when appropriate. Results and Discussion: Between november 2006 and january 2008, 185 of 217 consecutive patients were contacted at Day3 and analysed (105 distal PNBs and 80 proximal PNBs). Age, gender, body mass index, ASA score, postoperative pain scores were not different between groups. The musculocutaneous nerve was blocked in 23% of distal PNBs and in 81% of proximal ones (p< 0.001). Overall, distal PNBs induced less discomfort than proximal PNBs (p=0.041). Nevertheless, 20% of patients with distal PNBs express mild to very important discomfort, versus 30% of patients with proximal PNBs (p=0.124). Conclusion(s): Despite dramatic differences in anaesthetised and paralysed territories between the two groups, wrist PNBs induce only slightly less postoperative discomfort due to residual block than proximal PNBs. Therefore, the clinical impact of this discomfort seems limited since in both groups, 70 to 80% of patients reported no or minor discomfort
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Six-week gait retraining program reduces knee adduction moment, reduces pain, and improves function for individuals with medial compartment knee osteoarthritis
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Glenohumeral Joint OA
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This study examined the influence of a 6-week gait retraining program on the knee adduction moment (KAM) and knee pain and function. Ten subjects with medial compartment knee osteoarthritis and self-reported knee pain participated in weekly gait retraining sessions over 6 weeks. Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores and a 10-point visual-analog pain scale score were measured at baseline, post-training (end of 6 weeks), and 1 month after training ended. Gait retraining reduced the first peak KAM by 20% (p < 0.01) post-training as a result of a 7° decrease in foot progression angle (i.e., increased internal foot rotation), compared to baseline (p < 0.01). WOMAC pain and function scores were improved at post-training by 29% and 32%, respectively (p < 0.05) and visual-analog pain scale scores improved by two points (p < 0.05). Changes in WOMAC pain and function were approximately 75% larger than the expected placebo effect (p < 0.05). Changes in KAM, foot progression angle, WOMAC pain and function, and visual-analog pain score were retained 1 month after the end of the 6-week training period (p < 0.05). These results show that a 6-week gait retraining program can reduce the KAM and improve symptoms for individuals with medial compartment knee osteoarthritis and knee pain. © 2013 Orthopaedic Research Society.
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The expression of functional chemokine receptor CXCR4 is associated with the metastatic potential of human nasopharyngeal carcinoma
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MSTS 2018 - Femur Mets and MM
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PURPOSE: Chemokine receptors are implicated in metastasis of several malignant tumors. This study was done to evaluate the contribution of chemokine receptors CXCR4 and CCR7 to metastasis of human nasopharyngeal carcinoma.
EXPERIMENTAL DESIGN: Reverse transcription-PCR, immunohistochemistry, and flow cytometry were used to evaluate mRNA and protein expression of CXCR4 and CCR7 in nasopharyngeal carcinoma tumor tissues and cell lines. Chemotaxis assays were used to evaluate the function of CXCR4 in nasopharyngeal carcinoma cells. Antisense CXCR4 was used to inhibit receptor expression and to block metastasis of human nasopharyngeal carcinoma cells in vivo in athymic mice.
RESULTS: CXCR4 protein was detected in tumor cells in 31 of 40 primary human nasopharyngeal carcinoma and in 13 of 15 lymph node metastases. CXCR4 transcripts were detected in eight CXCR4 protein-positive primary nasopharyngeal carcinoma tissues and seven nasopharyngeal carcinoma cell lines tested. On the other hand, the transcripts for CCR7 were detected only in four primary nasopharyngeal carcinoma tissues and in none of the nasopharyngeal carcinoma cell lines. In functional experiments, metastatic nasopharyngeal carcinoma cell lines that expressed high levels of CXCR4 were found to migrate in response to the CXCR4 ligand SDF-1alpha. Transfection of antisense CXCR4 in metastatic nasopharyngeal carcinoma cells inhibited the expression of CXCR4 and SDF-1alpha-induced cell migration in vitro and reduced the capacity of the tumor cells to form metastasis in the lungs and lymph nodes when injected in athymic mice.
CONCLUSION: The expression of functional CXCR4 but not CCR7 is correlated with the metastatic potential of human nasopharyngeal carcinoma cells. Therefore, CXCR4 may be considered as a potential target for the prevention of nasopharyngeal carcinoma metastasis.
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A second decade lifetable survival analysis of the Oxford unicompartmental knee arthroplasty
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PJI DX Updated Search
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BACKGROUND: The role of unicompartmental arthroplasty in managing osteoarthritis of the knee remains controversial. The Oxford medial unicompartmental arthroplasty employs a fully congruent mobile bearing intended to reduce wear and increase the lifespan of the implant. Long-term second decade results are required to establish if the design aim can be met. QUESTIONS/PURPOSES: We report the (1) 20-year survivorship for the Oxford mobile bearing medial unicompartmental knee arthroplasty; (2) reasons for the revisions; and (3) time to revision. METHODS: We reviewed a series of 543 patients who underwent 682 medial Oxford meniscal bearing unicompartmental knee arthroplasties performed between 1983 and January 2005. The mean age at implantation was 69.7 years (range, 48-94 years). The median followup was 5.9 years (range, 0.5 to 22 years). One hundred and forty-one patients (172 knees) died. None were lost to followup. The primary outcome was 20-year survival, a key variable in assessing the longevity of arthroplasty. RESULTS: The 16-year all cause revision cumulative survival rate was 91.0% (CI 6.4, 71 at risk) and survival was maintained to 20 years (91.0%, CI 36.2, 14 at risk). There had been 29 revision procedures: 10 for lateral arthrosis, nine for component loosening, five for infection, two bearing dislocations, and three for unexplained pain. In addition, five patients had undergone bearing exchange, four for dislocation and one for bearing fracture. The mean time to revision was 3.3 years (range, 0.3-8.9 years). CONCLUSIONS: Mobile bearing unicompartmental knee arthroplasty is durable during the second decade after implantation. LEVEL OF EVIDENCE: Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence
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Correction of abnormally high nipples after reduction mammaplasty
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Reduction Mammoplasty for Female Breast Hypertrophy
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One of the most common complications after reduction mammaplasty is the abnormally high location of the nipple. The deformity may appear immediately after surgery if there was faulty planning before or during surgery. Or it may appear a few months after surgery due to migration of the breast tissue downward as a result of gravity, leaving the relatively fixed nipples at a higher location. This is more pronounced in cases of gigantic breasts and in virginal hypertrophy of the breast. The purpose of this article is to describe an alternative technique for correction of the highly located nipple.
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Management of non-melanoma skin cancer in immunocompromised solid organ transplant recipients
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Reconstruction After Skin Cancer
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Opinion statement: The management of non-melanoma skin cancers (NMSCs) in solid organ transplant recipients (OTRs) presents a variety of clinical challenges for physicians. OTRs are at a 65-fold increased risk for developing cutaneous squamous cell carcinomas (SCC), the most common NMSC that develops after transplantation. Risk factors contributing to the development of NMSCs in OTRs include a past medical history of any previous skin cancer, a personal history of significant sun exposure and a fair skin complexion or phototype. Further, greater immunosuppressive medication levels lead to an increased risk of NMSCs. Among immunosuppressants, specific older agents such as azathioprine and cyclosporine may increase the risk of developing NMSCs in contrast to newer agents such as sirolimus. Early skin biopsy and treatment of premalignant and malignant lesions are essential for treating these patients successfully. In this regard, the concept of field cancerization has been instructive in broadening treatments to include entire affected areas rather than individual lesions given that the areas with significant ultraviolet irradiation will continue to develop numerous individual precancerous and cancerous lesions. Field therapy with photodynamic therapy or topical 5-fluorouracil, imiquimod or diclofenac is often used in OTRs according to individual patient tolerability. Prompt excision or Mohs micrographic surgery is the standard of care of primary, uncomplicated squamous cell and basal cell carcinomas. For patients with in-transit or metastatic squamous cell carcinomas, adjuvant radiation, chemotherapy, and staging by sentinel lymph node dissection may be employed. For patients who develop numerous SCC per year, chemoprophylaxis can be effective in limiting the burden of disease. In consultation with the multidisciplinary transplant team, the immunosuppressive regimen can be revised to lower overall immunosuppression or altered to include newer drugs that have decreased oncogenic potential in OTRs. The greatest impact may be made by the prevention of NMSCs through simple, but rigorous, patient education on the benefits of UV protection, periodic self-skin examinations, and regular follow-ups. Accordingly, vitamin D and calcium supplementation should also be incorporated in transplant recipients. Management of OTRs requires patient education, frequent motivation for vigilance, regular follow-up, and interdisciplinary collaboration between transplant surgeons, nephrologists, hepatologists, cardiologists, transplant nurses, dermatologists, oncologists, pharmacists, and other relevant physicians ideally orchestrated by the essential transplant coordinators. © 2012 Springer Science+Business Media, LLC.
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Silicone implant arthroplasty in patients with idiopathic osteoarthritis of the metacarpophalangeal joint
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Distal Radius Fractures
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PURPOSE: The outcome of silicone metacarpophalangeal (MCP) joint implant arthroplasty in the osteoarthritic patient population has not been well established. Typically patients with idiopathic osteoarthritis have no history of underlying systemic disease and may respond well to treatment with MCP joint implant arthroplasty. This study examined the efficacy of silicone MCP joint implant arthroplasty for patients with idiopathic osteoarthritis for whom nonsurgical treatment had failed.
METHODS: Of 14 patients (15 arthroplasties) who had silicone MCP joint implant arthroplasty for idiopathic osteoarthritis 12 (13 arthroplasties) returned for follow-up evaluation at an average of 40 months after surgery. There were 9 index finger and 4 middle finger arthroplasties. The average age at the time of surgery was 62 years. Patients completed a subjective questionnaire and were examined by a certified therapist. Range of motion and strength were recorded and the Jebsen-Taylor examination was administered to assess function. Range of motion values at final follow-up evaluation were compared with preoperative and early postoperative values. Radiographs were taken at final follow-up evaluation and compared with preoperative and early postoperative films to assess joint position, wear, and radioulnar alignment.
RESULTS: At final follow-up evaluation excellent (9 patients) and good (3 patients) overall improvement were reported. Nine patients (10 implants) reported greater than 75% functional improvement. A notable increase was seen in MCP joint flexion. Grip and lateral pinch strengths were below age-matched normative data. Of the 11 patients (12 implants) who came in for follow-up evaluation 7 performed all tasks of the Jebsen-Taylor examination within the allotted time. At final follow-up evaluation all silicone implants were located and showed no signs of subluxation. Radiographic radioulnar alignment was maintained. One implant was revised at 35 months secondary to fracture.
CONCLUSIONS: Silicone implant arthroplasty is a motion-sparing procedure that provides good pain relief and maintenance of function at intermediate follow-up evaluation in patients with idiopathic osteoarthritis of the MCP joint.
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0 |
Management of open fractures of the lower limb
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DoD SSI (Surgical Site Infections)
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This article gives a practical guide for the management of open lower limb fractures. It outlines the referral criteria and pathway for definitive care in a specialist centre, the initial management steps that should be taken in the emergency department, and the principles of fixation, soft tissue coverage and antibiotic therapy.
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Do Orthopaedic Surgeons Acknowledge Uncertainty?.[Erratum appears in Clin Orthop Relat Res. 2016 Jun;474(6):1530-1; PMID: 26861152]
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DoD PRF (Psychosocial RF)
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BACKGROUND: Much of the decision-making in orthopaedics rests on uncertain evidence. Uncertainty is therefore part of our normal daily practice, and yet physician uncertainty regarding treatment could diminish patients' health. It is not known if physician uncertainty is a function of the evidence alone or if other factors are involved. With added experience, uncertainty could be expected to diminish, but perhaps more influential are things like physician confidence, belief in the veracity of what is published, and even one's religious beliefs. In addition, it is plausible that the kind of practice a physician works in can affect the experience of uncertainty. Practicing physicians may not be immediately aware of these effects on how uncertainty is experienced in their clinical decision-making.
QUESTIONS/PURPOSES: We asked: (1) Does uncertainty and overconfidence bias decrease with years of practice? (2) What sociodemographic factors are independently associated with less recognition of uncertainty, in particular belief in God or other deity or deities, and how is atheism associated with recognition of uncertainty? (3) Do confidence bias (confidence that one's skill is greater than it actually is), degree of trust in the orthopaedic evidence, and degree of statistical sophistication correlate independently with recognition of uncertainty?
METHODS: We created a survey to establish an overall recognition of uncertainty score (four questions), trust in the orthopaedic evidence base (four questions), confidence bias (three questions), and statistical understanding (six questions). Seven hundred six members of the Science of Variation Group, a collaboration that aims to study variation in the definition and treatment of human illness, were approached to complete our survey. This group represents mainly orthopaedic surgeons specializing in trauma or hand and wrist surgery, practicing in Europe and North America, of whom the majority is involved in teaching. Approximately half of the group has more than 10 years of experience. Two hundred forty-two (34%) members completed the survey. We found no differences between responders and nonresponders. Each survey item measured its own trait better than any of the other traits. Recognition of uncertainty (0.70) and confidence bias (0.75) had relatively high Cronbach alpha levels, meaning that the questions making up these traits are closely related and probably measure the same construct. This was lower for statistical understanding (0.48) and trust in the orthopaedic evidence base (0.37). Subsequently, combining each trait's individual questions, we calculated a 0 to 10 score for each trait. The mean recognition of uncertainty score was 3.2 +/- 1.4.
RESULTS: Recognition of uncertainty in daily practice did not vary by years in practice (0-5 years, 3.2 +/- 1.3; 6-10 years, 2.9 +/- 1.3; 11-20 years, 3.2 +/- 1.4; 21-30 years, 3.3 +/- 1.6 years; p = 0.51), but overconfidence bias did correlate with years in practice (0-5 years, 6.2 +/- 1.4; 6-10 years, 7.1 +/- 1.3; 11-20 years, 7.4 +/- 1.4; 21-30 years, 7.1 +/- 1.2 years; p < 0.001). Accounting for a potential interaction of variables using multivariable analysis, less recognition of uncertainty was independently but weakly associated with working in a multispecialty group compared with academic practice (beta regression coefficient, -0.53; 95% confidence interval [CI], -1.0 to -0.055; partial R(2), 0.021; p = 0.029), belief in God or any other deity/deities (beta, -0.57; 95% CI, -1.0 to -0.11; partial R(2), 0.026; p = 0.015), greater confidence bias (beta, -0.26; 95% CI, -0.37 to -0.14; partial R(2), 0.084; p < 0.001), and greater trust in the orthopaedic evidence base (beta, -0.16; 95% CI, -0.26 to -0.058; partial R(2), 0.040; p = 0.002). Better statistical understanding was independently, and more strongly, associated with greater recognition of uncertainty (beta, 0.25; 95% CI, 0.17-0.34; partial R(2), 0.13; p < 0.001). Our full model accounted for 29% of the variability in recognition of uncertainty (adjusted R(2), 0.29).
CONCLUSIONS: The relatively low levels of uncertainty among orthopaedic surgeons and confidence bias seem inconsistent with the paucity of definitive evidence. If patients want to be informed of the areas of uncertainty and surgeon-to-surgeon variation relevant to their care, it seems possible that a low recognition of uncertainty and surgeon confidence bias might hinder adequately informing patients, informed decisions, and consent. Moreover, limited recognition of uncertainty is associated with modifiable factors such as confidence bias, trust in orthopaedic evidence base, and statistical understanding. Perhaps improved statistical teaching in residency, journal clubs to improve the critique of evidence and awareness of bias, and acknowledgment of knowledge gaps at courses and conferences might create awareness about existing uncertainties.
LEVEL OF EVIDENCE: Level 1, prognostic study.
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Integrative testimonial therapy: an Internet-based, therapist-assisted therapy for German elderly survivors of the World War II with posttraumatic stress symptoms
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DoD PRF (Psychosocial RF)
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Trauma-focused cognitive behavioral treatments are known to be effective for posttraumatic stress disorder (PTSD) in adults. However, evidence for effective treatments for older persons with PTSD, particularly elderly war trauma survivors, is scarce. In an open trial, 30 survivors of World War II aged 65 to 85 years (mean, 71.73 years; SD, 4.8; n = 17 women) with PTSD symptoms were treated with a Web-based, therapist-assisted cognitive-behavioral/narrative therapy for 6 weeks. Intent-to-treat analyses revealed a significant decrease in PTSD severity scores (Cohen's d = 0.43) and significant improvements on secondary clinical outcomes of quality of life, self-efficacy, and posttraumatic growth from pretreatment to posttreatment. All improvements were maintained at a 3-month follow-up. The attrition rate was low (13.3%), with participants who completed the trial reporting high working alliance and treatment satisfaction. Results of this study suggest that integrative testimonial therapy is a well accepted and potentially effective treatment for older war trauma survivors experiencing PTSD symptoms.
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Treatment of pathological fractures due to simple bone cysts by extended curettage grafting and intramedullary decompression
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MSTS 2022 - Metastatic Disease of the Humerus
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OBJECTIVE: Effectiveness and morbidity of curettage grafting and intramedullary decompression in the treatment of pathological fractures due to simple bone cysts (SBCs) were evaluated.
METHODS: Between 2005 and 2012, 34 children with SBCs were treated with extended curettage grafting and intramedullary decompression. Average age of the patients (23 male, 11 female) at surgery was 11.7 years (range: 6-21 years). The lesions were localized in the humerus (19), femur (12), tibia (2), and ulna (1). Pathological micro- or displaced fractures occurred in 31 patients. Surgical procedure included extended curettage by using cauterization and high-speed burring, bone grafting, and intramedullary decompression with elastic nails. Six patients had been treated conservatively or surgically in other institutions previously. Radiographic and functional results were evaluated by Capanna criteria and MSTS scores respectively. Early and late complications and additional surgical procedures were recorded.
RESULTS: The average follow-up was 37 months (range: 18-89 months). The average time to heal for pathological fractures was 8 weeks (range: 6-12 weeks). Radiographic evaluation revealed Grade 1 healing in 28 patients (82%) and Grade 2 healing in 6 patients (18%). The average MSTS score based on final follow-up was 28.5 (range: 17-30); excellent (32 patients; 94%) and good (2 patients; 6%) functional results were obtained. There was no early or late infection, refracture or implant failure. Malunion developed following treatment of 2 humeral and 2 femoral lesions. With the exception of 2 implant removals, no patients required additional surgical intervention.
CONCLUSION: Complete cyst healing and satisfactory functional results can be obtained by curettage grafting and intramedullary decompression. This technique restores bone integrity by allowing early motion and prevents refracture and subsequent deformity in the majority of patients.
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Prevalence, characteristics, neuropsychiatric symptoms and quality-of-life of young people with acquired brain injury in Dutch nursing homes: study design
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DoD PRF (Psychosocial RF)
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Objectives: Little is known about young patients with severe acquired brain injury (ABI) needing intensive care due to chronic physical and/or behavioural disabilities who reside in nursing homes. Epidemiologic data and evidenceâ?based guidelines for ABI in longâ?term care do not exist. In order to achieve a suitable provision of care for these patients, establishing the prevalence and investigating the characteristics, neuropsychiatric symptoms (NPS) and qualityâ?ofâ?life is the first step in this process. The Dutch situation provides an excellent opportunity. The Netherlands is a small and densely populated country with more than 180 longâ?term care organizations well spread throughout the country. These organizations are specialized in somatic and psychogeriatric care, provided by multidisciplinary teams led by an Elderly Care Physician (ECP). The primary goal of this study is to investigate the prevalence, characteristics, NPS and qualityâ?ofâ?life in young patients with ABI in all Dutch nursing homes. Methods: A crossâ?sectional, observational, multiâ?centre, quantitative study among young patients (18â?65 years) with ABI admitted to specific ABI wards in Dutch nursing homes. Studying the characteristics, NPS and qualityâ?ofâ?life will be preceded by a nationwide prevalence study. Young patients in the chronic stage of ABI will be enrolled from the ABI wards of all Dutch nursing homes. Patient characteristics will be collected from medical files. Health status will be assessed by the Medical Outcome Study Short Form, qualityâ?ofâ?life by the Qualityâ?ofâ?Life after Traumatic Brain Injury, NPS by the NeuroPsychiatric Inventory NH, aggression by the Cohen Mansfield Agitation Inventory, sexual inappropriate behaviour by the St Andrews Sexual Behaviour Assessment. We focus specifically on aggression and inappropriate sexual behaviour because a pilot survey among nursing staff showed these are the most problematic NPS with the highest impact. Cognition is measured with the Mini Mental State Examination and activities of daily living by the Disability Rating Scale. Medication will be retrieved from the prescription/pharmacy system. Conclusions: The results will provide insight into the prevalence, characteristics, NPS and the qualityâ?ofâ?life of young patients with ABI in Dutch nursing homes, which will help care providers to match their care supply with the patients' care needs and to enhance the awareness of the consequences of ABI. Results could lead to recommendations for a suitable provision of care, including psychoâ?social interventions and psychoâ?education and improvement of quality of longâ?term care through ABI specific guidelines.
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No positive effect of autologous platelet gel after total knee arthroplasty: A double-blind randomized controlled trial: 102 patients with a 3-month follow-up
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PRP (Platelet-Rich Plasma)
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Background and purpose Activated platelets release a cocktail of growth factors, some of which are thought to stimulate repair. We investigated whether the use of autologous platelet gel (PG) in total knee arthroplasty (TKA) would improve wound healing and knee function, and reduce blood loss and the use of analgesics. Patients and methods 102 patients undergoing TKA were randomly assigned to a PG group (n 50) or to a control (C) group (n 52). The primary analysis was based on 73 participants (PG: 32; C: 41) with comparison of postoperative wound scores, VAS, WOMAC, knee function, use of analgesics, and the pre- and postoperative hemoglobin values after a follow-up of 3 months. 29 participants were excluded due to insufficient data. Results The characteristics of the protocol-compliant patients were similar to those of the patients who were excluded. Analysis was per protocol and focused on the remaining 73 patients. At baseline and after 3 months of follow-up, there were no statistically significant differences between both groups regarding age, height, weight, sex, side of operation, platelet count, hemoglobin values, severity of complaints (WOMAC), and level of pain. Interpretation In our patients undergoing TKA, application of PG to the wound site did not promote wound healing. Also, we found that PG had no effect on pain, knee function, or hemoglobin values. © 2009 Nordic Orthopedic Federation.
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Determinants of bone mineral density in older men
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Management of Hip Fractures in the Elderly
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Osteoporosis is a significant health problem and contributor to disability and premature mortality among older men. Incidence rates for hip fracture have stabilized in women, but continue to increase in men. A major risk factor for hip fracture is bone mineral density level. The determinants of bone mineral density (BMD) are well defined in women, but not in men. The primary goal of the current research was to increase our understanding of the determinants of BMD of the proximal femur in a large community-based sample of older male volunteers. Eligibility requirements included age of 50 years or older, ambulatory, and not having undergone a bilateral hip replacement. Five hundred twenty-three men, mean mean age 66.6 years, met all eligibility requirements and participated in the Study of Osteoporotic Risk in Men or STORM. Information on demographics, medical history, anthropometry, leisure-time and occupational physical activity, muscular strength, cigarette smoking, alcohol consumption, dietary calcium intake, and medication use (thiazide diuretics and glucocorticoids) were obtained by questionnaire, interview, and examination, BMD of the proximal femur (femoral neck, greater trochanter, and Ward's triangle) was measured by dual-energy X-ray absorptiometry using the Hologic QDR-1000 and QDR-2000. The cross-sectional determinants of BMD included age, blond hair color, current body weight, thiazide diuretic use, historical physical activity, and quadriceps strength. Several variables commonly thought to be determinants of BMD were not related to BMD in this population of older men, including current cigarette smoking, alcohol consumption, current leisure-time physical activity, dietary calcium intake, vitamin D use, and caffeine intake. However, failure to find associations among BMD and some of the potential determinants may be due to lack of statistical power. Identification of the determinants of BMD could lead to the development of interventions aimed at maximizing BMD in men and could potentially decrease the risk of hip fractures
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Contractures in burn injury: defining the problem
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DoD LSA (Limb Salvage vs Amputation)
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This study prospectively examined the incidence and severity of large joint contractures after burn injury and determined predictors of contracture development. Data were collected prospectively from 1993 to 2002 for consecutive adult burn survivors admitted to a regional burn center. Demographic and medical data were collected on each subject. The primary outcome measures included the presence of contractures, number of contractures per patient, and severity of contractures at each of four joints (shoulder, elbow, hip, knee) at time of hospital discharge. Logistic regression analysis was performed to determine predictors of the presence and severity of contractures and a negative binomial regression was performed to determine predictors of the number of contractures. Of the 985 study patients, 381 (38.7%) developed at least one contracture at hospital discharge. Among those with at least one contracture, the mean is three contractures per person. The shoulder was the most frequently contracted joint (38%), followed by the elbow (34%) and knee (22%). Most contractures were mild (60%) or moderate (32%) in severity. Statistically significant predictors of contracture development were length of stay (P < .005) and extent of burn (P = .033) and graft (P < .005). Predictors of the severity of contracture include graft size (P < .005), amputation (P = .034), and inhalation injury (P = .036). More than one third of the patients with a major burn injury developed a contracture at hospital discharge, which highlights the importance of therapeutic positioning and intensive therapy intervention during acute hospitalization. Furthermore, this challenges the burn care community to find new and better ways of preventing contractures after burn injury.
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1 |
Arthroplasty in veterans: analysis of cartilage, bone, serum, and synovial fluid reveals differences and similarities in osteoarthritis with and without comorbid diabetes
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Surgical Management of Osteoarthritis of the Knee CPG
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Osteoarthritis patients with diabetes who receive total knee arthroplasty are more vulnerable to complications, including aseptic loosening and need for revision surgery. To elucidate mechanisms related to arthroplasty failure in diabetes, we examined serum and synovial fluid markers as well as collagen crosslinks in bone and cartilage of 20 patients (10 with diabetes, 10 controls without) undergoing this procedure. Hemoglobin A1c, body mass index, bone alkaline phosphatase, leptin, osteocalcin, and pyridinium were analyzed along with tissue content of the crosslinks hydroxylysylpyridinoline, lysylpyridinoline, and pentosidine. Pentosidine levels in tissue specimens from diabetic subjects were higher than in control subjects. Osteocalcin levels negatively correlated with hydroxylysylpyridinoline levels in cartilage. Osteocalcin levels also negatively correlated with pentosidine levels in cartilage, but only in subjects with diabetes. This study suggests potential metabolic mechanisms for arthroplasty failure in patients with diabetes
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A new approach for the treatment of recurrent large abdominal hernias: The overlap flap
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Panniculectomy & Abdominoplasty CPG
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In this article we report a new technique for the treatment of recurrent large abdominal hernias and skin laxity: the overlap flap. This technique combines abdominoplasty with hernia repair. Obese patients with recurrent large abdominal hernias and skin laxity could benefit from this operation. This operation could not be performed in patients with a wide absence of the abdominal wall. A total of six patients were treated with this technique in our clinic. Follow-up of the patients has ranged from 1 to 4 years. Cosmetic results were excellent in all patients. No recurrence of the hernias has been observed in any of the patients. Two flaps are prepared; the lower one is deepithelialized, and it is used as an autogenous mesh in place of a prosthetic material to reinforce the abdominal wall, and the upper flap is prepared and overlapped on this lower one.
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A Retrospective Analysis to Evaluate Seasonal Pressure Injury Incidence Differences Among Hip Fracture Patients in a Tertiary Hospital in East China
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Hip Fx in the Elderly 2019
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Patients with a hip fracture are at high risk for pressure injury. A retrospective review of the electronic medical records of consecutive patients with a hip fracture treated in 2016 in a single tertiary hospital in east China were examined to investigate whether time of year affected the incidence of hospital-acquired pressure injury. Data collected included demographic characteristics (patient name, hospital number, age, gender, and body mass index); possible risk factors for pressure injury, such as presence of diabetes mellitus, admission hemoglobin, admission albumin, length of surgery, and the lowest and/or last Braden Scale score before pressure injury developed; and pressure injury information, which included time of occurrence (days after surgery), location (sacrum and coccyx, ischial tuberosity, or heel), stage, and treatment outcome. Pressure injury incidence was calculated with 95% confidence intervals (CIs) in each month and season (spring, summer, autumn, and winter). Odds ratios (ORs) and 95% CIs were calculated as estimates of risk. Multivariate logistic regression was used for risk factors. Of the 235 patients with a hip fracture included in the study, 95 (40.4%) were male, 140 (59.6%) were female, and mean age was 70.4 +/- 10.5 (range 48-81) years. Thirty-one (31) patients (13.2%, 95% CI 9.1%-18.2%) developed 37 pressure injuries, 30 of which (81.1%) were Stage 1. The incidence of pressure injury was lowest in November (5.0%; 95% CI: 0.0%-24.9%) and highest in June (22.7%; 95% CI: 7.8%-45.4%). Average Braden Scale scores (14.2 +/- 3.2) were lower in June than in November (16.6 +/- 3.5), owing to differences in the Braden Scale skin moisture subscale. Seasonally, the incidence of pressure ulcers was 20.8% (95% CI: 12.2%-32.0%) in the summer compared to 7.5% (2.5%-16.6%) in autumn (crude OR 3.3; 95% CI:1.0-12.1; P = .025). Multivariate logistic regression analysis showed the Braden Scale score was the only independent risk factor (P <.05) for pressure injury incidence. Adjusting for the Braden score, the OR of summer season was 1.537 (95% CI: 0.964-2.872). The findings suggest that humidity and temperature levels, which are very high in the summer in China, may affect pressure injury incidence and that the Braden Scale score - especially the skin-moisture level subscore - is a valid predictor of pressure injury risk in this population. While more research is needed, additional pressure injury prevention strategies should be provided for patients hospitalized with a hip fracture in the summer months.
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Azithromycin and dentistry - a useful agent?
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Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures
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OBJECTIVES: Azithromycin has recently replaced clindamycin oral suspension for prop hylaxis of infective endocarditis (IE) in children. It is also currently recommended by the American Heart Association as an alternative to penicillin, along with clindamycin for prophylaxis of infective endocarditis in adults. The objectives of this paper were to firstly, review the current literature on the efficacy of azithromycin as a suitable prophylactic agent in the prevention of infective endocarditis; and secondly, to review its pharmacological properties as a suitable therapeutic agent in the management of odontogenic infections. DESIGN: A review of the literature. CONCLUSIONS: The available evidence from animal models on infective endocarditis supports the efficacy of this drug as a prophylactic agent against oral streptococci. The pharmacological properties of this agent would make it a very promising therapeutic adjunct in the management of odontogenic infections. At present there are only a small number of studies available with valuable data on the efficacy of this relatively new drug. Further investigations comparing this compound with other commonly used adjuncts would be of great benefit
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Clinical analysis of 28 children suffering from intracranial hematoma and multiple injuries following traffic accidents
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DoD SSI (Surgical Site Infections)
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OBJECTIVE: To evaluate the result of diagnosis and treatment of intracranial hematoma and multiple injuries caused by road traffic accidents.
METHODS: Twenty-eight patients, aged from 1 to 14 years, receiving craniotomy and other surgical treatments were retrospectively reviewed.
RESULTS: Among the 28 cases, 23 cured with the recovery rate of 82.3%, 2 had a sequel of moderate disability, and 3 died from severe brain injury, hemorrhagic shock, and other visceral complications. The clinical symptoms and signs were severe and perplexing. The major characters included: severe head injury, usually combined by multiple injuries, and easy of access to missed diagnosis and misdiagnosis.
CONCLUSIONS: The occurrence of infection is high after traffic accidents as a result of depression of humoral and cellular immunity, long-term bed rest, and fractures of limbs. Hence, on the basis of maintaining vital signs, the management of primary wound is essential to reduce infection and underlying death. In addition to the management of brain injury, concurrent injuries should also be highlighted so as to reach a good result for their patients.
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First in vivo detection and characterization of hyaluronan-coated extracellular vesicles in human synovial fluid
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OAK 3 - Non-arthroplasty tx of OAK
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Extracellular vesicles (EVs) function in intercellular signaling by transporting different membrane and cytosolic molecules, including hyaluronan (HA) and its synthesis machinery. As both EVs and HA are abundant in synovial fluid, we hypothesized that HA synthesized in synovial membrane would be carried on the surface of EVs. Synovial fluid (n = 15) and membrane samples (n = 5) were obtained from knee surgery patients. HA concentrations were analyzed in synovial fluid and HA and its synthesis machinery were examined with histochemical stainings in synovial membrane. To assess the size distribution of EVs in synovial fluid and to visualize HA on EVs, nanoparticle tracking analysis (NTA), confocal laser scanning microscopy (CLSM) and transmission electron microscopy (TEM) were utilized. The average HA concentration in synovial fluid was 2.0 +/- 0.21 mg/ml without significant differences between the patients with trauma/diagnostic arthroscopy and primary or post-traumatic osteoarthritis. Positive stainings of HA synthases (HAS1-3), HA and its receptor CD44 in synovial cells indicated active HA secretion in synovial membrane. According to NTA, EVs were abundant in synovial fluid and their main populations were <=300 nm in diameter after differential centrifugation. There were no significant differences in the EV counts between the patients with primary or post-traumatic osteoarthritis. TEM verified that HA-positive particles detected by CLSM were lipid membrane vesicles surrounded by a HA coat. Our results provide the first in vivo evidence that human synovial fluid contains HA-positive EVs, one source of which presumably is the long HAS-positive protrusions of synovial fibroblasts. © 2016 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 34:1960-1968, 2016.
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Cost effectiveness and cost utility of risedronate for osteoporosis treatment and fracture prevention in women: a Swiss perspective
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Management of Hip Fractures in the Elderly
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OBJECTIVES: To assess the incremental cost-effectiveness ratio (ICER) and incremental cost-utility ratio (ICUR) of risedronate compared to no intervention in postmenopausal osteoporotic women in a Swiss perspective. METHODS: A previously validated Markov model was populated with epidemiological and cost data specific to Switzerland and published utility values, and run on a population of 1,000 women of 70 years with established osteoporosis and previous vertebral fracture, treated over 5 years with risedronate 35 mg weekly or no intervention (base case), and five cohorts (according to age at therapy start) with eight risk factor distributions and three lengths of residual effects. RESULTS: In the base case population, the ICER of averting a hip fracture and the ICUR per quality-adjusted life year gained were both dominant. In the presence of a previous vertebral fracture, the ICUR was below euro45,000 (pound30,000) in all the scenarios. For all osteoporotic women>or=70 years of age with at least one risk factor, the ICUR was below euro45,000 or the intervention may even be cost saving. Age at the start of therapy and the fracture risk profile had a significant impact on results. CONCLUSION: Assuming a 2-year residual effect, that ICUR of risedronate in women with postmenopausal osteoporosis is below accepted thresholds from the age of 65 and even cost saving above the age of 70 with at least one risk factor
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1 |
Arthroplasty versus internal fixation of femoral neck fractures: a clinical decision analysis
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Management of Hip Fractures in the Elderly
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BACKGROUND: The optimal surgical management of displaced femoral neck fractures in the elderly remains controversial. Treatment alternatives include arthroplasty and internal fixation. Options for arthroplasty include total hip arthroplasty and hemiarthroplasty, whereas options for internal fixation include multiple screws and sliding hip screws. We sought to compare arthroplasty and internal fixation alternatives and determine the key factors influencing final outcomes using a clinical decision analysis. MATERIALS AND METHODS: We constructed a decision analytic model representing potential outcomes after arthroplasty and internal fixation alternatives. Probabilities of events following each procedure were systematically derived from a literature review. Relative outcome preferences were estimated using health utility questionnaires with surgeons and lay persons. Sensitivity analyses determined threshold values that would alter the preferred decision. RESULTS: In the arthroplasty comparison, patients treated with total hip arthroplasty achieved higher expected utility values than patients treated with hemiarthroplasty (0.80 versus 0.74). In the internal fixation analysis, sliding hip screw fixation yielded higher expected utility values than multiple screws (0.76 versus 0.73). Overall, total hip arthroplasty achieved higher expected utility values than either approach to internal fixation. The superiority of arthroplasty over internal fixation was maintained over a wide range of probabilities and utilities. CONCLUSIONS: When outcomes and their values are considered in a systematic manner, arthroplasty results in better patient outcomes when compared to internal fixation in the management of displaced hip fractures in the elderly
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Arthroscopic repair of massive rotator cuff tears: a prospective cohort with 2- to 4-year follow-up
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Optimizing the Management of Full-Thickness Rotator Cuff Tears
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PURPOSE: The goal of this study is to report on the complete arthroscopic repair of massive rotator cuff tears. TYPE OF STUDY: Prospective cohort study. METHODS: Between 1997 and 1999, 37 patients underwent complete arthroscopic repair of massive rotator cuff tears. The preoperative and postoperative outcomes of these 37 patients were analyzed using the constant score, American Shoulder and Elbow Society (ASES) index, visual analog pain scale (VAS), a single question of percent function compared with the opposite unaffected extremity, and a single question reflecting satisfaction (Would you undergo the surgery and the postoperative rehabilitation to achieve the result you have today?). The null hypothesis that was tested was that there was no difference between the preoperative and postoperative outcomes. The 37 patients were divided, by cohort design, into 2 groups; massive anterosuperior (AS; subscapularis, supraspinatus, and infraspinatus with or without the teres minor) and massive posterosuperior (PS; supraspinatus and infraspinatus, with or without the teres minor) tears. Additionally, the null hypothesis that there was no difference between outcomes for massive AS and massive PS subgroups was tested. RESULTS: There was no statistically significant difference between either subset of massive rotator cuff tears with respect to preoperative and postoperative outcomes. The null hypothesis was supported for between groups. All but 2 patients said that they would undergo surgery again to achieve the postoperative state. CONCLUSIONS: The arthroscopic repair of massive rotator cuff tears is effective for decreasing pain and improving the functional status of the shoulder for most patients. Complete coverage was achieved in 78% of the patients at the time of surgery. A subset of patients who did not have complete coverage or coverage at a second setting showed similar outcomes as those with full coverage. The patient satisfaction rate was 95%
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Functional outcome measures in a surgical model of hip osteoarthritis in dogs
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OAK 3 - Non-arthroplasty tx of OAK
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BACKGROUND: The hip is one of the most common sites of osteoarthritis in the body, second only to the knee in prevalence. However, current animal models of hip osteoarthritis have not been assessed using many of the functional outcome measures used in orthopaedics, a characteristic that could increase their utility in the evaluation of therapeutic interventions. The canine hip shares similarities with the human hip, and functional outcome measures are well documented in veterinary medicine, providing a baseline for pre-clinical evaluation of therapeutic strategies for the treatment of hip osteoarthritis. The purpose of this study was to evaluate a surgical model of hip osteoarthritis in a large laboratory animal model and to evaluate functional and end-point outcome measures.
METHODS: Seven dogs were subjected to partial surgical debridement of cartilage from one femoral head. Pre- and postoperative pain and functional scores, gait analysis, radiographs, accelerometry, goniometry and limb circumference were evaluated through a 20-week recovery period, followed by histological evaluation of cartilage and synovium.
RESULTS: Animals developed histological and radiographic evidence of osteoarthritis, which was correlated with measurable functional impairment. For example, Mankin scores in operated limbs were positively correlated to radiographic scores but negatively correlated to range of motion, limb circumference and 20-week peak vertical force.
CONCLUSIONS: This study demonstrates that multiple relevant functional outcome measures can be used successfully in a large laboratory animal model of hip osteoarthritis. These measures could be used to evaluate relative efficacy of therapeutic interventions relevant to human clinical care.
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1 |
Clinical comparison of the second and third generation of intramedullary devices for trochanteric fractures of the hip - Blade vs screw
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Management of Hip Fractures in the Elderly
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With industrial societies getting older the incidence of femoral fractures is increasing. Complication rates up to 20% have led to a continuous improvement of intramedullar nailing systems and the third generation of implants is in clinical application. They seem superior to the second generation. But as clinical data is still fragmentary, we wanted to compare a second generation implant, the Proximal Femur Nail with three devices of the third generation: the Gleitnagel, Trochanter Fixation Nail and the Proximal Femur Nail Antirotation with a clinical study. We analysed whether fracture reduction and implant position could possibly be indicators for implant complications. Patients with a trochanteric fracture type A1-A3 (AO/ASIF classification) admitted at the department of traumatology Augsburg were enrolled. Postoperative X-rays were analysed in the matter of fracture reduction for the fracture gap, the Garden Alignment Index and for the matter of implant position in the femur head with the cleaveland zones and the Tip Apex Distance. 322 patients were enrolled. Most frequent was the A2 (n = 240) and the A3 type of fracture (n = 80) followed by A1 (n = 29). Time to hospital discharge was 17 days (9/25), 12 patients died (3.2%). The complication rate (cutting out) in the third generation was lower (2.5-7%) than in the second generation (14%). The postoperative range of mobilisation compared to the old social status was in the groups with 34% similar after 3 months. The third generation nails are safe and reliable implants. Compared with second generation devices, fewer complications are observed. A correlation might be seen in the postoperative X-rays between the fracture reduction or implant position and implant related mechanical complications (cutting out). (copyright) 2010 Elsevier Ltd. All rights reserved
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