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Humeral cortical thickness in female Bantu--its relationship to the incidence of femoral neck fracture
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Management of Hip Fractures in the Elderly
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Measurements of the humeral cortical thickness demonstrate that generalised osteoporosis in female Bantu commences in the fifth decade and gradually increases until, in the ninth decade, all subjects are osteoporotic. The combined cortical thickness (CCT) of the humerus in young adults is very similar to that found previously in a white London population and the loss of cortex with age is very similar. It is concluded that the known low incidence of femoral neck fracture in Bantu is not due to a lower incidence of generalised osteoporosis but to environmental factors. The chief environmental factor postulated is the greater amount of physical work performed by the Bantu. A more careful mode of walking is suggested as a subsidiary cause
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The clinical and radiographic course of early knee and hip osteoarthritis over 10 years in CHECK (Cohort Hip and Cohort Knee)
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OAK 3 - Non-arthroplasty tx of OAK
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Objective: To describe the radiographic and symptomatic course in subjects with hip or knee complaints suspected of early osteoarthritis (OA). Design: CHECK (Cohort Hip and Cohort Knee) is a multicenter, prospective observational cohort study of 1,002 subjects with first complaints in knee(s) and/or hip(s) (age 56 ± 5 years; 79% female; body mass index (BMI) 26 ± 4 kg/m2). Visits took place at baseline and at 2, 5, 8, and 10 year follow-up. At each visit, questionnaires were administered, physical examination performed, and X-ray images obtained. Clinical OA was defined according to the clinical American College of Rheumatism (ACR) criteria. Radiographic OA (ROA) was defined as Kellgren and Lawrence score (K&L) �2. Results: 83% of the subjects reported knee pain, 59% hip pain, and 42% reported both hip and knee pain at baseline. 85% of the subjects completed 10-year follow-up. Pain scores remained rather stable over time, although individual scores fluctuated. A total of 138 subjects never fulfilled the clinical American College of Rheumatology (ACR) criteria. 60% (n = 601) had ROA in one or both knees, and 51% (n = 513) had ROA in one or both hips at 10 years. Only 13.5% of the subjects did not develop ROA after 10 years. Most joint replacements (n = 52 (57%)) took place in subjects with multiple affected joints. Conclusions: The symptomatic course in subjects with hip or knee complaints suspected of OA remained fairly stable on population level, though individual scores fluctuated. The radiological course was progressive, with joint replacements particularly in subjects with both hip and knee OA.
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Interleukin-1beta affects the phospholipid biosynthesis of fibroblast-like synoviocytes from human osteoarthritic knee joints
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OAK 3 - Non-arthroplasty tx of OAK
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OBJECTIVE: Phospholipids (PLs), together with hyaluronan and lubricin, are involved in boundary lubrication within human articular joints. Levels of lubricants in synovial fluid (SF) have been found to be associated with the health status of the joint. However, the biosynthesis and release of PLs within human joints remains poorly understood. This study contributes to our understanding of the effects of cytokines on the biosynthesis of PLs using cultured fibroblast-like synoviocytes (FLS) from human osteoarthritic knee joints.
METHODS: Cultured FLS were stimulated with IL-1beta, TNFalpha, IL-6, or inhibitors of cell signaling pathways such as QNZ, SB203580 and SP600125 in the presence of stable isotope-labeled precursors of PLs. Lipids were extracted and quantified using electrospray ionization tandem mass spectrometry (ESI-MS/MS).
RESULTS: Our analyses provide for the first time a detailed overview of PL species being synthesized by FLS. IL-1beta increased the biosynthesis of both phosphatidylethanolamine (PE) and PE-based plasmalogens. We show here that the NF-kappaB, p38 MAPK and JNK signaling pathways are all involved in IL-1beta-induced PL biosynthesis. IL-6 had no impact on PLs, whereas TNFalpha increased the biosynthesis of all PL classes.
CONCLUSION: The biosynthesis of various PLs is controlled by IL-1beta and TNFalpha. Our detailed PL species analysis revealed that FLS can partly contribute to the elevated PL levels found in human osteoarthritis (OA) SF. IL-1beta in particular stimulates PE and PE-based plasmalogens which can act as cell-protective antioxidants. These results suggest that during OA progression, FLS undergo alterations in their PL composition to adapt to the new diseased environment.
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Is Radiographic Osteoporotic Hip Morphology A Predictor For High Mortality Following Intertrochanteric Femur Fractures?: Osteoporotic Hip Morphology & Mortality
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Hip Fx in the Elderly 2019
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INTRODUCTION: Factors related to mortality after intertrochanteric femur fractures (ITFF) have been investigated intensively in the literature except for radiographic osteoporotic hip morphology. The aim of this study is to investigate the relationship between mortality and radiographic osteoporotic hip morphology of patients with ITFF.
PATIENTS AND METHODS: Patients who underwent surgery between the dates of January 2012 and June 2018 due to ITFF were retrospectively reviewed. Osteoporotic status of the proximal femur was determined based on Singh Index grading and Dorr classification systems on preoperative anteroposterior pelvis radiographs of contralateral hips. The mortality rates of the patients were measured at 1st, 3rd, 6th, and 12th months. For controlling the confounders, multiple regression analysis was performed.
RESULTS: A total of 321 consecutive ITFFs were included in the study. The mean age of the patients was 81.5 +/- 6.6 years. All patients were treated with osteosynthesis utilizing a cephalomedullary nail. The overall mortality rates at 1st, 3rd, 6th, and 12th months were 7.2%, 13.4%, 16.2%, 22.7%, respectively. There was 2.196 (1.140 - 4.229) folds increase in the mortality rate of patients with the Dorr type C femurs at 6th month (p=0.019). However, Singh index grade was not significantly associated with mortality.
CONCLUSION: Patients with Dorr type C femur seem to have 2.1 times increased mortality at 6th months following ITFFs. A simple anteroposterior pelvis radiograph obtained during the initial evaluation of the patients may be used to estimate the mortality rate after ITFF.
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The effects of various physical non-operative modalities on the pain in osteoarthritis of the knee
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OAK 3 - Non-arthroplasty tx of OAK
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The purpose of this study was to evaluate the effect of various non-operative modalities of treatment (transcutaneous electrical nerve stimulation (TENS); neuromuscular electrical stimulation (NMES); insoles and bracing) on the pain of osteoarthritis (OA) of the knee. We conducted a systematic review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to identify the therapeutic options which are commonly adopted for the management of osteoarthritis (OA) of the knee. The outcome measurement tools used in the different studies were the visual analogue scale and The Western Ontario and McMaster Universities Arthritis Index pain index: all pain scores were converted to a 100-point scale. A total of 30 studies met our inclusion criteria: 13 on insoles, seven on TENS, six on NMES, and four on bracing. The standardised mean difference (SMD) in pain after treatment with TENS was 1.796, which represented a significant reduction in pain. The significant overall effect estimate for NMES on pain was similar to that of TENS, with a SMD of 1.924. The overall effect estimate of insoles on pain was a SMD of 0.992. The overall effect of bracing showed a significant reduction in pain of 1.34. Overall, all four non-operative modalities of treatment were found to have a significant effect on the reduction of pain in OA of the knee. This study shows that non-operative physical modalities of treatment are of benefit when treating OA of the knee. However, much of the literature reviewed evaluates studies with follow-up of less than six months: future work should aim to evaluate patients with longer follow-up.
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Treatment of deep infection of the hip associated with massive bone loss
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Hip Fx in the Elderly 2019
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We have carried out in 24 patients, a two-stage revision arthroplasty of the hip for infection with massive bone loss. We used a custom-made, antibiotic-loaded cement prosthesis as an interim spacer. Fifteen patients had acetabular deficiencies, eight had segmental femoral bone loss and one had a combined defect. There was no recurrence of infection at a mean follow-up of 4.2 years (2 to 7). A total of 21 patients remained mobile in the interim period. The mean Merle D'Aubigné and Postel hip score improved from 7.3 points before operation to 13.2 between stages and to 15.8 at the final follow-up. The allograft appeared to have incorporated into the host bone in all patients. Complications included two fractures and one dislocation of the cement prosthesis. The use of a temporary spacer maintains the function of the joint between stages even when there is extensive loss of bone. Allograft used in revision surgery after septic conditions restores bone stock without the risk of recurrent infection. ©2005 British Editorial Society of Bone and Joint Surgery.
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Transforming growth factor-beta1 gene polymorphisms and bone turnover, bone mineral density and fracture risk in southern Chinese women
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Management of Hip Fractures in the Elderly
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Genetic contributions play an important role in determining bone mineral density (BMD) and bone turnover. Transforming growth factor-beta (TGF-beta) is abundant in bone and has been implicated as an important regulator of both bone formation and resorption. Several polymorphisms of the TGF-beta1 gene have recently been suggested to be associated with BMD and susceptibility to osteoporotic spine fractures. To determine the relationship between TGF-beta1 polymorphisms and BMD in southern Chinese women, three SNPs at C(-1348) -T, T29 -C, and T(861-20) -C of TGF-beta1 gene were analyzed in 237 postmenopausal southern Chinese women by RFLP and direct sequencing. BMD at the lumbar spine and hip region, biochemical markers of bone turnover, as well as serum levels of TGF-beta1 were measured. Only the T29 -C polymorphism of TGF-beta1 gene was associated with BMD and fracture risk. The prevalence of fragility fractures was significantly higher in individuals with TC genotype (P < 0.05). Serum alkaline phosphatase and osteocalcin levels as well as urinary N-telopeptide excretion were significantly higher in women with TC than with TT or CC genotypes, and the difference remained significant after adjusting for age and BMI (all P < 0.05). Women with TC genotype had lower BMD at the trochanteric (P < 0.03) and total hip region (P = 0.05). No difference was observed in the serum TGF-beta1 levels among the three genotypes. In conclusion, an association between T29 -C polymorphisms of TGF-beta1 gene and BMD, bone turnover as well as fragility fractures were demonstrated in postmenopausal southern Chinese women
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Unstable intertrochanteric versus displaced femoral neck fractures treated with cementless bipolar hemiarthroplasty in elderly patients; a comparison of 80 matched patients
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Hip Fx in the Elderly 2019
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BACKGROUND: While hemiarthroplasty (HA) is considered the treatment of choice for displaced femoral neck (FN) fractures in elderly patients, HA has been partly performed as an alternative treatment option for unstable intertrochanteric (IT) fractures. However, there is a paucity of data regarding the risk and availability of HA for unstable IT fractures compared to HA for displaced FN fractures in elderly patients. Therefore, we performed this case-control study to determine whether HA for unstable IT fractures provides clinical results and survival comparable to HA for displaced FN fractures in elderly patients.
HYPOTHESIS: HA for unstable IT fractures in elderly patients provides clinical results and 1-year survival comparable to HA for displaced FN fractures in the same aging group.
MATERIALS AND METHODS: We identified 80 patients aged 75years or older, who underwent cementless bipolar HA for unstable IT fracture (AO/OTA type 31-A2.2/3 and A3.3). Their clinical results and 1-year survival were compared to the matched control group of 80 patients with displaced FN fractures (Garden type 3 and 4) treated with the same procedure. Perioperative results, postoperative complications, and 1-year survival were investigated between the two groups. Functional outcome was assessed by walking status and Harris hip score (HHS) 6months after surgery.
RESULTS: Operating time was significantly longer in the IT group than the FN group (97.3min [50 to 255] vs. 79.3min [40 to 175], P=0.016). However, the two groups did not significantly differ regarding perioperative results, such as total blood loss, transfusion, intraoperative fracture, length of hospital stay, and postoperative complication. No statistically significant differences in walking status and HHS were observed between the groups. No significant difference in cumulative survival was observed between the two groups (P=0.836), with a 1-year survival rate of 80% (95% confidence interval [CI], 71.8 to 87.5) in the IT group and 82% (95% CI, 73.1 to 89.4) in the FN group.
CONCLUSION: HA for unstable IT fractures in elderly patients showed clinical results and 1-year survival comparable to HA as the treatment of choice for displaced FN fractures in the same aging group.
LEVEL OF EVIDENCE: Level III, case-control study.
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Soft tissue reconstruction of open tibial fractures
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DoD SSI (Surgical Site Infections)
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Thirty patients admitted with traumatic open fractures of the tibia were reviewed with particular attention to soft tissue management over a period of 18 months. The injuries were classified according to Gustilo et al (1976,1984). Seven patients had Type II fractures and 23 had Type III fractures (8 type III a, 14 type III b, and 1 type III c ). Patients had early and staged wound debridement and fracture immobilization. Various procedures were employed for reconstructing the damaged soft tissues. Primary wound closure was done in 1, delayed primary closure in 3, local myoplasty in 7, split skin grafting in 16, pedicle cross leg flap grafting in 4 and 6 patients had no intervention. No free tissue transfer was performed. There were no major complications with the procedures. All patients had successful wound reconstruction and uneventful fracture union.
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Comparison of peri- and intraarticular analgesia with femoral nerve block after total knee arthroplasty: a randomized clinical trial
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AAHKS (4) Acetaminophen
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BACKGROUND: Postoperative pain after total knee arthroplasty (TKA) can be difficult to manage and may delay recovery. Recent studies have suggested that periarticular infiltration with local anesthetics may improve outcome.
METHODS: 80 patients undergoing TKA under spinal anesthesia were randomized to receive continuous femoral nerve block (group F) or peri- and intraarticular infiltration and injection (group I). Group I received a solution of 300 mg ropivacaine, 30 mg ketorolac, and 0.5 mg epinephrine by infiltration of the knee at the end of surgery, and 2 postoperative injections of these substances through an intraarticular catheter.
RESULTS: More patients in group I than in group F could walk < 3 m on the first postoperative day (29/39 vs. 7/37, p < 0.001). Group I also had significantly lower pain scores during activity and lower consumption of opioids on the first postoperative day. No differences between groups were seen regarding side effects or length of stay.
INTERPRETATION: Peri- and intraarticular application of analgesics by infiltration and bolus injections can improve early analgesia and mobilization for patients undergoing TKA. Further studies of optimal drugs, dosage, and duration of this treatment are warranted.
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Somatic effects of AAS abuse: A 30-years follow-up study of male former power sports athletes
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DoD PRF (Psychosocial RF)
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Objectives The aim of the present study was to investigate the association between somatic health and former abuse of AAS in former elite male athletes 30 years after the end of their active sports career. Design Retrospective follow-up study. Methods N = 996 former elite male athletes were sent a questionnaire concerning sociodemographic variables, previous and past sport activity and lifetime prevalence of seeking professional help for health problems. N = 683 (68.6%) answered the questionnaire. The lifetime prevalence of AAS-abuse was 21% (n = 143), while 79% (n = 540) did not admit having ever used AAS. Results Former AAS-abuse was associated with tendon ruptures (p = 0.01), depression (p = 0.001), anxiety (p = 0.01) and lower prevalence of prostate hypertrophy (p = 0.01) and decreased libido (p = 0.01). Former advanced AAS-abusers had higher anxiety (p = 0.004) compared to the former less advanced AAS-abusers. Moreover, former advanced AAS-abusers, compared to AAS-naïves, reported more psychiatric problems (p = 0.002), depression (p = 0.003) and anxiety (p = 0.00). Conclusions A former AAS-abuse seems to be associated with some somatic and mental health problem, although a former less advanced AAS-abuse is related to lower incidence of prostate hypertrophy. The results raise the question whether some of these associations might be dose- and frequency dependent. These findings should however be seen as hypothesis generating and further studies are needed.
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Nerve blocks (subcostal, lateral cutaneous, femoral, triple, psoas) for hip fractures
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Management of Hip Fractures in the Elderly
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BACKGROUND: Various nerve blocks using local anaesthetic agents have been used in order to reduce pain after hip fracture. OBJECTIVES: To determine the effects of nerve blocks (inserted either pre-operatively, operatively or post-operatively) as part of the treatment for a hip fracture. SEARCH STRATEGY: We searched the Cochrane Musculoskeletal Injuries Group specialised register (October 2001), MEDLINE -OVID WEB (1996 to October 2001) and reference lists of relevant articles. SELECTION CRITERIA: Randomised and quasi-randomised trials involving the use of nerve blocks as part of the care of a hip fracture patient. DATA COLLECTION AND ANALYSIS: Two reviewers independently assessed trial quality, by use of a nine item scale, and extracted data. Wherever appropriate, results of outcome measures were pooled. MAIN RESULTS: Eight randomised or quasi-randomised trials involving 328 patients were included. Three trials related to insertion of a nerve block pre-operatively and the remaining five to peri-operative insertion. Nerve blocks resulted in a reduction of the quantity of parenteral or oral analgesia administered to control pain from the fracture/operation or during surgery and/or a reduction in reported pain levels. It was not possible to demonstrate if this reduction in analgesia use was associated with any other clinical benefit. REVIEWER'S CONCLUSIONS: Because of the small number of patients included in this review and the differing type of nerve blocks and timing of insertion, it is not possible to determine if nerve blocks confer any significant benefit when compared with other analgesic methods as part of the treatment of a hip fracture. Further trials with larger numbers of patients and full reporting of clinical outcomes would be justified
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Is fast reversal and early surgery (within 24 h) in patients on warfarin medication with trochanteric hip fractures safe? A case-control study
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Hip Fx in the Elderly 2019
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BACKGROUND: Hip fracture patients in general are elderly and they often have comorbidities that may necessitate anticoagulation treatment, such as warfarin. It has been emphasized that these patients benefit from surgery without delay to avoid complications and reduce mortality. This creates a challenge for patients on warfarin and especially for those with trochanteric or subtrochanteric hip fractures treated with intramedullary nailing, as this is associated with increased bleeding compared to other types of hip fractures and surgical methods. The aim of the study was to evaluate if early surgery (within 24 h) of trochanteric or subtrochanteric hip fractures using intramedullary nailing is safe in patients on warfarin treatment after fast reversal of the warfarin effect.
METHODS: A retrospective case-control study including 198 patients: 99 warfarin patients and 99 patients without anticoagulants as a 1:1 ratio control group matched for age, gender and surgical implant. All patients were operated within 24 h with a cephalomedullary nail due to a trochanteric or subtrochanteric hip fracture. All patients on warfarin were reversed if necessary to INR <= 1.5 before surgery using vitamin K and/or four-factor prothrombin complex concentrate (PCC). Per- and postoperative data, transfusion rates, adverse events and mortality was compared.
RESULTS: There were no significant differences in the calculated blood-loss, in-house adverse events or mortality (in-house, 30-day or 1-year) between the groups. There were no significant differences in the pre- or peroperative transfusions rates, but there was an increased rate of postoperative transfusions in the control group (p = 0.02).
CONCLUSION: We found that surgical treatment with intramedullary nailing within 24 h of patients with trochanteric or subtrochanteric hip fractures on warfarin medication after reversing its effect to INR <= 1.5 using vitamin K and/or PCC is safe.
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Use of thromboelastometry in the assessment of coagulation before epidural insertion after massive transfusion
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Surgical Management of Osteoarthritis of the Knee CPG
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A British soldier presented to the UK Field Hospital, Afghanistan with bilateral traumatic lower limb amputations. Resuscitation and surgery followed accepted damage control principles. Blood component therapy was in keeping with UK military guidelines and included platelets and cryoprecipitate. The patient's trachea was extubated following insertion of an effective epidural. Ten days later, in the UK, he developed neurological symptoms and the presence of a subdural haematoma was confirmed on magnetic resonance imaging. Conventional laboratory coagulation results in this patient were above accepted limits for epidural insertion; however, thromboelastometry before insertion was suggestive of reduced platelet function. This case highlights the risk of relying solely on platelet count as a marker of platelet function following massive transfusion. Thromboelastometry provides additional information for the assessment of coagulation and should form part of the assessment of coagulation following massive transfusion before epidural insertion
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Knee injuries in golf
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AMP (Acute Meniscal Pathology)
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Thirty-five golfing patients with knee pain were studied in a 2-year period. Most patients were able to return to active golfing with conservative treatment and, in some cases, surgical management. Patients with total knee replacement were able to return to golf with minimal modifications.
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Correlates of gait speed in advanced knee osteoarthritis
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OAK 3 - Non-arthroplasty tx of OAK
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OBJECTIVE: This study aims to evaluate correlates of gait speed, a measure of disability, in older adults with advanced knee osteoarthritis (OA) and chronic pain.
DESIGN/SETTING/SUBJECTS/METHODS: Baseline data were analyzed from a clinical trial of 190 participants aged >50 with advanced knee OA (according to clinical and radiographic American College of Rheumatology criteria) and chronic pain. Data included 4-meter gait speed, quality of life (Short Form Health Survey 36 global health subscale), knee pain (Western Ontario and McMasters Universities Osteoarthritis Index [WOMAC]), depressive symptoms (Center for Epidemiologic Studies Depression Scale), coping strategies (catastrophizing subscale and Cognitive Strategies Questionnaire), self-efficacy (Athritis Self-efficacy Scale [ASES]), comorbidity (Cumulative Illness Rating Scale), analgesic use, and pain comorbidities (location, frequency, and intensity). A multivariable regression model was used to investigate these variables as they relate to gait speed.
RESULTS: In the univariate analysis, the following variables were associated with gait speed: knee pain (per WOMAC), age, depressive symptoms, global health, catastrophizing, ASES function and other, comorbidity, and opioid use (all P values <0.05). In the fully adjusted multivariate model, controlling for knee pain, significant associations between gait speed and age (beta = -0.006; P < 0.001), ASES function (beta = 0.003; P < 0.001), and opioid use (beta = -0.082; P = 0.009) persisted. The correlation between opioid dose and gait speed (among opioid users) was not statistically significant (r = 0.04; P = 0.81).
CONCLUSION: In a cross-sectional study of older adults with advanced knee OA and chronic pain, we found that age, arthritis function self-efficacy, and opioid use (but not dose) were significantly associated with decreased gait speed.
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Iatrogenic retractile quadriceps fibrosis within children in Benin: epidemiological, clinical, therapeutical aspects
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Pediatric Supracondylar Humerus Fracture 2020 Review
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BACKGROUND: In tropical countries, iatrogenic retractile quadriceps fibrosis (IRQF), the cause of walking handicap in children, is often the result of intraquadricipital injection of quinine salts. The aim of this review was to analyse the epidemiological, clinical, therapeutic aspects and outcome of IRQF in children admitted in three hospitals in Benin Republic. PATIENTS AND METHODS: It was a 10-year retrospective, descriptive and analytic survey of IRQF, involving 81 children aged from 8 months to 15 years. Iterative mobilization of the knee (IMK) or modified distal quadriceps plasty by Thompson-Payr's technique (MDQTPT), with a POP on the knee in flexion position, was performed with additional functional rehabilitation. The results were evaluated on knee flexion gain and walking quality. Data were processed using Epi Info 3.2 software. RESULTS: Patients' average age was 7.60 years. Children of 6-10 years were most affected; sex ratio was 1.02. Lesions were unilateral (71.6%) and bilateral (28.4%). The knees' stiffness was in flexion (10.57%), rectitude (64.42%) and recurvatum (25%). The amyotrophy of the thigh was found in 79.42 %. The IMK was successful in eight cases (7.69 %) and the MDQTPT was done in 98 cases (94.23%) associated with femoral osteotomy in 13 cases (12.50%). In post-surgical period, skin necrosis and fractures occurred respectively in 15.31% and 5.10%. Results were good in 92.31% of cases. CONCLUSIONS: IRQF in children do exist in our settings. The treatment that is based on MDQTPT associated to rehabilitation leads to acceptable outcome.
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Correlation between serum cholesterol level and electrophysiologic findings in patients with carpal tunnel syndrome
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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Purpose: Carpal tunnel syndrome (CTS) is most common peripheral nerve entrapment disease. Many previous studies reported various risk factors of CTS, such as obesity, DM, thyroid disease, ect. Method: Thirty-one patients with CTS was measured serum total cholesterol, triglyceride, LDL and HDL. Their electrophysiologic studies were compatible with CTS. We divided them 3 groups, mild, moderate and severe. Results: Triglyceride was correlation with CTS severity (P = 0.005). But, total cholesterol and HDL were not significant correlation with CTS severity (P < 0.01). Besides, LDL was revere correlation with CTS severity (P < 0.01). Conclusion: Triglyceride is one component of metabolic syndrome. These results may mean that metabolic syndrome is related with CTS. It needs to study about relations CTS with triglyceride or metabolic syndrome
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Total hip arthroplasty in adult patients who had childhood infection of the hip
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Developmental Dysplasia of the Hip CPG
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BACKGROUND: Adult patients with a history of infection of the hip in childhood present a challenge as candidates for total hip arthroplasty because of abnormal bone development, soft-tissue contractures, the possibility of reinfection, and their relative youth. The purpose of this study was to analyze the mid-term results of primary total hip arthroplasty in adult patients who had had infection of the hip in childhood. METHODS: We retrospectively analyzed 170 total hip arthroplasties that had been performed between 1983 and 1996 in patients who had had infection of the hip during childhood. Forty-seven hips had cemented or hybrid total hip replacements, and 123 hips had cementless total hip replacements. The age of the patients at the time that the infection was contracted was an average of 7.3 years (range, one to eleven years). The average age of the patients at the time of the index total hip arthroplasty was 41.9 years in the cemented or hybrid group and 42.7 years in the cementless group. The interval between active infection and arthroplasty was 34.9 years in the cemented or hybrid group and 31.9 years in the cementless group. All but two hips (one patient) had a quiescent period of infection of more than ten years. The average duration of follow-up was 9.8 years (range, seven to seventeen years) in the cemented or hybrid group and 10.8 years (range, seven to seventeen years) in the cementless group. RESULTS: All hips with a quiescent period of more than ten years had no recurrence of infection. The remaining two hips in one patient with a quiescent period of seven years had recurrence of the infection. The mean Harris hip scores improved from 50 points preoperatively to 85 points at the latest follow-up examination in the cemented or hybrid group and from 50 points preoperatively to 89 points at the latest follow-up examination in the cementless group. Eight (17%) of forty-seven hips with cemented or hybrid fixation and eighteen (15%) of 123 hips with cementless fixation had revision of both components because of aseptic loosening and/or osteolysis. The mean rate of linear wear of the polyethylene was 0.25 mm per year in the cemented or hybrid group and 0.29 mm per year in the cementless group. The prevalence of osteolysis was 53% (twenty-five of forty-seven hips) in the cemented or hybrid group and 59% (seventy-two of 123 hips) in the cementless group. CONCLUSIONS: There was no recurrence of infection after total hip arthroplasty in the patients with a quiescent period of infection of more than ten years. These young, active patients with technically difficult arthroplasties were at considerable risk for aseptic loosening. The prevalence of polyethylene wear and osteolysis was attributable to the less than optimal prosthetic designs and materials used during the time-period of this study
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Effect of Preoperative Deformity on Arthroscopic and Open Ankle Fusion Outcomes
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OAK 3 - Non-arthroplasty tx of OAK
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INTRODUCTION: Coronal deformity is considered a relative contraindication for arthroscopic ankle fusion. This study assessed whether preoperative coronal ankle joint deformity influenced the outcome of arthroscopic ankle fusion.
METHODS: Ninety-seven patients had 62 arthroscopic and 35 open ankle fusions between 2005 and 2012. Clinical outcomes were prospectively recorded with use of the Ankle Osteoarthritis Scale (AOS) and Ankle Arthritis Scale (AAS) preoperatively and at 6, 12, and 24 months and final follow-up. Radiological alignment was measured using the tibiotalar angle, the tibial plafond angle, the lateral talar station, and the lateral tibiotalar angle. Both groups had the same demographics.
RESULTS: Preoperative deformity was the same regarding sagittal alignment and overall coronal alignment, but the arthroscopic group had less tibial deformity (tibial plafond angle range 0-19 degrees vs 0-43 degrees). At final follow-up, the mean AOS was 34.2 for arthroscopic (95% confidence interval [CI], 23.3-45.2) vs 33.9 for open (95% CI, 17.8-49.9). The AAS at final follow-up was 26.0 for arthroscopic (95% CI, 21.0-31.0) vs 27.5 for open (95% CI, 19.7-35.2). Both groups had the same tibiotalar angle, lateral talar station, and lateral tibiotalar angle at follow-up. Regression analyses revealed no influence of type of surgery, preoperative deformity, postoperative radiological alignment, age, sex, body mass index, smoking status, etiology of the arthritis, and need for bone grafting on outcome scores (all P > .05).
CONCLUSION: Arthroscopic and open ankle fusion yielded equivalent results for both patient-reported outcome measure and radiographic alignment in patients with coronal and sagittal joint deformity. Patients with higher tibial plafond angles more often underwent open fusion.
LEVEL OF EVIDENCE: III, comparative series.
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Ex Vivo and In Vivo Evaluation of Overexpressed VLA-4 in Multiple Myeloma Using LLP2A Imaging Agents
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MSTS 2018 - Femur Mets and MM
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UNLABELLED: Very-late-antigen-4 (VLA-4, alpha4beta1 integrin, CD49d/CD29) is a transmembrane adhesion receptor that plays an important role in cancer and immune responses. Enhanced VLA-4 expression has been observed in multiple myeloma (MM) cells and surrounding stroma. VLA-4 conformational activation has been associated with MM pathogenesis. VLA-4 is a promising MM imaging and therapeutic biomarker.
METHODS: Specificity of (64)Cu-LLP2A ((64)Cu-CB-TE1A1P-PEG4-LLP2A), a high-affinity VLA-4 peptidomimetic-based radiopharmaceutical, was evaluated in alpha4 knock-out mice and by competitive blocking in wild-type tumor-bearing mice. (64)Cu-LLP2A PET/CT (static and dynamic) imaging was conducted in C57BL6/KaLwRij mice bearing murine 5TGM1-GFP syngeneic tumors generated after intravenous injection via the tail. Blood samples were collected for serum protein electrophoresis. Bone marrow and splenic cells extracted from tumor-bearing and control mice (n= 3/group) were coincubated with the optical analog LLP2A-Cy5 and mouse B220, CD4, Gr1, and Mac1 antibodies and analyzed by fluorescence-activated cell sorting. Human radiation dose estimates for (64)Cu-LLP2A were extrapolated from mouse biodistribution data (6 time points, 0.78 MBq/animal, n= 4/group). Ten formalin-fixed paraffin-embedded bone marrow samples from deceased MM patients were stained with LLP2A-Cy5.
RESULTS: (64)Cu-LLP2A and LLP2A-Cy5 demonstrated high specificity for VLA-4-positive mouse 5TGM1-GFP myeloma and nonmalignant inflammatory host cells such as T cells and myeloid/monocytic cells. Ex vivo flow cytometric analysis supported a direct effect of myeloma on increased VLA-4 expression in host hematopoietic microenvironmental elements. SUVs and the number of medullar lesions detected by (64)Cu-LLP2A PET corresponded with increased monoclonal (M) protein (g/dL) in tumor-bearing mice over time (3.29 +/- 0.58 at week 0 and 9.97 +/- 1.52 at week 3). Dynamic PET with (64)Cu-LLP2A and (18)F-FDG demonstrated comparable SUV in the prominent lesions in the femur. Human radiation dose estimates indicated urinary bladder wall as the dose-limiting organ (0.200 mGy/MBq), whereas the dose to the red marrow was 0.006 mGy/MBq. The effective dose was estimated to be 0.017 mSv/MBq. Seven of the ten human samples displayed a high proportion of cells intensely labeled with LLP2A-Cy5 probe.
CONCLUSION: (64)Cu-LLP2A and LLP2A-Cy5 demonstrated binding specificity for VLA-4 in an immune-competent murine MM model. (64)Cu-LLP2A displayed favorable dosimetry for human studies and is a potential imaging candidate for overexpressed VLA-4.
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Independent effects of sleep duration and body mass index on the risk of a work-related injury: Evidence from the US National Health Interview Survey (2004â??2010)
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DoD PRF (Psychosocial RF)
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Fatigue has been linked to adverse safety outcomes, and poor quality or decreased sleep has been associated with obesity (higher body mass index, BMI). Additionally, higher BMI is related to an increased risk for injury; however, it is unclear whether BMI modifies the effect of short sleep or has an independent effect on work-related injury risk. To answer this question, the authors examined the risk of a work-related injury as a function of total daily sleep time and BMI using the US National Health Interview Survey (NHIS). The NHIS is an in-person household survey using a multistage, stratified, clustered sample design representing the US civilian population. Data were pooled for the 7-yr survey period from 2004 to 2010 for 101 891 â??employedâ? adult subjects (51.7%; 41.1 ± yrs of age [mean ± SEM]) with data on both sleep and BMI. Weighted annualized work-related injury rates were estimated across a priori defined categories of BMI: healthy weight (BMI: p = .72); thus, the interaction term of the final logistic model included these two variables as independent predictors of injury, along with the aforementioned covariates. Statistically significant covariates (p â?¤ .05) included age, sex, weekly work hours, occupation, and if the worker was paid hourly. The lowest categories of usual sleep duration (p â?¤ .05) elevated injury risks than the referent category (7â??8 h sleep), whereas sleeping >7â??8 h did not significantly elevate risk. The adjusted injury risk odds ratio (OR) for a worker with a usual daily sleep of <6 h was 1.86 (95% confidence interval [CI]: 1.37â??2.52), and for 6â??6.9 h it was 1.46 (95% CI: 1.18â??1.80). With regards to BMI, the adjusted injury risk OR comparing workers who were obese (BMI: â?¥30) to healthy weight workers (BMI: <25) was 1.34 (95% CI: 1.09â??1.66), whereas the risk in comparing overweight workers (BMI: 25â??29.99) to healthy weight risk was elevated, but not statistically significant (OR = 1.08; 95% CI: .88â??1.33). These results from a large representative sample of US workers suggest increase in work-related injury risk for reduced sleep regardless of workerâ??s body mass. However, being an overweight worker also increases work-injury risk regardless of usual daily sleep duration. The independent additive risk of these factors on work-related injury suggests a substantial, but at least partially preventable, risk. (PsycINFO Database Record (c) 2016 APA, all rights reserved)
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Combination of arthrolysis by lateral and medial approaches and hinged external fixation in the treatment of stiff elbow
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Pediatric Supracondylar Humerus Fracture 2020 Review
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BACKGROUND: Various methods are available to treat the stiff elbow. However, there is no consensus on which one is most useful. This study involves the effects of combination of arthrolysis by lateral and medial approaches and hinged external fixation in the treatment of stiff elbow. PATIENTS: We treated 12 patients with stiff elbows using a combination of arthrolysis by lateral and medial approaches and hinged external fixation. The arthrolysis was applied to the elbow for complete soft-tissue release, and the hinged external fixation mainly for rehabilitation and stability of the elbow after arthrolysis. With the help of the hinged external fixation, nonsurgical treatment including exercises was effectively performed to maintain the stability and the results of arthrolysis. Before surgery, the mean extension was -35 degrees and the mean flexion 70 degrees. One patient had a loss of 70 degrees in pronation. RESULTS: Satisfactory follow-up was given to 11 patients with the mean length of 15 month. The mean postoperative extension was -8 degrees whereas flexion 122 degrees. Two of 11 patients had a transient ulnar paresthesia and returned to normal after 8-month follow-up. The loss of pronation in one patient reduced to 30 degrees afterward. There were no complicating infections. All patients reported satisfactory effect. CONCLUSION: The combination of arthrolysis by lateral and medial approaches and hinged external fixation in the treatment of stiff elbow is safe and effective.
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0 |
Denosumab for the treatment of bone disease in solid tumors and multiple myeloma
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MSTS 2018 - Femur Mets and MM
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Bone is a common site for malignant involvement, either as a site of metastasis, especially in breast or prostate cancer, or as a defining characteristic of the disease, as in multiple myeloma. Bone disease is a major source of morbidity, and half of patients with bone involvement develop skeletal-related events such as pathological fractures or cord compression requiring surgery and/or radiation. Skeletal involvement also increases mortality, as pathologic fractures increase the risk of dying by 20-40%. Osteoclast inhibition with bisphosphonates such as zoledronic acid and recently denosumab has been a significant improvement for bone disease. This review will focus on denosumab in the treatment of bone metastases and highlight the recent findings in multiple myeloma.
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Prevention of venous thromboembolism after total knee replacement by high-dose aspirin or intermittent calf and thigh compression
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AAHKS (8) Anesthetic Infiltration
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A prospective study of patients undergoing total knee replacement was carried out by using a combination of 125I-fibrinogen scanning and phlebography, and showed a high incidence of venous thromboembolic disease (TE). Ventilation-perfusion lung scanning was performed to detect pulmonary emboli in most patients. High doses of aspirin and an intermittent low-pressure pneumatic compression device (IPCD) were effective, even in women, in preventing TE. Low doses of aspirin and placebo were equally ineffective in preventing TE. Lung-scan abnormalities compatible with pulmonary emboli were found in six out of 10 patients with isolated calf-vein thrombi. Conventional tests of platelet function did not predict the development of TE. No significant differences were found between the patients receiving low and high doses of aspirin with respect to the mean template bleeding time or platelet aggregation in response to adenosine diphosphate, collagen, and epinephrine, although these variables were significantly abnormal in the two groups receiving aspirin compared with those treated with placebo and the IPCD. Thus high doses of aspirin and a new low-pressure IPCD were effective in preventing venous TE in patients (predominantly women) undergoing total knee replacement.
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0 |
Controversies in the Management of Distal Radius Fractures
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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Controversies span the entire spectrum of management of distal radius fractures-fracture assessment, diagnosis, treatment, and evaluation of outcomes. The utility of multiple radiographic views described in the literature has not been validated. Likewise, the several classification systems that exist have yet to demonstrate substantial interobserver and intraobserver reliability. Nonsurgical controversies involve fracture reduction, use of anesthesia, type of fracture immobilization, and forearm position during healing. Surgical controversies include surgical indications, need for release of carpal tunnel, fracture fixation method, and the need for augmentation (ie, bone graft). Postoperatively, rehabilitation, medication, and physical therapy also remain highly controversial. The best outcome measure has yet to be established. A strong need remains for high-level, prospective studies to determine the most effective way to assess, diagnose, treat, and measure outcomes in patients with distal radius fractures
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0 |
Assessment of the survival and the clinical results of Stanmore total knee replacements
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Surgical Management of Osteoarthritis of the Knee CPG
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We review 210 Stanmore knee replacements in 163 patients to assess the survival of the prostheses and the long-term results. The annual rate of failure reached a maximum of 4.6% in the fourth year after operation; thereafter it declined to reach zero by the eighth year. Between two and eight years after operation, 66.3% of the surviving knees were completely free of pain and 30.2% had mild retropatellar pain. Fixed flexion deformities present before operation were completely corrected in 73% of the knees, and varus or valgus deformities were invariably corrected. Stability was always restored to unstable knees and 80.8% of knees flexed to 90 degrees or more after replacement. Aseptic loosening (8.1%), prosthetic infection (4.3%) and femoral fracture (2.9%) led to 8.5% of the prostheses being revised or removed over eight years. Modifications in prosthetic design and operative techniques have been introduced to minimise such complications in the future
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A paradigm shift in flap selection protocols for zones of the lower extremity using perforator flaps
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DoD SSI (Surgical Site Infections)
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BACKGROUND: Significant lower limb wounds often require soft tissue coverage using vascularized flaps. Traditionally, local muscles have been used for the proximal lower extremity and free flaps for the distal leg and foot, but perforator flaps over the past decade have been shown to be a reliable alternative.
METHODS: The evolution of our lower limb flap selection for the period 1996 to 2000 was retrospectively compared with our current approach using perforator flaps. Flap selection was never random, but based according to wound location, severity, and flap availability.
RESULTS: In the preperforator flap era, 101 of 122 (82.8%) flaps were muscle flaps. Over the last 5 years, this relative usage decreased to 36.4%, whereas perforator flaps were chosen almost half the time (49.6%). Local flaps still predominated as the choice for the proximal lower limb, and free flaps more distally, with perforator free flaps chosen twice as often as muscle flaps. Major complications occurred most commonly in the more distal lower extremity and were related to microsurgical catastrophes and not flap subtype.
CONCLUSIONS: Perforator flaps can be another soft tissue choice for all zones of the lower extremity, recognizing that function preservation is their major asset as no muscle need be included. Peninsular, propeller, or advancement perforator flaps proved to be valuable local nonmicrosurgical flap alternatives.
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0 |
(untitled)
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AAHKS (2) Corticosteroids
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Osteoarthritis is a disorder caused by damage to articular cartilage, most commonly in older adults.<sup>1</sup> Aging, changes in metabolism, genetic and hormonal factors, biomechanical changes, and inflammation are all associated with the onset and progression of osteoarthritis.<sup>2</sup> Osteoarthritis can cause symptoms such as pain, limitation of movement, various degrees of inflammation, effusion, and disability.<sup>1</sup><sup>,</sup><sup>2</sup> Between 2010 and 2031, the prevalence of osteoarthritis has been projected to increase from 13.8% to 18.6% in Canada and the direct cost to increase from $2.9 billion to $7.6 billion Canadian dollars (2010 values).<sup>3</sup> Current treatment options include medications and surgery.<sup>1</sup> Drugs, such as local analgesics, nonsteroidal anti-inflammatory drugs, intra-articular injection of glucocorticoids, can be prescribed to aid with symptom control.<sup>1</sup> Surgery, such as total hip replacement, is often considered a last resort option for osteoarthritis, due to the risks of surgical complications (such as nerve injuries and dislocation).<sup>1</sup> In addition, these treatment options do not aim to delay the pathological progression of osteoarthritis.<sup>1</sup> Hyaluronic acid supplementation is another option for the treatment of osteoarthritis.<sup>1</sup> Hyaluronic acid constitutes synovial fluid in the joints and increases the viscosity.<sup>1</sup> It functions as shock absorbent within joints and protects cartilage and surrounding soft tissues.<sup>1</sup> Intra-articular injection of hyaluronic acid has been approved by the US Food and Drug Administration in 1999.<sup>1</sup> Some evidence has suggested that intra-articular injection of hyaluronic acid is effective in relieving pain associated with ankle osteoarthritis and is clinically effective in hip osteoarthritis.<sup>4</sup> Recently there are studies published to demonstrate the effectiveness of the intra-articular injection of hyaluronic acid for patients with osteoarthritis of the hip or ankle.<sup>1</sup><sup>,</sup><sup>5</sup><sup>,</sup><sup>6</sup> There is a need to update the review on intra-articular injection of hyaluronic acid. This report aims to review the clinical effectiveness of intra-articular injection of hyaluronic acid for osteoarthritis of the hip and ankle.
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A prospective, randomized trial, comparing analgesic efficacy and postoperative functional recovery of either single shot sciatic nerve block or posterior capsule infiltration combined with femoral block for total knee arthroplasty
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Surgical Management of Osteoarthritis of the Knee CPG
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Background: Many methods of pain relief have been implemented in an attempt to provide safe and effective analgesia to patients following total knee arthroplasty (TKA). Overall, the literature has strongly supported the use femoral nerve block, the addition of sciatic nerve block has been more controversial. This study will evaluate the hypothesis that a single shot sciatic nerve block compared to posterior capsule infiltration or placebo would yield significant benefit in patients having TKA who are receiving multimodal analgesia in conjunction with femoral nerve block. Methods: This interim analysis was performed following recruitment of 52 out of the total 96 patients required for the study. In a randomized, double-blind fashion, patients undergoing TKA received either femoral-sciatic, femoral-posterior capsule local anesthetic infiltration, or femoral-sham nerve block/sham infiltration after a standardized spinal anesthetic. Multimodal analgesia including acetaminophen, celecoxib and gabapentin was initiated preoperatively and continued for three day postoperatively. Patient-controlled analgesia (hydromorphone) was continued for 48 hours. Controlled-release oxycodone 10 mg every 8 hours was started the first morning after surgery. Once the PCA was discontinued, oxycodone 5 mg every hour as needed was available. Pain scores (at rest and with movement) and opioid consumption were recorded for 72 hours. The timed up and go test (TUG) and range of motion were performed as functional outcome measures. Statistics/Sample Size: Power analysis indicated that with a total of 96 patients entering this two treatment parallel-design study to detect a 30% reduction in pain score with a power of 80% and an (alpha) of 0.05. Demographics, opiate, and TUG scores were calculated using t-test analysis. Pain scores were analyzed using the t-test and Mann-Whitney U test. Outcomes such as range of motion, pain scores were analyzed using a repeated measure ANOVA looking at the interaction of group over time for the various scores. A p value of .05 was considered significant. Results: There were no significant differences found between groups for age, body mass index, or gender distribution. There were no reported surgical or anesthetic complications. Pain scores across all groups were relatively low. At the twelve hour mark, mean pain scores were 4.18, 3.37, 4.69, respectively for Groups A, B, and C. There are no significant differences in pain scores between treatment groups (table 1)and no differences in opioid consumption over the first 72 hours (table 2). The TUG analysis showed no significant difference (p=0.48). There were no significant time or pain score differences between groups in the TUG test or in knee flexion/extension (table 3). Discussion and Conclusion: In patients undergoing primary total knee replacement who receive a spinal anesthetic, a single shot femoral nerve block and a multimodal analgesic regimen; the addition of a single shot sciatic nerve block or the infiltration of local anesthetic into the posterior capsule of the knee block may not add any further analgesic benefit in the post operative period. Full recruitment and final analysis of the data will be required to adequately answer these questions. (Figure presented)
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Panic disorder in the elderly may be associated with depression or other comorbid conditions and typically requires long-term treatment
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Management of Hip Fractures in the Elderly
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Recurrent and unexpected panic attacks (panic disorder) occur less frequently in older age. An initial attack in an elderly person is often associated with a depressive illness. Other psychiatric and physical illnesses and problems with drugs may also contribute to symptoms. Selective serotonin reuptake inhibitors (SSRIs) are considered first-line drug treatments because of their favourable safety and pharmacokinetic profiles. The initial SSRI dosage should be low, to avoid an exacerbation of anxiety, and then gradually increased to the target dose. Time-limited adjunctive use of a benzodiazepine may also be useful while waiting for the onset of effect from antidepressant therapy. Cognitive behavioural therapy, both in standard and shorter forms, is also efficacious in panic disorder. (copyright) 2004 Adis Data Information BV. All rights reserved
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1 |
A comparison of hemiarthroplasty and total shoulder arthroplasty in the treatment of primary glenohumeral osteoarthritis: results of a multicenter study
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Glenohumeral Joint OA
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Six hundred one total shoulder arthroplasties and eighty-nine hemiarthroplasties were performed for primary osteoarthritis of the shoulder. Patients were evaluated with a physical examination, Constant score, and radiographic evaluation. The minimum follow-up was 2 years. At follow-up, the Constant score averaged 64 points, the adjusted Constant score averaged 86%, active anterior elevation averaged 130 degrees, and active external rotation averaged 36 degrees for the hemiarthroplasties. The Constant score averaged 70 points, the adjusted Constant score averaged 96%, active anterior elevation averaged 145 degrees, and active external rotation averaged 42 degrees for the total shoulder arthroplasties. Eighty-six percent of hemiarthroplasties and ninety-four percent of total shoulder arthroplasties had good or excellent results. Differences were statistically significant for all parameters. Total shoulder arthroplasty provided better scores for pain, mobility, and activity than hemiarthroplasty. Fifty-six percent of total shoulder arthroplasties had a radiolucent line around the glenoid component. Total shoulder arthroplasty provides results superior to those of hemiarthroplasty in primary osteoarthritis.
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0 |
Common work-related musculoskeletal strains and injuries
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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Muscles, tendons, joints and nerves are susceptible to injury when stressed or traumatised repetitively, or over an extended period of time. Regardless of the nature of the work, a large proportion of the working population's time is spent engaged in repetitive movements and maintaining postures for extended periods of time. The reported incidence of work-related back and neck pain, and carpal tunnel syndrome, is between 15-60%,(1-3) indicating that a high proportion of the working population is at risk of developing one or more work-related musculoskeletal disorders. The parts of the body that are most commonly affected are the lower back, neck and shoulder girdle, and upper limbs. Based on current literature, we shall discuss conditions affecting these areas in order to gain a better understanding of the conditions, as well as their prevention. (copyright) Medpharm
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0 |
Unicompartmental knee arthroplasty: Is it durable?
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Surgical Management of Osteoarthritis of the Knee CPG
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Aim: To analyse the long-term durability of unicompartmental knee arthroplasties using the Marmor/Mod 2 prosthetic. Methods: Survivorship analysis was used to retrospectively evaluate 113 medial unicompartmental knee arthroplasties performed between 1974 and 1989 in two New Plymouth hospitals. An outcome was determined for every case. Results: The survival rate was 95% at 10 years and 85% at 15 years. All 27 knees surviving at the time of the study were assessed clinically using the Knee Society Score, and 25 of the 27 knees underwent radiographic evaluation. The Knee Society Knee and Knee Society Functional scores were 72 points and 56 points respectively for the group of 27 surviving prostheses, and the 25 knees X-rayed showed no loosening or fracture of the prosthesis. Conclusions: Unicompartmental knee arthroplasty with the Marmor/Mod 2 prosthesis has provided satisfactory long-term durability in this cohort of elderly patients, in comparison with similar published studies featuring other prostheses. (copyright) NZMA
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[<sup>177</sup>Lu]pentixather: Comprehensive Preclinical Characterization of a First CXCR4-directed Endoradiotherapeutic Agent
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MSTS 2018 - Femur Mets and MM
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<b>Purpose:</b> Based on the clinical relevance of the chemokine receptor 4 (CXCR4) as a molecular target in cancer and on the success of [<sup>68</sup>Ga]pentixafor as an imaging probe for high-contrast visualization of CXCR4-expression, the spectrum of clinical CXCR4-targeting was expanded towards peptide receptor radionuclide therapy (PRRT) by the development of [<sup>177</sup>Lu]pentixather. <b>Experimental design:</b> CXCR4 affinity, binding specificity, hCXCR4 selectivity and internalization efficiency of [<sup>177</sup>Lu]pentixather were evaluated using different human and murine cancer cell lines. Biodistribution studies (1, 6, 48, 96h and 7d p.i.) and in vivo metabolite analyses were performed using Daudi-lymphoma bearing SCID mice. Extrapolated organ doses were cross-validated with human dosimetry (pre-therapeutic and during [<sup>177</sup>Lu]pentixather PRRT) in a patient with multiple myeloma (MM). <b>Results:</b> [<sup>177</sup>Lu]pentixather binds with high affinity, specificity and selectivity to hCXCR4 and shows excellent in vivo stability. Consequently, and supported by >96% plasma protein binding and a logP=-1.76, delaying whole-body clearance of [<sup>177</sup>Lu]pentixather, tumor accumulation was high and persistent, both in the Daudi model and the MM patient. Tumor/background ratios (7d p.i.) in mice were 499+/-202, 33+/-7, 4.0+/-0.8 and 116+/-22 for blood, intestine, kidney and muscle, respectively. In the patient, high tumor/kidney and tumor/liver dose ratios of 3.1 and 6.4 were observed during [<sup>177</sup>Lu]pentixather PRRT (7.8 GBq), with the kidneys being the dose-limiting organs. <b>Conclusions:</b> [<sup>177</sup>Lu]pentixather shows excellent in vivo CXCR4-targeting characteristics and a suitable pharmacokinetic profile, leading to high tumor uptake and retention and thus high radiation doses to tumor tissue during PRRT, suggesting high clinical potential of this [<sup>68</sup>Ga]pentixafor/[<sup>177</sup>Lu]pentixather based CXCR4-targeted theranostic concept.
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0 |
Soft-tissue injuries and muscle tears
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DOD - Acute Comp Syndrome CPG
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Soft-tissue injuries and muscle tears occur frequently in athletes. The mainstay of treatment in most cases is nonoperative management and aggressive rehabilitation. Most injuries result from direct trauma or contusion or indirect stretch injury. It is important to keep in mind the possibility of other potentially more serious conditions, such as compartment syndrome. More research is needed to define optimal treatment patterns and potential strategies for injury prevention.
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0 |
Predictors of fractures among the aged: A population-based study with 12-year follow-up in a Finnish municipality
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Management of Hip Fractures in the Elderly
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Background and aims: The incidence of fractures is high in older populations. More information is needed about long-term predictors of fractures, for preventive measures. The aim of this study was to analyze gender-specific predictors of fractures among persons aged 65 years or older during a 12-year follow-up. Methods: A true cohort study in the municipality of Lieto, southwestern Finland, started in October 1990. Baseline data and information about fractures in 1177 subjects (482 men, 695 women), mean age 73 years (range 65-97), were obtained individually from health care registers during 1991-2002. The mean follow-up period was 8.5 years. Subjects having sustained at least one fracture (n=295) were compared with subjects with no fractures during the follow-up. Predictors of fractures were analyzed using a Poisson regression model, separately by gender. Results: In multivariate Poisson regression analyses, the following predictors of fractures during the 12-year follow-up were identified: reduced handgrip strength (RR 1.6, 95% CI 1.1-2.3 in middle quartiles, RR 2.2, 95% CI 1.4-3.5 in lowest quartile) and body mass index (BMI) 25-29.9 (RR 1.9, 95% CI 1.3-2.7) or BMI <25 (RH 2.0, 95% CI 1.4-2.9) compared with BMI 30 or over among women, and a large number of depressive symptoms (RR 2.1, 95% CI 1.2-3.6) among men. A compression fracture in one or more thoracic or upper lumbar vertebrae on chest radiography at baseline was associated with fractures in both women (RR 2.0, 95% CI 1.3-3.0) and men (RR 3.5, 95% CI 1.9-6.7). Conclusions: The predictors of fractures among aged persons varied by gender, and were associated with both risk factors of falling and bone fragility. (copyright)2008, Editrice Kurtis
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Phase angle as a predictor of functional outcomes in patients undergoing in-hospital rehabilitation after hip fracture surgery
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Hip Fx in the Elderly 2019
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Objectives: To evaluate the association between the phase angle and functional outcomes in patients after in-hospital postoperative rehabilitation for fragility hip fracture. Methods: A prospective observational study was conducted in 68 patients over 65 years of age who had undergone a two-week postoperative rehabilitation for hip fracture. Phase angle of the non-fractured limb was used to reduce the error caused by postoperative edema. Participants were divided into groups according to phase angle terciles. Multivariable linear regression models adjusted for relevant factors known to affect functional outcomes after hip fracture were performed to identify the association between phase angle of the non-fractured limb and functional outcomes at discharge as evaluated the Functional Ambulation Category and Berg Balance Scale. Results: The mean age of this study population was 81.9 ± 6.2 years and the average phase angle of the non-fractured limb was 3.6 ± 1.3°. The lowest tercile of phase angle (<3.0°) was independently associated with worse functional outcomes as measured by the Functional Ambulation Category and Berg Balance Scale at discharge (adjusted coefficient [β] = -0.287, P = 0.004; β = -0.172, P = 0.049, respectively) after adjusting for relevant covariates. Conclusions: Low phase angle of the non-fractured limb was independently associated with worse functional outcomes at rehabilitation discharge in patients who undergoing hip fracture surgery. Phase angle may reflect both the pre-fracture body composition and functional status. It is a useful indicator for functional outcomes after postoperative rehabilitation for fragility hip fracture.
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0 |
Longitudinal study of bone density and periodontal disease in men
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Management of Hip Fractures in the Elderly
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Bone loss is a feature of both periodontitis and osteoporosis, and periodontal destruction may be influenced by systemic bone loss. This study evaluated the association between periodontal disease and bone mineral density (BMD) in a cohort of 1347 (137 edentulous) older men followed for an average of 2.7 years. Participants were recruited from the Osteoporotic Fractures in Men Study. Random half-mouth dental measures included clinical attachment loss (CAL), pocket depth (PD), calculus, plaque, and bleeding. BMD was measured at the hip, spine, and whole-body, by dual-energy x-ray absorptiometry, and at the heel by ultrasound. After adjustment for age, smoking, race, education, body mass index, and calculus, there was no association between number of teeth, periodontitis, periodontal disease progression, and either BMD or annualized rate of BMD change. We found little evidence of an association between periodontitis and skeletal BMD among older men
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0 |
Tumors and tumor-like lesions mimicking carpal tunnel syndrome
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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INTRODUCTION: Tumors and tumor-like lesions in or around the median nerve are uncommon causes of carpal tunnel syndrome (CTS). The purpose of the present study is to highlight the diagnostic approach and point out the profile of patients with CTS and potential underlying pathology. MATERIALS AND METHODS: Twenty-eight patients with 32 affected hands had CTS correlated to a mass in or around the nerve. In 20 hands a palpable mass was present. Diagnostic workup included nerve conduction studies, ultrasound and/or MRI. Pre- and postoperative examination included two-point discrimination (2PD), grip strength, visual analogue scale (for pain) (VAS) and disabilities of the arm, shoulder and hand (DASH) scores. RESULTS: Twelve of 28 patients were young (range 9-38 years) and 10 were male. Nerve compression was due to 27 extraneural lesions (8 abnormal muscles, 5 lipomas, 7 tenosynovitis, 4 vascular tumors, 2 ganglia, 1 Dupuytren's fibromatosis) and five intraneural tumors (three schwannomas, one neurofibroma, one sarcoma). Nerve decompression and excision of extraneural lesions were performed in all cases whereas in intraneural tumors, decompression was followed by excision in most cases and nerve grafting in one. Mean follow-up was 22 months (12-105 months). Extraneural masses were associated with a better outcome than nerve tumors. The mean postoperative VAS/DASH scores were 0.3/16.2 in extraneural lesions and 2.5/22 in intraneural lesions. The 2PD improved gradually in all patients (mean pre- and postoperative 12 and 5 mm). The mean grip strength increased from 28 to 31.3 kg postoperatively. CONCLUSIONS: Although rare, the surgeon should include in the differential diagnosis of CTS the unusual cause of tumors and tumor-like lesions, especially when the patients' profile is not typical (young, male, no repetitive stress or manual labor). In addition, the presence of a palpable mass at the distal forearm or palm dictates the need for imaging studies. The extent, location and aggressiveness of the mass will determine the approach and type of procedure
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0 |
Expression level of proteoglycan, collagen and type II collagen in osteoarthritis rat model is promoted and degradation of cartilage is prevented by glucosamine methyl ester
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OAK 3 - Non-arthroplasty tx of OAK
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OBJECTIVE: In the current study, the effect of glucosamine methyl ester on cartilage degeneration in osteoarthritis rat model was investigated.
MATERIALS AND METHODS: Forty Sprague-Dawley rats were assigned into 5 groups of 8 animals each. Osteoarthritis was induced in 4 groups using medial parapatellar incision followed by anterior cruciate ligament transection and meniscectomy. Normal and model osteoarthritis groups were given normal saline. The three treatment groups received 2, 5 and 10 mg/kg doses of glucosamine methyl ester daily for one month.
RESULTS: Microscopic examination of the knee cartilage showed a significant reduction in degeneration score in the treatment groups. Enzyme-linked immunosorbent assay revealed inhibition of interleukin-1beta expression and nitric oxide generation on treatment with glucosamine methyl ester. Expressions of matrix metalloproteinase-3 and -13 in the treatment groups were significantly lower compared to the model osteoarthritis group. Polymerase chain reaction revealed an increased expression of tissue inhibitor of metalloproteinases 1 on treatment of rats with glucosamine methyl ester. In the osteoarthritis rats treated with various doses of glucosamine methyl ester staining, the level of toluidine blue and Masson's trichrome increased. In addition, the level of type II collagen was also higher in the rats of treatment group. The level of proteoglycan, collagen and type II collagen in OA rats treated with 10 mg/kg doses was ~3.2- (p<0.01), 2.4- (p<0.02), and 3.6- (p<0.05) fold, respectively higher compared to the untreated animals.
CONCLUSIONS: Glucosamine methyl ester, therefore, prevents degeneration of cartilage in osteoarthritis rats. It exhibits its effect by promoting proteoglycan, collagen, type II collagen, tissue inhibitor of metalloproteinases 1, and decreasing matrix metalloproteinase. Therefore, glucosamine methyl ester exhibits therapeutic effect against osteoarthritis.
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1 |
AlloDerm performance in the setting of prosthetic breast surgery, infection, and irradiation
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Acellular Dermal Matrix
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BACKGROUND: The performance of AlloDerm (LifeCell Corp., Branchburg, N.J.) in the setting of prosthetic breast reconstruction, infection, and radiation therapy has not been well documented. The purpose of this study was to review the author's experience with AlloDerm-assisted prosthetic breast surgery and determine the tolerance in the setting of infection and irradiation. METHODS: A total of 361 women and 476 breasts underwent reconstruction or revision with prosthetic devices. Of these, 76 women and 100 breasts underwent reconstruction using AlloDerm assistance. RESULTS: The incidence of postoperative infection was 5.85 percent (22 of 376) when prosthetic devices were used without AlloDerm and 5 percent (five of 100) when prosthetic devices were used with AlloDerm. Radiation therapy was a factor in 23 of 100 breasts reconstructed with AlloDerm. Adherence of AlloDerm was noted in 100 percent (23 of 23) and infection was noted in 8.7 percent (two of 23). The timing of irradiation (before or after AlloDerm insertion) did not affect the adherence or the infection rate. The overall incidence of seroma was 5 percent, the incidence of skin necrosis was 3 percent, and the incidence of incisional dehiscence was 4 percent. CONCLUSIONS: This study demonstrates that prosthetic breast surgery using AlloDerm is safe and well-tolerated. AlloDerm viability has been demonstrated in the setting of infection and radiation therapy. The risk of prosthetic breast infection in the setting with AlloDerm is no different from in the setting without AlloDerm. Local complications such as dehiscence, skin necrosis, and seroma formation can occur in accordance with radiotherapy.
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1 |
Hip strengthening reduces symptoms but not knee load in people with medial knee osteoarthritis and varus malalignment: a randomised controlled trial
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OAK 3 - Non-arthroplasty tx of OAK
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OBJECTIVE: To determine whether hip abductor and adductor muscle strengthening reduces medial compartment knee load and improves symptoms in people with medial tibiofemoral OA and varus malalignment. METHODS: In a randomised controlled trial, 89 participants were randomly allocated to a hip strengthening group or to a control group with no intervention. The strengthening group performed a physiotherapist-supervised home exercise program targeting the hip abductor and adductor muscles for 12 weeks. The primary outcome was the peak external knee adduction moment measured using three-dimensional gait analysis by a blinded assessor. Secondary outcomes included a pain numeric rating scale, Western Ontario and McMaster Universities Osteoarthritis Index, step test, stair climb test, maximum isometric strength of hip and quadriceps muscles and participant-perceived rating of overall change. Intention-to-treat analyses were performed using linear regression modelling adjusting for baseline outcomes and other characteristics. RESULTS: The trial was completed by 76/89 participants (85%). There was no significant between-group difference in change in the knee adduction moment [mean difference (95% confidence interval (CI)) 0.134 (-0.069 to 0.337) Nm/BW x HT%]. All pain, physical function and muscle strength measures showed significantly greater improvement in the strengthening group (all P<0.05). The relative risk (95% CI) of participant-perceived overall improvement in the strengthening group compared to the control group was 20.02 (6.21-64.47). CONCLUSIONS: Although strengthening the hip muscles improved symptoms and function in this patient group, it did not affect medial knee load as measured by the knee adduction moment. Thus it is unlikely that hip muscle strengthening influences structural disease progression. TRIAL REGISTRATION: ACTR12607000001493.
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0 |
How patient centered are medical decisions?: Results of a national survey
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Surgical Management of Osteoarthritis of the Knee CPG
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IMPORTANCE: Informing and involving patients in their medical decisions is increasingly becoming a standard for good medical care, particularly for primary care physicians. OBJECTIVE: To learn how patients describe the decision-making process for 10 common medical decisions, including 6 that are most often made in primary care. DESIGN: A survey of a national sample of adults 40 years or older who in the preceding 2 years had either experienced or discussed with a health care provider 1 or more of 10 decisions: medication for hypertension, elevated cholesterol, or depression; screening for breast, prostate, or colon cancer; knee or hip replacement for osteoarthritis, or surgery for cataract or low back pain. SETTING: Adults living in households in the United States in 2011. PARTICIPANTS: A national sample of adults drawn from a probability sample-based web panel developed by Knowledge Networks. MAIN OUTCOMES AND MEASURES: Patients' perceptions of the extent to which the pros and cons were discussed with their health care providers, whether the patients were told they had a choice, and whether the patients were asked for their input. RESULTS: Responses were obtained from 2718 patients, with a response rate of 58.3%. Respondents reported much more discussion of the pros than the cons of all tests or treatments; discussions about the surgical procedures tended to be more balanced than those about medications to reduce cardiac risks and cancer screening. Most patients (60%-78%) said they were asked for input for all but 3 decisions: medications for hypertension and elevated cholesterol and having mammograms (37.3%-42.7%). Overall, the reported decision-making processes were most patient centered for back or knee replacement surgery and least for breast and prostate cancer screening. CONCLUSIONS AND RELEVANCE: Discussions about these common tests, medications, and procedures as reported by patients do not reflect a high level of shared decision making, particularly for 5 decisions most often made in primary care
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0 |
Does repetitive physical loading inhibit radial growth in female gymnasts?
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Distal Radius Fractures
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OBJECTIVE: Stress-related injuries to the distal radius have been noted in female gymnasts with potential for resultant premature closure and abnormal growth at this site. The purpose of this study was comprehensively to review and critically to appraise the available literature to examine the evidence related to this question: does repetitive physical loading inhibit growth of the radius in female gymnasts?
DATA SOURCES: MEDLINE and SPORT Discuss were searched from 1975 to the present by using "gymnast" in combination with injury, growth plate, epiphyseal, and ulnar variance. Additional references were retrieved from the bibliographies of the retrieved articles.
STUDY SELECTION: All descriptive and analytic studies that included data related to stress-related injuries affecting the distal radius of competitive female gymnasts were included. Conclusions regarding the effects of gymnastics training on radial growth of female gymnasts were limited to data from case reports, clinical series, cross-sectional studies, and descriptive cohort studies. Data from relevant experimental animal studies also were included.
DATA EXTRACTION AND SYNTHESIS: In reviewing the literature, particular attention was paid to the relative strengths of the different study designs. From these data, information associated with growth inhibition at the distal radius was examined.
MAIN RESULTS: The descriptive research reviewed included clinical, cross-sectional, and cohort studies that establish the existence of stress-related injuries affecting one or more constituent parts of the epiphyseal-physeal-metaphyseal (EPM) complex of the distal radius, symptomatic ulna-radial-length difference (URLD), and distal radius physeal arrest among female gymnasts. Five cross-sectional studies showed radiographic abnormalities consistent with distal radius physeal-stress reaction in 10-85% of gymnasts studied. Two cross-sectional studies indicated "abnormal" positive URLD in 8-20% of wrists radiographed. Four cross-sectional studies showed significant correlations between training intensity and URLD, suggesting a dose-response relation. Three cross-sectional studies indicate greater URLD in gymnasts compared with nongymnasts. Radiographic evidence of distal radius physeal arrest involving physically immature female gymnasts is presented in four studies (two clinical series, one cross-sectional, and one descriptive cohort). In animal studies, prolonged physical training has also been shown to inhibit or stop growth in weight-bearing long bones. However, there were no rigorous studies (i.e., randomized control trials or analytic cohorts) examining the question.
CONCLUSION: The results of this critical review of the scientific literature support the plausibility of stress-related distal radius physeal arrest with secondary URLD. However, the strength of evidence is inadequate to be conclusive. [References: 53]
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0 |
Present status of osseous grafting procedures
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Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures
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Osseous grafting techniques represent one mode of therapy to manage combination pocket-osseous defects. They have their greatest applicability in the intrabony defect although encouraging results have been noted in furcation and suprabony sites. Like all treatment modalities, their usage is dictated by the therapeutic objectives for specific problems and whether their respective advantages and limitations outweigh other management techniques. They are neither a panacea nor an unproven experimental venture. When properly employed, they are a valuable component of currently accepted therapy. When compared with other treatment approaches, the following relative advantages and limitations have been noted with osseous grafts: Advantages 1. Reconstruct lost periodontium. 2. Idealistic therapeutic objective. 3. Reversal of disease process. 4. Increase tooth support. 5. Enhance esthetics. 6. Improve function. Limitations 1. Additional treatment time. 2. Autograft disadvantages. 3. Availability of graft material. 4. Additional postoperative care. 5. Unique postoperative problems. 6. Variations in repair. 7. Longer post-treatment evaluation interval. 8. Predictability. 9. Greater expense. 10. Multistep therapy common. 11. Vulnerability to recurrence
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0 |
Charnley low-friction arthroplasty for the treatment of hips with late complications of femoral neck fractures
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Management of Hip Fractures in the Elderly
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Two hundred five Charnley low-friction arthroplasties (LFA) were performed in 205 patients for late complications of femoral neck fractures. LFA was an excellent procedure for relieving pain and restoring function with a good range of movement. The deep infection rate was 3.9%. A detailed analysis of the patients with infection showed a high incidence of previous superficial wound infection or positive bacteriologic culture swabs obtained from the wound at the time of LFA
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0 |
Fractures of the forefoot
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DoD - ACS - Interrater Reliability
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Fractures of the forefoot are common injuries of various causes. Although not crippling, forefoot fractures can be debilitating if they go undiagnosed or are mistreated. Whenever patients complain of foot pain with ambulation or difficulty ambulating, radiographs should be taken as part of a standard routine to assess for bony pathology. This article discusses the classification and treatment of metatarsal fractures, digital and sesamoid fractures, and open fractures about the forefoot. [References: 70]
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Harvest of superficial layers of fat with a microcannula and isolation of adipose tissue-derived stromal and vascular cells
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Panniculectomy & Abdominoplasty CPG
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BACKGROUND: Adipose tissue is a source of stromal and vascular cells suitable for regenerative medical applications. Cell recovery depends on several factors, including the characteristics of the cannula used to harvest tissue. OBJECTIVES: The authors assess whether aspiration of superficial layers of adipose tissue performed with a microcannula, rather than a standard cannula, allows for improved isolation of stromal and vascular cells, and they evaluate the angiogenic potential of the isolated cells in vitro and in vivo. METHODS: Adipose-derived stromal and stem cells (ADSC) were collected from the lipoaspirate of the abdomen and hip regions of 6 healthy female donors. For adipose tissue harvest, several options were compared: (1) a rounded-tip cannula with a length of 170 mm, a diameter of 3 mm, and a single elliptic suction port on the side near its distal end (port diameter: 3 x 9 mm) or (2) a rounded-tip infiltration cannula with a length of 170 mm, a diameter of 2 mm, and 5 round ports placed spirally along the sides of the distal cannula shaft (each port diameter: 1 mm) (Shipper Medical Technologies Corporation, Centennial, Colorado). Isolated cells were characterized for (1) expression of the endothelial specific marker CD31 by immunohistochemical and cytofluorimetric analyses and (2) tubular-like structure formation using a 3-dimensional angiogenesis assay on Matrigel. Human ADSC were transduced to express firefly luciferase as a marker suitable for bioluminescent tracking and transplantation studies into immunosuppressed mice were performed. RESULTS: ADSC yield was determined to be significantly higher in samples collected with the microcannula (P = .04). Moreover, isolated cells acquired typical endothelial-like morphology in vitro, formed capillary-like structures, and expressed the distinctive endothelial cell marker CD31. Cells implanted into immunosuppressed mice persisted for several weeks in areas undergoing neovascularization. CONCLUSIONS: These results suggest that aspiration of adipose tissue with a microcannula can be a minimally invasive method to obtain clinically relevant numbers of stromal and vascular cells useful for autologous transplant procedures and for promoting tissue regeneration and neovascularization.
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1 |
Workplace surveillance for carpal tunnel syndrome using hand diagrams
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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Four hundred and eleven workers from 4 different companies participated in a worksite screening program designed, in part, to estimate the prevalence of carpal tunnel syndrome (CTS). Each worker completed a discomfort survey and underwent limited nerve conduction testing of the median and ulnar sensory nerves in both wrists. The discomfort survey included a hand diagram which allowed subjects to shade in area(s) affected by numbness, burning, tingling, or pain. The discomfort survey also asked each worker to indicate whether she or he had experienced neuropathic symptoms (i.e., numbness, burning, tingling, or pain) in the wrist, hand or fingers of each hand, without regard to localization (i.e., median versus ulnar versus radial distribution), and also nocturnal occurrence of symptoms. Analyses involved comparing hand diagram scores and non localized wrist/hand/finger symptoms with electrodiagnostic test results. All configurations of hand diagram scores of the dominant hands had a statistically significant association with electrophysiologically determined median nerve dysfunction, but so did non localized symptom reports. The sensitivity, specificity, and positive predicted values of hand diagrams were poorer than those reported previously. While some test performance characteristics of hand diagrams were better than those for non localized distal extremity symptoms consistent with CTS, some were worse. Overall, our data suggest that hand diagrams are no better than using a questionnaire to determine if workers have experienced symptoms consistent with CTS in their wrists, hands or fingers without regard to localization. The choice of screening tool would depend on the goal of screening, in particular, whether it is more desirable to have slightly higher sensitivity or positive predictive value
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1 |
Platelet-rich plasma intra-articular injections for cartilage degeneration and osteoarthritis: single- versus double-spinning approach
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OAK 3 - Non-arthroplasty tx of OAK
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PURPOSE: To compare the safety and efficacy of two different approaches of platelet-rich plasma (PRP) production methods as intra-articular injection treatment for knee cartilage degenerative lesions and osteoarthritis (OA).
METHODS: The study involved 144 symptomatic patients affected by cartilage degenerative lesions and OA. Seventy-two patients were treated with 3 injections of platelet concentrate prepared with a single-spinning procedure (PRGF), the other 72 with 3 injections of PRP obtained with a double-spinning approach. The patients were evaluated prospectively at the enrollment and at 2, 6, and 12 months' follow-up with IKDC, EQ-VAS and Tegner scores; adverse events and patient satisfaction were also recorded.
RESULTS: Both treatment groups presented a statistically significant improvement in all the scores evaluated at all the follow-up times. Better results were achieved in both groups in younger patients with a lower degree of cartilage degeneration. The comparative analysis showed similar improvements with the two procedures: in particular, IKDC subjective evaluation increased from 45.0 +/- 10.1 to 59.0 +/- 16.2, 61.3 +/- 16.3, and 61.6 +/- 16.2 at 2, 6, and 12 months in the PRGF group, and from 42.1 +/- 13.5 to 60.8 +/- 16.6, 62.5 +/- 19.9, and 59.9 +/- 20.0 at 2, 6, and 12 months in the PRP group, respectively. Concerning adverse events, more swelling (P = 0.03) and pain reaction (P = 0.0005), were found after PRP injections.
CONCLUSIONS: Although PRP injections produced more pain and swelling reaction with respect to that produced by PRGF, similar results were found at the follow-up times, with a significant clinical improvement with respect to the basal level. Better results were achieved in younger patients with a low degree of cartilage degeneration.
Level of evidence: Ii.
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0 |
External fixation of displaced femoral shaft fractures in children: a consecutive study of 98 fractures
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DoD SSI (Surgical Site Infections)
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OBJECTIVE: To evaluate unilateral external fixation when applied as the standard treatment of children with displaced femoral shaft fractures.
SETTING: Two county hospitals in central Sweden.
DESIGN: A consecutive and prospective study including all children aged 3 to 15 years with displaced femoral fractures admitted to either of the two hospitals. Patients were followed clinically and radiographically until healing and at 1 year.
RESULTS: A total of 96 children with 98 fractures were treated with the same kind of external fixator during the period 1993-2000. The mean age was 8.1 years (range 3-15 years). Average hospital stay was 8.7 days (median 7 days). Average time of external fixation was 61 days (range 37-127 days; median 56 days). Minor complications included pin track inflammation/infection in 36 of 98 (37%) fractures. In 18 of 36 fractures, a short treatment with oral antibiotics was given. Other minor complications were one heterotopic ossification, one patient with two rereductions, nine cases of clinically insignificant malunion (varus = valgus > 5 degrees or procurvatum > 10 degrees ), and one leg-length discrepancy greater than 2 cm. Major complications (6%) included two refractures, one through a pinhole and one at the fracture site, both after significant trauma. Three of the older children with transverse fractures after high-energy injury developed a bending due to premature removal of the fixator prior to healing and required corrective osteotomies. One boy had a third rereduction because of displacement after a fall.
CONCLUSIONS: The use of external fixation as a standard treatment of uncomplicated displaced femoral shaft fractures in children gave satisfactory results. The surgical learning curve was short, and the advantages compared with nonsurgical treatment included shorter hospital stay, early mobilization, and fewer days out of school for the patient and out of work for the caregiver. We believe that the advantages far outweigh the complications, many of which can be avoided.
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0 |
Quality measures in osteoarthritis
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SR for PM on OA of All Extremities
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Published guidelines emphasize a multidisciplinary approach to management of patients with osteoarthritis (OA), yet studies have demonstrated substantial variation in the treatment approach of both primary care physicians and rheumatologists. During the past decade, quality indicators have been developed by several groups in order to provide a minimally acceptable standard of care. This article summarizes the results of a qualitative systematic review of the English-language literature on quality indicators for osteoarthritis and highlights relevant indicators published by the Arthritis Foundation and American College of Rheumatology
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1 |
Accuracy of MRI in comparison with clinical and arthroscopic findings in ligamentous and meniscal injuries of the knee
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Anterior Cruciate Ligament Injuries CPG
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Rapidly progressing medical technology sometimes obscures the importance of history and physical examination. This study was designed to assess the value of MRI and clinical examination in the diagnosis of ligamentous and meniscal knee injuries in comparison with arthroscopic findings. In the year 2003-2004, we conducted a prospective, single blind study to assess ligamentous and meniscal injuries of the knee in patients with acute knee trauma. The mean age was 27.9 years. The sex distribution was 81.4% male and 18.6% female; 42.9% of injuries affected the right knee and 57.1% the left knee. All the included patients were ordered a MRI, executed in five separate centres. All patients underwent arthroscopy by the author. Arthroscopic findings were the diagnostic reference. Clinical examination was accurate in 91.4%, and MRI in 88.5% of anterior cruciate ligament injuries. For posterior cruciate ligament injuries, clinical accuracy was 100% and MRI 94.6%. Clinical examination was accurate in 96.9% and MRI in 85.9% of medial meniscal injuries. For lateral meniscus injuries, clinical accuracy was 85.4% and MRI 73.8%. MRI findings showed the lowest correlation with arthroscopic findings in lateral meniscus injuries (r = 0/47). Clinical diagnostic performance was poorest in case of combined cruciate ligament and meniscal injuries. We found an excellent correlation between MRI and clinical findings. However, when MRI is normal, high clinical suspicion and a skilled clinical examination are more reliable
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Topical anesthesia for staple removal from surgical wounds on the knee: a prospective, double-blind, randomized trial
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AAHKS (8) Anesthetic Infiltration
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BACKGROUND: Staple removal from surgical wounds is painful. Only a few articles have provided expert opinions using anesthetic cream for such a problem; however, direct application of the anesthetic cream to a wound may cause infection. A safe alternative can be an anesthetic patch without wound contact.
MATERIALS AND METHODS: This was a prospective, double-blind, randomized clinical trial. Sixty patients who underwent primary total knee replacement were assigned to an experimental group or control group. One lidocaine patch was applied around the surgical wound for each patient in the experimental group. Alternatively, the adhesive sides of the lidocaine patches were shielded with waterproof films in the control group. A resident peeled off the patch before a single nursing practitioner removed the staples. Pain was assessed with the 10-cm visual analog scale, and a face pain scale-revised was performed. The patients and the nursing practitioner were blind to the management.
RESULTS: Mean visual analog scale and face pain scale-revised scores were significantly lower in the experimental group. The mean pain score was significantly lower in the experimental group if the application time was >47 min; for patients with application time of 47 min or shorter, the score was comparable with the mean pain scores of the control group (P = 0.215).
CONCLUSIONS: Removal of the metal skin staples after total knee arthroplasty is associated with moderate-to-severe pain. The lidocaine patch applied topically around the surgical wound could effectively reduce the pain during the procedure, without remarkable complications such as systemic adverse effects or wound contamination.
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0 |
Pediatric musculoskeletal trauma
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The Treatment of Pediatric Supracondylar Humerus Fractures AUC
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Continued research in the field of pediatric musculoskeletal trauma brings us closer to the goals of providing quality care for our patients. Ketamine may be safely used in the emergency room setting. Pediatric femur fractures may be treated with the use of a spica cast in patients younger than 10 years of age and weighing less than 80 pounds. Flexible intramedullary rods may be a useful treatment modality in selected fracture patterns. Children younger than 6 years of age with a presumptive toddler's fracture despite negative radiographic findings should be treated with cast immobilization. Distal tibial and fibular physeal fractures are commonly associated with growth plate disturbances and need to be followed closely. Stubbed toes should be evaluated for open fractures. Computed tomographic scans are not helpful in determining treatment in most pediatric pelvic fractures. Femoral neck fractures have a high complication rate. The etiology of fishtail deformities of the distal humerus is discussed. Deformities of the elbow following lateral condyle fractures are common, and methods of prevention are proposed. Timing of surgery for displaced supracondylar fractures remains controversial. Compartment syndrome poses a significant risk with combined displaced fractures of the distal humerus and displaced fractures of the forearm. Nonaccidental trauma remains difficult to characterize by radiographic technique alone, but the patient younger than walking age with a femoral shaft fracture remains a concern. (copyright) 2001 Lippincott Williams & Wilkins, Inc
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Results of knee arthroplasty using the cemented press-fit condylar prosthesis. Based on a preliminary report
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Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures
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Although retention of the posterior cruciate ligament in total knee arthroplasty remains controversial, several prostheses exist for this purpose and have been reported to have varying results. This study examines the short-term follow-up results of 107 total knee arthroplasties using a cemented press-fit condylar prosthesis. The mean follow-up period was 2.5 years, and the mean postoperative knee score was 96 points. Radiolucent lines were infrequently found and were incomplete. At short-term follow-up, no problems were identified with the cemented press-fit condylar prosthesis
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1 |
Comparison of the Frejka pillow and the von Rosen splint in treatment of congenital dislocation of the hip
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Developmental Dysplasia of the Hip CPG
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In southern Finland between 1966 through 1975, 920 newborns were treated with a Frejka pillow for dislocation of the hip. The treatment failed in 55 patients. The pillow was then rejected and replaced with the von Rosen splint. One hundred eighty patients were treated with the new method between 1978 and 1981. The treatment failed in one girl. At 3 years of age, one boy had slight features of avascular necrosis. Temporary skin irritation was found in 19% of patients. In two patients, the splint had to be replaced with a pillow because of skin problems. A treatment device which parents are allowed to take off between outpatient visits is not recommended
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0 |
Negative Stress Examination under Anesthesia Reliably Predicts Pelvic Ring Union Without Displacement
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Hip Fx in the Elderly 2019
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Objectives: To identify the negative predictive value of examination under anesthesia (EUA) for determining pelvic ring stability and union without further displacement. Design: Retrospective cohort study. Setting: Two academic Level 1 trauma centers. Patients/Participants: Thirty-four adult patients with closed pelvic ring injuries treated over a 5-year period. Interventions: Pelvic stress EUA. Main Outcome Measures: Pelvic ring union and pelvic ring displacement at final follow-up. Results: Thirty-four patients with closed pelvic ring injuries who underwent pelvic EUA during the study period and had a negative examination (indicating a stable pelvis) were identified. Mean age was 38 years (range 16-76), and 19 patients (55.9%) were male. Twenty-Two patients (64.7%) had Young-Burgess lateral compression (LC)-1 injuries with complete sacral fractures, 4 patients (11.8%) had LC-2 injuries, and 8 patients (23.5%) had anteroposterior compression (APC)-1 injuries. Eight patients (23.5%) had associated injuries requiring restricted weight-bearing on one or both lower extremities and were excluded from the analysis. Immediate weight-bearing as tolerated was permitted bilaterally in the remaining 26 patients. Mean pelvic ring displacement at the time of injury was 3.8 mm (range 1-15 mm) for LC injuries and 9.1 mm (range 2-20 mm) for APC injuries. Patients were followed for a mean of 8 months (range 3-34 months). At final follow-up, mean displacement was 3.7 mm (range 0-17 mm) for LC injuries and 7.1 mm (range 2-19 mm) for APC injuries. Mean change in displacement from injury to union was-0.1 mm for LC injuries and-2.0 mm for APC injuries, indicating decreased pelvic ring displacement at union. All patients were able to tolerate full weight-bearing bilaterally with no pain, and there were no instances of delayed operative fixation after negative EUA. Conclusions: Negative pelvic EUA after closed pelvic ring injury accurately predicts pelvic stability and union without displacement after nonoperative treatment with full weight-bearing bilaterally. Unless otherwise dictated by associated injuries, immediate weight-bearing as tolerated seems safe in patients with pelvic ring injuries who have had a negative EUA. Level of Evidence: Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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0 |
Intra-operative fractures in cementless bipolar hemiarthroplasty
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Hip Fx in the Elderly 2019
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PURPOSE: To compare patients with or without intra-operative fracture during cementless bipolar hemiarthroplasty.
METHODS: Records of 76 men and 202 women who underwent cementless bipolar hemiarthroplasty for femoral neck fractures were reviewed. Patients with and without intra-operative fractures and patients with different types of intra-operative fractures were compared.
RESULTS: Two men and 22 women aged 62 to 93 (mean, 80) years sustained intra-operative fractures at the lesser trochanter (n=18), the greater trochanter (n=5), and the subtrochanter (n=1). All 18 lesser trochanteric fractures and 4 of the greater trochanteric fractures were recognised intra-operatively and managed with cerclage wiring (n=21) or conversion to cemented hemiarthroplasty with cerclage wiring (n=1). The remaining 2 fractures were recognised postoperatively on radiographs and managed conservatively or with revision surgery and cerclage wiring and plating on day 4. Intra-operative fractures correlated with female gender (p=0.03) and operative delay to optimise patients (p=0.02), whereas the fracture site correlated with the time of fracture recognition (p=0.01). Postoperatively, 5 patients were allowed partial weight bearing and 18 were instructed to mobilise with a wheelchair for at least 6 weeks. One patient died from an unrelated cause. At one year, 21 patients reported no hip pain and 2 reported minimal pain. 17 could walk with or without aids and 6 were wheelchair-bound.
CONCLUSION: Surgeons should be familiar with the size difference in trial and actual implants used in bipolar hemiarthroplasty in order to better estimate the extent of broaching required. In most patients with an intra-operative fracture, the one-year outcome was not compromised, despite the poorer short-term outcome.
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Free lymph node flap transfer and laser-assisted liposuction: a combined technique for the treatment of moderate upper limb lymphedema
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Panniculectomy & Abdominoplasty CPG
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Upper limb lymphedema following breast cancer surgery is a challenging problem for the surgeon. Lymphatico-venous or lymphatico-lymphatic anastomoses have been used to restore the continuity of the lymphatic system, offering a degree of improvement. Long-term review indicates that lumen obliteration and occlusion at the anastomosis level commonly occurs with time as a result of elevated venous pressure. Lymph node flap transfer is another microsurgical procedure designed to restore lymphatic system physiology but does not provide a complete volume reduction, particularly in the presence of hypertrophied adipose tissue and fibrosis, common in moderate and advanced lymphedema. Laser-assisted liposuction has been shown to effectively reduce fat and fibrotic tissues. We present preliminary results of our practice using a combination of lymph node flap transfer and laser-assisted liposuction. Between October 2012 and May 2013, ten patients (mean 54.6 ± 9.3 years) with moderate (stage II) upper extremity lymphedema underwent groin or supraclavicular lymph node flap transfer combined with laser-assisted liposuction (high-power diode pulsed laser with 1470-nm wavelength, LASEmaR 1500-EUFOTON, Trieste, Italy). A significant decrease of upper limb circumference measurements at all levels was noted postoperatively. Skin tonicity was improved in all patients. Postoperative lymphoscintigraphy revealed reduced lymph stasis. No patient suffered from donor site morbidity. Our results suggest that combining laser liposuction with lymph node flap transfer is a safe and reliable procedure, achieving a reduction of upper limb volume in treated patients suffering from moderate upper extremity lymphedema.
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1 |
Physician and dentist compliance with American Heart Association guidelines for prevention of bacterial endocarditis
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Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures
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To determine the rate of physician and dentist compliance with the American Heart Association's (AHA) recommendations for prophylaxis against bacterial endocarditis--considered the standard of care--questionnaires were mailed to 1,131 dental and medical practitioners. They were asked to identify various cardiac conditions requiring prophylaxis and dental procedures that would cause a bacteremia, and to write prescriptions for prophylactic antibiotics for five different scenarios. Both groups had low compliance with AHA recommendations (32.9% collectively) when prescribing appropriate antibiotic regimens for bacterial endocarditis prophylaxis
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0 |
Epidemiology of osteoporotic hip fractures in Western Romania
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Hip Fx in the Elderly 2019
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PURPOSE: Fragility hip fractures represent a major health and social burden. To date, there are no reports regarding mortality and factors that influence outcomes after osteoporotic hip fractures in Romania.
MATERIAL AND METHODS: The electronic database of the largest healthcare provider in the western part of the country was searched for hip fracture admissions between 2008 and 2012. Inclusion criteria were age over 55 and the diagnosis of intra or extracapsular fractures, corresponding to ICD-10 S72.0 and S72.1 codes, respectively.
RESULTS: A total of 1,866 patients met the criteria and were selected for data analysis. The gain in rates and crude numbers was caused mainly by a rise of fractures in males. The opposite is seen for the female-to-male ratio. Even though the mean age steadily increased for a total of 1.5 over a five-year period the patients are still younger than the European averages, which might explain the slightly better one-year survival. The age-gender adjusted hip fracture incidence increased dramatically with age, especially in women. The relative risk of dying in the first year is 1.359 times higher if the fracture is extracapsular (95% CI 1.12-1.65). In total, 21.1% of all patients die by one year after the fracture. This was drastically reduced for the following years. The survival function is significantly dependent on age group, level of fracture and time from hospital admission until surgery (p < 0.001).
CONCLUSIONS: Increased age, extracapsular fractures and delayed surgery have worse outcomes. Regarding gender, even if not significant at the 0.05 level, probability of survival for females is higher for all time intervals. Updated, regional studies could be used in patient management to improve outcomes whilst decreasing costs.
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0 |
Another cause of median nerve compression by a lumbrical muscle in the carpal tunnel
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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A case is described in which division of a flexor digitorum profundus tendon allowed the proximal end of the tendon to retract, drawing its lumbrical muscle into the carpal tunnel where it caused compression of the median nerve
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0 |
Tartrate-resistant acid phosphatase isoform 5b (TRACP 5b) as a serum maker for cancer with bone metastasis
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MSTS 2018 - Femur Mets and MM
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The spread of cancer to bone is considered a terminal event. Two main types of bone metastasis can manifest, i.e. osteoblastic and osteolytic. Irrespective of metastatic type, uncoupled bone remodeling is always present and perpetuates a vicious cycle of excess bone resorption and destruction. Biochemical markers of bone metabolism are potentially useful to diagnose metastatic bone disease and to monitor treatment response in cancer patients. Tartrate-resistant acid phosphatase isoform 5b (TRACP 5b) is a biochemical marker of osteoclast number and activity. Mounting evidence has demonstrated serum TRACP 5b as a useful marker of bone resorption and therefore bears clinical applicability in diagnosis and management of metabolic and pathologic bone diseases. Serum TRACP 5b is among one of the many bone resorption biochemical markers that have been studied to be a surrogate marker of bone metastasis in cancer patients. Its serum level may reflect the degree of lytic bone metastasis and, in turn, the tumor burden within the bone milieu. This review summarizes the development of specific immunoassays for serum TRACP 5b as well as current evidence for its exploitation as a biomarker for diagnosis, treatment response, and prognosis in various cancers with high incidence of bone metastasis including breast, prostate, lung, and multiple myeloma. © 2010.
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1 |
Does Patient Perception Differ Following Adductor Canal Block and Femoral Nerve Block in Total Knee Arthroplasty? A Simultaneous Bilateral Randomized Study
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AAHKS (9/10) Regional Nerve Blocks
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Background Femoral nerve block (FNB) has been used as part of the multimodal analgesia after total knee arthroplasty (TKA), but leads to weakness in the quadriceps muscles. Recently, adductor canal block (ACB) was reported to provide effective pain relief while sparing the strength of the quadriceps. This simultaneous bilateral randomized study investigated whether patients perceived differences between ACB and the FNB after same-day bilateral TKA. Methods We performed a prospective simultaneous bilateral randomized study in 50 patients scheduled to undergo same-day bilateral TKA. One knee was randomly assigned to ACB and the other knee was assigned to FNB. All ACB and FNB were performed using ultrasound-guided single-shot procedures. These 2 groups were compared for pain visual analogue scale, straight leg raising ability and knee extension while sitting, and motor grade. At postoperative week 1, the peak torque for the quadriceps muscle was measured in both knees with an isokinetic dynamometer. Results There were no differences in pain levels between ACB and FNB during the entire study period. During the first 48 h after TKA, more of the knees that received ACB could perform straight leg raising and knee extension with greater quadriceps strength compared with FNB. However, no group differences in quadriceps functional recovery were found after postoperative 48 h and isometric quadriceps strength at postoperative 1 week. Conclusion This simultaneous bilateral randomized study demonstrates that patients did not perceive differences in pain level, but experienced substantial differences in quadriceps strength recovery between knees during the first 48 h (Identifier: NCT02513082).
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Povidone-iodine used as an adjunct to non-surgical treatment of furcation involvements
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Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures
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Background: The aim of this clinical trial was to evaluate the effect of topically applied povidone-iodine (polyvinylpyrrolidone and iodine [PVP-I]) used as an adjunct to non-surgical therapy of furcation involvements. Methods: Forty-four patients presenting at least one Class II furcation involvement that bled on probing with probing depth (PD) (greater-than or equal to)5 mm were recruited. Patients were stratified into two treatment groups: 1) subgingival instrumentation by an ultrasonic device using PVP-I (10%) as the cooling liquid (test); and 2) identical treatment using distilled water as the cooling liquid (control). The following clinical outcomes were evaluated: plaque index, bleeding on probing (BOP), position of the gingival margin, relative attachment level (RAL), PD, and relative horizontal attachment level (RHAL). The N-benzoyl-L-arginine-p-nitroanilide (BAPNA) test was used to analyze the trypsin-like activity in dental biofilm. The clinical and biochemical parameters were evaluated at baseline and 1, 3, and 6 months after therapy. Results: Both groups had similar means of PD reduction and RAL and RHAL gain. At 6 months, these variables were, respectively, 2.31, 1.17, and 1.00 mm in the control group and 2.31, 1.23, and 1.02 mm in the test group. There was also no difference between groups regarding the number of furcation sites presenting RAL gain (greater-than or equal to)2 mm. The results of the BAPNA test failed to demonstrate significant differences between groups. Conclusion: Non-surgical therapy can effectively treat Class II furcation involvements, and the use of topically applied PVP-I as an adjunct to subgingival instrumentation does not provide additional benefits
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Arthroscopic Management of Elbow Osteoarthritis
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DoD SSI (Surgical Site Infections)
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The incidence of osteoarthritis in the general population is low, but it can be seen in manual laborers, throwing athletes, and people dependent on crutches and wheelchairs. Patients often complain of pain at the terminal extents of motion, and imaging shows osteophyte formation at the tips of the coronoid and olecranon processes as well as thickening of the bone between the coronoid and the olecranon fossae. Recent advances in arthroscopic instrumentation and techniques have led to a growing interest in the arthroscopic treatment of elbow osteoarthritis. This article provides a review of basic arthroscopic elbow anatomy and the most common procedures, including diagnostic arthroscopy, loose body removal, and arthroscopic osteocapsular and ulnohumeral arthroplasty. As techniques advance, there might be interest in further procedures including arthroscopic-assisted interpositional arthroplasty. Although complications such as persistent drainage and nerve injury are frequently mentioned with elbow arthroscopy, the actual incidence of such complications remains low.
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0 |
Conjoint Removal of Hip Screw-Femur Head during Hip Replacement after Previous Dynamic Hip Screw Fixation
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Hip Fx in the Elderly 2019
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The purpose of this study was to demonstrate the reduced chances of iatrogenic femoral neck fracture while removing the Richard's screw using the dynamic hip screw-femur head conjoint removal technique. This retrospective cohort study analyzed 16 hips operated on with total hip arthroplasty from March 2010 to February 2015. All cases were previously treated with dynamic hip screws (DHS) for proximal femur fractures. The age of the patients ranged from 20 to 75 years. We used uncemented sockets in 15 patients and cemented sockets in 1 patient. We used conical fluted straight stems in 9 cases, ML (Mediolateral) tapered stems in 5 patients and CLS (Cementless Spotorno) stems in 2 patients. The head of the femur was removed together with the attached Richard's screw after taking a neck cut during hip replacement after previous dynamic hip screw fixation. At 2-year follow-up, there was a statistically significant improvement in the Harris hip score: from a mean preoperative score of 35 +/- 7.975 to a mean postoperative score of 89.38 +/- 4.870 (P < 0.001). Stem sinking and Type A<sub>L</sub> (Vancouver classification for periprosthetic fracture) periprosthetic fracture in 1 patient with a tapered stem was noted. Good acetabular inclination was achieved in all cases. At 2-year follow-up, all patients were able to carry out their daily activities. This is a novel technique with the advantage of avoiding iatrogenic femoral neck fracture in an osteoporotic bone.
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1 |
Posterior Root Meniscal Tears: Preoperative, Intraoperative, and Postoperative Imaging for Transtibial Pullout Repair
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AMP (Acute Meniscal Pathology)
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The menisci play an important biomechanical role in axial load distribution of the knees by means of hoop strength, which is contingent on intact circumferentially oriented collagen fibers and meniscal root attachments. Disruption of the meniscal root attachments leads to altered biomechanics, resulting in progressive cartilage loss, osteoarthritis, and subchondral edema, with the potential for development of a subchondral insufficiency fracture. Identification of meniscal root tears at magnetic resonance (MR) imaging is crucial because new arthroscopic surgical techniques (transtibial pullout repair) have been developed to repair meniscal root tears and preserve the tibiofemoral cartilage of the knee. An MR imaging classification of posterior medial meniscal root ligament lesions has been recently described that is dedicated to the posterior root of the medial meniscus. An arthroscopic classification of meniscal root tears has been described that can be applied to the anterior and posterior roots of both the medial meniscus and the lateral meniscus. This arthroscopic classification includes type 1, partial stable root tears; type 2, complete radial root tears; type 3, vertical longitudinal bucket-handle tears; type 4, complex oblique tears; and type 5, bone avulsion fractures of the root attachments. Knowledge of these classifications and the potential contraindications to meniscal root repair can aid the radiologist in the preoperative reporting of meniscal root tear types and the evaluation of the tibiofemoral cartilage. As more patients undergo arthroscopic repair of meniscal root tears, familiarity with the surgical technique and the postoperative radiographic and MR imaging appearance is important to adequately report the imaging findings. <sup>©</sup>RSNA, 2016.
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Morphologic, biomechanical and experimental in vivo studies of laser-assisted meniscus resection
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AMP (Acute Meniscal Pathology)
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Arthroscopic meniscectomy is associated with an irregularly shaped resection rim leading to further degeneration and a considerable rate of iatrogenic lesions to the adjacent cartilage. In a controlled experimental trial the clinical value of laser-assisted meniscectomy was assessed with special reference to whether laser application can overcome these common shortcomings of conventional surgery. An XeCl excimer laser (lambda = 308 nm, pulsewidth: 20 ns, repetition rate: 10-70 Hz, radiant exposure: 10-50 mJ/mm2) and a continuous wave Nd:YAG laser (lambda = 1064 nm, energy density: 21-93 W/mm2) were used with 600 microns and 800 microns quartz fibers, respectively. The study comprised an analysis of morphological and biomechanical characteristics of the meniscus exposed to laser treatment and an evaluation of reparative and degenerative changes following laser meniscectomy in an animal model. Light microscopy and scanning electron microscopy showed that excimer laser irradiation leads to well delineated resection borders with a transitional zone measuring 20 microns. Specimens exposed to Nd:YAG laser irradiation present extensive vaporization zones with the surface covered by an amorphous structure. Menisci irradiated by excimer or Nd:YAG laser energy show increased stiffness; the maximum value of radial strain at flexion is reduced, with a mean value of 1.5 +/- 0.3% following Nd:YAG laser irradiation and a mean value of 2.4 +/- 0.3% following excimer laser irradiation, compared with 3.0 +/- 0.5% in nonirradiated menisci. In vivo experiments show that laser energy prevents fibrillation of the menisceal structure, which was common in the control group; menisceal regeneration was not observed in any of the experimental groups. The extent of cellular infiltration in the synovial membrane is significantly increased following laser meniscectomy, indicating reactive synovitis (P < 0.05). Radiographs show enhanced progression of degenerative changes following laser surgery compared with conventional menisectomy; measurements of the subchondral bone density in the tibial plateau reveal significantly increased density following Nd:YAG (P < 0.01) and excimer laser irradiation (P < 0.05), confirming these observations. The proteoglycan content in the femoral cartilage corresponding to the zone of meniscus resection is significantly lower in the laser group than in the group subjected to conventional meniscectomy (P < 0.01). These results have various implications for clinical practice.(ABSTRACT TRUNCATED AT 400 WORDS)
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Effect of alendronate and MK-677 (a growth hormone secretagogue), individually and in combination, on markers of bone turnover and bone mineral density in postmenopausal osteoporotic women
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Management of Hip Fractures in the Elderly
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GH increases bone turnover and stimulates osteoblast activity. We hypothesized that administration of MK-677, an orally active GH secretagogue, together with alendronate, a potent inhibitor of bone resorption, would maintain a higher bone formation rate relative to that seen with alendronate alone, thereby generating greater enhancement of bone mineral density (BMD) in women with postmenopausal osteoporosis. We determined the individual and combined effects of MK-677 and alendronate administration on insulin-like growth factor I levels and biochemical markers of bone formation (osteocalcin and bone-specific alkaline phosphatase) and resorption [urinary N-telopeptide cross-links (NTx)] for 12 months and BMD for 18 months. In a multicenter, randomized, double blind, placebo-controlled, 18-month study, 292 women (64-85 yr old) with low femoral neck BMD were randomly assigned in a 3:3:1:1 ratio to 1 of 4 daily treatment groups for 12 months: MK-677 (25 mg) plus alendronate (10 mg); alendronate (10 mg); MK-677 (25 mg); or a double dummy placebo. Patients who received MK-677 alone or placebo through month 12 received MK-677 (25 mg) plus alendronate (10 mg) from months 12-18. All other patients remained on their assigned therapy. All patients received 500 mg/day calcium. The primary results, except for BMD, are provided for month 12. MK-677, with or without alendronate, increased insulin-like growth factor I levels from baseline (39% and 45%; P < 0.05 vs. placebo). MK-677 increased osteocalcin and urinary NTx by 22% and 41%, on the average, respectively (P < 0.05 vs. placebo). MK-677 and alendronate mitigated the reduction in bone formation compared with alendronate alone based on mean relative changes in serum osteocalcin (-40% vs. -54%; P < 0.05, combination vs. alendronate) and reduced the effect of alendronate on resorption (NTx) as well (-52% vs. -61%; P < 0.05, combination vs. alendronate). MK-677 plus alendronate increased BMD at the femoral neck (4.2% vs. 2.5% for alendronate; P < 0.05). However, similar enhancement was not seen with MK-677 plus alendronate in BMD of the lumbar spine, total hip, or total body compared with alendronate alone. GH-mediated side effects were noted in the groups receiving MK-677, although adverse events resulting in discontinuation from the study were relatively infrequent. In conclusion, the anabolic effect of GH, as produced through the GH secretagogue MK-677, attenuated the indirect suppressive effect of alendronate on bone formation, but did not translate into significant increases in BMD at sites other than the femoral neck. Although the femoral neck is an important site for fracture prevention, the lack of enhancement in bone mass at other sites compared with that seen with alendronate alone is a concern when weighed against the potential side effects of enhanced GH secretion
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Pulsed Electromagnetic Fields and Tissue Engineering of the Joints
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OAK 3 - Non-arthroplasty tx of OAK
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BACKGROUND: Bone and joint formation, maintenance, and regeneration are regulated by both chemical and physical signals. Among the physical signals there is an increasing realization of the role of pulsed electromagnetic fields (PEMF) in the treatment of nonunions of bone fractures. The discovery of the piezoelectric properties of bone by Fukada and Yasuda in 1953 in Japan established the foundation of this field. Pioneering research by Bassett and Brighton and their teams resulted in the approval by the Food and Drug Administration (FDA) of the use of PEMF in the treatment of fracture healing. Although PEMF has potential applications in joint regeneration in osteoarthritis (OA), this evolving field is still in its infancy and offers novel opportunities.
METHODS: We have systematically reviewed the literature on the influence of PEMF in joints, including articular cartilage, tendons, and ligaments, of publications from 2000 to 2016.
CONCLUSIONS: PEMF stimulated chondrocyte proliferation, differentiation, and extracellular matrix synthesis by release of anabolic morphogens such as bone morphogenetic proteins and anti-inflammatory cytokines by adenosine receptors A2<sub>A</sub> and A3 in both in vitro and in vivo investigations. It is noteworthy that in clinical translational investigations a beneficial effect was observed on improving function in OA knees. However, additional systematic studies on the mechanisms of action of PEMF on joints and tissues therein, articular cartilage, tendons, and ligaments are required.
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The organization of work: implications for injury and illness among immigrant Latino poultry-processing workers
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DoD PRF (Psychosocial RF)
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The US poultry-processing industry employs a large number of immigrants and has among the highest occupational illness rates for manufacturing. Previous research has not studied the potential health effects of psychosocial indicators of how poultry-processing work is organized. The investigators collected survey data from 200 immigrant Latinos working in poultry processing. Management practices (eg, poor commitment to safety, abusive supervision) and indicators of job design (eg, authority, variety, psychological workload, frequent awkward posture, and repetitive movement) were associated with risk of recent musculoskeletal problems, respiratory problems, and self-reported injury/illness. The results provide preliminary evidence suggesting that the organization of work underlies injury and illness among immigrant workers in poultry processing.
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Computerized tomographic evaluation of acute distal radial fractures
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Distal Radius Fractures
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To learn whether computerized tomography offered additional useful information over conventional radiographic evaluation of acute distal radial fractures in the younger adult, we scanned 22 consecutive injured wrists. Of the distal radial fractures in 19 wrists, sixteen were defined on plain films as intra-articular. In contrast, computerized tomography demonstrated that all fractures of the distal radius had intra-articular extension. In 3 wrists interpreted as being normal on plain films, despite clinical suspicion of a fracture, fractures were confirmed by computerized tomography. As a result of computerized tomography, injuries were assigned a higher Frykman value in 5 cases, and consideration of alternative patient management became necessary in 5 of the 22 patients.
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The Effect of Point-of-care Ultrasound Guidance for Distal Radius Fracture Reduction
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Distal Radius Fractures
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Distal radius (Colle's) fractures in adult patients are commonly reduced in the emergency department before casting. Standard of care currently requires that xâ?rays be performed before and after fracture reduction, and inadequate reductions may be subject to repeat attempts and are at a higher risk to require surgery. This study will assess the use of pointâ?ofâ?care ultrasound (POCUS) in addition to standard care as a tool to decrease the angulation at the fracture site after a reduction is performed. If this angulation is decreased, it would suggest that POCUS for distal radius fracture reduction could decrease the number of failed reduction attempts and therefore the number of repeated reduction attempts.
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Ropivacaine versus bupivacaine for 3-in-1 block during total knee arthroplasty
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AAHKS (8) Anesthetic Infiltration
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PURPOSE: To compare the use of ropivacaine versus bupivacaine for 3-in-1 block during total knee arthroplasty (TKA) in terms of efficacy and safety (lack of toxicity).
METHODS: 14 men and 26 women aged 58 to 77 (median, 70) years who had the American Society of Anesthesiologists (ASA) grades I to III physical status were randomised to receive ropivacaine (n=20) or bupivacaine (n=20) of a concentration of 0.5% for 3-in-1 block during TKA. The dosage was 0.5 ml/kg. In addition, a sciatic nerve block (20 ml of prilocaine 1%) was used. The onset of the block, duration of postoperative analgesia, level of motor block, and any side-effects were compared.
RESULTS: The median time to onset of block was significantly shorter in those receiving ropivacaine than bupivacaine (13 vs. 17.5 minutes, p<0.001), but the levels of motor blockade were not significantly different (p=0.355). Complete analgesia was achieved throughout the procedure. There was no significant difference between the ropivacaine and bupivacaine groups in terms of the mean duration of analgesia (398 vs. 367 minutes, p=0.62), the mean VAS scores at all time points, and the mean total morphine consumption. One patient in the ropivacaine group developed a joint haematoma and 2 patients in the bupivacaine group had excessive wound drainage. Both conditions resolved after antibiotic use.
CONCLUSION: Ropivacaine and bupivacaine showed similar anesthetic and analgesic effects, but the former had a significantly faster onset time.
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Effect on osteoarthritis of spa therapy at Bourbonne-les-Bains
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Management of Hip Fractures in the Elderly
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OBJECTIVES: Several studies suggest a beneficial overall effect of spa therapy in chronic musculoskeletal diseases. The present open controlled study investigated the effects of spa therapy at Bourbonne-Les-Bains, France, in patients with hip or knee osteoarthritis or low back pain. PATIENTS andMETHODS: In 1998, 102 men and women older than 50 years were included in the study. All had low back pain or lower limb osteoarthritis, and none had contraindications to spa therapy. Quality of life was assessed three times at intervals of 4 weeks, twice before and once immediately after 3 weeks of spa therapy, using the Duke Health Profile (five dimensions and five dysfunctions).RESULTS: Mean age was 66.4 years, and 67% of the patients were women. Quality of life was markedly decreased as compared to the population at large (1996, CFES). The two pretreatment evaluations produced similar quality-of-life scores. Spa therapy was associated with significant improvements in overall quality of life (P=0.004), self-esteem (P=0.009), and pain (P=0.01).CONCLUSION: These findings support those of other studies conducted in France and in other European countries. They indicate that patients report meaningful improvements in their quality of life after spa therapy
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Minimally invasive unicondylar knee arthroplasty for the treatment of unicompartmental osteoarthritis: an outpatient arthritic bypass procedure
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Surgical Management of Osteoarthritis of the Knee CPG
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This review summarizes past studies examining the progression of osteoarthritis (OA) of the knee that have led to the conclusion that the disease is slow, progressive, and typically limited to one tibiofemoral compartment. Treatments such as unicondylar knee arthroplasty (UKA) that address the single diseased compartment, preserving bone and soft tissue, seem appropriate. The senior author's minimally invasive surgical technique for performing UKA also is described
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Automatic quantitative analysis of the electromyogram in partially denervated distal muscles: comparison with motor unit counting
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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Using the ANOPS-101 minicomputer, an automatic analysis of muscle action potentials (MAP) was performed on a total of 53 extensor digitorum brevis (EDB) and abductor pollicis brevis (APB) muscles in patients with other evidence of denervation. The results were compared with observations made on 27 control subjects and they were also matched against estimates of functioning motor units made by the incremental stimulating technique of McComas et al (1971). Although the incidence of abnormal MAP parameters was relatively low in both muscles, it was possible to improve the diagnostic yield by combining the results for individual muscles. The relative merits and disadvantages of motor unit counting and automatic MAP analysis are discussed
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Long-term results of RTOG trial 8911 (USA Intergroup 113): a random assignment trial comparison of chemotherapy followed by surgery compared with surgery alone for esophageal cancer
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Reconstruction After Skin Cancer
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PATIENTS AND METHODSThe chemotherapy group received preoperative cisplatin plus fluorouracil. Outcome based on the type of resection (R0, R1, R2, or no resection) was evaluated. The main end point was overall survival. Disease-free survival, relapse pattern, the influence of postoperative treatment, and the relationship between response to preoperative chemotherapy and outcome were also evaluated.RESULTSTwo hundred sixteen patients received preoperative chemotherapy, 227 underwent immediate surgery. Fifty-nine percent of surgery only and 63% of chemotherapy plus surgery patients underwent R0 resections (P = .5137). Patients undergoing less than an R0 resection had an ominous prognosis; 32% of patients with R0 resections were alive and free of disease at 5 years, only 5% of patients undergoing an R1 resection survived for longer than 5 years. The median survival rates for patients with R1, R2, or no resections were not significantly different. While, as initially reported, there was no difference in overall survival for patients receiving perioperative chemotherapy compared with the surgery only group, patients with objective tumor regression after preoperative chemotherapy had improved survival.CONCLUSIONFor patients with localized esophageal cancer, whether or not preoperative chemotherapy is administered, only an R0 resection results in substantial long-term survival. Even microscopically positive margins are an ominous prognostic factor. After a R1 resection, postoperative chemoradiotherapy therapy offers the possibility of long-term disease-free survival to a small percentage of patients.PURPOSEWe update Radiation Therapy Oncology Group trial 8911 (USA Intergroup 113), a comparison of chemotherapy plus surgery versus surgery alone for patients with localized esophageal cancer. The relationship between resection type and between tumor response and outcome were also analyzed.
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Temporal trends in the incidence, treatment and outcomes of hip fracture after first kidney transplantation in the United States
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Hip Fx in the Elderly 2019
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It is currently unknown whether any secular trends exist in the incidence and outcomes of hip fracture in kidney transplant recipients (KTR). We identified first-time KTR (1997-2010) who had >1 year of Medicare coverage and no recorded history of hip fracture. New hip fractures were identified from corresponding diagnosis and surgical procedure codes. Outcomes studied included time to hip fracture, type of surgery received and 30-day mortality. Of 69,740 KTR transplanted in 1997-2010, 597 experienced a hip fracture event during 155,341 person-years of follow-up for an incidence rate of 3.8 per 1000 person-years. While unadjusted hip fracture incidence did not change, strong confounding by case mix was present. Using year of transplantation as a continuous variable, the hazard ratio (HR) for hip fracture in 2010 compared with 1997, adjusted for demographic, dialysis, comorbid and most transplant-related factors, was 0.56 (95% confidence interval [CI]: 0.41-0.77). Adjusting for baseline immunosuppression modestly attenuated the HR (0.68; 95% CI: 0.47-0.99). The 30-day mortality was 2.2 (95% CI: 1.3-3.7) per 100 events. In summary, hip fractures remain an important complication after kidney transplantation. Since 1997, case-mix adjusted posttransplant hip fracture rates have declined substantially. Changes in immunosuppressive therapy appear to be partly responsible for these favorable findings.
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Quantitative bone scintigraphy: usefulness in the survey of patients treated for bone metastasis of prostatic cancer
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MSTS 2018 - Femur Mets and MM
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The purpose of this study was to develop a quantitative bone scintigraphy (QBS) method in order to evaluate the evolution of bone metastases in patients treated for disseminated prostatic cancer. Data obtained by whole body scintigraphy after injection of 99mTc-methylene diphosphonate enabled us to define three indexes, GR, R1 and R2. They respectively represent the amount of activity retained in the bones, in the metastatic sites and in pathological sites related to the global activity of the skeleton. Repeated QBSs have been performed on 59 patients with prostatic carcinoma treated for bone metastasis with hormonal therapy. Results of QBS are well correlated to clinical findings, particularly pain evolution. In addition, the calculated indexes of QBS made it possible to distinguish three groups of patients according to regression, stabilization or evolution of their lesions under hormonal therapy. QBS seems to be a sensitive and useful test for the evaluation of the therapeutic efficiency on bone metastases from prostatic carcinoma.
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Microbiology of the infected knee arthroplasty: Report from the Swedish Knee Arthroplasty Register on 426 surgically revised cases
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Surgical Management of Osteoarthritis of the Knee CPG
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Surgically revised deep infected primary knee arthroplasties reported to the Swedish knee arthroplasty register during the years 19862000 were studied with respect to microbiology, antimicrobial susceptibility pattern and changes over time. In early, delayed and late infections, coagulase-negative staphylococci (CoNS) were most prevalent (105/299, 35.1%), and twice as common as Staphylococcus aureus (55/299, 18.4%). In haematogenous infections, S. aureus was the dominating pathogen (67/99, 67.7%), followed by streptococci and Gram-negative bacteria. Methicillin resistance was found in 1/84 tested isolates of S. aureus and 62/100 tested isolates of CoNS. During the study period, methicillin resistance among CoNS increased (p=0.002). Gentamicin resistance was found in 1/28 tested isolates of S. aureus and 19/29 tested CoNS isolates. A relative decrease in infections caused by S. aureus was observed, while enterococci increased. In empiric treatment of infected knee arthroplasty the type of infection should direct the choice of antibiotics. Awareness of the fact that most early infections are caused by CoNS can increase the chances of successful treatment with retained implant. Due to the high rate of gentamicin resistance among CoNS in infected knee arthroplasty, other antibiotics should be used in bone cement at revision
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Can a Novel Scoring System Improve on the Mirels Score in Predicting the Fracture Risk in Patients with Multiple Myeloma?
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MSTS 2022 - Metastatic Disease of the Humerus
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BACKGROUND: Stratification of the fracture risk is an important treatment component for patients with multiple myeloma, which is associated with up to an 80% risk of pathologic fracture. The Mirels score, which is commonly used to estimate the fracture risk for patients with osseous lesions, was evaluated in a cohort in which fewer than 15% of lesions were caused by multiple myeloma. The behavior of multiple myeloma lesions often differs from that of lesions caused by metastatic disease, and accurate risk stratification is critical for effective care. To our knowledge, the Mirels score has not been validated specifically for multiple myeloma.
QUESTIONS/PURPOSES: Our purpose was: (1) To develop a novel scoring system for the prediction of pathologic fracture in patients with long-bone lesions from multiple myeloma; and (2) to compare the sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and receiver operating characteristic (ROC) area under curve (AUC) between the novel scoring system and the Mirels system.
METHODS: Between 2003 and 2017, 763 patients at one center with the diagnosis of multiple myeloma were reviewed, of whom 174 presented with long-bone disease involvement. Of those, 5% (nine of 174) were missing data or radiographs at a minimum of 1 year and had not reached an endpoint (fracture or surgery) before that time and were therefore excluded. Many patients have more than one lesion; consequently, we used the largest lesion in each patient, resulting in 163 lesions in as many patients. Ten percent (16 of 163) of these patients eventually developed a fracture and 4% (six of 163) underwent prophylactic stabilization (excluded from analysis because of outcome uncertainty). During the study period, prophylactic stabilization was performed at the discretion of the orthopaedic oncologist. Fifty-one percent (83 of 163) of patients were female, and the mean (+/- SD) age was 60 +/- 10 years at radiographic lesion identification. All lesions were characterized before determining whether the patient underwent pathologic fracture. We identified variables associated with pathologic fracture on univariate analysis. Variables independently significant on logistic regression analysis were used to generate scoring algorithms at varying weights and scoring cutoffs for comparison via ROC curves. We then selected a novel score based on ROC performance, and compared the sensitivity, specificity, PPV, and NPV of that scoring system to that of Mirels score. ROC AUCs were compared after bootstrapping 100,000 iterations. Alpha was set at 0.05.
RESULTS: After controlling for potential confounders, such as age, sex, and duration of myeloma diagnosis, we found the following factors were independently associated with the occurrence of pathologic fracture: larger lesion size (area, cm2) (log odds 0.17; p = 0.03), longer lesion latency (years from diagnosis to lesion identification) (log odds 0.25; p = 0.03), presence of pain (relative risk [RR] 2.9; p = 0.04), and metaphyseal location (RR 3.2, compared with epiphyseal or diaphyseal; p = 0.003). These variables were used to formulate a novel scoring system. Compared with the Mirels system, the novel system was more sensitive (69% [95% CI 61 to 76] versus 38% [95% CI 30 to 46]; p < 0.05) but not different in terms of specificity (87% [95% CI 80 to 91] versus 87% [95% CI 81 to 92]; p > 0.05), PPV (37% [95% CI 29 to 45] versus 25% [95% CI 19 to 33]; p > 0.05), NPV (96% [95% CI 91 to 99] versus 92% [95% CI 87 to 96]; p > 0.05), or AUC (0.85 [95% CI 0.74 to 0.92] versus 0.67 [95% CI 0.51 to 0.81]; p > 0.05).
CONCLUSION: The novel scoring system was found to be more sensitive than the Mirels system for predicting pathologic fracture in our retrospective cohort of patients with multiple myeloma-related bone disease. Specificity, PPV, NPV, and ROC AUC were not different with the numbers available. Thus, the novel scoring system may serve as a more effective screening tool to determine which patients with multiple myeloma would benefit from further radiologic or orthopaedic evaluation based on a skeletal survey.
LEVEL OF EVIDENCE: Level III, diagnostic study.
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0 |
Roll, Spin, Wash, or Filter? Processing of Lipoaspirate for Autologous Fat Grafting: An Updated, Evidence-Based Review of the Literature
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Panniculectomy & Abdominoplasty CPG
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BACKGROUND: The use of autologous adipose tissue harvested through liposuction techniques for soft-tissue augmentation has become commonplace among cosmetic and reconstructive surgeons alike. Despite its longstanding use in the plastic surgery community, substantial controversy remains regarding the optimal method of processing harvested lipoaspirate before grafting. This evidence-based review builds on prior examinations of the literature to evaluate both established and novel methods for lipoaspirate processing. METHODS: A comprehensive, systematic review of the literature was conducted using Ovid MEDLINE in January of 2015 to identify all relevant publications subsequent to the most recent review on this topic. Randomized controlled trials, clinical trials, and comparative studies comparing at least two of the following techniques were included: decanting, cotton gauze (Telfa) rolling, centrifugation, washing, filtration, and stromal vascular fraction isolation. RESULTS: Nine articles comparing various methods of processing human fat for autologous grafting were selected based on inclusion and exclusion criteria. Five compared established processing techniques (i.e., decanting, cotton gauze rolling, centrifugation, and washing) and four publications evaluated newer proprietary technologies, including washing, filtration, and/or methods to isolate stromal vascular fraction. CONCLUSIONS: The authors failed to find compelling evidence to advocate a single technique as the superior method for processing lipoaspirate in preparation for autologous fat grafting. A paucity of high-quality data continues to limit the clinician's ability to determine the optimal method for purifying harvested adipose tissue. Novel automated technologies hold promise, particularly for large-volume fat grafting; however, extensive additional research is required to understand their true utility and efficiency in clinical settings.
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Balloon expulsion test as a screen for outlet obstruction in children with chronic constipation
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Pediatric Supracondylar Humerus Fracture 2020 Review
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OBJECTIVE: Chronic constipation (CC) is a common problem in pediatrics and is often the result of obstructed defecation. The aim of the present study was to study the feasibility and efficacy of the balloon expulsion test (BET) in the diagnosis and management of children with CC. METHODS: Retrospective study comparing BET and high-resolution anorectal manometry (ARM). The BET was done together with ARM in 29 children, ages 8 to 19 years, with CC. For BET, a 60-mL balloon was used. Passage of balloon in 1 minute or less was considered normal. RESULTS: Fifteen of the 29 children had a normal BET. Of these, 14 also had an ARM, all of which were normal (except for 2 cases with a hypertonic baseline anal sphincter). Thus 12 of 14 with BET and ARM were normal on both (correlation between the tests 86%). Of the 14 children that failed BET, 10 had distal abnormalities by ARM, contrast studies, EMG, or assessment by a pelvic physical therapist. All of the patients with a nonrelaxing sphincter or outlet obstruction were treated with laxatives, anal sphincter Botox, and/or pelvic physical therapy and biofeedback. In follow-up of at least 3 months, all of the patients with a failed BET were improved. CONCLUSIONS: We found a high correlation between a normal ARM and BET. If the BET is abnormal and the ARM does not identify a cause for the distal obstruction, additional studies may be needed, including contrast enema, defecography, or electromyography. BET appears to be a safe, reliable, and useful test in the evaluation and management of CC in children.
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Intramedullary nail versus dynamic hip screw for intertrochanteric fracture in the elderly: circulatory blood volume
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Hip Fx in the Elderly 2019
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BACKGROUND: The key of intertrochanteric fractures in elderly patients is to select the appropriate fixation, but few clinical studies concerned different fixation methods for blood volume of blood circulation system in elderly patients with intertrochanteric fractures. OBJECTIVE: To compare the effects of proximal femoral intramedullary nail and dynamic hip screw on blood volume of blood circulation system in elderly patients with intertrochanteric fractures. METHODS: A total of 48 elderly patients with intertrochanteric fractures, who were treated in the Jiangyin Hospital Affiliated to Nanjing University of Traditional Chinese Medicine from January 2012 to September 2014, were enrolled in this study. These patients were assigned to two groups (n=24). Patients in the observation group received treatment with proximal femoral intramedullary nail, and patients in the control group received treatment with dynamic hip screw. Postoperative blood loss, perioperative blood transfusion, preoperative and 3â?day postoperative hemoglobin difference, incidence of postoperative complications, dominant blood loss, and hidden blood loss were compared between the two groups. Range of motion of the hip and Harris score of the hip were compared between the two groups at 4 and 12 months post surgery. RESULTS AND CONCLUSION: Intraoperative blood loss was less in the observation group than in the control group (P < 0.05). No significant differences in perioperative blood transfusion and preoperative and 3â?day postoperative hemoglobin were detected between the two groups (P > 0.05). The operation time was significantly longer in the observation group than in the control group (P < 0.05). The incidence of postoperative complications was significantly lower in the observation group than in the control group (P < 0.05). No significant difference in length of hospital stay was detected between the two groups (P > 0.05). Within the same time period, the range of motion of the hip and Harris score of the hip were better in the observation group than in the control group (P < 0.05). The total amount of blood loss and dominant blood loss were less in the observation group than in the control group (P < 0.05). These findings indicate that compared with the dynamic hip screw, proximal femoral nail fixation for intertrochanteric fracture has less intraoperative blood loss, lower incidence of postoperative complications, postoperative range of motion of the hip and better hip score. However, operation time of proximal femoral nail was long. There were no significant differences in hemoglobin difference and perioperative blood transfusion between the two fixation methods. Copyright © 2015, Journal of Clinical Rehabilitative Tissue Engineering Research. All rights reserved.
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Surface ultrastructure of rheumatoid articular cartilage
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AMP (Acute Meniscal Pathology)
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Six rheumatoid articular cartilage specimens, which appeared grossly normal and were shown to be free of pannus when examined under the light microscope, were examined electron microscopically. For comparison, normal-appearing cartilage specimens from 2 patients with meniscus injury and 2 with degenerative joint disease (DJD) were also examined. In all cases the normal-appearing joint surface of rheumatoid cartilage was abnormal. Amorphous-appearing material was present to a depth varying between 6 and 25 micron. Some of this material had the appearance of fibrin deposited at the cartilage surface, but much appeared to represent breakdown products of the cartilage matrix, i.e. degraded collagen and proteoglycan. DJD cartilage did not show similar changes. The findings suggest that the surface of rheumatoid articular cartilage, even when grossly normal in appearance, is degraded by enzymes either present in the synovial fluid or released by polymorphonuclear cells in close contact with the cartilage surface.
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Elastic nails for fibular fracture in adult tibiofibular fractures
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PJI DX Updated Search
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Treatment of adult tibiofibular fractures, especially severely comminuted fractures, is technically challenging due to the lack of reduction markers and difficulty in restoring the alignment. Fixation of the fibula can facilitate reduction of the tibia fracture and restoration of the lower-extremity alignment. However, there are few literatures mentioned using intramedullary nail fixation for fibular fractures. Twenty-three cases of tibiofibular fractures were treated with elastic nails fixation fibular fractures and intramedullary nail or plate stabilization tibial fractures between January 2012 and December 2012. Adult tibiofibular fractures with fibular neck fractures or fibular fracture line apart from the ankle joint surface within 8 cm was ruled out. There were 19 males and 4 females with an average age of 41 years (range, 21-59 years). The injury causes included 11 falls and 12 traffic accidents. The left side was involved in 11 cases and the right side was involved in 12 cases. Seventeen cases were closed fractures and 6 cases were open fractures, all were Gustilo type I and II fractures. According to the AO classification, six fractures were defined as type 42A, 11 as type 42B, and 6 as type 42C. The average interval between injury and surgery was 5.8 d (range, 3-22 d). The operation time of elastic nails fixation fibular fractures was 24 minutes (range, 15-42 minutes). Primary wound healing was achieved in all patients. No complications such as infection and wound necrosis occurred. Twenty-one patients were followed up for a mean follow-up period of 16.3 months (range, 12-26 months). The mean duration of fracture healing in the radiographs was 4.1 months (range, 3-8 months). No recurrent fracture dislocation and breakage of implant were observed. At the last follow-up visit, the lower-extremity alignment was excellent. Two degrees of varus deformity was found in 3 cases, and 2 degrees of valgus deformity was observed in 2 cases, but there were no serious varus or valgus deformity affecting the lower-extremity function or causing pain. The results of Tornetta's ankle function scoring were excellent in 17 cases, good in 3 cases, and fair in 1 case; and the good-to-excellent rate was 95.2%. In the case of adult tibiofibular fractures, elastic nails fixed fibular fracture is helpful to maintain and adjust the lower limbs axis, help tibial fracture reduction, and increase stability
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Treatment of compound tibial fracture with free osteomuscular latissimus dorsi scapula flap
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DoD LSA (Limb Salvage vs Amputation)
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BACKGROUND: Compound tibial fractures with extensive comminution and soft tissue defects are limb-threatening reconstructive challenges. The purpose of this study was to assess the long-term outcomes and the reliability of the latissimus dorsi scapula flap for this indication. METHODS: The hospital records of 26 compound tibial fracture patients treated with the latissimus dorsi scapula flap were reviewed. An overall assessment was performed in several steps based on a preinformation and two function-related questionnaires together with radiographs, clinical overviews, and functional tests. RESULTS: In 85% of the cases, the fractures had resulted from high-energy trauma and had extensive zone of injury. The mean follow-up time was 6.2 years. Nine patients required reconstruction because of prolonged sequelae after infection, nonunion, or tissue deficiency. One flap loss occurred leading to amputation. Six patients required an additional operation to enhance bony union. Full weight-bearing was allowed in 3 months and the mean time to bony union was 10 months. Overall, 90% returned to their pretrauma occupation. Overall 11 patients were lost to follow-up. A total of 14 patients answered the questionnaires whereas 12 outpatients attended the clinical assessment. The main finding after evaluating the results of the functional tests and reviewing the questionnaires was the limitation in ankle movement while the donor site performed well. CONCLUSION: This study confirms that osteomuscular latissimus dorsi scapula flap reconstruction is a suitable alternative for compound and comminuted tibia fractures especially in the case of extensive soft tissue injury with bony loss or significant comminution and with high probability of amputation.
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Use of a shorter humeral stem in revision reverse shoulder arthroplasty
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Glenohumeral Joint OA
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Background The purpose of this study was to examine the outcomes of revision reverse arthroplasty using short bone-preserving humeral components in revising a long-stemmed component. Methods During a 7-year period, 39 patients who underwent revision reverse shoulder arthroplasty using the long to short humeral component technique were included. The mean age was 72 years. Prior implants used in the primary setting included anatomic (n = 26), hemiarthroplasty (n = 11), and reverse (n = 2). Results At a follow-up of 3 years (2-5), 5 shoulders (13%) required revision surgery, including 1 for a periprosthetic humerus fracture and 4 for glenoid component loosening. The survival free of revision for any reason and revision for humeral disease was 84% and 94%, respectively. One patient experienced a nondisplaced greater tuberosity fracture at 18 months postoperatively that healed without operative intervention. There were no dislocations or infections. Overall, patients experienced excellent overall improvements in their pain levels and shoulder motion (P <.001), with a postoperative 91% satisfaction rate as well as postoperative American Shoulder and Elbow Surgeons score of 68 and Simple Shoulder Test score of 6.7. At most recent radiographic follow-up, 1 (5%) patient had grade 3 humeral lucency. Conclusions Preserving bone stock through conversion to a shorter reverse humeral stem in the revision setting is a reasonable option with good short- to intermediate-term results and low rates of humeral complications. Using the shorter stem components provides adequate stability and high rates of humeral component ingrowth.
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Type III tibial fractures in the elderly: results of 23 fractures in 20 patients
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DoD LSA (Limb Salvage vs Amputation)
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A series of 23 type III fractures of the tibia in 20 elderly patients (over 60 years of age) presenting for combined plastic and orthopaedic surgical management over a period of 15 years are reviewed. Overall limb salvage was 53 per cent, with an average inpatient duration not significantly different from that for amputation, suggesting that an age of over 60 years is not necessarily a contraindication to attempts at limb salvage in type III injuries.
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Upper extremities fractures in Alnajaf/Iraq
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Pediatric Supracondylar Humerus Fracture 2020 Review
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Purpose To take an idea about the size of an important socioeconomically public health problem, which are fractures of the upper extremities Material and Methods: All the patients who sustained upper extremities fractures in one year (between 1st Jan. till 31st Dec. 2018)included in this study. Data collected from the documents of alsader medical city in Alnajaf, it included the types of fractures, ages, gender, side of fracture,and causes. Analysis of these data was done and the results were demonstrated in tables. Results: The total number of the patients were (3067),males 2231 and females 835.The number of fracture clavicle 168, proximal humerus 28, shaft humerus 163, supracondylar fracture 169, elbow fractures 85, forearm fractures 823, lower radius in children 292, wrist fracture 193, and hand fracture 310. People in the 1st decade were the most 1132 followed by the 2nd decade 949, 3rd decade 421, 4th decade 256, 5th decade 141, 6th decade 104 7th decade 36, and above 70 (28) patient. The most common cause of the fractures was fall in 1263 patient followed by fall from height 810, sport (football) 292 direct hit 243, RTA 214, and fall of heavy object 155 patients. Conclusion: Children and adolescent are mostly affected. Planes from all the government administrations showed decrease the occurrence of such injuries by learning programes to avoid fractures in all ages, in order to decrease the socioeconomically burden on the community.
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Restoration of Opposition
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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Opposition is not grasp but a preposition for grasp that involves 3 components of thumb movements: abduction, flexion, and pronation. Thumb opposition is usually lost with paralysis of the thenar muscles innervated by the median nerve. Many opposition transfers have been described that differ in the donor tendon, route of transfer, and method of attachment to the thumb. No one transfer is applicable for every clinical condition, and each transfer has its advantages and disadvantages. Many factors must be evaluated to decide if surgery is likely to be beneficial and then decide on the optimum treatment. (copyright) 2012 Elsevier Inc
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Reversed Contralateral LISS Plate for Vancouver B1 Periprosthetic Femoral Shaft Fractures
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DoD SSI (Surgical Site Infections)
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The authors reviewed all patients treated for periprosthetic femur fractures between March 1, 2007, and January 31, 2010 at the senior author's institution. Demographic features, mechanism of injury, radiographs, and computed tomography scans were reviewed to determine the type and stability of the femoral implant at the time of injury. All Vancouver B1 fractures were treated with a novel technique that used a contoured distal femoral locking plate intended for the contralateral femur and reversed to accommodate the ipsilateral femoral bow and contour of the proximal femur. Fixation was achieved around the implant with percutaneously placed unicortical and/or bicortical screws. Radiographs were reviewed for fracture healing, malunion, implant failure, and prosthetic loosening. Fifteen patients were identified and underwent the procedure as described. One patient died soon after surgery of complications from a ruptured preexisting esophageal ulcer. Of the remaining 14 patients, the average duration of follow-up was 25 months (range, 6-31 months). Two patients did not achieve union; however, repeat interpretation of the presenting radiographs showed likely misdiagnosed Vancouver B2 fractures. The first patient had late aseptic loosening and underwent revision surgery 22 weeks postoperatively. The other had early loss of fixation that required revision with a long stem prosthesis. Other complications included 1 deep venous thrombosis and 2 superficial wound infections. The infections were successfully treated with a single formal irrigation and debridement, primary closure, and a short course of oral antibiotics. Ultimately, in 86% of patients (12/14), fracture healing occurred with this biologically friendly technique.
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Minimally invasive periprosthetic plate osteosynthesis using the locking attachment plate
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Hip Fx in the Elderly 2019
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OBJECTIVE: Stable fixation of periprosthetic or periimplant fractures with an angular stable plate and early weight bearing as tolerated.
INDICATIONS: Periprosthetic femur fractures around the hip, Vancouver type B1 or C. Periprosthetic femur and tibia fractures around the knee. Periprosthetic fractures of the humerus. Periimplant fractures after intramedullary nailing.
CONTRAINDICATIONS: Loosening of prosthesis. Local infection. Osteitis.
SURGICAL TECHNIQUE: Preoperative planning is recommended. After minimally invasive fracture reduction and preliminary fixation, submuscular insertion of a large fragment femoral titanium plate or a distal femur plate. The plate is fixed with locking head screws and/or regular cortical screws where possible. If stability is insufficient, one or two locking attachment plates (LAP) are mounted to the femoral plate around the stem of the prosthesis. After fixing the LAP to one of the locking holes of the femoral plate, 3.5 mm screws are used to connect the LAP to the cortical bone and/or cement mantle of the prosthesis.
POSTOPERATIVE MANAGEMENT: Weight bearing as tolerated starting on postoperative day 1 is suggested under supervision of a physiotherapist.
RESULTS: In 6 patients with periprosthetic fractures and 2 patients with periimplant fractures, no surgical complications (e.g., wound infection or bleeding) were observed. The mean time to bony union was 14 weeks. No implant loosening of the locking attachment plate was observed. At the follow-up examination, all patients had reached their prefracture mobility level.
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Tarsal Tunnel Syndrome: A Compression Neuropathy Involving Four Distinct Tunnels
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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Although tarsal tunnel remains a difficult diagnosis and problem to treat, advances in the procedure have improved surgical outcomes. The advent of neurosensory PSSD testing or adjunct EMG/NCV testing has resulted in a more complete understanding of the level of entrapment. Futhermore, surgical outcomes have dramatically improved with a more comprehensive release of the foot nerves in addition to the tibial nerve. Internal neurolysis facilitates a second level of nerve decompression in needed cases. Early motion prevents nerve scarring and soft tissue scar formation, and physical therapy protocols have made it possible for patients to return to ambulation with limited long- term down time. Tarsal tunnel syndrome still remains a complex and often under-diagnosed or misdiagnosed condition that affects the foot and ankle. It is essential to keep this problem in mind when treating heel pain, posterior tibial pain, and pain at the arch or ball of the foot. A proper work-up, thorough treatment, and supportive care in physical therapy, can make it possible for anyone who suffers from tarsal tunnel syndrome to return to full and unrestricted activity with minimal to no pain. (copyright) 2006 Elsevier Inc. All rights reserved
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Prevalence of dementia in elderly patients with hip fracture
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Management of Hip Fractures in the Elderly
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Hip fractures occur commonly and are a cause of disability for older adults and lead to increased dependence and requirements for social support. Dementia is one of the possible risk factors for falling and hip fracture, a potential source for complications during surgery and during the postoperative period, difficulties in rehabilitation and a risk factor for hip fracture reccurence. However, in previous studies of hip fracture patients, cognitive status has not been formally assessed during the inpatient stay and diagnosis was based only on previous history. Additionally, no previous studies have compared prevalence of dementia between elderly patients with hip fracture and patients with other surgical pathology. Our aim was to define whether dementia was more prevalent in older subjects with hip fracture than in other elderly patients undergoing surgery. In this study, we prospectively assessed all patients aged 68 and older admitted to our hospital for hip fracture surgery during a one year period and compared them with age and gender matched patients attending other surgical departments. 80 hip fracture patients and 80 controls were assessed for dementia. Dementia was common in both groups, presumably reflecting the advanced mean age of both groups and cognitive deterioration due to hospitalization-status. Dementia was significantly higher in the hip fracture group (85%) compared to the control group (61.5%; p=0.002). Dementia is very common in older patients admitted for surgery to a general hospital and extremely common in those with hip fracture. It seems that dementia is under diagnosed in elderly hospitalised patients. Our data confirm that dementia is a major risk factor for hip fracture in the elderly
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Predictors and moderators in the randomized trial of multifamily psychoeducational psychotherapy for childhood mood disorders
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DoD PRF (Psychosocial RF)
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This study investigated predictors and moderators of mood symptoms in the randomized controlled trial (RCT) of Multi-Family Psychoeducational Psychotherapy (MF-PEP) for childhood mood disorders. Based on predictors and moderators in RCTs of psychosocial interventions for adolescent mood disorders, we hypothesized that children's greater functional impairment would predict worse outcome, whereas children's stress/trauma history and parental expressed emotion and psychopathology would moderate outcome. Exploratory analyses examined other demographic, functioning, and diagnostic variables. Logistic regression and linear mixed effects modeling were used in this secondary analysis of the MF-PEP RCT of 165 children, ages 8 to 12, with mood disorders, a majority of whom were male (73%) and White, non-Hispanic (90%). Treatment nonresponse was significantly associated with higher baseline levels of global functioning (i.e., less impairment; Cohen's d = 0.51) and lower levels of stress/trauma history (d = 0.56) in children and Cluster B personality disorder symptoms in parents (d = 0.49). Regarding moderators, children with moderately impaired functioning who received MF-PEP had significantly decreased mood symptoms (t = 2.10, d = 0.33) compared with waitlist control. MF-PEP had the strongest effect on severely impaired children (t = 3.03, d = 0.47). Comprehensive assessment of demographic, youth, parent, and familial variables should precede intervention. Treatment of mood disorders in high-functioning youth without stress/trauma histories and with parents with elevated Cluster B symptoms may require extra therapeutic effort, whereas severely impaired children may benefit most from MF-PEP.
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