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Biomechanical changes after carpal tunnel release: A cadaveric model for comparing open, endoscopic, and step-cut lengthening techniques
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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We used a previously described cadaveric model for evaluating changes in flexor tendon biomechanics after open carpal tunnel release to evaluate endoscopic and step-cut lengthening techniques. A 26% and 18% increase in tendon excursion consumed by wrist motion was demonstrated for flexor digitorum profundus and flexor digitorum superficialis tendons respectively after open transection of the transverse carpal ligament. A 21% and 15% increase in tendon excursion was demonstrated after endoscopic carpal tunnel release and a 21% and 16% increase after step-cut lengthening of the transverse carpal ligament. Increased excursion was noted after 20-30(degrees) of wrist flexion as tendon bowstringing occurred. Although division of the transverse carpal ligament by all methods resulted in a significant increase in tendon excursion, the differences between methods of carpal tunnel release were not significant. This cadaveric study evaluates one potential cause for weakness after carpal tunnel release, palmar displacement of the flexor tendons, which results in increased flexor tendon excursion consumed by wrist motion
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Ankylosing neurogenic myositis ossificans of the hip. An enhanced volumetric CT study
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Management of Hip Fractures in the Elderly
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Neurogenic myositis ossificans is a disabling condition affecting the large joints of patients with severe post-traumatic impairment of the central nervous system. It can result in ankylosis of the joint and vascular or neural compression. Surgery may be hazardous with potential haemorrhage, neurovascular injury, iatrogenic fracture and osteochondral injury. We undertook pre-operative volumetric CT assessment of 45 ankylosed hips with neurogenic myositis ossificans which required surgery. Helical CT with intravenous contrast, combined with two- and three-dimensional surface reconstructions, was the only pre-operative imaging procedure. This gave good differentiation of the heterotopic bone from the adjacent vessels. We established that early surgery, within 24 months of injury, was neither complicated by peri-operative fracture nor by the early recurrence of neurogenic myositis ossificans. Surgical delay was associated with a loss of joint space and a greater degree of bone demineralisation. Enhanced volumetric CT is an excellent method for the pre-operative assessment of neurogenic myositis ossificans and correlates well with the operative findings
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Persistent postsurgical pain: risk factors and prevention
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DoD PRF (Psychosocial RF)
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Acute postoperative pain is followed by persistent pain in 10-50% of individuals after common operations, such as groin hernia repair, breast and thoracic surgery, leg amputation, and coronary artery bypass surgery. Since chronic pain can be severe in about 2-10% of these patients, persistent postsurgical pain represents a major, largely unrecognised clinical problem. Iatrogenic neuropathic pain is probably the most important cause of long-term postsurgical pain. Consequently, surgical techniques that avoid nerve damage should be applied whenever possible. Also, the effect of aggressive, early therapy for postoperative pain should be investigated, since the intensity of acute postoperative pain correlates with the risk of developing a persistent pain state. Finally, the role of genetic factors should be studied, since only a proportion of patients with intraoperative nerve damage develop chronic pain. Based on information about the molecular mechanisms that affect changes to the peripheral and central nervous system in neuropathic pain, several opportunities exist for multimodal pharmacological intervention. Here, we outline strategies for identification of patients at risk and for prevention and possible treatment of this important entity of chronic pain.
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The effectiveness of femoral/sciatic nerve blocks on postoperative pain management in total knee arthroplasty
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AAHKS (9/10) Regional Nerve Blocks
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PURPOSE: Total knee arthroplasty (TKA) generates severe postoperative pain in 60% of patients and moderate pain in 30% of patients. Lack of adequate pain control can hinder early intensive physical therapy, the most influential factor for a good outcome. The purpose of this study was to evaluate the effectiveness of the femoral/sciatic block with postoperative pain management in comparison with conventional pain management in patients who have undergone unilateral primary TKA.
SAMPLE: Following unilateral TKA, 130 patients were evaluated: 65 in the general/spinal group and 65 in the general/femoral/sciatic group.
METHODS: This is a retrospective, comparative study. Participants who underwent primary TKA were randomly selected from a computer list generated by the hospitals medical records department between May 2001 to May 2002 and May 2004 to May 2005. Data collected included demographics, anesthesia type, knee range of motion, pain scores, complications, and length of stay.
FINDINGS: The general/femoral/sciatic group members experienced less pain as evidenced by the lower visual analog scale scores and less use of adjunct narcotics. They also performed better with increased knee flexion and extension scores than those in the general/spinal group. There was no difference in length of stay or significant differences between the groups with medical complications.
DISCUSSION: Findings indicate that femoral/sciatic nerve blocks in unilateral TKA are an effective method of postoperative pain management.
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Prospective study on incidence, risk factors, and long-term outcome of osteonecrosis in pediatric acute lymphoblastic leukemia
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AAHKS (2) Corticosteroids
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PURPOSE: We studied cumulative incidence, risk factors, therapeutic strategies, and outcome of symptomatic osteonecrosis in pediatric patients with acute lymphoblastic leukemia (ALL).
PATIENTS AND METHODS: Cumulative incidence of osteonecrosis was assessed prospectively in 694 patients treated with the dexamethasone-based Dutch Child Oncology Group-ALL9 protocol. Osteonecrosis was defined by development of symptoms (National Cancer Institute grade 2 to 4) during treatment or within 1 year after treatment discontinuation, confirmed by magnetic resonance imaging. We evaluated risk factors for osteonecrosis using logistic multivariate regression. To describe outcome, we reviewed clinical and radiologic information after antileukemic treatment 1 year or more after osteonecrosis diagnosis.
RESULTS: Cumulative incidence of osteonecrosis at 3 years was 6.1%. After adjustment for treatment center, logistic multivariate regression identified age (odds ratio [OR], 1.47; P < .01) and female sex (OR, 2.23; P = .04) as independent risk factors. Median age at diagnosis of ALL in patients with osteonecrosis was 13.5 years, compared with 4.7 years in those without. In 21 (55%) of 38 patients with osteonecrosis, chemotherapy was adjusted. Seven patients (18%) underwent surgery: five joint-preserving procedures and two total-hip arthroplasties. Clinical follow-up of 35 patients was evaluated; median follow-up was 4.9 years. In 14 patients (40%), symptoms completely resolved; 14 (40%) had symptoms interfering with function but not with activities of daily living (ADLs; grade 2); seven (20%) had symptoms interfering with ADLs (grade 3). In 24 patients, radiologic follow-up was available; in six (25%), lesions improved/disappeared; in 13 (54%), lesions remained stable; five (21%) had progressive lesions.
CONCLUSION: Six percent of pediatric patients with ALL developed symptomatic osteonecrosis during or shortly after treatment. Older age and female sex were risk factors. After a median follow-up of 5 years, 60% of patients had persistent symptoms.
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Primary cutaneous leiomyosarcoma. A histological and immunohistochemical study of 9 cases, with ultrastructural correlation
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MSTS 2018 - Femur Mets and MM
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Leiomyosarcoma (LMS) of dermal and subcutaneous tissues is an uncommon neoplasm. In order to analyze the specialized pathologic features of this tumor, we undertook a histological, ultrastructural, and immunohistochemical study of 9 superficial LMS, including 7 dermal lesions and 2 subcutaneous neoplasms. These were compared with 12 examples of "deep" extracutaneous LMS. Metastases to the skin from two of the latter neoplasms were also examined. Immunohistochemistry was found to be a useful diagnostic adjunct to light microscopic and ultrastructural studies in that all LMS coexpressed vimentin and desmin, regardless of site, and 90% also expressed muscle-specific actin. Variable expression of cathepsin B and myelin basic protein was noted in 8 and 10 tumors, respectively, whereas none contained cytokeratin. Weak cytoplasmic positivity for epithelial membrane antigen was seen in 1 dermal and 3 extracutaneous LMS. Of 7 dermal LMS, 4 contained S-100 protein, whereas this determinant was found in only 1 of 12 extracutaneous tumors. Conversely, Leu 7 reactivity was present in 7 of 12 extracutaneous LMS, but only 2 of 9 superficial lesions. Review of clinical features confirmed that subcutaneous LMS is capable of aggressive behaviour, whereas dermal LMS was more likely to behave in an indolent fashion. However, one example of dermal LMS exhibited aggressive local recurrences and distant metastasis, ultimately leading to the death of the patient. Therefore, careful clinical followup is indicated in all cases.
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Regional anesthesia as compared with general anesthesia for surgery in geriatric patients with hip fracture: Does it decrease morbidity, mortality, and health care costs? Results of a single-centered study
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Management of Hip Fractures in the Elderly
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Introduction. Hip fracture in geriatric patients has a substantial economic impact and represents a major cause of morbidity and mortality in this population. At our institution, a regional anesthesia program was instituted for patients undergoing surgery for hip fracture. This retrospective cohort review examines the effects of regional anesthesia (from mainly after July 2007) vs general anesthesia (mainly prior to July 2007) on morbidity, mortality and hospitalization costs. Methods. This retrospective cohort study involved data collection from electronic and paper charts of 308 patients who underwent surgery for hip fracture from September 2006 to December 2008. Data on postoperative morbidity, in-patient mortality, and cost of hospitalization (as estimated from data on hospital charges) were collected and analyzed. Seventy-three patients received regional anesthesia and 235 patients received general anesthesia. During July 2007, approximately halfway through the study period, a regional anesthesia and analgesia program was introduced. Results. The average cost of hospitalization in patients who received surgery for hip fracture was no different between patients who receive regional or general anesthesia ($16,789+631 vs $16,815+643, respectively, P=0.9557). Delay in surgery and intensive care unit (ICU) admission resulted in significantly higher hospitalization costs. Age, male gender, African American race and ICU admission were associated with increased in-hospital mortality. In-hospital mortality and rates of readmission are not statistically different between the two anesthesia groups. Conclusions. There is no difference in postoperative morbidity, rates of rehospitalization, in-patient mortality or hospitalization costs in geriatric patients undergoing regional or general anesthesia for repair of hip fracture. Delay in surgery beyond 3 days and ICU admission both increase cost of hospitalization. Wiley Periodicals, Inc
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The Knee injury and Osteoarthritis Outcome Score (KOOS): from joint injury to osteoarthritis
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AMP (Acute Meniscal Pathology)
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The Knee injury and Osteoarthritis Outcome Score (KOOS) was developed as an extension of the WOMAC Osteoarthritis Index with the purpose of evaluating short-term and long-term symptoms and function in subjects with knee injury and osteoarthritis. The KOOS holds five separately scored subscales: Pain, other Symptoms, Function in daily living (ADL), Function in Sport and Recreation (Sport/Rec), and knee-related Quality of Life (QOL). The KOOS has been validated for several orthopaedic interventions such as anterior cruciate ligament reconstruction, meniscectomy and total knee replacement. In addition the instrument has been used to evaluate physical therapy, nutritional supplementation and glucosamine supplementation. The effect size is generally largest for the subscale QOL followed by the subscale Pain. The KOOS is a valid, reliable and responsive self-administered instrument that can be used for short-term and long-term follow-up of several types of knee injury including osteoarthritis. The measure is relatively new and further use of the instrument will add knowledge and suggest areas that need to be further explored and improved. [References: 23]
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Home rehabilitation after hip fracture. A randomized controlled study on balance confidence, physical function and everyday activities
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Hip Fx in the Elderly 2019
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OBJECTIVE: To investigate whether home rehabilitation can improve balance confidence, physical function and daily activity level compared to conventional care in the early phase after hip fracture. DESIGN: A randomized controlled study. SETTING: Geriatric rehabilitation clinic. SUBJECTS: One hundred and two community-dwelling elderly people. INTERVENTIONS: A geriatric, multiprofessional home rehabilitation programme focused on supported discharge, independence in daily activities, and enhancing physical activity and confidence in performing daily activities was compared with conventional care in which no structured rehabilitation after discharge was included. MAIN MEASURES: Falls efficacy, degree of dependency and frequency in daily activities, habitual physical activity and basic functional performance. RESULTS: When comparing status one month after discharge with baseline, the home rehabilitation group showed a higher degree of recovery in self-care (P<0.0001), mobility (P = 0.002), locomotion (P = 0.0036) and domestic activities (P = 0.0098), as well as larger increase in balance confidence on stairs (P = 0.0018) and instrumental activities (mean increase home rehabilitation 19.7 and conventional care 7.1, P<0.0001) compared with the conventional care group. At one month, a majority of the home rehabilitation participants (88%) took outdoor walks, compared with less than half (46%) of the conventional care group (P<0.001) and were also more independent in outdoor activities (P = 0.0014). CONCLUSIONS: This study indicates that home rehabilitation, focused on supported discharge and enhancing self-efficacy, improves balance confidence, independence and physical activity in community-dwelling older adults in the early phase after hip fracture.
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Linear regression analysis of Hospital Episode Statistics predicts a large increase in demand for elective hand surgery in England
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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INTRODUCTION: We integrated two factors, demographic population shifts and changes in prevalence of disease, to predict future trends in demand for hand surgery in England, to facilitate workforce planning. METHODS: We analysed Hospital Episode Statistics data for Dupuytren's disease, carpal tunnel syndrome, cubital tunnel syndrome, and trigger finger from 1998 to 2011. Using linear regression, we estimated trends in both diagnosis and surgery until 2030. We integrated this regression with age specific population data from the Office for National Statistics in order to estimate how this will contribute to a change in workload over time. RESULTS: There has been a significant increase in both absolute numbers of diagnoses and surgery for all four conditions. Combined with future population data, we calculate that the total operative burden for these four conditions will increase from 87,582 in 2011 to 170,166 (95% confidence interval 144,517-195,353) in 2030. DISCUSSION: The prevalence of these diseases in the ageing population, and increasing prevalence of predisposing factors such as obesity and diabetes, may account for the predicted increase in workload. The most cost effective treatments must be sought, which requires high quality clinical trials. Our methodology can be applied to other sub-specialties to help anticipate the need for future service provision
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Outcome of opening wedge high tibial osteotomy augmented with a Biosorb(R) wedge and fixed with a plate and screws in 124 patients with a mean of ten years follow-up
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Surgical Management of Osteoarthritis of the Knee CPG
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The objective of this work was firstly to evaluate the long-term results of medial opening wedge high tibial osteotomy (HTO) and secondly to evaluate the tolerance and integration of a Biosorb(R) wedge (beta Tricalcium Phosphate, SBM Company, Lourdes, France). The series consisted of 124 knees in 110 patients, 74 men and 36 women, with mean age of 53.23+/-10.68 years (range 32-74) and treated between June 1995 and November 2000 for medial compartment knee osteoarthritis by the senior author. The mean preoperative Lysholm and Tegner functional score was 65.44+/-13.32 (range 27-80) and the preoperative HKA angle was 172.51 degrees +/-3.8 degrees (range 162-179 degrees ). According to the modified Ahlback classification there were 27 stage I, 42 stage II, 44 stage III and 11 stage IV knees. All patients were reviewed clinically and radiologically with a mean follow-up of 10.39+/-1.98 years (range 8-14 years). Immediate postoperative complications consisted of nine undisplaced lateral tibial plateau fractures of no clinical significance, two deep vein thromboses and three pulmonary emboli which resolved with appropriate treatment. At a later stage, there were seven delayed unions without development of pseudarthrosis, and three screw breakages when the AO T-plate was used, leading to a secondary angulation in one case, requiring revision by femoral osteotomy. Postoperative mean weightbearing HKA angle was 182 degrees +/-1.8 degrees (range 178-186 degrees ) and 73.4% of axes were 184 degrees +/-2 degrees . Fifteen knees (12.1%) underwent total knee arthroplasty (TKA) after a mean delay of 8.87+/-3.04 years and were excluded from the final analysis. Concerning the long-term results (n = 107 knees), the mean Lysholm-Tegner score was 88+/-12.7 points (51-100) and the KOOS score was 86+/-14.6 points (25-100) with 94 patients satisfied or very satisfied (87.85%). In terms of the HTO survivorship curve, with failure consisting of revision to TKA or another operation, survival was 88.8% at five years and 74% at ten years. Concerning Biosorb(R), this was completely integrated in 100% of cases and there was complete resorption in 12.1% of cases and greater than 50% resorption in 52.3% of cases
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Effects of low-intensity pulsed ultrasound and hyperbaric oxygen on human osteoarthritic chondrocytes
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Surgical Management of Osteoarthritis of the Knee CPG
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BACKGROUND: Although the individual effects of hyperbaric oxygen (HBO) and low-intensity pulsed ultrasound (LIPUS) on osteoarthritic (OA) chondrocytes have been reported, the effects of HBO combined with LIPUS treatment are unknown. METHODS: OA chondrocytes were obtained from patients undergoing knee replacement surgery. RNA was isolated for real-time polymerase chain reaction (PCR) analysis of inducible nitric oxide synthase (iNOS), type-II collagen, and aggrecan gene expression. The protein levels of MMP-3 and TIMP-1 were quantified by enzyme-linked immunosorbent assay (ELISA) after LIPUS or HBO treatment. The data are given as mean +/- standard deviation (SD) of the results from three independent experiments. A p value less than 0.05 was defined as statistically significant. RESULTS: Our data suggested that ultrasound and HBO treatment increased cell bioactivity of OA chondrocytes. Real-time PCR analysis showed that HBO treatment increased the mRNA of type-II collagen, aggrecan, and TIMP-1 but suppressed the iNOS expression of OA chondrocytes. LIPUS treatment increased the type-II collagen and iNOS expression of OA chondrocytes. ELISA data showed that HBO or LIPUS treatment increased TIMP-1 production of OA chondrocyte. MMP-3 production was suppressed by HBO treatment. HBO combined with LIPUS treatments resulted in additive effect in TIMP-1 production and compensatory effect in iNOS expression. CONCLUSION: HBO combined with LIPUS treatment-induced increase of the anabolic factor (TIMP-1)/catabolic factor (MMP-3) ratio may provide an additive therapeutic approach to slow the course of OA degeneration
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Latissimus dorsi tendon transfer for massive irreparable rotator cuff tears: a systematic review
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SR for PM on OA of All Extremities
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Tendon transfers have been proposed as a possible solution to restore pain-free functions, strength, and range of motion in patients with massive and irreparable cuff tears. The aim of this review is to establish the outcomes of (1) latissimus dorsi tendon transfer (LDT-T) surgery performed as a single procedure or in combination with other muscle-tendon transfer procedures, replacement, or both; (2) LDT-T in primary and revision surgery for massive irreparable rotator cuff tears; (3) the LDT-T procedure in relation to subscapularis and teres minor integrity; (4) the LDT-T procedure in relation to the reattachment position on the humeral head of the transferred tendon; (5) the LDT-T procedure performed as a single or a double incision; (6) arthroscopic, open, or combined approach: and (7) the LDT-T procedure in patients with preoperative osteoarthritis and a nonosteoarthritic condition with the evaluation of osteoarthritis progression. A systematic review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Studies of levels of evidence I-IV were included. The LDT-T surgical procedure, outcomes, and complications were evaluated. Twenty-two studies describing 493 shoulders in 487 patients were included in our study. There were no prospective randomized, controlled studies. LDT-T is a promising strategy for the management of massive and irreparable rotator cuff tears, even though no agreement was found on several aspects and options of LDT-T. Randomized prospective control studies are still awaited on this subject
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Is There a Difference in Revision Risk Between Metal and Ceramic Heads on Highly Crosslinked Polyethylene Liners?
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Developmental Dysplasia of the Hip 2020 Review
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BACKGROUND: The most common bearing surface used among primary THAs worldwide is a metal or ceramic femoral head that articulates against a highly crosslinked ultrahigh-molecular-weight polyethylene (HXLPE) acetabular liner. Despite their widespread use, relatively little is known about the comparative effectiveness of ceramic versus metal femoral heads with respect to risk of revision and dislocation as well as the role of head size in this relationship. QUESTIONS/PURPOSES: The purpose of this study was to evaluate the risk of (1) all-cause revision in metal versus ceramic femoral heads when used with an HXLPE liner, including an evaluation of the effect of head size; and (2) dislocation in metal versus ceramic femoral heads when used with an HXLPE liner as well as an assessment of the effect of head size. METHODS: Data were collected as part of the Kaiser Permanente Total Joint Replacement Registry between 2001 and 2013. Patients in this study were on average overweight (body mass index = 29 kg/m(2)), 67 years old, mostly female (57%), and had osteoarthritis (93%) as the primary indication for surgery. The material of the femoral head (metal, ceramic) was crossed with head size (< 32, 32, 36, > 36 mm), yielding eight device groupings. Only uncemented devices were evaluated. The primary outcome was all-cause revision (n = 28,772) and the secondary outcome was dislocation within 1 year (n = 19,623). Propensity scores were used to adjust for potential confounding at the implant/patient level using between-within semiparametric survival models that control for surgeon and hospital confounding and adjust estimates for the within-cluster correlation among observations on the response. RESULTS: For all-cause revision, there was no difference between ceramic versus metal (reference) heads in combination with an HXLPE liner (hazard ratio [HR] = 0.82 [0.65-1.04], p = 0.099). Smaller metal head sizes of < 32 mm were associated with increased risk of revision relative to 36 mm (HR = 1.66 [1.20-2.31], p = 0.002, adjusted p = 0.025). For dislocation, ceramic heads increased risk relative to metal at < 32 mm only (HR = 4.39 [1.72-11.19], p = 0.002, adjusted p = 0.020). Head sizes < 32 mm were associated with increased risk of dislocation relative to 36 mm for metal (HR = 2.99 [1.40-6.39], p = 0.005, adjusted p = 0.047) and ceramic heads (HR = 15.69 [6.07-40.55], p < 0.001, adjusted p < 0.001). CONCLUSIONS: The results did not provide evidence for use of one femoral head material over another when used with HXLPE liners for the outcome of revision, but for dislocation, metal performed better than ceramic with < 32-mm heads. Overall, the findings suggest increased risk of revision/dislocation with head sizes < 32 mm. LEVEL OF EVIDENCE: Level III, therapeutic study.
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Effect of an integrated approach of yoga therapy on quality of life in osteoarthritis of the knee joint: A randomized control study
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OAK 3 - Non-arthroplasty tx of OAK
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AIM: This study was designed to evaluate the efficacy of addition of integrated yoga therapy to therapeutic exercises in osteoarthritis (OA) of knee joints. MATERIALS AND METHODS: This was a prospective randomized active control trial. A total of t participants with OA of knee joints between 35 and 80 years (yoga, 59.56 +/- 9.54 and control, 59.42 +/- 10.66) from the outpatient department of Dr. John's Orthopedic Center, Bengaluru, were randomly assigned to receive yoga or physiotherapy exercises after transcutaneous electrical stimulation and ultrasound treatment of the affected knee joints. Both groups practiced supervised intervention (40 min per day) for 2 weeks (6 days per week) with followup for 3 months. The module of integrated yoga consisted of shithilikaranavyayama (loosening and strengthening), asanas, relaxation techniques, pranayama, meditation and didactic lectures on yama, niyama, jnana yoga, bhakti yoga, and karma yoga for a healthy lifestyle change. The control group also had supervised physiotherapy exercises. A total of 118 (yoga) and 117 (control) were available for final analysis. RESULTS: Significant differences were observed within (P < 0.001, Wilcoxon's) and between groups (P < 0.001, Mann-Whitney U-test) on all domains of the Short Form-36 (P < 0.004), with better results in the yoga group than in the control group, both at 15(th) day and 90(th) day. CONCLUSION: An integrated approach of yoga therapy is better than therapeutic exercises as an adjunct to transcutaneous electrical stimulation and ultrasound treatment in improving knee disability and quality of life in patients with OA knees.
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Vocal fold augmentation by autologous fat injection with lipostructure procedure
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Panniculectomy & Abdominoplasty CPG
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BACKGROUND: Fat is theoretically the ideal implant for vocal fold augmentation because it is soft, easily available and biocompatible. However, reabsorption is a frequent cause of long-term failure. OBJECTIVE: We prospectively tested Coleman's "lipostructure" technique used for facial recontouring in the treatment of glottic incompetence. STUDY DESIGN AND SETTING: Fourteen patients (aged 18-74 years, mean 48) with breathy dysphonia secondary to laryngeal hemiplegia (7) or anatomical defects (7) underwent vocal fold lipoinjection. Fat harvested by liposuction was centrifuged, and the fat cell layer injected into the vocalis muscle. The patients underwent pre- and postoperative videolaryngostroboscopy, maximum phonation time (MPT) measurements, GRBAS perceptual evaluations, and Voice Handicap Index (VHI) self-assessments. RESULTS: Voice quality improved soon after surgery and remained stable over 3-26 months (mean 10.6), being confirmed by the GRBAS, MPT and VHI evaluations (P < 0.005). The results were best in the seven patients with paralytic dysphonia. CONCLUSION: Lipostructure is a valuable technique for voice rehabilitation in glottic incompetence. Copyright © 2005 by the American Academy of Otolaryngology-Head and Neck Surgery Foundation, Inc.
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Impact of perioperative allogeneic and autologous blood transfusion on acute wound infection following total knee and total hip arthroplasty
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Surgical Management of Osteoarthritis of the Knee CPG
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Background: Patients undergoing total hip or knee arthroplasty frequently receive blood transfusions. The relationship between transfusion and the risk of infection following total joint arthroplasty is unclear. In this study, we sought to examine the impact of allogeneic and autologous transfusion on the risk of acute infection following total hip and total knee arthroplasty. Methods: Weperformedaretrospectivestudyofconsecutiveprimarytotalkneearthroplastiesand- tot alhiparthroplasties.Patients who had a reoperation for suspected infection within threemonths after the arthroplasty were identified. Differences in risk factors were assessed across transfusion groups: no transfusion, autologous only, and allogeneic exposure (allogeneic with or without additionalautologoustransfusion).Backward- stepwiselogisticregressionanalysiswasusedtocomparereoperations(asoutcomes) between cases with and those without allogeneic exposure. Prespecified covariates were body mass index, diabetes, an American Society of Anesthesiologists (ASA) score of >2, preoperative hematocrit, and total number of units transfused perioperatively. Results: Weidentified 3352 patients treated with a total hip or knee arthroplasty (1730 total knee arthroplasties and 1622 total hip arthroplasties) for inclusion in the study. Transfusion was given in 1746 cases: 836 of them had allogeneic exposure, and 910 had autologous-only transfusion. There were thirty-two reoperations (0.95%) for suspected infection. Between-group riskfactor differences were observed. The mean age and the rates of diabetes, immunosuppression, ASA scores of >2, and bilateral surgery were highest in the allogeneic group, aswere estimated blood loss, surgery duration, and total number of units transfused (p < 0.001). In the unadjusted analyses, the rate of reoperations for suspected infection was higher in the cases with allogeneic exposure (1.67%) than in those without allogeneic exposure (0.72%) (p = 0.013). Autologous-only transfusion was not associated with a higher reoperation rate. However, multivariable logistic regression demonstrated that the total number of units transfused (p = 0.011) and an ASA score of >2 (p = 0.008)-but not allogeneic exposure-were significantly predictive of a reoperation. Conclusions: Perioperative allogeneic transfusion was associated with a higher rate of reoperations for suspected acute infection. However, patients with allogeneic exposure had increased infection risk factors. After adjustment for the total number of units transfused and an ASA score of >2, allogeneic exposure was not significantly predictive of a reoperation for infection. Copyright (copyright) 2014 By The Journal of Bone and Joint Surgery, Incorporated
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The role of biomechanical factors in OA development
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Surgical Management of Osteoarthritis of the Knee CPG
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INTRODUCTION : Excessive or abnormal mechanical loading of the joint is arguably the most important aetiological factor in the development of osteoarthritis (OA). Although such changes could occur by excessive wear and tear leading to attrition of the articular surfaces, it is now generally accepted that OA is not a passive process, but relies upon activation of specific matrix proteases which lead to break down of the two major extracellular matrix proteins, aggrecan and type II collagen. In the mouse a disintegrin and metalloproteinase with thrombospondin motif (ADAMTS)-5 is crucial for this process1. We investigated how biomechanical factors influence expression of proteases within the joint following destabilisation of the medial meniscus (DMM), a well characterized model of murine OA. METHODS: We studied the progression of OA in mice in which joint loading had been altered by cutting the sciatic and/or femoral nerves at the same time as performing DMM surgery. Gait and activity levels were measured in the neurectomised mice. Joints were examined histologically 12 weeks following surgery. Genes expressed by the joint at early points following surgery (DMM or sham surgery with or without neurectomy) were initially assessed by microarray, then validated by RT-PCR. Gene expression was also examined in joints which had undergone DMM, but which had been completely immobilized (by prolonged anaesthesia). RESULTS: Mice that had undergone sciatic neurectomy were still able to weight bear, but walked on a fully extended knee by flexing at the hip. Mice that had undergone femoral neurectomy walked with a slapping gait - with exaggerated flexion at both the hip and the knee. Mice that had undergone both femoral and sciatic neurectomy dragged the affected limb behind them. When DMM surgery was performed in combination with neurectomy, the cartilage in the sciatic neurectomised mice was completely protected from cartilage degradation. No protection was seen in the femoral neurectomised mice. Gene expression data from the joint at early time points following DMM surgery (6h, 3 and 7 days) revealed strong regulation of many inflammatory response genes including CCL2, TNF-stimulated gene 6 (TSG6), activin A, serum amyloid A (SAA) and IL-6. There was a low fold increase in ADAMTS5 (1.5 fold) which was highly consistent and significantly elevated above sham operated controls. Following sciatic neurectomy there was selective abrogation of a number of genes including CCL2, SAA and ADAMTS5. Genes such as TSG6 and activin A were completely unaffected when DMM surgery was performed in combination with sciatic neurectomy. When gene expression was studied in joints which had been completely immobilised (by sustained anaesthesia), almost all gene responses following DMM surgery were abrogated. DISCUSSION & CONCLUSIONS: These results show that expression of disease in a surgically-destabilised joint is highly dependent upon the biomechanical environment and suggest that sheer forces associated with flexion at the knee may be essential for development of disease. The results also reveal that gene expression within the joint following destabilisation is highly mechanosensitive, and that protection against OA is associated with selective abrogation of a number of inflammatory genes including ADAMTS5. The observation that partial and complete immobilisation leads to abrogation of different sets of genes suggest that there may be distinct biomechanical thresholds in vivo which when exceeded turn on different sets of genes and determine disease outcome
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Optimal Level of Femoral Neck for Predicting Postoperative Stem Anteversion in Total Hip Arthroplasty for Crowe Type I Dysplastic Hip
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Hip Fx in the Elderly 2019
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Objective: To investigate the optimal level of femoral neck for measuring femoral anteversion to predict postoperative stem anteversion in Crowe type I developmental dysplasia of the hip. Methods: This retrospective study analyzed 108 Crowe type I hips that underwent THA between January 2016 and December 2017, including 70 women and 19 men with a mean age of 63.08 ± 9.13 (range, 41â??83) years. The single-wedge stem was used in 37 hips, the double-wedge stem was used in 71 hips. Computed tomography scans were performed pre- and post-operation. Femoral anteversion at six levels of the proximal femur were measured via preoperative two-dimensional computed tomography. Femoral anteversion at the level of the femoral neck osteotomy plane and postoperative stem anteversion were measured via three-dimensional reconstructed models. Results: The mean follow-up period was 18.5 months (range, 12â??27 months). The mean preoperative Harris Hip Score was 51.5 ± 8.7 and improved to 90.4 ± 7.8 (P < 0.001) by the last follow-up. There were no intraoperative fractures, and no infections occurred during the follow-up period. Two patients developed deep venous thrombosis. There was no sign of prosthetic loosening in all hips. No significant correlations were found between the height of the femoral neck osteotomy plane and postoperative stem anteversion (r = â??0.119, P = 0.220). Femoral anteversion decreased gradually from 64.00° ± 10.51° at the center of lesser trochanter to 15.21° ± 13.31° at the headâ??neck junction, which was changed from more to less than stem anteversion (24.37° ± 13.86°). The femoral anteversion at femoral headâ??neck junction (15.21° ± 13.31°) was significantly less than postoperative stem anteversion (P = 0.000), with a difference of â??9.16° ± 9.27°. The femoral anteversion at the level of the osteotomy plane (28.48° ± 15.34°) was significantly more than the postoperative stem anteversion (P = 0.000), with a difference of 4.11° ± 9.56°. Among all six levels and the level of osteotomy, femoral anteversion at the 10-mm level above the proximal base of lesser trochanter (22.65 ± 12.92) displayed the smallest difference (â??1.72° ± 8.90°) and a good correlation (r = 0.764) with postoperative stem anteversion for all 108 hips, with a moderate correlation of 0.465 for single-wedge stem hips and an excellent correlation of 0.821 for double-wedge stem hips. Conclusion: For Crowe type I hips, femoral anteversion would be different if it was measured via different levels of the femoral neck. The 10-mm level above the proximal base of the lesser trochanter could be an optimum choice for measuring femoral anteversion to predict postoperative stem anteversion.
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0 |
Sleep problems and dissociation in preschool victims of sexual abuse
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DoD PRF (Psychosocial RF)
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Objective: Child sexual abuse (CSA) is associated with a host of deleterious impacts, yet little is known about the short-term correlates in children. This study aimed to investigate the association between dissociation and sleep problems in a sample of preschool-age sexual abuse victims while controlling for potentially confounding variables, including gender, age, polytrauma, CSA characteristics, and parental distress. Method: The sample consisted of 179 children (ages 3â??6 years) and their non-offending parents. Parents completed questionnaires assessing their childâ??s dissociative symptoms and sleep problems as well as their own level of psychological distress. Results: Regression analyses revealed that sleep problems were significantly associated with dissociative symptoms over and above all other control variables (childrenâ??s gender and age, polytrauma, and parental distress). A longer duration of sexual abuse also predicted greater dissociative symptoms in preschool children. Conclusion: Findings highlight the association between sleep problems and dissociation in preschool-age victims of CSA. Further research is needed to understand their impact on childrenâ??s development to design appropriate treatment and prevention initiatives aimed at fostering resilience in young vulnerable children. (PsycINFO Database Record (c) 2017 APA, all rights reserved)
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Systematic review and meta-analysis of closed suction drainage versus non-drainage in primary hip arthroplasty
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PJI DX Updated Search
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The routine use of drains in surgery has been dogmatically instituted in some disciplines. Orthopaedic surgery is one such sub-speciality. The use of postoperative closed suction drainage in total hip arthroplasty (THA) has become increasingly controversial with multiple randomised control trials performed to assess the benefit to outcome in THA. The hypothesis of this systematic review is that closed suction drainage does not infer a benefit and increase transfusion requirements of primary total hip arthroplasty patients. A systematic review and meta-analysis was conducted adhering to the PRISMA guidelines. A search of the available literature was performed on PubMed, Cochrane Central Registry of Controlled Trials, MEDLINE (OVID) and EMBASE using a combination of MeSH terms and Boolean operators. All data analysis was performed using the Cochrane Collaboration's Review Manager 5.1. Sixteen studies (n=2705) were included in the analysis. Post-operative closed suction drainage was found to increase total blood loss and blood transfusion requirements (p<0.05). Surgical site infection demonstrated no significant difference between the two groups (p=0.82). No significant difference in haematoma formation between groups (p=0.19) was elicited. The routine use of closed suction drainage systems post primary hip arthroplasty is not supported by this meta-analysis. However, the heterogeneity between studies does limit the accuracy of the meta-analysis
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0 |
The association between structure-function relationships and cognitive impairment in elderly glaucoma patients
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Upper Eyelid and Brow Surgery
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Accurate measurement of visual field (VF) is important in accessing glaucoma, however this may not be achieved in patients with dementia or mild cognitive impairment (CI). We investigated the association between CI and structure-function relationships in elderly glaucoma patients. The study included 94 eyes of 51 glaucoma patients aged >/=75 years with no diagnoses of dementia. CI was assessed using the Mini Mental State Examination (MMSE). Using the leave-one-out cross-validation, the mean deviation (MD) of the Humphrey 30-2 VF was predicted from measurements of optical coherence tomography, and the relationship between the squared prediction error and the MMSE score, together with age, fixation loss (FL), false positive (FP), and false negative (FN) percentages that were analyzed using the linear mixed model. A high prevalence of MCI or dementia was observed in the elderly population. The squared prediction error value of the MD was 17.0 +/- 21.1 (mean +/- standard deviation). The squared prediction error increased with decreasing MMSE total score, but age, FL, FP, and FN were not related. Careful consideration is needed when interpreting the VF results of these patients, because VF can be over- or underestimated, as suggested by the decreased structure-function relationships.
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Risk factors for periprosthetic joint infection after primary artificial hip and knee joint replacements
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DoD SSI (Surgical Site Infections)
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Introduction: We aimed to explore the risk factors for periprosthetic joint infection (PJI) after primary artificial hip and knee joint replacements by performing a case-control study. Methodology: The clinical data of patients receiving primary hip and knee joint replacements were retrospectively analyzed. The case group included 96 patients who suffered from PJI, comprising 42 cases of hip joint replacement and 54 cases of knee joint replacement. Another 192 patients who received joint replacement at the ratio of 1:2 in the same period and did not suffer from PJI were selected as the control group. Differences between the two groups were compared in regard to etiology, pathogen, blood type, urine culture, body mass index (BMI), surgical time, intraoperative blood loss, postoperative 1st day and total drainage volumes, length of hospitalization stay, and history of surgery at the affected sites. Results: Gram-positive bacteria were the main pathogens for PJI. The most common infection after hip joint replacement was caused by Staphylococcus epidermidis, which accounted for 38.10%, while Staphylococcus aureus was mainly responsible for the infection of knee joint (40.74%). High BMI, long surgical time, large postoperative drainage volume, long hospitalization stay, history of surgery at incisions, previous use of immunosuppressants, preoperative hypoproteinemia and superficial infection were independent risk factors (p < 0.05). Conclusions: PJI after primary replacement was mainly caused by gram-positive bacteria, and patients with high BMI, long surgical time, large postoperative drainage volume, long hospitalization stay, history of surgery at incisions, previous use of immunosuppressants, preoperative hypoproteinemia and superficial infection were more vulnerable.
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0 |
Decrease in central venous catheter placement due to use of ultrasound guidance for peripheral intravenous catheters
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DOD - Acute Comp Syndrome CPG
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Study Objectives: Obtaining intravenous (IV) access in the emergency department (ED) can be especially challenging, and physicians often resort to placement of central venous catheters (CVCs). Use of ultrasound-guided peripheral IV catheters (USGPIVs) can prevent many unnecessary CVCs, but the true impact of USGPIVs has never been quantified. This study set out to determine the reduction in CVCs by USGPIV placement. Methods: This was a prospective, observational study conducted in 2 urban EDs. Patients who were to undergo placement of a CVC due to inability to establish IV access by other methods were enrolled. Ultrasound-trained physicians then attempted USGPIV placement. Patients were followed up for up to 7 days to assess for CVC placement and related complications. Results: One hundred patients were enrolled and underwent USGPIV placement. Ultrasound-guided peripheral IV catheters were initially successfully placed in all patients but failed in 12 patients (12.0%; 95 confidence interval [CI], 7.0%-19.8%) before ED disposition, resulting in 4 central lines, 7 repeated USGPIVs, and 1 patient requiring no further intervention. Through the inpatient follow-up period, another 11 patients underwent CVC placement, resulting in a total of 15 CVCs (15.0%; 95 CI, 9.3%-23.3%) placed. Of the 15 patients who did receive a CVC, 1 patient developed a catheter-related infection, resulting in a 6.7% (95 CI, 1.2%-29.8%) complication rate. Conclusion: Ultrasound prevented the need for CVC placement in 85% of patients with difficult IV access. This suggests that USGPIVs have the potential to reduce morbidity in this patient population. © 2012 Elsevier Inc. All rights reserved.
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Effects of l-Carnitine Supplementation on Serum Inflammatory Factors and Matrix Metalloproteinase Enzymes in Females with Knee Osteoarthritis: A Randomized, Double-Blind, Placebo-Controlled Pilot Study
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OAK 3 - Non-arthroplasty tx of OAK
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OBJECTIVE: Considering the importance of inflammation in the pathogenesis of osteoarthritis (OA) and induction of pain, this study was aimed to investigate the effect of L-carnitine supplementation on serum inflammatory mediators and OA-associated pain in females with knee OA.
METHODS: In this clinical trial, 72 females with mild to moderate knee osteoarthritis started the study, divided into 2 groups to receive 750 mg/day L-carnitine (n = 36) or placebo (n = 36) for 8 weeks. Serum levels of Interleukine-1beta (IL-1beta), high-sensitivity C-reactive protein (hs-CRP), matrix metalloproteinases (MMPs)-1 and -13, and visual analog scale (VAS) for pain were assessed before and after supplementation. Data were analyzed by t test, Wilcoxon signed rank test, Mann-Whitney U test, and analysis of covariance.
RESULTS: Only 69 patients (33 in the L-carnitine group and 36 in the placebo group) completed the study. L-Carnitine supplementation decreased serum IL-1beta and MMP-1 levels significantly (p = 0.001 and p = 0.021, respectively); however, serum hs-CRP and MMP-13 levels did not change significantly (p > 0.05). In the placebo group, serum IL-1beta levels increased significantly (p = 0.011), whereas other studied biomarkers did not change significantly. The mean VAS score decreased significantly in the L-carnitine and placebo groups by 52.67% and 21.82%, respectively (p < 0.001). Significant differences were only observed between the 2 groups in serum IL-1beta (p < 0.001) and MMP-1 (p = 0.006) levels and mean VAS score (p = 0.002) after adjusting for baseline values and covariates.
CONCLUSION: Despite observed beneficial effects of short-term supplementation of L-carnitine in decreasing serum inflammatory mediators and improving pain in knee OA patients, further studies are needed to achieve concise conclusions.
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0 |
Results of the percutaneous pinning of proximal humerus fractures with a modified palm tree technique
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Pediatric Supracondylar Humerus Fracture 2020 Review
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Purpose Many techniques are available for closed reduction and percutaneous fixation of proximal humeral fractures. The palm tree technique was described by Kapandji in 1989. In that technique three curved wires are inserted through one hole at the V-shaped insertion of the deltoid muscle. It is a good technique but it has some disadvantages. In this study we introduced some modifications for the technique, and we evaluated the clinical results of the modified technique in treatment of 18 cases. Methods Eighteen patients with displaced proximal humeral fractures were treated by closed reduction and percutaneous fixation with the palm tree technique after minor modifications. The age of the patients ranged from 38 to 75 years with an average of 56 years. Eleven were females and seven were males. The fractures were twopart in 13 cases and three-part fractures in five cases. Results The average time of healing was seven weeks. The follow-up period ranged from 14 months to 39 months with an average of 22 months. The Constant score ranged from 45 to 88 with a mean of 73. The results were satisfactory in 77% and unsatisfactory in 23% of the cases. The complications included pin tract infection in two cases, intraarticular wire migration in one case, skin necrosis around the wires in three cases and malunion with varus deformity in one case. No cases were complicated by neurovascular injury, loss of fixation or avascular necrosis of the humeral head. Conclusions The palm tree technique is a good method for fixation of proximal humeral fractures. It produces good grip in both of the proximal and distal fragments and allows for early joint movements. Our modifications allow for easy insertion of the wires, increase the stability of fixation and minimize the risk of complications. © 2010 Springer-Verlag.
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Clinical effectiveness of orthogeriatric and fracture liaison service models of care for hip fracture patients: population-based longitudinal study
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Hip Fx in the Elderly 2019
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OBJECTIVES: to evaluate orthogeriatric and nurse-led fracture liaison service (FLS) models of post-hip fracture care in terms of impact on mortality (30 days and 1 year) and second hip fracture (2 years).
SETTING: Hospital Episode Statistics database linked to Office for National Statistics mortality records for 11 acute hospitals in a region of England.
POPULATION: patients aged over 60 years admitted for a primary hip fracture from 2003 to 2013.
METHODS: each hospital was analysed separately and acted as its own control in a before-after time-series design in which the appointment of an orthogeriatrician or set-up/expansion of an FLS was evaluated. Multivariable Cox regression (mortality) and competing risk survival models (second hip fracture) were used. Fixed effects meta-analysis was used to pool estimates of impact for interventions of the same type.
RESULTS: of 33,152 primary hip fracture patients, 1,288 sustained a second hip fracture within 2 years (age and sex standardised proportion of 4.2%). 3,033 primary hip fracture patients died within 30 days and 9,662 died within 1 year (age and sex standardised proportion of 9.5% and 29.8%, respectively). The estimated impact of introducing an orthogeriatrician on 30-day and 1-year mortality was hazard ratio (HR) = 0.73 (95% CI: 0.65-0.82) and HR = 0.81 (CI: 0.75-0.87), respectively. Following an FLS, these associations were as follows: HR = 0.80 (95% CI: 0.71-0.91) and HR = 0.84 (0.77-0.93). There was no significant impact on time to second hip fracture.
CONCLUSIONS: the introduction and/or expansion of orthogeriatric and FLS models of post-hip fracture care has a beneficial effect on subsequent mortality. No evidence for a reduction in second hip fracture rate was found.
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0 |
Analysis of prognostic factors for survival in patients with primary spinal chordoma using the SEER Registry from 1973 to 2014
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MSTS 2022 - Metastatic Disease of the Humerus
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BACKGROUND: Spinal chordomas are rare primary osseous tumors that arise from the remnants of the notochord. They are commonly considered slow-growing, locally invasive neoplasms with little tendency to metastasize, but the high recurrent rate of spinal chordomas may seriously affect the survival rate and quality of life of patients. The aim of the study is to describe the epidemiological data and determine the prognostic factors for decreased survival in patients with primary spinal chordoma. METHODS: The Surveillance, Epidemiology, and End Results (SEER) Registry database, a US population-based cancer registry database, was used to identify all patients diagnosed with primary spinal chordoma from 1973 to 2014. We utilized Kaplan-Meier method and Cox proportional hazards regression analysis to evaluate the association between patients overall survival and relevant characteristics, including age, gender, race, disease stage, treatment methods, primary tumor site, marital status, and urban county background. RESULTS: In the data set between 1973 and 2014, a total of 808 patients were identified with primary spinal chordoma. The overall rate of distant metastatic cases in our cohort was only 7.7%. Spinal chordoma was more common occurred in men (62.6%) than women (37.3%). Majority of neoplasms were found in the White (87.9%), while the incidence of the Black is relatively infrequent (3.3%). Three hundred fifty-seven spinal chordomas (44.2%) were located in the vertebral column, while 451 patients' tumor (55.8%) was located in the sacrum or pelvis. Age =?60 years (HR = 2.72; 95%CI, 1.71 to 2.89), distant metastasis (HR = 2.16; 95%CI, 1.54 to 3.02), and non-surgical therapy (HR = 2.14; 95%CI, 1.72 to 2.69) were independent risk factors for survival reduction in analysis. Survival did not significantly differ as a factor of tumor site (vertebrae vs sacrum/pelvis) for primary spinal chordoma (HR = 0.93, P?=?0.16). Race (P?=?0.52), gender (P?=?0.11), marital status (P?=?0.94), and urban background (P?=?0.72) were not main factors which affected overall survival rate. CONCLUSION: There was no significant difference in overall survival rate between chordomas located in the sacrum and vertebral column. Spinal chordoma patients with an elderly age (age =?60), performing non-surgical therapy, and distant metastasis were associated with worse overall survival. Performing surgery was an effective and reliable treatment method for patients with spinal chordoma, and public health efforts should pay more attention to the elderly patients with spinal chordoma prior to distant metastasis.
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1 |
Helical versus conventional CT in detecting meniscal injuries
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AMP (Acute Meniscal Pathology)
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PURPOSE: We compared volumetric helical and conventional CT in the study of meniscal injuries.
MATERIAL AND METHODS: Thirty-three patients with suspected meniscal tear underwent helical and conventional CT. Common parameters were 512 x 512 matrix, 14-15 cm FOV, 120 kV and 175 mA; helical CT was performed with 2 mm beam thickness, 1.5 mm/s table feed, 1 mm reconstruction index and conventional CT with 2 s scan time, 1 mm slice thickness and 1 mm table feed. All scans were photographed with a Laser printer using the same window (180/100). All patients also underwent sagittal and coronal T2* GE MRI at .5-T; slice thickness was 5 mm and interslice gap 1 mm. Nonparametric scales were used to study the menisci, as follows: for CT we had A = no visible injury; B = diffuse hypodensity (degenerative condition); C = questionable meniscal tear; D = unquestionable meniscal tear. For MRI, we had A = no visible injury; B = grade 1 or 2 injury; C = grade 3 injury; D = grade 4 injury. We used the 1-4 MR grading by Lotysch et al. and by Crues et al. MRI was used as the gold standard. The agreement between helical CT, conventional CT and MRI was calculated with kappa statistics.
RESULTS: Helical and conventional CT found 23 and 15 patterns A, 6 and 10 B, 3 and 1 C and 1 and 7 D, respectively. MRI found 15 A, 8 B, 3 C and 7 D. There was no agreement between helical CT and MRI and between helical CT and conventional CT because of the meniscal tears underestimated by the former. Agreement was very high between conventional CT and MRI (p < .001).
DISCUSSION AND CONCLUSIONS: The main result of our experience is that helical CT appears less sensitive than conventional CT in detecting meniscal tears. The helical CT section profile (more roundish than that of conventional CT) and the lower radiation dose used by helical CT (with increased quantum noise) may have played a key role in its underestimation of meniscal tears.
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0 |
Apoptosis and mitochondrial dysfunction in human chondrocytes following exposure to lidocaine, bupivacaine, and ropivacaine
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Surgical Management of Osteoarthritis of the Knee CPG
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BACKGROUND: Several mechanisms have been proposed to explain toxicity of local anesthetics to chondrocytes, including the blockade of potassium channels and mitochondrial injury. The purposes of this investigation were to study the effects of lidocaine, bupivacaine, and ropivacaine on human chondrocyte viability and mitochondrial function in vitro and to characterize the type of cell death elicited following exposure. METHODS: Primary chondrocyte cultures from patients with osteoarthritis undergoing knee replacement were treated with saline solution and the following concentrations of local anesthetics: 2%, 1%, and 0.5% lidocaine, 0.5% and 0.25% bupivacaine, and 0.5% and 0.2% ropivacaine for one hour. Cell viability and apoptosis were measured by flow cytometry at twenty-four hours and 120 hours after treatment. Nuclear staining and caspase 3 and 9 cleavage assays (Western blot) were used to further establish the induction of apoptosis. Mitochondrial dysfunction was evaluated by the accumulation of mitochondrial DNA damage (quantitative Southern blot), changes in adenosine triphosphate production (bioluminescence kit), and mitochondrial protein levels (Western blot analysis). RESULTS: Exposure of primary human chondrocytes to a 2% concentration of lidocaine caused massive necrosis of chondrocytes after twenty-four hours, 1% lidocaine and 0.5% bupivacaine caused a detectable, but not significant, decrease in viability after twenty-four hours, while 0.5% lidocaine, 0.25% bupivacaine, and both concentrations of ropivacaine (0.5% and 0.2%) did not affect chondrocyte viability. Flow cytometry analysis of chondrocytes 120 hours after drug treatment revealed a significant decrease in viability (p < 0.05) with a concomitant increase in the number of apoptotic cells at all concentrations of lidocaine, bupivacaine, and ropivacaine analyzed, except 0.2% ropivacaine. Apoptosis was verified by observation of condensed and fragmented nuclei and a decrease in procaspase 3 and 9 levels. Local anesthetics induced mitochondrial DNA damage and a decrease in adenosine triphosphate and mitochondrial protein levels. CONCLUSIONS: Lidocaine, bupivacaine, and ropivacaine cause delayed mitochondrial dysfunction and apoptosis in cultured human chondrocytes
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0 |
Supine and Standing AP Pelvis Radiographs in the Evaluation of Pincer Femoroacetabular Impingement
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Hip Fx in the Elderly 2019
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BACKGROUND: Pelvic tilt can affect the presence of the ischial spine sign and crossover sign. Numerous studies of pelvic tilt on radiographic measurements of pincer impingement have shown that increasing anterior tilt is associated with more radiographic signs of pincer impingement. However, to our knowledge, no study has directly compared supine and standing plain radiographs in patients with respect to lateral center-edge (LCE) angle, acetabular inclination, crossover sign, and ischial spine sign.
QUESTIONS/PURPOSES: The purpose of this study was to evaluate the differences in supine and standing AP pelvis radiographs as they relate to the radiographic parameters of pincer impingement in an adult population evaluated for femoroacetabular impingement, specifically intrapelvic distances (sacrococcygeal to symphysis [SC-S] and coccyx tip to symphysis [T-S]), crossover sign (presence and percentage), LCE angle, inclination, and ischial spine sign.
METHODS: Between August 2013 and June 2014, we obtained supine and standing radiographs for all new patients younger than 60 years who were evaluated for hip pain, when the diagnosis of fracture was not being considered; these formed the basis of this retrospective study. Patients were excluded if they had arthritis (Tonnis grade >= 2), lumbar fusion, previous hip surgery, or malrotated films. Forty-six hips, symptomatic side, met the inclusion criteria (age of patients, 33 +/- 14 years; 13 males, 33 females). Radiographic data that were collected included SC-S distance, T-S distance, LCE angle, acetabular inclination, presence and percentage of crossover sign, and presence of ischial spine sign. A paired t-test was used to compare continuous variables and chi-square test was used for categorical variables. Two independent readers performed measurements.
RESULTS: From supine to standing films, the T-S distance decreased from 19 +/- 18 mm to 6 +/- 19 mm (p < 0.001), and SC-S distance decreased from 47 +/- 19 mm to 32 +/- 20 mm (p < 0.001), indicating less pelvic tilt in the standing position. The number of hips that had crossover signs decreased from supine (n = 18, 39%) to standing (n = 9, 20%) (p = 0.039). The amount of crossover decreased from 23% +/- 10% to 11% +/-13% (p < 0.001). LCE angle did not change (27degree +/- 7degree to 27degree +/- 8degree) (p = 0.64) and inclination angle increased by a small amount (4.2degree +/- 5degree to 5.3degree +/- 5degree) (p = 0.002). The ischial spine sign decreased from supine (n = 20, 43%) to standing (n = 7, 15%) position (p = 0.003).
CONCLUSIONS: There is a decrease in the amount of pelvic tilt on standing AP pelvis radiographs resulting in a decrease in the incidence and amount of crossover sign and ischial spine sign, and a small increase in inclination. Standing radiographs should be the standard in evaluation of nonarthritic hip pain, specifically pincer femoroacetabular impingement. Surgeons should use caution in interpreting supine AP radiographs in the evaluation of pincer impingement, specifically the crossover sign.
LEVEL OF EVIDENCE: Level III, diagnostic study.
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0 |
FimA, a major virulence factor associated with Streptococcus parasanguis endocarditis
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Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures
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Adherence of microorganisms to damaged heart tissue is a crucial event in the pathogenesis of infective endocarditis. In the present study, we investigated the role of the FimA protein as a potential virulence factor associated with Streptococcus parasanguis endocarditis. FimA is a 36-kDa surface protein that is a recognized adhesin in the oral cavity where it mediates adherence to the salivary pellicle. An insertion mutant and a deletion mutant of S. parasanguis were employed in the rat model of endocarditis to determine the relevance of FimA in endocarditis pathogenesis. Catheterized rats were infected with either the fimA deletion mutant VT929, the fimA insertion mutant VT930, or the isogenic, wild-type S. parasanguis FW213. Rats inoculated with FW213 developed endocarditis more frequently (50.9%) than animals inoculated with either the deletion mutant (2.7%) or the insertion mutant (7.6%) (P < 0.001). A series of in vitro assays were performed to explore the mechanism(s) by which FimA enhanced the infectivity of S. parasanguis. FimA did not inhibit the uptake or the subsequent killing of S. parasanguis by phagocytic granulocytes. Similarly, FimA did not play a role in the adherence to or the aggregation of platelets. Significant differences were noted between FW213 and VT929 (P < 0.05) and FW213 and VT930 (P < 0.001) in their abilities to bind to fibrin monolayers. The mean percent adherence of FW213 to fibrin monolayers (2.1%) was greater than those of VT929 (0.5%) and VT930 (0.12%). Taken together, these results indicate that FimA is a major virulence determinant associated with S. parasanguis endocarditis and further suggest that its role is associated with initial colonization of damaged heart tissue
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Super Obesity Is an Independent Risk Factor for Complications After Primary Total Hip Arthroplasty
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PJI DX Updated Search
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BACKGROUND: Recent studies have reported higher postoperative complication rates in obese and morbidly obese patients undergoing total hip arthroplasty (THA). Less data are available regarding super-obese (body mass index [BMI] >50 kg/m2) patients. This study aims to quantify the risk of complications after THA in super-obese patients on a national scale and to put these risks in context by comparing them to patients of other BMI classes as well as those undergoing revision THA. METHODS: Utilizing a national insurance database, complication rates after THA in super-obese patients (n = 3244) were compared to nonobese, obese, and morbidly obese patients undergoing primary THA and all patients undergoing revision THA. A logistic regression analysis controlling for demographic and comorbidity variables was utilized to determine the independent effect of super obesity on complication rates after THA. RESULTS: Super-obese patients had significantly higher rates of most complications than nonobese, obese, morbidly obese, and revision THA patients, including venous thromboembolism, infection, blood transfusion, medical complications, dislocation, readmission, and revision THA. CONCLUSION: Super-obese patients (BMI >50 kg/m2) have higher rates of postoperative complications after THA than nonobese, obese, morbidly obese, and revision THA patients. Super obesity is an independent risk factor for increased rates of most postoperative complications including the need for early revision THA
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Epidemiology and mortality of hip fracture among patients on dialysis: Taiwan National Cohort Study
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HipFx Supplemental Cost Analysis
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Chronic kidney disease increases the risk for hip fractures. Hip fractures are associated with increased mortality, decreased quality of life, and higher economic burden. To determine whether dialysis modality is associated with a higher incidence of hip fractures in patients with end-stage renal disease (ESRD), we used the Taiwan National Health Insurance Research Database to examine the records of 51,473 patients who began dialysis between 1999 and 2005. The patients were followed until death, transplantation, dialysis cessation, or 31 December 2008. The follow-up period was (mean+/-SD) 4.14+/-2.48 years. The cumulative incidence rate of hip fracture was calculated using Kaplan-Meier methods. Predictors of hip fracture were determined using Cox models. During the study period, 1903 patients had a hip fracture. The overall incidence rate of hip fracture was 89.21/10,000 patient-years. Patients on hemodialysis (HD) had a 31% higher incidence of hip fracture than those on peritoneal dialysis (PD) (HR 1.31, 95% CI: 1.01-1.70). Patients >/=65 years old had more than 13 times the risk of a hip fracture than did those 18-44 years old (HR: 13.65; 95% CI: 10.12-18.40). Other factors that increased the risk of a hip fracture were a prior hip fracture (HR: 1.44; 95% CI: 1.15-1.80), osteoporosis (HR: 1.24; 95% CI: 1.07-1.45), DM (HR: 1.66; 95% CI: 1.51-1.83), and liver cirrhosis (HR: 1.37, 95% CI: 1.15-1.64). The overall in-hospital mortality rate was 3.2%. The cumulative survival rates after a hip fracture were 74.6% at one year and only 29.6% at seven years. Our findings supported the notion that being on HD is a risk for hip fracture. Additionally, old age, female gender, a prior hip fracture, osteoporosis, DM and liver cirrhosis were also risk factors for hip fracture in patients with ESRD and undergoing dialysis
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1 |
Safety and Efficacy of Third-Generation Ultrasound-Assisted Liposuction: A Series of 261 Cases
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Panniculectomy & Abdominoplasty CPG
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BACKGROUND: The introduction of third-generation ultrasound-assisted liposuction (3rd UAL) allows for a less invasive modality of both deep and superficial lipectomy while offering improved skin retraction and reduced rate of complications. This study examined the efficacy and safety profile of this technology over 15 years of clinical experience. METHODS: A consecutive series of patients treated from 2005-2020 by the senior author were reviewed for demographic and anthropometric measurements, intraoperative settings, surgical outcomes, and complications via retrospective chart review. Body-Q survey was used to assess patient satisfaction. RESULTS: A total of 261 patients underwent 3rd UAL in 783 areas. There were 238 female and 23 male patients with an average age of 43.5 years and BMI of 27.4 kg/m(2). The most frequently treated areas were the trunk and lower limbs. An average of 2840 mL of wetting solution was used with an average of 2284 mL of lipocrit aspirate. About 65% of the cases were done in conjunction with another procedure. Overall complication rate was 4.6%, contour irregularity (1.9%), seroma (0.8%), cellulitis (0.8%), pigmentation changes (0.4%), and electrolyte imbalance (0.4%), with a minimum follow-up of 6 months. 78% of patient would undergo the procedure again and 86% would recommend it. CONCLUSION: Third-generation ultrasound-assisted liposuction can be used effectively and safely, either alone, or in conjunction with other plastic surgery procedures. VASER liposuction allows surgeons to address superficial fat plane and enhanced skin tightening. Rate of complications are lower than that of traditional liposuction with equivalent or higher patient satisfaction. LEVEL OF EVIDENCE IV: 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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0 |
Relation of regional articular cartilage morphometry and meniscal position by MRI to joint space width in knee radiographs
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AMP (Acute Meniscal Pathology)
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OBJECTIVE: To ascertain the contribution of articular cartilage morphometry and meniscal position on MRI to joint space width (JSW) measured in the Lyon schuss radiograph of the knee.
DESIGN: 62 obese women with knee OA and 99 non-obese female controls (mean age 56.6 years) were imaged using 3T MRI and coronal water excitation spoiled gradient echo sequences. Segmentation of femorotibial cartilage morphology and regional morphometric analysis was performed using custom software. Meniscal position was measured quantitatively in sagittal and coronal planes. Minimum space width (mJSW) was measured in the Lyon Schuss knee radiograph; Kellgren and Lawrence grades (KLG) were assigned on standing anteroposterior knee films. The relative contribution of regional cartilage thickness and meniscal position to mJSW was assessed initially in univariate models and subsequently with multivariable modelling.
RESULTS: 65% of the variation in mJSW was explained by regional cartilage thickness measures, different KLG and meniscal coverage. Of these measures the medial tibia cartilage thickness measures and central region of the central medial femur (ccMF) play a consistent role in variations in mJSW observed across all KLG. Further ccMF and the addition of percent meniscal coverage to this model explains the remaining differences in mean mJSW found between those subjects with definite joint space narrowing (KLG3) and those without OA.
CONCLUSION: The variation in radiographic mJSW is best described by five regional cartilage thickness measures and percent meniscal coverage. The magnitude of each measures contribution differs according to radiographic severity with more variability explained by cartilage thickness of ccMF cartilage thickness and percent meniscal coverage with more severe disease.
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Extracorporeal lung support technologies - Bridge to recovery and bridge to lung transplantation in adult patients
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DOD - Acute Comp Syndrome CPG
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For cases of acute respiratory distress syndrome (ARDS) and progressive chronic respiratory failure, the first choice or treatment is mechanical ventilation. For decades, this method has been used to support critically ill patients in respiratory failure. Despite its life-saving potential, however, several experimental and clinical studies have suggested that ventilator-induced lung injury can adversely affect the lungs and patient outcomes. Current opinion is that by reducing the pressure and volume of gas delivered to the lungs during mechanical ventilation, the stress applied to the lungs is eased, enabling them to rest and recover. In addition, mechanical ventilation may fail to provide adequate gas exchange, thus patients may suffer from severe hypoxia and hypercapnea. For these reasons, extracorporeal lung support technologies may play an important role in the clinical management of patients with lung failure, allowing not only the transfer of oxygen and carbon dioxide (CO 2) but also buying the lungs the time needed to rest and heal. Objective: The objective of this analysis was to assess the effectiveness, safety, and cost-effectiveness of extracorporeal lung support technologies in the improvement of pulmonary gas exchange and the survival of adult patients with acute pulmonary failure and those with end-stage chronic progressive lung disease as a bridge to lung transplantation (LTx).The application of these technologies in primary graft dysfunction (PGD) after LTx is beyond the scope of this review and is not discussed. Clinical Applications of Extracorporeal Lung Support: Extracorporeal lung support technologies [i.e., Interventional Lung Assist (ILA) and extracorporeal membrane oxygenation (ECMO)] have been advocated for use in the treatment of patients with respiratory failure. These techniques do not treat the underlying lung condition; rather, they improve gas exchange while enabling the implantation of a protective ventilation strategy to prevent further damage to the lung tissues imposed by the ventilator. As such, extracorporeal lung support technologies have been used in three major lung failure case types: 1) As a bridge to recovery in acute lung failure - for patients with injured or diseased lungs to give their lungs time to heal and regain normal physiologic function. 2) As a bridge to LTx - for patients with irreversible end stage lung disease requiring LTx. 3) As a bridge to recovery after LTx - used as lung support for patients with PGD or severe hypoxemia. Ex-Vivo Lung Perfusion and Assessment Recently, the evaluation and reconditioning of donor lungs ex-vivo has been introduced into clinical practice as a method of improving the rate of donor lung utilization. Generally, about 15% to 20% of donor lungs are suitable for LTx, but these figures may increase with the use of ex-vivo lung perfusion. The ex-vivo evaluation and reconditioning of donor lungs is currently performed at the Toronto General Hospital (TGH) and preliminary results have been encouraging (Personal communication, clinical expert, December 17, 2009). If its effectiveness is confirmed, the use of the technique could lead to further expansion of donor organ pools and improvements in post-LTx outcomes. Extracorporeal Lung support Technologies: ECMO The ECMO system consists of a centrifugal pump, a membrane oxygenator, inlet and outlet cannulas, and tubing. The exchange of oxygen and CO2 then takes place in the oxygenator, which delivers the reoxygenated blood back into one of the patient's veins or arteries. Additional ports may be added for haemodialysis or ultrafiltration. Two different techniques may be used to introduce ECMO: venoarterial and venovenous. In the venoarterial technique, cannulation is through either the femoral artery and the femoral vein, or through the carotid artery and the internal jugular vein. In the venovenous technique cannulation is through both femoral veins or a femoral vein and internal jugular vein; one cannula acts as inflow or arterial line, and the other as an outflow or venous line. Venoven us ECMO will not provide adequate support if a patient has pulmonary hypertension or right heart failure. Problems associated with cannulation during the procedure include bleeding around the cannulation site and limb ischemia distal to the cannulation site. ILA Interventional Lung Assist (ILA) is used to remove excess CO2 from the blood of patients in respiratory failure. The system is characterized by a novel, low-resistance gas exchange device with a diffusion membrane composed of polymethylpentene (PMP) fibres. These fibres are woven into a complex configuration that maximizes the exchange of oxygen and CO2 by simple diffusion. The system is also designed to operate without the help of an external pump, though one can be added if higher blood flow is required. The device is then applied across an arteriovenous shunt between the femoral artery and femoral vein. Depending on the size of the arterial cannula used and the mean systemic arterial pressure, a blood flow of up to 2.5 L/min can be achieved (up to 5.5 L/min with an external pump). The cannulation is performed after intravenous administration of heparin. Recently, the first commercially available extracorporeal membrane ventilator (NovaLung GmbH, Hechingen, Germany) was approved for clinical use by Health Canada for patients in respiratory failure. The system has been used in more than 2,000 patients with various indications in Europe, and was used for the first time in North America at the Toronto General Hospital in 2006. Evidence-Based Analysis The research questions addressed in this report are: 1. Does ILA/ECMO facilitate gas exchange in the lungs of patients with severe respiratory failure? 2. Does ILA/ECMO improve the survival rate of patients with respiratory failure caused by a range of underlying conditions including patients awaiting LTx? 3. What are the possible serious adverse events associated with ILA/ECMO therapy? To address these questions, a systematic literature search was performed on September 28, 2009 using OVID MEDLINE, MEDLINE In-Process and Other Non-Indexed Citations, EMBASE, the Cumulative Index to Nursing & Allied Health Literature (CINAHL), the Cochrane Library, and the International Agency for Health Technology Assessment (INAHTA) for studies published from January 1, 2005 to September 28, 2008. Abstracts were reviewed by a single reviewer and, for those studies meeting the eligibility criteria, full-text articles were obtained. Reference lists were also examined for any additional relevant studies not identified through the search. Articles with an unknown eligibility were reviewed with a second clinical epidemiologist and then a group of epidemiologists until consensus was established. Inclusion Criteria â? Studies in which ILA/ECMO was used as a bridge to recovery or bridge to LTx â? Studies containing information relevant to the effectiveness and safety of the procedure â? Studies including at least five patients Exclusion Criteria â? Studies reporting the use of ILA/ECMO for interhospital transfers of critically ill patients â? Studies reporting the use of ILA/ECMO in patients during or after LTx â? Animal or laboratory studies â? Case reports Outcomes of Interest â? Reduction in partial pressure of CO2 â? Correction of respiratory acidosis â? Improvement in partial pressure of oxygen â? Improvement in patient survival â? Frequency and severity of adverse events The search yielded 107 citations in Medline and 107 citations in EMBASE. After reviewing the information provided in the titles and abstracts, eight citations were found to meet the study inclusion criteria. One study was then excluded because of an overlap in the study population with a previous study. Reference checking did not produce any additional studies for inclusion. Seven case series studies, all conducted in Germany, were thus included in this review (see Table 1). Also included is the recently published CESAR trial, a multicentre RCT in the UK in which ECMO was compared with conventional intensive care management. The results of the CESAR trial w re published when this review was initiated. In the absence of any other recent RCT on ECMO, the results of this trial were considered for this assessment and no further searches were conducted. A literature search was then conducted for application of ECMO as bridge to LTx patients (January, 1, 2005 to current). A total of 127 citations on this topic were identified and reviewed but none were found to have examined the use of ECMO as bridge to LTx. Quality of Evidence To grade the quality of evidence, the grading system formulated by the GRADE working group and adopted by MAS was applied. The GRADE system classifies the quality of a body of evidence as high, moderate, low, or very low according to four key elements: study design, study quality, consistency across studies, and directness. Results: Trials on ILA Of the seven studies identified, six involved patients with ARDS caused by a range of underlying conditions; the seventh included only patients awaiting LTx. All studies reported the rate of gas exchange and respiratory mechanics before ILA and for up to 7 days of ILA therapy. Four studies reported the means and standard deviations of blood gas transfer and arterial blood pH, which were used for meta-analysis. Fischer et al. reported their first experience on the use of ILA as a bridge to LTx. In their study, 12 patients at high urgency status for LTx, who also had severe ventilation refractory hypercapnea and respiratory acidosis, were connected to ILA prior to LTx. Seven patients had a systemic infection or sepsis prior to ILA insertion.
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Detection of bacteria with molecular methods in prosthetic joint infection: sonication fluid better than periprosthetic tissue
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PJI DX Updated Search
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Background and purpose - The correct diagnosis of prosthetic joint infection (PJI) can be difficult because bacteria form a biofilm on the surface of the implant. The sensitivity of culture from sonication fluid is better than that from periprosthetic tissue, but no comparison studies using molecular methods on a large scale have been performed. We assessed whether periprosthetic tissue or sonication fluid should be used for molecular analysis. Patients and methods - Implant and tissue samples were retrieved from 87 patients who underwent revision operation of total knee or total hip arthroplasty. Both sample types were analyzed using broad-range (BR-) PCR targeting the 16S rRNA gene. The results were evaluated based on the definition of periprosthetic joint infection from the Workgroup of the Musculoskeletal Infection Society. Results - PJI was diagnosed in 29 patients, whereas aseptic failure was diagnosed in 58 patients. Analysis of sonication fluid using BR-PCR detected bacteria in 27 patients, whereas analysis of periprosthetic tissue by BR-PCR detected bacteria in 22 patients. In 6 of 7 patients in whom BR-PCR analysis of periprosthetic tissue was negative, low-virulence bacteria were present. The sensitivity and specificity values for periprosthetic tissue were 76% and 93%, respectively, and the sensitivity and specificity values for sonication fluid were 95% and 97%. Interpretation - Our results suggest that sonication fluid may be a more appropriate sample than periprosthetic tissue for BR-PCR analysis in patients with PJI. However, further investigation is required to improve detection of bacteria in patients with so-called aseptic failure
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Cyclic phosphatidic acid relieves osteoarthritis symptoms
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OAK Recommendation 9 Articles
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BACKGROUND: Cyclic phosphatidic acid (cPA) is a naturally occurring phospholipid mediator with a unique cyclic phosphate ring at the sn-2 and sn-3 positions of its glycerol backbone. Natural cPA and its chemically stabilized cPA derivative, 2-carba-cPA (2ccPA), inhibit chronic and acute inflammation, and 2ccPA attenuates neuropathic pain. Osteoarthritis (OA) is a degenerative disease frequently associated with symptoms such as inflammation and joint pain. Because 2ccPA has obvious antinociceptive activity, we hypothesized that 2ccPA might relieve the pain caused by OA. We aimed to characterize the effects of 2ccPA on the pathogenesis of OA induced by total meniscectomy in the rabbit knee joint. RESULTS: Intra-articular injection of 2ccPA (twice a week for 42 days) significantly reduced pain and articular swelling. Histopathology showed that 2ccPA suppressed cartilage degeneration in OA. We also examined the effects of 2ccPA on the inflammatory and catabolic responses of human OA synoviocytes and chondrosarcoma SW1353 cells in vitro. 2ccPA stimulated synthesis of hyaluronic acid and suppressed production of the metalloproteinases MMP-1, -3, and -13. However, it had no effect on the production of interleukin (IL)-6, an inflammatory cytokine. The suppressive effect of 2ccPA on MMP-1 and -3 production in synoviocytes and on MMP-13 production in SW1353 cells was not mediated by the lysophosphatidic acid receptor, LPA1 receptor (LPA1R). CONCLUSIONS: Our results suggest that 2ccPA significantly reduces the pain response to OA by inducing hyaluronic acid production and suppressing MMP-1, -3, and -13 production in synoviocytes and chondrocytes
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1 |
Reuse of external fixation components: a randomized trial
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Distal Radius Fractures
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OBJECTIVES: External fixation devices are sold in the United States as single-use devices and can be costly. Approved processes for refurbishment of nonimplantable components are available. We evaluated one such program for safety, efficacy, and fiscal ramifications.
DESIGN: Randomized clinical trial
SETTING: Single center, Level I trauma center
PATIENTS/PARTICIPANTS: During the 30-month enrollment period (November 16, 2001 to May 16, 2004), 41 patients (13%) of 315 patients were not able to consent and were excluded. A total of 178 (65%) of the 274 eligible patients who were offered entry into a randomized trial of new versus refurbished external fixation components for their injury refused to participate, leaving 96 (35%) of the 274 eligible patients entered into the study.
INTERVENTION: Consented patients were entered into a trial of new versus refurbished nonimplantable external fixation components for their injury (all pins were new).
MAIN OUTCOME MEASUREMENTS: The frames were evaluated at the time of removal for efficacy and the complications of pin tract infections, loss of fixation, or loosening of components.
RESULTS: A total of 48 distal radius fractures, 29 pilon fractures, and 19 tibial plateau fractures were entered into the study. With the 96 fractures treated in our study (50 new frames, 46 reused frames), we found no statistical differences in the incidence of pin tract infections (46% versus 52%, P=0.32), loss of fixation (4% versus 4%, P=0.70), or loosening of the components (1% versus 1%, P=1.0).
CONCLUSIONS: Sixty-five percent of consentable patients did not wish to have an external fixation frame with refurbished clamps. Our study demonstrated that this type of program is safe and effective with an actual cost savings of $65,452. The potential savings of such a program is 25% of the cost of all new frames.
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1 |
Normal meniscal dimensions at different patient ages-MRI evaluation
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AMP (Acute Meniscal Pathology)
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OBJECTIVE: The purpose of this work is to evaluate the normal meniscal and tibial dimensions in relation to age and gender in different children using conventional MRI sequences.
MATERIALS AND METHODS: Morphometric measurements of the menisci were retrospectively performed on knee MRIs of children (< 18 years). All knee MRIs over a 7-year period were collected. Exclusion criteria included: prior knee surgery or diseases involving the knee joint. A total of 186 children were included, 110 boys and 76 girls, with a mean age of 8.2 years (range, 0.3-17.8 years). Menisci and tibial measurement changes with age and gender as well as differences between the medial and lateral menisci were evaluated.
RESULTS: The medial menisci measurements increased with age (p value < 0.001). The lateral menisci measurements increased with age (p value < 0.001), except for the coronal meniscal width (p = 0.084). Coronal and sagittal percentage of meniscal coverage of the tibia decreased with age (p < 0.001). Medial menisci have greater sagittal width and anterior horn height than lateral menisci (p value < 0.001). Lateral menisci are larger in their coronal width and height, and sagittal posterior horn height in comparison to medial menisci (p < 0.001).
CONCLUSIONS: Menisci increase in all dimensions in correlation with age; except in the coronal meniscal width, which is a useful dimension to diagnose discoid meniscus on MRI, based on this, it would seem that the currently published size criteria, based on adults, could be applicable to children. The tibia has a faster rate dimension increase in correlation with age in comparison to the menisci.
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Mulberroside A alleviates osteoarthritis via restoring impaired autophagy and suppressing MAPK/NF-kappaB/PI3K-AKT-mTOR signaling pathways
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AMP (Acute Meniscal Pathology)
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Osteoarthritis (OA) is a trauma-/age-related degenerative disease characterized by chronic inflammation as one of its pathogenic mechanisms. Mulberroside A (MA), a natural bioactive withanolide, demonstrates anti-inflammatory properties in various diseases; however, little is known about the effect of MA on OA. We aim to examine the role of MA on OA and to identify the potential mechanisms through which it protects articular cartilage. In vitro, MA improved inflammatory response, anabolism, and catabolism in IL-1beta-induced OA chondrocytes. The chondroprotective effects of MA were attributed to suppressing the MAPK, NF-kappaB, and PI3K-AKT-mTOR signaling pathways, as well as promoting the autophagy process. In vivo, intra-articular injection of MA reduced the cartilage destruction and reversed the change of anabolic and catabolic-related proteins in destabilized medial meniscus (DMM)-induced OA models. Thus, the study indicates that MA exhibits a chondroprotective effect and might be a promising agent for OA treatment.
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Doxycycline-induced dizziness in dental patient. Case report
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Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures
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Many dentists are unaware of the documented adverse drug reaction of doxycycline: induced dizziness. Because doxycycline is frequently prescribed in dentistry, it is important for dentists and patients to be aware of this significant adverse reaction to prevent medical complications. A clinical case is reported in which a patient developed dizziness after taking doxycycline that was prescribed following periodontal surgery. The dizziness resolved when the doxycycline was stopped. Patients and dentists should be educated to recognize the signs and symptoms of doxycycline's adverse reactions
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1 |
Incidence, prognosis and nomograms of breast cancer with bone metastases at initial diagnosis: a large population-based study
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MSTS 2022 - Metastatic Disease of the Humerus
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BACKGROUND: Bone is the most common metastatic site for breast cancer, and patients' condition will deteriorate when it occurs.
METHODS: We performed a retrospective analysis on 6482 breast cancer patients with bone metastases (BCBM), who were selected from the Surveillance, Epidemiology, and End Result (SEER) 18 registry database. The optimal age cut-points were generated by using the X-tile software. By using Cox regression, we selected independent prognostic factors from 21 variables, and plotted a visual nomogram to predict the probability of surviving to the median survival time. We also diagrammed a competing risk nomogram on the basis of competitive risk model.
RESULTS: Compared with other three common metastatic sites, the incidence of bone metastasis was the highest for patients with breast cancer. The incidence of BCBM peaked around the age of 60, and a large majority of patients were between the ages of 50 and 70. The survival rate decreased with age, and the median survival time was about 19 months. Factors of age, race, marital status, grade, human epidermal growth factor receptor-2 (HER2) receptor, hormone receptor, concurrent brain metastasis, concurrent liver metastasis, concurrent lung metastasis, surgery and chemotherapy are strongly related to the prognosis of patients with BCBM. It was revealed that the C-index of the nomogram was 0.72 and the calibration curves showed good agreement between the nomogram prediction and actual observation.
CONCLUSION: Our practical nomograms provide a visual and user-friendly tool in the risk evaluation and prognostic prediction for breast cancer patients with bone metastases.
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Saliva: potential diagnostic value and transmission of 2019-nCoV
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Coronavirus Disease 2019 (COVID-19)
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2019-nCoV epidemic was firstly reported at late December of 2019 and has caused a global outbreak of COVID-19 now. Saliva, a biofluid largely generated from salivary glands in oral cavity, has been reported 2019-nCoV nucleic acid positive. Besides lungs, salivary glands and tongue are possibly another hosts of 2019-nCoV due to expression of ACE2. Close contact or short-range transmission of infectious saliva droplets is a primary mode for 2019-nCoV to disseminate as claimed by WHO, while long-distance saliva aerosol transmission is highly environment dependent within indoor space with aerosol-generating procedures such as dental practice. So far, no direct evidence has been found that 2019-nCoV is vital in air flow for long time. Therefore, to prevent formation of infectious saliva droplets, to thoroughly disinfect indoor air and to block acquisition of saliva droplets could slow down 2019-nCoV dissemination. This review summarizes diagnostic value of saliva for 2019-nCoV, possibly direct invasion into oral tissues, and close contact transmission of 2019-nCoV by saliva droplets, expecting to contribute to 2019-nCoV epidemic control.
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Spinal anesthesia for ureterorenoscopy and in situ lithotripsy for upper ureteric solitary pelvic calculi: An experience at POF hospital, Wah Cantt
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Surgical Management of Osteoarthritis of the Knee CPG
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Objective To evaluate the possibility of performing ureterorenoscopy and insitu lithotripsy for upper ureteric and solitary pelvic calculi under spinal anesthesia. Methods This descriptive study was conducted at POF Hospital, Wah Cant from June 2008 to December 2008. A total of 125 ASA-I patients, 75 male and 50 female, age ranging from 18 to 70 years, having upper ureteric or solitary pelvic calculi, were enrolled for the study. All received spinal anesthesia with 25G spinal needle at L3-4 interspace using 0.75% bupivacaine 15 mg and underwent ureterorenoscopy or insitu lithotripsy. Intraoperative and postoperative complications including hypotension, vomiting, pain on visual analgesia scale and duration of hospital stay were noted. Results All patients had a successful motor block of hip and knee and sensory block up to T8. All with the exception of 3 patients achieved adequate anesthesia for the procedures. Ten patients had hypotension and 4 had bradycardia intraoperatively. Vomiting occurred in 3 patients and PDPH in two. All patients were shifted to ward 4 hours post operatively after confirmation of complete reversal of block and hemodynamic stability. The average stay of all patients in the hospital was 36 hours. Conclusions Spinal anesthesia can be safely used for insitu lithotripsy of upper ureteric calculi and solitary renal pelvic calculi with decreased hospital stay and minimal post operative complications. (Rawal Med J 2009;34:210-212)
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Past and present of the use of cerclage wires in orthopedics
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Pediatric Supracondylar Humerus Fracture 2020 Review
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Cerclage wiring is a simple technique that has been practiced widely since the advent of surgical treatment of fractures. Many studies have reported the use of various cerclage technologies with a wide range of results and clinical applications. The increasing numbers of periprosthetic fractures have led to a revival of interest for this simple technique. When cerclages function as implants, they may be used alone or together with a protecting device such as external or internal splints (such as plates, nails, stems of prosthesis or a combination of thereof). This article presents a review of the available literature relating cerclage-wiring techniques and updates the recommendations for clinical use.
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Complications of femoral nerve block for total knee arthroplasty
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Surgical Management of Osteoarthritis of the Knee CPG
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Preemptive and multimodal pain control protocols have been introduced to enhance rehabilitation after total knee arthroplasty (TKA). We determined the complication rate associated with preoperative femoral nerve block (FNB) for TKA. Among 1018 TKA operations, we performed 709 FNBs using a single-injection technique into the femoral nerve sheath and confirming position with nerve stimulation before induction. After TKA, weightbearing as tolerated was initiated using a walker or crutches on postoperative Day 1. Twelve patients (1.6%) treated with FNB sustained falls, three (0.4%) of whom underwent reoperations. Five patients had postoperative femoral neuritis, which may have been secondary to the block. One patient had new onset of atrial fibrillation after FNB, and the TKA was postponed. Femoral nerve block before TKA is not a harmless intervention. We recommend postoperative protocols be modified for patients who have FNB to account for decreased quadriceps function in the early postoperative period, which can lead to falls. LEVEL OF EVIDENCE: Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence
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Running circular suture technique for reduction mammaplasty and mastopexy
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Reduction Mammoplasty for Female Breast Hypertrophy
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Many reports have described various technical aspects of reduction mammaplasty and mastopexy procedures. The authors present their technique, which combines a number of techniques already described in the literature regarding repositioning of the nipple-areola complex, reduction of the diameter of the base of the breast, and long-term retention of mammary cone projection. This study evaluated the results for patients of various ages and phenotypes in terms of scar dimensions, breast positioning, and patient satisfaction in the short, medium, and long terms. Mammaplasty was performed using the inverted T technique. The preoperative skin markings differed from those described in the literature in that they did not use the future position of the nipple-areola complex as the main reference point. A running circular suture was used to fix the breast to the pectoralis major fascia and to reduce the diameter of the base of the breast, resulting in a reduced horizontal scar in the inframammary fold. The skin-marking technique allowed for better postoperative breast symmetry regardless of preoperative variations in shape and volume. The outcomes were considered satisfactory in the majority of cases by both the patient (p = 0.78) and the physician (p = 0.58). Adequate fullness of the upper pole was maintained in 94.7 % of the breasts. The described technique results in a reduced diameter of the base of the breast, repair of ptosis, repositioning of the nipple-areola complex, and long-term upper pole fullness. Complications can occur with any technique, but it is important to choose a technique with good quality outcomes overall. LEVEL OF EVIDENCE IV: 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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Orienting of attention in unmedicated patients with schizophrenia, prodromal subjects and healthy relatives
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Upper Eyelid and Brow Surgery
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In typical orienting of attention tasks subjects have to respond as fast as possible to targets which appear in the periphery of the visual field and are preceded by spatial cues (e.g. brightening of a peripheral box where the target may subsequently appear). Reaction times (RT) are facilitated when cue and target appear at the same location (valid cueing) and the cue target interval is short (<250 ms). However, RTs slow down again when the target follows a valid cue after an interval of 250 ms and longer. This latter phenomenon is called Inhibition of Return (IOR) and is thought to reflect an automatic, inhibitory mechanism to protect the organism from redundant and distracting stimuli. Deficits of IOR were repeatedly reported in patients with schizophrenia. However, the role of medications and the nature of the deficit (trait or vulnerability indicator?) were unclear. In the present study we examined 15 unmedicated patients with schizophrenia (age: 31.2+/-11.1, m/f: 11/4, global scores SAPS: 48.33+/-33.09, SANS: 19.22+/-26.16), 29 subjects who were putatively in a prodromal state of psychosis, 30 first-degree relatives, another 8 first-degree relatives who had one child and at least one more relative with schizophrenia, and 50 healthy controls. We found an impairment of IOR only in the unmedicated patient group. In conclusion, blunted IOR in schizophrenia is not secondary to medications. According to this and previous studies blunted IOR may be most probably viewed as a trait cognitive feature of the schizophrenic disorder.
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Displaced fracture of the distal radius in children
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Distal Radius Fractures
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We retrospectively reviewed 183 children with a simple fracture of the distal radius, with or without fracture of the ulna, treated by closed reduction and cast immobilisation. The fracture redisplaced after an initial, acceptable closed reduction in 46 (25%). Complete initial displacement was identified as the most important factor leading to redisplacement. Other contributing factors were the presence of an ipsilateral distal ulnar fracture, and the reduction of completely displaced fractures under deep sedation or local haematoma block. We recommend that completely displaced fractures of the distal radius in children should be reduced under general anaesthesia, and fixed by primary percutaneous Kirschner wires even when a satisfactory closed reduction has been achieved. ©2005 British Editorial Society of Bone and Joint Surgery.
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Mandibular cortical shape index in non-standardised panoramic radiographs for identifying patients with osteoporosis as defined by the German Osteology Organization
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Hip Fx in the Elderly 2019
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The aim of this prospective controlled study was to determine the validity of the mandibular cortical shape index (CI) on panoramic radiographs in distinguishing patients with osteoporosis as defined by the German Osteology Organization (Dachverbands der Deutschsprachigen Osteologischen Fachgesellschaften, DVO). The study group contained 50 patients (33 female, 17 male, mean age: 74.9 years), who had a high risk of osteoporosis. 50 young patients (33 female, 17 male, mean age: 37.9 years) with no anamnestic evidence of osteoporosis served as control. Three blinded observers evaluated panoramic views of the study and the control group in a mixed manner regarding the mandibular cortical shape index. The study group underwent bone mineral density measurement using dual energy X-ray absorptiometry and received a diagnosis according to the Organization's guidelines (normal, osteopenia, osteoporosis). The CI showed a high sensitivity of 72.2% and a high specificity of 93.9% with a highly significant predictive value (Chi-square = 22.96, p < 0.001), while the observer's agreement was moderate (kappa = 0.47). We concluded that patients with a cortical shape index of the category assessed as "severe" on non-standardised panoramic radiographs have a higher risk of suffering systemic osteoporosis. The CI in panoramic radiographs is a good screening tool, which could be implemented in the routine assessment of panoramic radiographs in elder patients. © 2012 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights.
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Carpal arch alteration after carpal tunnel release
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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A retrospective clinical study quantitated postoperative widening of the transverse carpal arch after carpal tunnel release in a group of 50 patients. The relationship of this widening with postoperative pain, forearm circumference, grip strength, and wrist range of motion was evaluated. Mean widening of the transverse carpal arch after carpal tunnel release is 10.4% or 2.7 mm. A direct relationship exists between widening of the transverse carpal arch and loss of grip strength. Residual pain, forearm circumference, and wrist range of motion are not related to widening of the transverse carpal arch
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Cone-Beam computed tomography as an adjunct to performance of percutaneous cementoplasty of the acetabulum
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PJI DX Updated Search
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Acetabuloplasty is a valuable palliative adjunct for the treatment of patients with painful metastatic disease to the pelvis in selected cases. We report the case of a 45-year-old woman with morbid obesity and with breast carcinoma who was technically difficult to treat under fluoroscopic guidance due to very poor visualization secondary to her body habitus. It was possible to perform radiofrequency ablation and acetabuloplasty with the use of cone-beam computed tomography for guidance. é 2012 Canadian Association of Radiologists. All rights reserved
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Primary and revision THA using a stemless metaphyseal-loading implant above distorted proximal femoral anatomy
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DoD LSA (Limb Salvage vs Amputation)
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Total hip arthroplasty is well established as a successful treatment for end stage arthritis, with a wide variety of components currently available. Using traditional stemmed implants in patients with a distorted proximal femur can be technically challenging with an increased risk of complications. We present seven patients with distorted proximal femoral anatomy or failed hip arthroplasty in whom a short, metaphyseal loading implant was utilised. At minimum two-year follow-up there have been no complications with all stems stable and well fixed radiologically. Average improvement in Oxford Hip Score is 32. We suggest that a short, metaphyseal loading prosthesis can be considered in cases where a conventional stemmed implant may not be suitable due to challenging proximal femoral anatomy. © 2012 Wichtig Editore - ISSN 1120-7000.
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Oral infections in the immunocompromised host
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Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures
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The prevalence of infections in the immunocompromised host is increasing. The oral cavity is a primary or sole site in many cases. It is important for the practicing clinician to recognize the more common infections in this growing patient population. Oral examinations are an essential component of all physical examinations, especially when immunosuppression is known or suspected. We recommend that all patients starting immunosuppressive therapy receive a comprehensive oral examination before the institution of such therapy to eliminate potential sources of oral and odontogenic infections. The examination should include full mouth dental radiographs and a complete soft-tissue examination. Timely, accurate diagnoses may have important implications with regard to management, prognosis, cost, morbidity, and mortality
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A novel subchondral bone-grafting procedure for the treatment of giant-cell tumor around the knee: A retrospective study of 27 cases
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OAK 3 - Non-arthroplasty tx of OAK
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The vast majority of giant-cell tumors occur around the knee and characteristically affect the subchondral bone. Thermal damage to the articular cartilage arising from the application of polymethylmethacrylate (PMMA) or extensive intralesional curettage presents a challenging problem to orthopedic surgeons and patients due to compliance issues. For this reason, we developed a new subchondral bone-grafting procedure to restore massive bone defects and reduce degenerative changes in the knee.The aim of this study was to describe the novel subchondral bone-grafting procedure and evaluate clinical outcomes in patients with giant-cell tumors around the knee.This retrospective single-center study included a total of 27 patients with giant-cell tumors in the distal femur and proximal tibia admitted to our department from January 2012 to December 2015 and treated with aggressive intralesional curettage. Eleven males and 16 females were included. All cases underwent subchondral autograft bone grafting followed by bone cement reconstruction and instrument internal fixation. The Musculoskeletal Tumor Society (MSTS) score and short form-36 (SF-36) were applied to assess the functional outcome of the knee joint and quality of life. Tumor recurrence, Kellgren and Lawrence (KL) grade, and the distance of the cement to the articular surface were assessed throughout the sample.All cases were followed up after surgery for an average of 32.9 +/- 7.1 months (range 25-57 months). At the end of the follow-up period, all patients were alive and free from pulmonary metastasis. Complications associated with this surgery occurred only in 1 patient (3.7%), who presented with an incision infection that resolved with regular dressing and antibiotics. No fractures, instrument breakage, or joint fluid leakage occurred. Local recurrence occurred in 1 case (3.7%) at the distal femur after 23 months and was treated by wide resection followed by prosthesis reconstruction. Twenty-four patients (89%) did not develop radiographic findings of osteoarthritis: at the final follow-up 2 patients (7.4%), had progressed to KL1 and 1 patient had progressed to KL2. According to the MSTS scoring system, the functional score of the affected knee joint at the last follow-up ranged from 80% to 97%, with an average of 87.3%. The quality of life parameters assessed by the SF-36 survey at the last follow-up ranged from 47 to 96, with an average of 77.For patients with giant-cell tumor of bone near the knee, subchondral bone grafting combined with bone cement reconstruction is recommended as a feasible and effective treatment modality.
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Professional interventions for general practitioners on the management of musculoskeletal conditions
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Glenohumeral Joint OA
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BACKGROUND: Musculoskeletal conditions require particular management skills. Identification of interventions which are effective in equipping general practitioners (GPs) with such necessary skills could translate to improved health outcomes for patients and reduced healthcare and societal costs.
OBJECTIVES: To determine the effectiveness of professional interventions for GPs that aim to improve the management of musculoskeletal conditions in primary care.
SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL), 2010, Issue 2; MEDLINE, Ovid (1950 - October 2013); EMBASE, Ovid (1980 - Ocotber 2013); CINAHL, EbscoHost (1980 - November 2013), and the EPOC Specialised Register. We conducted cited reference searches using ISI Web of Knowledge and Google Scholar; and handsearched selected issues of Arthritis and Rheumatism and Primary Care-Clinics in Office Practice. The latest search was conducted in November 2013.
SELECTION CRITERIA: We included randomised controlled trials (RCTs), non-randomised controlled trials (NRCTs), controlled before-and-after studies (CBAs) and interrupted time series (ITS) studies of professional interventions for GPs, taking place in a community setting, aiming to improve the management (including diagnosis and treatment) of musculoskeletal conditions and reporting any objective measure of GP behaviour, patient or economic outcomes. We considered professional interventions of any length, duration, intensity and complexity compared with active or inactive controls.
DATA COLLECTION AND ANALYSIS: Two review authors independently abstracted all data. We calculated the risk difference (RD) and risk ratio (RR) of compliance with desired practice for dichotomous outcomes, and the mean difference (MD) and standardised mean difference (SMD) for continuous outcomes. We investigated whether the direction of the targeted behavioural change affects the effectiveness of interventions.
MAIN RESULTS: Thirty studies met our inclusion criteria.From 11 studies on osteoporosis, meta-analysis of five studies (high-certainty evidence) showed that a combination of a GP alerting system on a patient's increased risk of osteoporosis and a patient-directed intervention (including patient education and a reminder to see their GP) improves GP behaviour with regard to diagnostic bone mineral density (BMD) testing and osteoporosis medication prescribing (RR 4.44; (95% confidence interval (CI) 3.54 to 5.55; 3 studies; 3,386 participants)) for BMD and RR 1.71 (95% CI 1.50 to 1.94; 5 studies; 4,223 participants) for osteoporosis medication. Meta-analysis of two studies showed that GP alerting on its own also probably improves osteoporosis guideline-consistent GP behaviour (RR 4.75 (95% CI 3.62 to 6.24; 3,047 participants)) for BMD and RR 1.52 (95% CI 1.26 to 1.84; 3.047 participants) for osteoporosis medication) and that adding the patient-directed component probably does not lead to a greater effect (RR 0.94 (95% CI 0.81 to 1.09; 2,995 participants)) for BMD and RR 0.93 (95% CI 0.79 to 1.10; 2,995 participants) for osteoporosis medication.Of the 10 studies on low back pain, seven showed that guideline dissemination and educational opportunities for GPs may lead to little or no improvement with regard to guideline-consistent GP behaviour. Two studies showed that the combination of guidelines and GP feedback on the total number of investigations requested may have an effect on GP behaviour and result in a slight reduction in the number of tests, while one of these studies showed that the combination of guidelines and GP reminders attached to radiology reports may result in a small but sustained reduction in the number of investigation requests.Of the four studies on osteoarthritis, one study showed that using educationally influential physicians may result in improvement in guideline-consistent GP behaviour. Another study showed slight improvements in patient outcomes (pain control) after training GPs on pain management.Of three studies on shoulder pain, one study reported that there may be little or no improvement in patient outcomes (functional capacity) after GP education on shoulder pain and injection training.Of two studies on other musculoskeletal conditions, one study on pain management showed that there may be worse patient outcomes (pain control) after GP training on the use of validated assessment scales.The 12 remaining studies across all musculoskeletal conditions showed little or no improvement in GP behaviour and patient outcomes.The direction of the targeted behaviour (i.e. increasing or decreasing a behaviour) does not seem to affect the effectiveness of an intervention. The majority of the studies did not investigate the potential adverse effects of the interventions and only three studies included a cost-effectiveness analysis.Overall, there were important methodological limitations in the body of evidence, with just a third of the studies reporting adequate allocation concealment and blinded outcome assessments. While our confidence in the pooled effect estimate of interventions for improving diagnostic testing and medication prescribing in osteoporosis is high, our confidence in the reported effect estimates in the remaining studies is low.
AUTHORS' CONCLUSIONS: There is good-quality evidence that a GP alerting system with or without patient-directed education on osteoporosis improves guideline-consistent GP behaviour, resulting in better diagnosis and treatment rates.Interventions such as GP reminder messages and GP feedback on performance combined with guideline dissemination may lead to small improvements in guideline-consistent GP behaviour with regard to low back pain, while GP education on osteoarthritis pain and the use of educationally influential physicians may lead to slight improvement in patient outcomes and guideline-consistent behaviour respectively. However, further studies are needed to ascertain the effectiveness of such interventions in improving GP behaviour and patient outcomes.
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Controversies and techniques in the surgical management of patellofemoral arthritis
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Surgical Management of Osteoarthritis of the Knee CPG
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Historically, the patellofemoral articulation has been a topic of less interest among orthopaedists and has been subject to fewer studies when compared with other major joints in the body. Patellofemoral arthritis is a common and debilitating condition, and greater awareness of this has led to a new interest and recent increase in the number of clinical investigations pertaining to this condition. It is hoped that an overview of patellofemoral kinematics, forces, and contact patterns will help in understanding the progression of patellofemoral arthritis. Furthermore, this understanding will ultimately allow the surgeon to apply these basic principles to more effective nonsurgical and surgical treatment options. Treatment methods for patellofemoral arthritis include both conservative as well as surgical interventions. Specifically, these treatments range from stretching and water exercises to patellar realignment procedures and the recently developed procedure of custom patellofemoral arthroplasty. In addition, many new and innovative treatments are on the horizon. This renewed interest in the patellofemoral articulation bodes well for patients who suffer from this condition
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Distal femoral bone mineral density decreases following patellofemoral arthroplasty: 1-year follow-up study of 14 patients
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Surgical Management of Osteoarthritis of the Knee CPG
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Background. The bone mineral density (BMD) of the distal femur decreases by 16-36% within one year after total knee arthroplasty (TKA) because of the femoral component's stress-shielding effect. The aim of this prospective study was to determine the quantitative change from the baseline BMD in the distal femur 1 year after patellofemoral arthroplasty using dual-energy X-ray absorptiometry (DXA). Methods. Between December 2007 and December 2008, 14 patients had patellofemoral arthroplasty for isolated patellofemoral osteoarthritis. Distal femoral BMD was assessed using DXA in 2 regions of interest (ROI) on the lateral view 2 weeks before and 12 months after patellofemoral arthroplasty. The contra-lateral knee was used as a control, with BMD measurements performed in identical ROIs. Results. The mean change from baseline BMD in the operated knees after 1 year was -0.169 g/cm(2) (95% CI: -0.293 to -0.046 g/cm(2)) behind the anterior flange (-15%), and -0.076 g/cm(2) (95% CI: -0.177 to 0.024 g/cm(2)) in the supracondylar area 1 cm above the prosthesis (-8%) (p = 0.01 and p = 0.13, respectively). The mean change from baseline BMD in the non-operated knees after 1 year was 0.016 g/cm(2) (95% CI: -0.152 to 0.185 g/cm(2)) behind the anterior flange (2%), and 0.023 g/cm(2) (95% CI: -0.135 to 0.180 g/cm(2)) in the supracondylar area 1 cm above the prosthesis (2%) (p = 0.83, and p = 0.76, respectively). Conclusions. Our findings suggest that patellofemoral arthroplasty results in a statistically significant decrease in BMD behind the anterior flange. (copyright) 2010 van Jonbergen et al; licensee BioMed Central Ltd
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Transconjunctival blepharoplasty
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Panniculectomy & Abdominoplasty CPG
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Cosmetic blepharoplasty is directed at the surgical correction of undesirable changes of the eyelids that are usually of an acquired nature and caused by aging. The goals are to improve the appearance and, many times, the function of the eyelids. Just as important as attaining these goals is avoiding any complications or undesirable sequelae of a blepharoplasty procedure. In this article, the technique and application of transconjunctival blepharoplasty are reviewed. The differences in the preseptal and retroseptal approaches are discussed and illustrated. The transconjunctival technique can be expanded through the use of various other techniques in order to apply it to a wider variety of patients. These expanded techniques of transconjunctival blepharoplasty allow the surgeon to manage excess skin and rhytids more effectively. Transconjunctival blepharoplasty, therefore, represents a technique in the armamatarium of surgeons performing cosmetic blepharoplasty that has gained new popularity. The technique can be effectively applied to a wide variety of patients. Transconjunctival blepharoplasty allows the surgeon to accomplish many of the esthetic goals of blepharoplasty while reducing the incidence of many of the associated problems, i.e., lid malposition and a visible cutaneous scar.
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Autologous osteochondral mosaicplasty in osteochondritis dissecans of the patella in adolescents
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Osteochondritis Dissecans 2020 Review
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PURPOSE: Osteochondritis dissecans of the patella (OCDP) is rare in adolescents. The objective of this study was to evaluate functional results of OCDP management in adolescents with mosaicplasty and to analyze proper integration of osteochondral grafts via MRI. METHODS: This is a retrospective series of eight cases of OCDP treated by mosaicplasty. Mean age at the surgery was 15Â years (range 12-17). Clinical features were represented by retropatellar pain, hydarthrosis, locking and crepitus. All patients benefited from knee radiographs as well as pre-operative MRI. Six OCDP were evaluated International Cartilage Repair Society (ICRS) grade III and two were ICRS grade IV. Mean surface of the lesion was 97.5Â mm(2). The pre- and post-operative assessments were conducted with scores obtained on the IKDC subjective knee evaluation form, Lysholm knee score, and Tegner activity scale. These assessments were completed by post-operative MRI. The magnetic resonance observation of cartilage repair tissue (MOCART) score was calculated from the latest MRI examination conducted after surgery. RESULTS: Mean follow-up was 28.6Â months. At the latest follow-up, the mean IKDC score was 86.5, Lysholm score was 89, and Tegner activity scale score was 6.2 (pre-operative scores were respectively 49.9, 53.8, and 4.5). Radiographs and MRI showed a complete integration of grafts at the latest follow-up with a satisfactory reconstruction of the joint surface. Mean MOCART score was 75/100. CONCLUSIONS: Autologous osteochondral mosaicplasty to manage OCDP in adolescents appears to be a reliable technique on the short term to restore patellar joint surface and obtain satisfactory functional results.
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Contribution of vitamin C administration for increasing lipolysis
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Panniculectomy & Abdominoplasty CPG
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This experiment was designed to investigate whether addition of vitamin C to the solution used in tumescent technique of liposuction might increase lipolysis and whether increased fibrosis might improve skin retraction where liposuction did not work properly and the skin had poor retraction ability. Eighteen Sprague-Dawley rats were used in two groups. Both inguinal fat pads of rats with their vascular structures were elevated and the right inguinal fat pad was injected with 1 cc tumescent solution as a control and the left fat pad with a 1 cc vitamin C-tumescent solution. Histopathological examination showed that all fat pads injected with tumescent solution had normal adipocytes. Those injected with vitamin C-tumescent were shown to have extreme fibrosis and occasional adipocytes.
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Infant Medical Trauma in the Neonatal Intensive Care Unit (IMTN): A Proposed Concept for Science and Practice
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DoD PRF (Psychosocial RF)
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BACKGROUND: Trauma is an innately subjective experience ensuing from a deeply distressing event. Research has demonstrated that while the environment of the neonatal intensive care unit (NICU) is capable of providing extraordinary lifesaving measures following birth, the experience may be disruptive to several key aspects of early development, placing infants at risk for adverse behavioral, cognitive, and emotional outcomes.
PURPOSE: This article provides rationale for the concept of Infant Medical Trauma in the NICU (IMTN) as a means of describing this unique stress experience. A triad of cumulative early life NICU experiences (stress, parental separation, and pain) is proposed to influence an infant's swinging neurodevelopmental pendulum amid the potential outcomes of risk and resilience.
IMPLICATIONS FOR PRACTICE AND RESEARCH: Creating language that describes the infant experience brings meaning and calls caregivers and parents to action to consider strategies that may improve long-term health. Actively seeking opportunities to decrease the allostatic load of at-risk infants may support an infant's pendulum to swing toward a path of resilience, thereby moderating his or her early life adverse experience.
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Treatment of Multiple Myeloma: Current Management and New Approaches
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MSTS 2022 - Metastatic Disease of the Humerus
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The management of multiple myeloma (MM) has undergone many developments in the last 30 years. Initially, melphalan was used as a single agent and this was followed by the discovery of corticosteroids as highly active agents and the design of multiagent cytotoxic regimens. However, although response rates have improved, little impact has been achieved on survival. Interferon has been extensively examined in early as well as relapsed disease. Currently, a benefit in survival is only evident in maintenance phase, where there is a small but significant difference. However, this has to be evaluated in the context of adverse effects and the impact on quality of life. In recent years, autologous stem cell transplantation has become established as the standard therapy for eligible patients. An advantage in survival has been established in at least one randomized trial, and response rates have been improved. Unfortunately, relapse after an autotransplant is almost inevitable, and the possible benefits of more than one transplant continue to be examined. To date, allotransplantation has assumed a much smaller role in MM, predominantly because of a high transplant-related mortality (TRM). An important innovation has been the use of donor lymphocyte infusions to harness the graft versus myeloma effect, either in relapse after allogeneic transplantation or in the novel strategy of nonmyeloablative allotransplants, with the aim of reducing TRM and increasing the eligibility of patients for allogeneic transplantation. Thalidomide, which has immunomodulatory and antiangiogenic properties, has been used as a single agent or in combination with other cytotoxic regimens in relapsed/ refractory disease, with response rates of approximately 30%. Its role in early disease is currently being evaluated. Bisphosphonates are now established as standard therapy in myeloma bone disease and are associated with the reduction of skeletal complications. Possible benefits in early 'smoldering' disease and effects on survival continue to be evaluated. Immunotherapy is one of the most intensely studied and promising developments in myeloma management. A variety of techniques ranging from tumor vaccination to the use of monoclonal antibodies are under active evaluation. Other experimental agents include the development of proteosome inhibitors, immunomodulatory thalidomide analogs, other antiangiogenic agents, arsenic trioxide, antisense oligonucleotides, anti-bone resorption agents such as osteoprotegerin and farnesyl transferase inhibitors, which are currently at preclinical or early clinical phases of investigation.
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Economic evaluations of antibiotic use and resistance--a perspective: report of Task Force 6
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Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures
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The economic consequences of antibiotic prophylaxis and therapy for bacterial infections in humans are profound. The reduction in real-dollar terms in the amount of illness and disability resulting from the use of developed and marketed antibiotics far outweighs costs of adverse effects, including resistance. Although bacterial infections continue to cause substantial mortality and morbidity worldwide, standard criteria for assessing the relation of infection to death or the contribution of resistance to mortality and morbidity do not exist. While local outbreaks of resistance may have serious consequences, bacterial susceptibility to antimicrobial therapy has remained virtually unchanged nationally where studied. Nevertheless, discriminating use of antimicrobial agents is held widely to be the keystone for minimizing resistance. It is not clear whether risk of selecting resistance is lowered by current community or clinical practices. Some analysts concentrate on the "problem" and "cost" of resistance and forget the benefits of the use of antibiotics. Development of resistance is a natural consequence of antibiotic use, but further quantification of this relation is required. Reports that resistance is increasing worldwide have presented a scientific challenge and economic opportunity to the pharmaceutical industry for the development of new antimicrobial agents. However, if a reasonable rate of return cannot be foreseen, capital for research and development is likely to be invested in areas that appear more financially attractive
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Lateral epicondylitis: review of injection therapies
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PRPs for Lateral Epicondylitis/Elbow Tendinopathies
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Lateral epicondylitis has several different treatment methods, with no single agreed upon therapy. This article summarizes the current literature on injection therapies for lateral epicondylitis. Glucocorticoid, botulinum toxin, autologous blood, platelet-rich plasma, hyaluronic acid, polidocanol, glycosaminoglycan, and prolotherapy injections are discussed.
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New and emerging antiresorptive treatments in osteoporosis
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MSTS 2018 - Femur Mets and MM
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Bisphosphonates have for many years been the mainstay of antiresorptive treatment, acting predominantly by inducing apoptosis of mature osteoclasts. During recent years, an advanced understanding of the genetic and biological mechanism involved in bone resorption has revealed new therapeutic targets for antiresorptive treatments. Several of these new drugs act by targeting specific pathways within the osteoclastic cells and may reduce bone resorption without a concomitant decrease in bone formation. Such an uncoupling may result in a net bone formation, thereby causing a bone "anabolic" effect through an antiresorptive mechanism. Moreover, in contrast to bisphosphonates several of the new drugs are not deposited within bone and therefore their duration of action is related to their presence in plasma. Accordingly, their antiresorptive effect is quickly reversible, which may be advantageous if reversal of a suppressed bone turnover is warranted under certain clinical conditions such as osteonecrosis of the jaw. In this paper, we will review the pharmacological properties and clinical effects of the drugs that recently have been (denosumab, bazedoxifene, lasofoxifene), or currently are being tested in large phase III clinical trials (Catepsin K inhibitor), as well as drugs that have shown potential beneficial effects in phase I or II trials and may be tested in upcoming phase III trials (integrin antagonists, c-Src kinase inhibitor, inhibitors of the acidification process within the resorption lacuna, and glucagon-like peptide). © 2011 Bentham Science Publishers Ltd.
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Musculoskeletal MR: knee
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Diagnosis and Treatment of Osteochondritis Dissecans AUC
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Magnetic resonance imaging is the most sensitive, specific, and accurate noninvasive method for diagnosing internal derangement of the knee. During the past 15 years knowledge of pathologic conditions of the knee had evolved significantly. Beyond the basic principles of imaging knee injuries great impact was made on the understanding of indirect or collateral findings, even in rare diseases. In this article the spectrum of disorders of the knee are reviewed and an overview of the current literature is given. This includes considerations about how to achieve a high-standard MR imaging study of the knee, and principles of imaging anterior cruciate ligament and meniscal tears. A focus is put on distinct diseases including intra-articular and intraosseous ganglion cysts, iliotibial band friction syndrome, transient osteoporosis, osteonecrosis, osteochondritis dissecans, and imaging of the articular cartilage
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Kinematics of knees with osteoarthritis show reduced lateral femoral roll-back and maintain an adducted position. A systematic review of research using medical imaging
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OAK 3 - Non-arthroplasty tx of OAK
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BACKGROUND: While several studies describe kinematics of healthy and osteoarthritic knees using the accurate imaging and computer modelling now possible, no systematic review exists to synthesise these data.
METHOD: A systematic review extracted quantitative observational, quasi-experimental and experimental studies from PubMed, Scopus, Medline and Web of Science that examined motion of the bony or articular surfaces of the tibiofemoral joint during any functional activity. Studies using surface markers, animals, and in vitro studies were excluded.
RESULTS: 352 studies were screened to include 23 studies. Dynamic kinematics were recorded for gait, step-up, kneeling, squat and lunge and quasi-static squat, knee flexion in side-lying or supine leg-press. Kinematics were described using a diverse range of measures including six degrees of freedom kinematics, contact patterns or the projection of the femoral condylar axis above the tibia. Meta-analysis of data was not possible since no three papers recorded the same activity with the same measures. Visual evaluation of data revealed that knees with osteoarthritis maintained a more adducted position and showed less posterior translation of the lateral femoral condylar axis than healthy knees. Variability in activities and in recording measures produced greater variation in kinematics, than did knee osteoarthritis.
CONCLUSION: Differences in kinematics between osteoarthritic and healthy knees were observed, however, these differences were more subtle than expected. The synthesis and progress of this research could be facilitated by a consensus on reference systems for axes and kinematic reporting.
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Extracorporeal Shock Wave Therapy shows Superiority over Injections for Pain Relief and Grip Strength Recovery in Lateral Epicondylitis: A Systematic Review and Network Meta-Analysis
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PRPs for Lateral Epicondylitis/Elbow Tendinopathies
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PURPOSE: To examine the efficacy of extracorporeal shock wave therapy (ESWT) and injection therapies by synthesizing direct and indirect evidence for all pairs of competing therapies for lateral epicondylitis.
METHODS: PubMed, EMBASE, and Web of Science databases were searched for all appropriate randomized controlled trials (RCTs) assessing the effect of ESWT or injection therapies. The primary outcome was short-term (<=3 months) and medium-term (>3 months but <=12 months) pain, while the secondary outcomes were grip strength and patient-reported outcome measures. All outcomes were assessed using standardized mean differences (SMDs) with 95% confidence intervals (CIs) and were ranked using surface under the cumulative ranking curve (SUCRA) probabilities to determine a hierarchy of treatments. Sensitivity analysis was performed to eliminate potential therapeutic effects of normal saline (NS) and exclude trials that included patients with acute lateral epicondylitis (LE).
RESULTS: 40 RCTs were included to evaluate ESWT and five different injection therapies, including corticosteroids (CSs), autologous whole blood, platelet-rich plasma (PRP), botulinum toxin A (BoNT-A), and dextrose prolotherapy (DPT). DPT (-0.78 [-1.34 to -0.21]), ESWT (0.57 [-0.89 to -0.25]), PRP (-0.48 [-0.85 to -0.11]), and BoNT-A (-0.43 [-0.84 to -0.02]) outperformed placebo for short-term pain relief; ESWT (-0.44 [-0.85 to -0.04]) outperformed placebo for medium-term pain relief. DPT was ranked as the most optimal short-term and medium-term pain reliever (SUCRA, 87.3% and 98.6%, respectively). ESWT was ranked as the most optimal short-term and medium-term grip strength recovery (SUCRA, 79.4% and 86.4%, respectively).
CONCLUSIONS: DPT and ESWT were the best two treatment options for pain control and ESWT was the best treatment option for grip strength recovery. CSs were not recommended for the treatment of LE. More evidence is required to confirm the superiority in pain control of DPT among all these treatment options on LE.
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Width of excision of malignant melanoma of thickness 2 mm or greater. A randomized study - 1 cm vs 3 cm
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Reconstruction After Skin Cancer
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British Association of Surgical Oncology. 46th Scientific Meeting of the Association held at Glan Clwyd Hospital, Rhyl, North Wales on 18 June 1993. Abstracts of members' papers.
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The Effect of Reduction Mammaplasty on Quality of Life in Adolescents With Macromastia
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Reduction Mammoplasty for Female Breast Hypertrophy
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OBJECTIVES: To measure changes in health-related quality of life and breast-related symptoms after reduction mammaplasty in adolescents.
METHODS: In this longitudinal cohort study, we administered the Short-Form 36v2 (SF-36), Rosenberg Self-Esteem Scale (RSES), Breast-Related Symptoms Questionnaire (BRSQ), and Eating Attitudes Test-26 to 102 adolescents with macromastia and 84 female controls, aged 12 to 21 years. Patients with macromastia completed surveys preoperatively and after reduction mammaplasty at 6 months and 1, 3, and 5 years. Controls completed baseline and follow-up surveys at the same intervals.
RESULTS: Patients with macromastia demonstrated significant score improvements postoperatively from baseline on the RSES, BRSQ, and in 7 out of 8 SF-36 domains: physical functioning, role-physical, bodily pain, vitality, social functioning, role-emotional, mental health (P < .001, all). By the 6-month follow-up visit, postoperative subjects scored similarly to or more favorably than controls on the RSES, BRSQ, Eating Attitudes Test-26 , and SF-36; these benefits persisted for at least 5 years and were not significantly affected by BMI category or age.
CONCLUSIONS: Reduction mammaplasty was significantly associated with improvements in health-related quality of life and breast-related symptoms of adolescent patients, with measureable improvements in physical and psychosocial well-being evident by 6 months postoperatively and still demonstrable after 5-years. These results largely do not vary by BMI category or age. Patients and providers should be aware of the potential positive impact that reduction mammaplasty can provide adolescents with symptomatic macromastia. Historic concerns regarding age and BMI category at the time of surgery should be reconsidered.
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Enhanced Recovery after Surgery: The Plastic Surgery Paradigm Shift
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Panniculectomy & Abdominoplasty CPG
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Background: With a focus on providing high quality care and reducing facility based expenses there has been an evolution in perioperative care by way of enhanced recovery after surgery (ERAS). ERAS allows for a multidisciplinary and multimodal approach to perioperative care which not only expedites recovery but maximizes patient outcomes. This paradigm shift has been generally accepted by most surgical specialties, including plastic surgery. Objectives: The goal of this study was to evaluate the impact of ERAS on outcomes in cosmetic plastic surgery. Methods: A prospective study consisting of phone call questionnaires was designed where patients from two senior plastic surgeons (N.H.R. and J.D.F.) were followed. The treatment group (n = 10) followed an ERAS protocol while the control group (n = 12) followed the traditional recovery after surgery which included narcotic usage. Patients were contacted on postoperative days (POD) 0 through 7+ and surveyed about a number of outcomes measures. Results: The ERAS group demonstrated a significant reduction in postoperative pain on POD 0, 1, 2, and 3 (all P < 0.01). There was also statistically less nausea/vomiting, fatigue/drowsiness, constipation, and hindrance on ambulation compared to the control group (all P < 0.05). Significance was achieved for reduction in fatigue/drowsiness on POD 0 and 1 (P < 0.01), as well as ability to ambulate on POD 0 and 3 (P = 0.044). Lastly, opioid use (P < 0.001) and constipation (P = 0.003) were decreased. Conclusions: ERAS protocols have demonstrated their importance within multiple surgical fields, including cosmetic plastic surgery. The utility lies in the ability to expedite patient's recovery while still providing quality care. This study showed a reduction in postoperative complaints by avoiding narcotics without an increase in complications. Our findings signify the importance of ERAS protocols within cosmetic plastic surgery.
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Functional, Magnetic Resonance Imaging, and Second-Look Arthroscopic Outcomes After Pullout Repair for Avulsion Tears of the Posterior Lateral Meniscus Root
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AMP (Acute Meniscal Pathology)
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BACKGROUND: Little data exist in the literature regarding second-look arthroscopic outcomes after pullout repair for avulsion tears of the posterior lateral meniscus root.
PURPOSE: To (1) assess the functional, magnetic resonance imaging (MRI), and second-look arthroscopic outcomes after pullout repair for avulsion tears of the posterior lateral meniscus root; (2) determine which demographic and clinical factors influenced healing of the repaired posterior lateral meniscus root; and (3) compare outcomes between different meniscal healing status groups.
STUDY DESIGN: Case series; Level of evidence, 4.
METHODS: A total of 31 patients underwent pullout repair for avulsion tears of the posterior lateral meniscus root and had a minimum 2-year follow-up. Functional outcomes were assessed using patient-reported scores (Lysholm, Tegner, and International Knee Documentation Committee [IKDC] scores). Lateral meniscal extrusion, cartilage degeneration of the lateral compartment, and healing of the repaired posterior lateral meniscus root were assessed via MRI. The healing status was also assessed using second-look arthroscopic surgery, and the patients were divided into different healing status groups.
RESULTS: The postoperative patient-reported scores improved significantly compared with the preoperative values (P = .001). Lateral meniscal extrusion was reduced significantly from 3.37 +/- 0.82 mm preoperatively to 0.63 +/- 0.80 mm at final follow-up (P = .001). The grade of cartilage degeneration of the lateral compartment progressed from 0.69 +/- 0.67 preoperatively to 0.95 +/- 0.83 at final follow-up (P = .213). MRI scans showed complete healing in 28 patients (90.3%) and partial healing in 3 patients (9.7%). Second-look arthroscopic surgery showed stable healing in 18 of 23 patients (78.3%) and lax healing in 5 of 23 patients (21.7%). Patients with stable healing had significantly higher Lysholm and IKDC scores, more reduction of meniscal extrusion, and less progression of cartilage degeneration than did patients with lax healing (P < .05). Concomitant anterior cruciate ligament reconstruction was found to significantly positively influence healing of the repaired posterior lateral meniscus root (P = .047).
CONCLUSION: Pullout repair for avulsion tears of the posterior lateral meniscus root yielded significantly improved patient-reported scores, reduced meniscal extrusion, and a satisfactory healing rate at final follow-up. Patients with stable healing had significantly better functional and MRI outcomes than did patients with lax healing.
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Clinical efficacy of treatment with salmon calcitonin, administered intranasally for 1 year, in stabilized postmenopausal osteoporosis
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Distal Radius Fractures
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Several controlled clinical studies have confirmed the rationale of calcitonin therapy in postmenopausal osteoporosis. However, administration by injection and sideâ?effects reduced patient compliance and flexibility of dosage. Recently, evidence has been given that an intranasal spray may provide an effective alternative administration route for calcitonin. Forty women with established postmenopausal osteoporosis (at least on vertebral crush fracture) divided into three groups, entered and completed a oneâ?year controlled study on the effects of treatment with synthetic salmon calcitonin nasal spray on bone mass and mineral metabolism. The first group (n = 20) received a daily treatment with 100 I.U. of salmon calcitonin (sCT) nasal spray; the second group (n = 10) received 100 I.U. of sCT by subcutaneous injection every second day; the control group (n = 10) received an oral calcium supplement, 1 g per day. Bone mineral content (BMC), evaluated by dual photon absorptiometry, was measured at the distal radius before and after 6 and 12 months of treatment. Every three months, throughout the year, an evaluation of some parameters of bone remodeling was made. BMC increased (p less than 0.01) in the treatment groups, whereas at the end of treatment, a decrease (p less than 0.05) was observed in the control group. Biochemical estimates of bone resorption, such as urinary hydroxyproline excretion showed a significant decrease in the calcitonin groups. No changes in markers of bone formation, serum alkaline phosphatase and osteocalcin were observed in all patients. This study demonstrates that oneâ?year treatment with sCT nasal spray is able to increase bone mass in osteoporotic patients without important local sideâ?effects.
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Synovial DKK1 expression is regulated by local glucocorticoid metabolism in inflammatory arthritis
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TO: WNT2 Pathway Modulator
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INTRODUCTION: Inflammatory arthritis is associated with increased bone resorption and suppressed bone formation. The Wnt antagonist dickkopf-1 (DKK1) is secreted by synovial fibroblasts in response to inflammation and this protein has been proposed to be a master regulator of bone remodelling in inflammatory arthritis. Local glucocorticoid production is also significantly increased during joint inflammation. Therefore, we investigated how locally derived glucocorticoids and inflammatory cytokines regulate DKK1 synthesis in synovial fibroblasts during inflammatory arthritis.
METHODS: We examined expression and regulation of DKK1 in primary cultures of human synovial fibroblasts isolated from patients with inflammatory arthritis. The effect of TNFalpha, IL-1beta and glucocorticoids on DKK1 mRNA and protein expression was examined by real-time PCR and ELISA. The ability of inflammatory cytokine-induced expression of the glucocorticoid-activating enzyme 11beta-hydroxysteroid dehydrogenase type 1 (11beta-HSD1) to sensitise fibroblasts to endogenous glucocorticoids was explored. Global expression of Wnt signalling and target genes in response to TNFalpha and glucocorticoids was assessed using a custom array.
RESULTS: DKK1 expression in human synovial fibroblasts was directly regulated by glucocorticoids but not proinflammatory cytokines. Glucocorticoids, but not TNFalpha, regulated expression of multiple Wnt agonists and antagonists in favour of inhibition of Wnt signalling. However, TNFalpha and IL-1beta indirectly stimulated DKK1 production through increased expression of 11beta-HSD1.
CONCLUSIONS: These results demonstrate that in rheumatoid arthritis synovial fibroblasts, DKK1 expression is directly regulated by glucocorticoids rather than TNFalpha. Consequently, the links between synovial inflammation, altered Wnt signalling and bone remodelling are not direct but are dependent on local activation of endogenous glucocorticoids.
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Mobile Technology to Support Physical Therapy Exercise
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OAK 3 - Non-arthroplasty tx of OAK
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Osteoarthritis (OA) is the leading cause of disability in the U.S. The rate of activity limitation due to OA is progressing faster than expected while prevalence is projected to increase as a result of the obesity epidemic and population aging, making it a major public health problem. Exercise is an evidenceâ?based treatment option that improves pain and disability outcomes in adults with osteoarthritis, but previous research has shown that adherence to prescribed exercise is low. Referral to physical therapy is common for people with OA with the standard of care including exercise prescription through paper handouts with brief instruction and static pictures. Such approaches do not incorporate known determinants of behavior change related to exercise adherence. Recent technology products such as mobile applications (apps) for phones and tablets offer the potential to enhance communication between physical therapists and patients. The investigators aim to test a pragmatic intervention focused on supporting people with osteoarthritis to remain engaged with an exercise program. The specific aims of the project are to: 1. Compare the effectiveness of mobile app supported exercise prescription to usual care (paper exercise prescription) on exercise adherence among midâ?life and older adults receiving similarly dosed physical therapy for lower extremity OA. The investigators will also examine secondary outcomes of exercise selfâ?efficacy, physical function, stiffness, and pain. 2. Examine the feasibility and acceptability of mobile app supported exercise prescription through recruitment and retention rates, satisfaction with care ratings, and qualitative feedback.
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The frequency of osteoporosis screening in men with inflammatory bowel disease
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DoD PRF (Psychosocial RF)
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Osteoporosis is underdiagnosed in men, and osteoporosis-related fractures carry high morbidity and mortality. Recent recommendations on osteoporosis screening in men from the American College of Physicians state that screening and risk factor assessment need to occur earlier in men at high risk. Men with inflammatory bowel disease are at high risk for osteoporosis and fragility fractures due to corticosteroid use, malabsorption from intestinal resection, potential vitamin D deficiency, and fluctuations in weight. This study examines the rate of corticosteroid use, vitamin D screening, and bone mineral density screening of men with inflammatory bowel disease in a gastroenterology practice. The vast majority of men with inflammatory bowel disease are at high risk for osteoporosis. Screening and risk factor assessment should be emphasized. (PsycINFO Database Record (c) 2016 APA, all rights reserved)
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Clinical study of anterior hip ultrasound (van Douveren's method)-assisted Pavlik harness
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Developmental Dysplasia of the Hip 2020 Review
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PURPOSE: To investigate the use of anterior hip ultrasound (van Douveren's method)-assisted Pavlik harness in developmental dysplasia of the hip (DDH). METHODS: Weekly anterior hip ultrasound scanning was performed in children with fixed Pavlik harness to detect whether hip reduction was achieved with the help of harness (the superior ramus of the pubis, the acetabulum, the femoral head, and the femoral neck being depicted in one plane indicated concentric reduction of the hip), and the stability of the reduction was checked by ultrasonography. RESULTS: A total of 39 child patients and 51 dysplastic hips were successfully detected by anterior ultrasound, and stable reduction was achieved in 37 hips (15 Graf type D and 22 type III) right after the help of Pavlik harness, in seven hips (6 type III and 1 type IV) two weeks after the help of Pavlik harness; the remaining seven hips (2 type III and 5 type IV) failed to reach stable reduction after two weeks. CONCLUSION: The anterior hip ultrasound (van Douveren's method) can be used to detect the reduction and stability of hip after Pavlik harness treatment in children with DDH. The majority of Graf type D and III hips can achieve a stable concentric reduction right after the help of Pavlik harness, while severely dislocated type IV hips have a low success rate for harness treatment, and abandonment of harness therapy should be considered in early stage.
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T-condylar fractures of the distal humerus in children: report on three cases
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The Treatment of Pediatric Supracondylar Humerus Fractures AUC
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T-condylar fractures of the distal humerus are very rare in children. Because of their rarity, there is a lack of evidence in the literature on the best method to treat such fractures. We report the cases of three paediatric patients with T-condylar fracture of the distal humerus. A high degree of attention is needed in order not to miss the presence of intra-articular fracture, especially in the case of a low supracondylar fracture and in those with a history of high-energy trauma. Anatomic intra-articular fracture reduction is the key to success in managing this rare injury
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The American Association for the Surgery of Trauma PROspective Observational Vascular Injury Treatment (PROOVIT) registry: multicenter data on modern vascular injury diagnosis, management, and outcomes
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DoD LSA (Limb Salvage vs Amputation)
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BACKGROUND: There is a need for a prospective registry designed to capture trauma-specific, in-hospital, and long-term outcomes related to vascular injury. METHODS: The American Association for the Surgery of Trauma PROspective Vascular Injury Treatment (PROOVIT) registry was used to collect demographic, diagnostic, treatment, and outcome data on vascular injuries. RESULTS: A total of 542 injuries from 14 centers (13 American College of Surgeons-verified Level I and 1 American College of Surgeons-verified Level II) have been captured since February 2013. The majority of patients are male (70.5%), with an Injury Severity Score (ISS) of 15 or greater among 32.1%. Penetrating mechanisms account for 36.5%. Arterial injuries to the head/neck (26.7%), thorax (10.4%), abdomen/pelvis (7.8%), upper extremity (18.4%), and lower extremity (26.0%) were identified, along with 98 major venous injuries. Hard signs of vascular injury, including hypotension (systolic blood pressure < 90 mm Hg, 11.8%), were noted in 28.6%. Prehospital tourniquet use for extremity injuries occurred in 20.2% (47 of 233). Diagnostic modalities included exploration (28.8%), computed tomographic angiography (38.9%), duplex ultrasound (3.1%), and angiography (10.7%). Arterial injuries included transection (24.3%), occlusion (17.3%), partial transection/flow limiting defect (24.5%), pseudoaneurysm (9.0%), and other injuries including intimal defects (22.7%). Nonoperative management was undertaken in 276 (50.9%), with failure in 4.0%. Definitive endovascular and open repair were used in 40 (7.4%) and 126 (23.2%) patients, respectively. Damage-control maneuvers were used in 57 (10.5%), including ligation (31, 5.7%) and shunting (14, 2.6%). Reintervention of initial repair was required in 42 (7.7%). Amputation was performed in 7.7% of extremity vascular injuries, and overall hospital mortality was 12.7%. Follow-up ranging from 1 month to 7 months is available for 48 patients via a variety of modalities, with reintervention required in 1 patient. CONCLUSION: The PROOVIT registry provides a contemporary picture of the management of vascular injury. This resource promises to provide needed information required to answer questions about optimal diagnosis and management of these patients-including much needed long-term outcome data. LEVEL OF EVIDENCE: Epidemiologic study, level V.
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Can squeaking with ceramic-on-ceramic hip articulations in total hip arthroplasty be avoided?
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PJI DX Updated Search
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Squeaking is a recognized complication of total hip arthroplasty with ceramic on ceramic bearings but the etiology has not been well identified. We evaluated 183 hips in 148 patients who had undergone ceramic-on-ceramic noncemented total hip arthroplasties at one center between 1997-2007 by standardized telephone interviews and radiographic review. Audible squeaking was reported from 22 hips (12% of 183) of 19 patients. Prevalence of squeaking was associated with younger age; obesity; lateralized cup position; use of beta titanium alloy femoral components and shortened head length options; and higher reported activity level, greater pain, and decreased satisfaction at the time of the interview. Squeaking was described as having little personal significance by most patients. Squeaking might be preventable in part through medialization of the acetabular cup and avoidance of the use of shortened femoral necks. é 2013 Elsevier Inc
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Close reduction and percutaneous pinning in displaced supracondylar humerus fractures in children
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Pediatric Supracondylar Humerus Fracture 2020 Review
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BACKGROUND: Displaced supracondylar fractures of the humerus in children are common pediatric injuries treated by orthopedic surgeons. They also have a high rate of complications if not reduced and stabilized in optimal position which may lead to serious neurovascular injuries and residual deformity. Amongst the various methods used for treating these fractures, closed reduction and percutaneous pinning has shown improved results. METHOD: Between March 2005 and April 2010, 277 cases of supracondylar humeral fractures (Gartland grade II and III) with less then 1 week old were included in this study. They were treated with closed reduction and percutaneous pinning with crossed Kirschner wires under image intensifier control. Clinical outcome were assessed according to Flynn's criteria. RESULTS: The mean age at the time of operation was 6 years (range 2-10 years) and the average duration of follow-up was 4.6 years (range 2.1-7.2 years). The Flynn's criteria were excellent in 202, good in 68, fair in 5 and only 2 with poor results. CONCLUSION: Closed reduction and percutaneous pinning is a sound and effective treatment for displaced supracondylar fractures.
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A novel Wnt pathway inhibitor, SM04690, for the treatment of moderate to severe osteoarthritis of the knee: results of a 24-week, randomized, controlled, phase 1 study
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OAK 3 - Non-arthroplasty tx of OAK
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OBJECTIVE: To assess the safety, pharmacokinetics, and exploratory efficacy of SM04690, a novel Wnt pathway inhibitor, as a potential disease modifying treatment for knee osteoarthritis (OA).
DESIGN: Subjects with Kellgren-Lawrence grade 2-3 knee OA were randomized in successive dose-escalation cohorts to receive a knee intra-articular (IA) injection with 0.03, 0.07, or 0.23 mg SM04690, or placebo (PBO) (4:1 ratio). Safety, pharmacokinetics, efficacy (WOMAC Total/Function/Pain, Pain VAS, Physician Global Assessment [MDGA], and OMERACT-OARSI Response), OA-related biomarker (P1NP, s-CTX, and cartilage oligomeric matrix protein [COMP]), and radiographic/imaging data were collected at baseline and during 24-week follow-up.
RESULTS: 61 subjects (SM04690 n = 50; PBO n = 11) enrolled. Two dose limiting toxicities (DLTs), increased pain following injection and paroxysmal tachycardia (also the single serious AE), were reported in the 0.07 mg cohort. A total of 72 AEs were reported; Sixteen (occurring in eight subjects) were considered related to study medication. There were three discontinuations; one due to an AE (0.03 mg cohort). Bone marrow edema (BME) remained constant for most subjects. No doses were excluded from further study due to DLT criteria. Plasma levels of SM04690 were below the limit of detection at all time points. At Week 24, improvements from baseline were seen in all cohorts for the exploratory measures WOMAC Total, WOMAC Function, WOMAC Pain, MDGA, Pain VAS, and OMERACT-OARSI response. Joint space width (JSW) improvement was observed in the 0.07 mg cohort (P = 0.02 vs PBO).
CONCLUSION: SM04690 appeared safe and well tolerated, with no evidence of systemic exposure. Exploratory efficacy analyses suggested positive trends for measurements of OA pain, function and disease-modifying osteoarthritis drug (DMOAD) properties. CLINICALTRIALS.
Gov registration: Nct02095548.
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What is a reasonable rate for specific osteoporosis drug therapy in older fragility fracture patients?
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Pediatric Supracondylar Humerus Fracture 2020 Review
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Background: Osteoporosis is the most common condition contributing to 95% of fractures in older patients hospitalized for fracture treatment. Despite the significant impact of fragility fractures on patient morbidity and mortality, efforts in optimizing osteoporotic treatment and prevention remain inadequate. In contrast, in patients with limited life expectancy, withholding specific osteoporosis drug treatment appears reasonable. The threshold between under- and overtreatment is still unclear. Methods: In 2016, we implemented a fracture liaison service (FLS) for 18Â months to improve the quality of osteoporosis care. We collected prospectively the patientâ??s history, current treatment for osteoporosis, and risk factors for fragility fractures using a standardized protocol. Recommendations for drug therapy are discussed during the interdisciplinary ward round. The primary outcome parameter was a recommendation for specific osteoporosis drug treatment. We included 681 patients (mean age 82.5Â years, 502 (73.7%) females). The inclusion criteria were the following: age of 70Â years or older, admission to geriatric fracture center between April 2016 and December 2018. Results: Based on our data, specific osteoporosis drug therapy was recommended in 467 (68.6%) patients. Six hundred fifty-one (95.6%) patients received vitamin D3, and 546 (80.2%) calcium. After adjustment, only age (every 5Â years, OR 0.57; 95% CI 0.45â??0.72; p < 0.0001), cognitive impairment (OR 0.41; 95% CI 0.23â??0.74; p = 0.003), pre-fracture mobility (OR 1.54; 95% CI 1.34â??1.75; p < 0.0001), and living in a nursing home (OR 0.52; 95% CI 0.27â??0.99; p = 0.049) remained as independent predictors for an indication of specific osteoporosis drug therapy. Conclusion: We found a higher rate of recommendations for specific osteoporosis drug therapy compared with usual treatment rates in literature. Though in some cases withholding of specific osteoporosis drug therapy seems reasonable, the main proportion of fragility fracture patients is undertreated. Our results could be a benchmark for the quality of osteoporosis care in older fragility fracture patients treated in a geriatric fracture center.
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Omnifit acetabular component: a solution to preventing and treating dislocation
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Management of Hip Fractures in the Elderly
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PURPOSE: To assess short- to medium-term outcome of the Omnifit constrained acetabular component in preventing dislocation in at-risk patients after total hip arthroplasty (THA). METHODS: 81 patients (mean age, 77 years) underwent either primary or revision THA with an Omnifit constrained acetabular component and were followed up clinically and radiologically for a mean period of 24 months. RESULTS: There was one dislocation and one revision for avulsion of the acetabulum. The remaining prostheses remained well fixed. CONCLUSIONS: In the short- to medium-term, the Omnifit constrained acetabular component is effective in preventing primary and recurrent dislocation in at-risk patients. Long-term follow-up is needed to assess whether good fixation is maintained. The Omnifit acetabular cup is recommended for elderly patients with limited life expectancy and functional demands
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Comparison of Efficacy and Complications Among Various Spacer Grafts in the Treatment of Lower Eyelid Retraction: A Systematic Review
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Upper Eyelid and Brow Surgery
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Background: Lower eyelid retraction is a difficult problem to treat, but it is a prevalent condition and a common complication of blepharoplasty. The use of spacer grafts to increase eyelid height and improve symptoms has been described for a long time, but the optimal choice of spacer graft material is unknown. Objectives: The authors reviewed the currently available evidence to determine the best available spacer graft material in terms of efficacy and complications. Methods: A systematic review of all available literature published between 1985 and the present was performed using the Pubmed, Ovid MEDLINE, and Cochrane library databases. Inclusion criteria were that the studies contain original content assessing the treatment of lower eyelid retraction in humans using a spacer graft and provide quantitative outcomes data. Results: One hundred and twelve articles were reviewed following an initial screen using titles, and 19 articles were chosen for inclusion in this systematic review. Analysis of these articles revealed no spacer graft material that is clearly superior to others. Conclusions: Due to a lack of high quality evidence, this review did not reveal one spacer graft material that is clearly superior to others. However, a narrative summary of the available evidence reveals unique sets of advantages and disadvantages associated with the various materials currently available. Further research in the form of well-designed studies will be necessary to further clarify advantages of certain spacer graft materials over others. Level of Evidence: 5.
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Strontium ranelate for preventing and treating postmenopausal osteoporosis
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Management of Hip Fractures in the Elderly
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BACKGROUND: Strontium ranelate is a new treatment for osteoporosis therefore, its benefits and harms need to be known. OBJECTIVES: To determine the efficacy and safety of strontium ranelate for the treatment and prevention of postmenopausal osteoporosis. SEARCH STRATEGY: We searched MEDLINE (1996-March 2005), EMBASE (1996-week 9 2005), the Cochrane Library (1996-Issue 1 2005), reference lists of relevant articles and conference proceedings from the last two years. Additional data was sought from authors. SELECTION CRITERIA: We included randomized controlled trials (RCTs) of at least one year duration comparing strontium ranelate to placebo and reporting fracture incidence, bone mineral density (BMD) or adverse events in postmenopausal women. Treatment population was defined as women with prevalent vertebral fractures and/or lumbar spine BMD T-score < -2.5 SD. DATA COLLECTION AND ANALYSIS: Two reviewers independently determined study eligibility, assessed study validity, graded the evidence and extracted relevant data. Disagreements were resolved by consensus. RCTs were grouped by dose and treatment duration. Where possible, meta-analysis was conducted using the random effects model. MAIN RESULTS: Four trials met the inclusion criteria. Three had losses to follow-up > 20% and only one provided an adequate description of allocation concealment. Three included a treatment population (0.5 to 2 g/day of strontium ranelate) and one a prevention population (0.125, 0.5 and 1 g/day). A 37% reduction in vertebral fractures (RR 0.63, 95% CI 0.56, 0.71), and a 14% reduction in non-vertebral fractures with the upper boundary of the confidence interval approaching one (RR 0.86, 95% CI 0.75, 0.98), were demonstrated over three years with 2 g of strontium ranelate daily in a treatment population. An increase in BMD was shown at all sites after two to three years of treatment in both populations. Lower doses of strontium ranelate were superior to placebo and the highest dose demonstrated the greatest reduction in vertebral fractures and increase in BMD. An increased risk of diarrhea with 2 g of strontium ranelate daily was found; however, adverse events did not affect the risk of discontinuing treatment nor did it increase the risk of serious side effects, gastritis or death. Additional data suggests that the risk of vascular and nervous system side-effects is increased with taking 2 g of strontium ranelate daily over three to four years. AUTHORS' CONCLUSIONS: There is silver level evidence (www.cochranemsk.org) to support the efficacy of strontium ranelate for the reduction of fractures (vertebral and to a lesser extent, non-vertebral) in postmenopausal osteoporotic women and an increase in BMD in postmenopausal women with/without osteoporosis. Diarrhea may occur, however, adverse events leading to study withdrawal were not significantly increased. Potential vascular and neurological side-effects need to be further explored. STRONTIUM RANELATE FOR OSTEOPOROSIS IN WOMEN AFTER MENOPAUSE: This summary of a Cochrane review presents what we know from research about the effect of strontium ranelate for osteoporosis in women after menopause. The review shows that: There is silver level evidence (www.cochranemsk.org) that for treatment of osteoporosis in women after menopause, 2 g of strontium ranelate daily over 3 years decreases fractures in the spine and slightly decreases fractures not in the spine. Most women do not have side effects that would cause them to stop taking strontium ranelate. However, other research shows that harms could include a chance of blood clots and seizures, memory loss and consciousness.What is osteoporosis and how can strontium ranelate help?Osteoporosis is a condition in which bone loss occurs. Bone loss leads to weak brittle bones that can break easily, even during everyday activities. Breaks (fractures) of the spine or non-spine (e.g. wrist and hip) are the most common type. There are many drugs and minerals that work to treat osteoporosis. Strontium ranelate is a drug that decreases the chance of fractures by slowing the loss of bone and possibly by building new bone. It is a new drug and therefore its benefits and harms need to be known.What are the results of this review?Women in the studies took 2 g of strontium ranelate or a placebo (fake tablets or powder). After 2 to 3 years, the number of fractures that occurred and bone mineral density was measured. Bone mineral density is a lab test to measure how dense or strong bones are in the hip, spine or neck. The higher the bone density the better.Benefits of strontium ranelateIn women after menopause who have osteoporosis:- strontium ranelate decreases spine fractures:13 out of 100 women had spine fractures taking strontium ranelate21 out of 100 women had spine fractures taking a placebo- strontium ranelate may decrease fractures that are not in the spine:10 out of 100 women had non-spine fractures taking strontium ranelate12 out of 100 women had non-spine fractures taking a placebo- strontium ranelate increases bone mineral density1 in 3 women had an increase in spine and hip bone mineral density taking strontium ranelateHarms of strontium ranelateIn women after menopause who have osteoporosis:- strontium ranelate did not cause side effects that would make them stop taking it- strontium ranelate did not lead to serious side effects, stomach infections, back pain or death- strontium ranelate increased diarrhea6 out of 100 women had diarrhea taking strontium ranelate4 out of 100 women had diarrhea taking a placeboOther research shows that harms could include a chance of blood clots, and seizures, memory loss and consciousness. The cause of these vascular and neurological side effects are not known.This review has several limitations which include difficulty interpreting the change in bone mineral density due to the unique aspects of strontium in bone as well, incomplete follow-up of some patients within the individual trials
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Cellular and Clinical Analyses of Autologous Bone Marrow Aspirate Injectate for Knee Osteoarthritis: A Pilot Study
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BMAC (Bone Marrow Aspirate Concentrate)
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INTRODUCTION: Knee osteoarthritis (OA) is characterized by pain and functional deficits. Common conservative strategies include medications, physical therapy, and intra-articular injections. Recently, treatment using autologous cell injections has increased.
OBJECTIVE: To characterize the cellular content of bone marrow aspirate (BMA) and to evaluate the effect of intra-articular autologous BMA injections in patients with mild knee OA.
DESIGN: Prospective pilot observational study.
SETTING: Academic institution.
PATIENTS: Eleven patients with unilateral or bilateral mild knee OA (15 knees) were included in the cellular analysis. Ten patients (13 knees) were included in the overall (cellular and clinical) analysis.
INTERVENTIONS: BMA was aspirated from patients' iliac crests and then injected intra-articularly under fluoroscopic and/or ultrasound guidance. BMA samples were analyzed using flow cytometry, colony forming unit (CFU) assays, and enzyme-linked immunosorbent assays. Questionnaires assessing pain and function were administered preinjection and at 1, 3, 6, and 12 months postinjection. Side effects and satisfaction were assessed.
MAIN OUTCOME MEASURES: Total nucleated cell (TNC) concentration, mesenchymal stem cell (MSC) concentration, CFU count, and interleukin-1 receptor antagonist (IL-1Ra) concentration.
RESULTS: BMA sample analyses revealed wide ranges in TNC concentration (173300-4 491 050 cells/mL), MSC concentration (0-500 cells/mL), CFUs (0-19), and IL-1Ra concentration (2806-29 394 pg/mL). Improvements in Knee Injury and Osteoarthritis Outcomes Score for Joint Replacement were observed throughout the 12-month follow-up period (F[4,12] = 12.29, P < .001). Additionally, current, usual, best, and worst numerical rating scale pain scores significantly decreased over time (P < .001). Patient satisfaction was high (range: 8.1 +/- 2.1-8.8 +/- 1.9), and side effects were uncommon.
CONCLUSIONS: The cellular content of BMA samples varied widely between patients and was lower than the anticipated yield reported by the device's manufacturer. However, intra-articular BMA injections for knee OA in a small pilot cohort appeared to be safe with potential therapeutic value. Larger, prospective, double-blinded studies are warranted.
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Lung Cancer Diagnosis and Treatment as a Traumatic Stressor in DSM-IV and DSM-5: Prevalence and Relationship to Mental Health Outcomes
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DoD PRF (Psychosocial RF)
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Little research has examined how lung cancer survivors whose cancer experience met the Diagnostic and Statistical Manual of Mental Disorders (DSM) traumatic stressor criterion differ with regard to posttreatment mental health status from survivors whose cancer experience did not. No research of which we are aware has examined the impact of the revised DSM-5 traumatic stressor criterion on this question. Non-small-cell (NSC) lung cancer survivors (N = 189) completed a telephone interview and questionnaire assessing distress and growth/benefit-finding. Survivors were categorized into Trauma and No Trauma groups using both the DSM-IV and DSM-5 stressor criterion. Using the DSM-IV criterion, the Trauma group (n = 70) reported poorer status than the No Trauma group (n = 119) on 10 of 10 distress indices (mean ES = 0.57 SD) and better status on all 7 growth/benefit-finding indices (mean ES = 0.30 SD). Using the DSM-5 stressor criterion, differences between the Trauma (n = 108) and No Trauma (n = 81) groups for indices of distress (mean ES = 0.26 SD) and growth/benefit-finding (mean ES = 0.17 SD) were less pronounced. Those who experience cancer as a traumatic stressor show greater distress and growth/benefit-finding, particularly when the more restrictive DSM-IV stressor criterion defines trauma exposure.
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Simplified method for closed femoral nailing
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Management of Hip Fractures in the Elderly
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We describe the method to simplify the procedure and shorten the operating time during closed femoral nailing. This includes early surgery, using a special reduction device, a marker to help interpretation of fracture alignment, limiting the surgical field to the trochanteric area with the thigh undraped to facilitate mobilization of the undraped C-arm, avoiding unnecessary intermediate reamers, less cortical reaming and a second team for distal locking when required. For 60 simple unlocked nailings and 15 locked nailings, the operation times were 40.4 and 58.7 min, respectively. These are much shorter than in previous reports
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1 |
Management of shoulder pain by UK general practitioners (GPs): a national survey
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Trial Systematic Review Project
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OBJECTIVES: Studies in Canada, the USA and Australia suggested low confidence among general practitioners (GPs) in diagnosing and managing shoulder pain, with frequent use of investigations. There are no comparable studies in the UK; our objective was to describe the diagnosis and management of shoulder pain by GPs in the UK.
METHODS: A national survey of a random sample of 5000 UK GPs collected data on shoulder pain diagnosis and management using two clinical vignettes that described primary care presentations with rotator cuff tendinopathy (RCT) and adhesive capsulitis (AdhC).
RESULTS: Seven hundred and fourteen (14.7%) responses were received. 56% and 83% of GPs were confident in their diagnosis of RCT and AdhC, respectively, and a wide range of investigations and management options were reported. For the RCT presentation, plain radiographs of the shoulder were most common (60%), followed by blood tests (42%) and ultrasound scans (USS) (38%). 19% of those who recommended a radiograph and 76% of those who recommended a USS did so 'to confirm the diagnosis'. For the AdhC presentation, the most common investigations were blood tests (60%), plain shoulder radiographs (58%) and USS (31%). More than two-thirds of those recommending a USS did so 'to confirm the diagnosis'. The most commonly recommended treatment for both presentations was physiotherapy (RCT 77%, AdhC 71%) followed by non-steroidal anti-inflammatory drugs (RCT 58%, AdhC 74%). 17% opted to refer the RCT to secondary care (most often musculoskeletal interface service), compared with 31% for the AdhC.
CONCLUSIONS: This survey of GPs in the UK highlights reliance on radiographs and blood tests in the management of common shoulder pain presentations. GPs report referring more than 7 out of 10 patients with RCT and AdhC to physiotherapists. These findings need to be viewed in the context of low response to the survey and, therefore, potential non-response bias.
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0 |
Does PFNA II avoid lateral cortex impingement for unstable peritrochanteric fractures?
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Management of Hip Fractures in the Elderly
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Background Proximal femoral nail antirotation devices (PFNAs) are considered biomechanically superior to dynamic hip screws for treating unstable peritrochanteric fractures and reportedly have a lower complication rate. The PFNA II was introduced to eliminate lateral cortex impingement encountered with the PFNA. However, it is unclear whether the new design in fact avoids lateral cortex impingement without compromising stability of fixation and fracture healing. Questions/Purposes We therefore asked whether the PFNA II: (1) eliminates the lateral cortex impingement and fracture displacement experienced with PFNA; and (2) provides stable fracture fixation with a low major complication rate for unstable fractures in European patients. Methods We retrospectively reviewed 108 patients with an unstable peritrochanteric fracture, 58 treated with PFNA and 50 with
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Evaluation of POSSUM scoring system in the treatment of osteoporotic fracture of the hip in elder patients
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Management of Hip Fractures in the Elderly
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OBJECTIVE: To evaluate the applicability of the modified physiological and operative severity score for enumeration of mortality and morbidity (POSSUM) scoring system in predicting mortality in the patients undergoing hip joint arthroplasty. METHODS: A total of 295 patients with hip fractures were analyzed using the modified POSSUM surgical scoring system. The mean ages of the patients were 66.59 years in the complicative group, 62.28 years in noncomplicative group, 77.89 years in the death group and 63.25 years in the living group, respectively. The comparisons between the observed and predicted morbidity, between the observed and predicted mortality were made within 30 days after operation. RESULTS: The average physiological scores and operative severity scores was 18.96+/-4.83 and 13.47+/-2.01 in complicative group, while 15.65+/-3.66 and 11.74+/-2.26 in noncomplicative group (P less than 0.05). The average physiological scores and operative severity scores was 25.56+/-3.78 and 14.22+/-0.67 in death group, while 16.46+/-4.09 and 12.25+/-2.33 in living group (P less than 0.05). Though POSSUM scoring system over-predicted the overall risk of death, its estimate was very close in the high risk groups (larger than 10% ). There was perfect consistence between the observed and the predicted morbidity as calculated by published predictor equation for morbidity, and consistence for mortality in the high risk band. CONCLUSIONS: Modified POSSUM scoring system may be used to predict the morbidity in patients with hip fracture. Furthermore, POSSUM scoring system overpredicts the overall risk of death, but its estimate is close to the actual data in the high risk band (larger than 10%)
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Osteoporosis after orchiectomy for prostate cancer
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Management of Hip Fractures in the Elderly
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PURPOSE: The possibility of increased osteoporosis and osteoporotic fractures following therapeutic orchiectomy in men with prostate cancer was investigated. MATERIALS AND METHODS: A total of 235 men with nonstage A prostate cancer diagnosed between 1983 and 1990 was analyzed for therapeutic orchiectomy, other osteoporotic risk factors and subsequent hospital treatment for osteoporotic fractures. The 17 castrated men alive in 1995 were interviewed, and femoral neck bone mineral density was compared to that of 23 controls of similar age. RESULTS: Risk factors for osteoporosis, including smoking, slender habitus and atrophic testes, were common among men treated with orchiectomy. Of the men in the study cohort 10 had osteoporotic fractures: 8 of 59 treated with and 2 of 176 without orchiectomy (13.6 versus 1.1%, p < 0.001). First fracture cumulative incidence rates 7 years after castration or diagnosis were 28 and 1%, respectively (p < 0.001). Osteoporotic fractures were much more common than pathological fractures or those due to major trauma (1 each). Bone mineral density averaged 0.91, 0.84, 0.79 and 0.66 gm./cm.2 in 9 controls without prostate cancer, 14 men with prostate cancer before orchiectomy, 9 men at 9 to 60 and 8 men at 60 to 115 months after orchiectomy, respectively. Of the 16 men surviving for longer than 60 months after orchiectomy 6 had osteoporotic fractures, as did 5 of 6 and 5 of 7 with a bone mineral density of less than 0.70 gm./cm.2 and less than 75% of normal for age, respectively. CONCLUSIONS: Orchiectomy for prostate cancer is frequently followed by severe osteoporosis, some of which had developed before castration. Appropriate therapy should be identified that does not diminish the antitumorigenic effectiveness of androgen ablation
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The use of a constrained acetabular component for recurrent dislocation
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Management of Hip Fractures in the Elderly
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The poor results of surgical treatment of chronic instability after total hip arthroplasty (THA) led to the development of a constrained acetabular component. In this study, 87 constrained THAs implanted for recurrent instability were reviewed retrospectively. Eighty-five hips were available for follow-up evaluation, with an average follow-up period of 58 months. These 85 hips were evaluated at a minimum of 3 years. Two recurrent dislocations were seen, caused by dissociation of the liner from the shell. Four acetabular components and 1 femoral component were revised. Overall, a 2.4% dislocation rate and an 8.2% revision rate were seen. The recurrent dislocation rate of 2.4% represents a significant improvement over other methods reported. Repeat dislocation was only seen in dissociation of cemented liners into well-fixed shells. We do not recommend this mode of fixation. (copyright) 2003 Elsevier Inc. All rights reserved
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Defining a Safe Zone for All-Inside Lateral Meniscal Repairs in Pediatric Patients: A Magnetic Resonance Imaging Study
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AMP (Acute Meniscal Pathology)
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PURPOSE: To establish a safe zone for all-inside meniscal fixation in pediatric patients by use of magnetic resonance imaging (MRI) measurements between the popliteal tendon (PT) and popliteal neurovascular bundle (PNVB).
METHODS: Patients aged 5 to 16 years with normal or nearly normal knee MRI scans were included. They were grouped by age: group I, 5 to 7 years (n = 61); group II, 8 to 10 years (n = 59); group III, 11 to 13 years (n = 60); and group IV, 14 to 16 years (n = 70). At the level of the lateral meniscus, 2 lines starting at the lateral patellar tendon border and ending at the medial edge of the PT (D1) and the lateral edge of the PNVB (D2) were made on an axial knee MRI scan. A third line (D3) connected D1 to D2 at the meniscocapsular junction of the posterior horn of the lateral meniscus (PHLM). A fourth line (D4), derived geometrically, was parallel and 8 mm anterior to D3, simulating the anterior edge of the PHLM.
RESULTS: Axial MRI scans of 250 pediatric patients (aged 5-16 years) were retrospectively reviewed. Analysis showed significant correlation between age and sex for D3 (P < .0001). For D3, there were significant differences among all age groups, except between groups III and IV. The average D3 by age group was 14.1 mm (standard deviation [SD], 3.1 mm) for group I, 15.8 mm (SD, 2.5 mm) for group II, 17.0 mm (SD, 3.3 mm) for group III, and 17.2 mm (SD, 3.1 mm) for group IV. The average D4 was 11.39 mm (SD, 2.6 mm), 13.24 mm (SD, 2.24 mm), 14.59 mm (SD, 2.89 mm), and 14.80 mm (SD, 2.79 mm), respectively. There were significant differences in D3 and D4 in male versus female patients (17.6 mm vs 15.7 mm, P < .001, and 14.9 mm vs 13.2 mm, P < .001, respectively), particularly in groups III and IV (17.0 mm vs 13.8 mm and 16.8 mm vs 13.9 mm, respectively).
CONCLUSIONS: This study provides normative data of the distance between the PNVB and PT at the meniscocapsular junction (D3) and anterior edge of the PHLM (D4) with the knee in full extension. Combined with previous studies showing that the addition of knee flexion increases the distance between the meniscus and the neurovascular bundle, these data can be used by surgeons to improve the safety of PHLM repair in pediatric patients.
LEVEL OF EVIDENCE: Level III, diagnostic study of nonconsecutive patients.
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Satisfaction and quality-of-life issues in body contouring surgery patients: a qualitative study
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Panniculectomy & Abdominoplasty CPG
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BACKGROUND: Body contouring, which encompasses a range of surgical procedures on different areas of the body, is one of the most rapidly growing areas of plastic surgery. Little is known about outcomes from the perspective of post-weight loss body contouring patients. The aim of our qualitative study was to identify the health and aesthetic concerns of such patients through in-depth patient interviews. METHODS: Forty-three bariatric surgery post-weight loss body contouring patients were recruited between September 2009 and January 2011 from the offices of five plastic surgeons located in the USA and Canada. Interviews were used to explore the impact that obesity, weight loss, and body contouring surgery had on all aspects of the patient's life. Interviews were transcribed and data analysis involved coding and the use of the constant comparison method to develop categories and themes. Interviewing continued until no new themes emerged. RESULTS: Patients described a range of important health and aesthetic concerns related to body contouring surgery following massive weight loss, including the following: appearance-related concerns, physical health concerns, sexual health concerns, psychological health concerns, and social health concerns. Body contouring surgery played an instrumental role in the completion of the entire weight loss process for patients. CONCLUSIONS: The removal of excess skin leads to improvements in a patient's appearance and enhanced physical, psychological, and social health and well-being. In order to appropriately measure the impact of body contouring procedures from the patient's perspective, a well-developed psychometrically sound patient-reported outcome instrument is needed.
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Conservative treatment using a sponge cast for transfer fractures in nursing home patients
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Hip Fx in the Elderly 2019
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Background: Transfer fractures in the lower limbs of bedridden and chair-bound nursing home patients can result from trauma induced by the usual lifting, moving, turning, or transferring maneuvers. Treatment entails immobilization for pain control and position change; however, splints/hard casts increase the risk of pressure sores. Therefore, we evaluated the use of a sponge cast.
Materials and methods: Between March 2011 and October 2017, 17 patients with a lower limb transfer fracture due to transferring maneuvers in a nursing home were recruited. We evaluated the improvement in pseudo-motion and divided the patients as having bony union, fibrous union, or remaining pseudo-motion. We also investigated the occurrence of pressure sores due to immobilization up until the final follow-up.
Results: Femur fractures occurred in 15 patients and lower leg fractures in two. Six of the 15 femur fractures were periprosthetic (four hip arthroplasty and two knee arthroplasty). Pseudo-motion was improved in 15 of 17 cases, within an average of 17.3 weeks for the improvement (14-23 weeks; bony union: 11 cases and fibrous union: four cases). Pseudo-motion remained in two cases: one periprosthetic fracture around the knee arthroplasty and the other, a femur neck fracture. No pressure sores occurred.
Conclusions: A sponge cast appears to be one of the effective treatment options available for bedridden or chair-bound patients with a lower limb fracture due to its low risk of complications and satisfactory clinical results.
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