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Resilience under conditions of extreme stress: A multilevel perspective
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DoD PRF (Psychosocial RF)
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Resilience has been conceptualized as a dynamic developmental process encompassing the attainment of positive adaptation within the context of significant threat, severe adversity, or trauma. Until the past decade, the empirical study of resilience predominantly focused on behavioral and psychosocial correlates of, and contributors to, the phenomenon and did not examine neurobiological or genetic correlates of and contributors to resilience. Technological advances in molecular genetics and neuroimaging, and in measuring other biological aspects of behavior, have made it more feasible to begin to conduct research on pathways to resilient functioning from a multilevel perspective. Child maltreatment constitutes a profound immersion in severe stress that challenges and frequently impairs development across diverse domains of biological and psychological functioning. Research on the determinants of resilience in maltreated children is presented as an illustration of empirical work that is moving from single-level to multilevel investigations of competent functioning in the face of adversity and trauma. These include studies of personality, neural, neuroendocrine, and molecular genetic contributors to resilient adaptation. Analogous to neural plasticity that takes place in response to brain injury, it is conjectured that it may be possible to conceptualize resilience as the ability of individuals to recover functioning after exposure to extreme stress. Multilevel randomized control prevention and intervention trials have substantial potential for facilitating the promotion of resilient functioning in diverse high-risk populations that have experienced significant adversity. Determining the multiple levels at which change is engendered through randomized control trials will provide insight into the mechanisms of change, the extent to which neural plasticity may be promoted, and the interrelations between biological and psychological processes in the development of maladaptation, psychopathology, and resilience.
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0 |
Identification of the saphenous nerve at arthroscopy
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AMP (Acute Meniscal Pathology)
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Injury to the saphenous nerve can be a troublesome complication of arthroscopic procedures to the posterior half of the medial meniscus. In this article, we outline a technique for accurately identifying saphenous nerve position using transillumination of the saphenous vein.
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Expression of C-X-C chemokine receptor types 1/2 in patients with gastric carcinoma: Clinicopathological correlations and significance
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MSTS 2018 - Femur Mets and MM
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C-X-C chemokine receptor types 1/2 (CXCR1/2) may play multiple roles in the development and progression of a number of types of tumor. The abnormal expression of CXCR1/2 in various types of malignant tumors has been reported, but less is known with regard to gastric carcinoma. The present study was preliminarily conducted to elucidate the correlation between clinicopathological factors and the immunohistochemical expression of CXCR1/2 in patients with gastric carcinoma. The expression of CXCR1/2 in 69 specimens of sporadic gastric carcinoma and their corresponding non-neoplastic mucosa obtained by gastrectomy was assayed by immunohistochemistry (IHC) using a polyclonal anti-CXCR1/2 antibody. ERK1/2 and AKT phosphorylation and the expression of indicators of proliferation, growth and apoptosis (Bcl-2 and Bax, Cyclin D1, EGFR and Ki-67), angiogenesis (VEGF and CD34), invasion and metastasis (MMP-9, MMP-2, TIMP-2 and E-cadherin) were also detected by IHC. A total of 68 (98.6%) of the 69 patients with gastric carcinoma were found to have positive CXCR1/2 expression, which appeared to be significantly higher in gastric carcinoma compared with corresponding non-neoplastic mucosa tissues. The expression of CXCR1/2 in gastric carcinoma was significantly associated with invasion, metastasis and TNM staging (P<0.001). Correlation analysis between CXCR1/2 and pAKT (P=0.032), pERK (P<0.001), Cyclin D1 (P=0.049), EGFR (P=0.013), Bcl-2 (P=0.003), microvessel density (P=0.001), MMP-9 (P=0.013) and MMP-2 (P=0.027) expression using the Spearman test showed significant correlation in gastric carcinoma. Univariate and multivariate logistic regression analysis showed that, compared with negative or weak expression, overexpression of CXCR1/2 protein was a significant risk factor for TNM stage (P<0.001). These results preliminarily suggest that CXCR1/2 may be a useful maker for progression of the tumors and a promising target for gastric carcinoma therapy.
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1 |
Post-traumatic glenohumeral cartilage lesions: a systematic review
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Glenohumeral Joint OA
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BACKGROUND: Any cartilage damage to the glenohumeral joint should be avoided, as these damages may result in osteoarthritis of the shoulder. To understand the pathomechanism leading to shoulder cartilage damage, we conducted a systematic review on the subject of articular cartilage lesions caused by traumas where non impression fracture of the subchondral bone is present.
METHODS: PubMed (MEDLINE), ScienceDirect (EMBASE, BIOBASE, BIOSIS Previews) and the COCHRANE database of systematic reviews were systematically scanned using a defined search strategy to identify relevant articles in this field of research. First selection was done based on abstracts according to specific criteria, where the methodological quality in selected full text articles was assessed by two reviewers. Agreement between raters was investigated using percentage agreement and Cohen's Kappa statistic. The traumatic events were divided into two categories: 1) acute trauma which refers to any single impact situation which directly damages the articular cartilage, and 2) chronic trauma which means cartilage lesions due to overuse or disuse of the shoulder joint.
RESULTS: The agreement on data quality between the two reviewers was 93% with a Kappa value of 0.79 indicating an agreement considered to be 'substantial'. It was found that acute trauma on the shoulder causes humeral articular cartilage to disrupt from the underlying bone. The pathomechanism is said to be due to compression or shearing, which can be caused by a sudden subluxation or dislocation. However, such impact lesions are rarely reported. In the case of chronic trauma glenohumeral cartilage degeneration is a result of overuse and is associated to other shoulder joint pathologies. In these latter cases it is the rotator cuff which is injured first. This can result in instability and consequent impingement which may progress to glenohumeral cartilage damage.
CONCLUSION: The great majority of glenohumeral cartilage lesions without any bony lesions are the results of overuse. Glenohumeral cartilage lesions with an intact subchondral bone and caused by an acute trauma are either rare or overlooked. And at increased risk for such cartilage lesions are active sportsmen with high shoulder demand or athletes prone to shoulder injury. [References: 45]
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Increasing hip fracture incidence in California Hispanics, 1983 to 2000
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Management of Hip Fractures in the Elderly
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BACKGROUND: Hip fracture incidence in non-Hispanic whites (NHW) has decreased nationwide for the past 20 years. Little is known regarding hip fracture incidence among Hispanics, the largest, fastest growing minority in the United States. OBJECTIVE: To assess the change in standardized hip fracture incidence from 1983 through 2000 in California Hispanics relative to other racial groups. DESIGN: Hospitalizations for individuals older than 55 years with hip fracture requiring repair in acute care hospitals. Annual population estimates based on US Census Bureau estimates. Incidence standardized to national gender-age strata. Change in annual incidence calculated by weighted linear regression with robust variance estimates. RESULTS: 372,078 hip fractures were identified. Age-adjusted annual incidence of hip fractures declined by 0.74% per year among women (655 to 568 per 100,000), but was unchanged among men (247 to 238 per 100,000). Among NHW women, the standardized annual incidence fell by 0.6% (4.0 fractures per 100,000) per year. Annual incidence among Hispanic women increased 4.9% (11.1 fractures per 100,000) per year. Annual incidence among Hispanic men increased by 4.2% (4.5 fractures per 100,000) per year and among NHW men by 0.5% (1.2 fractures per 100,000) per year. No significant change occurred among black or Asian women or men. CONCLUSIONS: Among California women, hip fracture incidence has doubled among Hispanics since 1983, while remaining unchanged or declining in other groups. Greater attention should be given to identification of individuals at risk for hip fracture and initiation of preventive measures in Hispanic populations
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0 |
Bone mineral density and bone metabolism in children treated for bone sarcomas
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MSTS 2022 - Metastatic Disease of the Humerus
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In adolescent bone sarcoma patients, bone mass acquisition is potentially compromised at a time in which it should be at a maximum. To evaluate the problem we measured bone mineral density (BMD) and serum markers of bone formation and resorption in a series of pediatric patients with bone tumors. BMD was measured by dual-energy x-ray absorptiometry, at clinical remission, for lumbar spine and the neck of the femur in 38 osteosarcoma and 25 Ewing's sarcoma patients. Mean age was 20.65 and 19.13 y respectively. Serum markers of bone metabolism were: OC, PICP, ICTP, 25-OH vit D and 1,25-(OH)2 vit D, IGF-I, IGFBP-3 and intact PTH. Serum was sampled throughout anti-tumoral treatments and follow-up. We analyzed 85 samples from 59 osteosarcoma patients and 54 samples from 36 Ewing's sarcoma patients. Patients had decreased lumbar and femoral BMD. The decrease was more pronounced in pubertal patients compared with those who had completed pubertal development at the time of disease diagnosis. Multivariate analysis indicated that sex, age, weight and BMI were significant in lumbar BMD depletion. Weight and BMI were significant in femoral BMD depletion. Serum markers of bone formation (PICP and OC) and resorption (ICTP) were, throughout, lower than reference values. Significant alterations in other markers were also observed. Up to a third of osteosarcoma and Ewing's sarcoma patients in clinical remission had some degree of BMD deficit. The corresponding increased risk of pathologic bone fractures constitutes a reduction in future quality of life. Copyright © 2006 International Pediatric Research Foundation, Inc.
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Concept of Apabahuka in the lights of modern science: A review
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Glenohumeral Joint OA
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Apabahuka is one among the vatavyadhi (diseases due to vitiated vata dosha) which affects the normal functioning of the upper limbs thereby the normal routine lifestyle of an individual is affected too. The only classical symptom explained regarding Apabahuka is bahupraspanditahara (restricted movement of affected shoulder). Whereas, some of the other symptoms clinically observed are pain in the affected shoulder, stiffness, muscle wasting etc. On analysing the etio-pathogenesis, it can be understood that the disease Apabahuka manifests due to both dhatuksaya (due to tissue loss) as well as marga avarana (due to obstruction of vata dosha by one or more doshas). While comparing with modern science, most of the shoulder joint pathologies such as Adhesive capsulitis, Rotator cuff Injuries, Bicipital tendinitis, Cervical spondylosis, Osteoarthritis of the shoulder joint etc. can be incorporated under the broad heading 'Apabahuka'. The present paper deals with some of the possible modern correlations of Apabahuka.
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1 |
Deep postoperative wound infection after carpal tunnel release
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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Between January 1976 and December 1985, 3620 carpal tunnel releases were done at the Mayo Clinic. A deep postoperative infection developed in 17 (0.47%) patients. These 17 were compared control group of 102 patients to identify possible risk factors. Statistically significant risk factors included intraoperative instillation of steroid solution into the carpal canal, flexor tendon synovectomy, prolonged operative time, and use of a surgical drain. Infection incidence was 0.87% in males and 0.25% in females (statistically significant). Seven (41%) of the 17 patients had a suboptimal result at final follow-up
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0 |
Value of the autotransfusion of blood recovered from the post-operative wound in arthroplasty patients
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Management of Hip Fractures in the Elderly
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BACKGROUND: The authors present their experiences with autotransfusion of blood recovered from the post-operative wound in 178 patients after a hip or knee arthroplasty operated on in 2006 and 2007. MATERIAL AND METHODS: We operated on 93 women and 63 men who underwent 33 emergency and 123 elective hip arthroplasties and 22 women who underwent elective knee arthroplasty. We used Unomedical's HandyVac ATS apparatus to recover and then auto-transfuse blood from the post-operative wound. Hemoglobin and hematocrit levels were determined in all patients before surgery and at 6 and 12 hours post-operatively. RESULTS: For the entire group of 178 patients, we recovered 64,600 ml of blood by draining the post-operative wound. Of these, 112 (62.9%) patients did not require additional transfusions of allogeneic blood. Of the 123 patients who underwent elective hip arthroplasty, 28 women and 4 men required additional transfusions of allogeneic blood products. Of the 33 patients who underwent emergency surgery, 19 women and 6 men received allogeneic transfusions. Of the 22 female patients with gonarthrosis, 9 required allogeneic transfusion. The mean decrease in hemoglobin following the operation and autotransfusion of blood recovered from the post-operative wound was 2.76 g% in women and 2.91 g% in men after elective hip arthroplasty, and 2.15 g% after knee arthroplasty. In patients following emergency surgery, hemoglobin levels decreased by a mean of 3.2 g% in women and 3.1 g% in men. CONCLUSIONS: Autotransfusion of blood recovered from the post-operative wound in patients after arthroplasty makes it possible to avoid transfusion of allogeneic blood products and reduces the postoperative decrease in hemoglobin levels
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0 |
Cost-effectiveness analysis for joint pain treatment in patients with osteoarthritis treated at the Instituto Mexicano del Seguro Social (IMSS): Comparison of nonsteroidal anti-inflammatory drugs (NSAIDs) vs. cyclooxygenase-2 selective inhibitors
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SR for PM on OA of All Extremities
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BACKGROUND: Osteoarthritis (OA) is one of the main causes of disability worldwide, especially in persons >55 years of age. Currently, controversy remains about the best therapeutic alternative for this disease when evaluated from a cost-effectiveness viewpoint. For Social Security Institutions in developing countries, it is very important to assess what drugs may decrease the subsequent use of medical care resources, considering their adverse events that are known to have a significant increase in medical care costs of patients with OA. Three treatment alternatives were compared: celecoxib (200 mg twice daily), non-selective NSAIDs (naproxen, 500 mg twice daily; diclofenac, 100 mg twice daily; and piroxicam, 20 mg/day) and acetaminophen, 1000 mg twice daily. The aim of this study was to identify the most cost-effective first-choice pharmacological treatment for the control of joint pain secondary to OA in patients treated at the Instituto Mexicano del Seguro Social (IMSS). METHODS: A cost-effectiveness assessment was carried out. A systematic review of the literature was performed to obtain transition probabilities. In order to evaluate analysis robustness, one-way and probabilistic sensitivity analyses were conducted. Estimations were done for a 6-month period. RESULTS: Treatment demonstrating the best cost-effectiveness results [lowest cost-effectiveness ratio $17.5 pesos/patient ($1.75 USD)] was celecoxib. According to the one-way sensitivity analysis, celecoxib would need to markedly decrease its effectiveness in order for it to not be the optimal treatment option. In the probabilistic analysis, both in the construction of the acceptability curves and in the estimation of net economic benefits, the most cost-effective option was celecoxib. CONCLUSION: From a Mexican institutional perspective and probably in other Social Security Institutions in similar developing countries, the most cost-effective option for treatment of knee and/or hip OA would be celecoxib
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Recovery of Walking Ability and Return to Community Living within 60 Days of Hip Fracture Does Not Differ Between Male and Female Survivors
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Hip Fx in the Elderly 2019
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OBJECTIVES: To compare risk-adjusted differences between men and women 30 and 60 days after hip fracture surgery in not walking, ability to return home in a community-dwelling subset, not walking in a nursing home resident subset, and mortality within 60 days.
DESIGN: Cohort study.
SETTING: Data were from a randomized clinical trial that compared two blood transfusion protocols after hip fracture.
PARTICIPANTS: Individuals with hip fracture (N = 2,016; 489 (24%) male).
MEASUREMENTS: Walking, dwelling, and mortality were determined in telephone follow-up 30 and 60 days after randomization, which occurred within 3 days of surgery. Sex differences for each outcome were compared using univariate and multivariate regression adjusting for potential confounders.
RESULTS: Men were younger (P < .001) and more likely to have comorbidity (P = .003) than women at the time of hip fracture and to die within 60 days, even after risk adjustment (odds ratio (OR) = 1.76, 95% confidence interval (CI) = 1.15-2.69). After risk adjustment, male survivors were as likely as female survivors not to walk (OR = 1.03, 95% CI = 0.78-1.34) and no less likely to return home (OR = 0.90, 95% CI = 0.69-1.17) 60 days after hip fracture. No differences were noted between male and female nursing home residents in not walking within 60 days (OR = 0.95, 95% CI = 0.32-2.86).
CONCLUSION: Although men experience higher mortality, male survivors can expect recovery of walking ability similar to that of female survivors and are as likely to return to community living.
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0 |
Action-blindsight in healthy subjects after transcranial magnetic stimulation
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Upper Eyelid and Brow Surgery
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Clinical cases of blindsight have shown that visually guided movements can be accomplished without conscious visual perception. Here, we show that blindsight can be induced in healthy subjects by using transcranial magnetic stimulation over the visual cortex. Transcranial magnetic stimulation blocked the conscious perception of a visual stimulus, but subjects still corrected an ongoing reaching movement in response to the stimulus. The data show that correction of reaching movements does not require conscious perception of a visual target stimulus, even in healthy people. Our results support previous results suggesting that an efference copy is involved in movement correction, and this mechanism seems to be consistent even for movement correction without perception.
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0 |
Patellofemoral pain syndrome
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Osteochondritis Dissecans 2020 Review
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Patellofemoral pain syndrome (PFPS) is one of the most common causes of anterior knee pain encountered in the outpatient setting in adolescents and adults younger than 60 years. The incidence in the United States is between 3% and 6%. The cardinal feature of PFPS is pain in or around the anterior knee that intensifies when the knee is flexed during weight-bearing activities. The pain of PFPS often worsens with prolonged sitting or descending stairs. The most sensitive physical examination finding is pain with squatting. Examining a patientâ??s gait, posture, and footwear can help identify contributing causes. Plain radiographs of the knee are not necessary for the diagnosis of PFPS but can exclude other diagnoses, such as osteoarthritis, patellar fracture, and osteochondritis. If conservative treatment measures are unsuccessful, plain radiography is recommended. Treatment of PFPS includes rest, a short course of nonsteroidal anti-inflammatory drugs, and physical therapy directed at strengthening the hip flexor, trunk, and knee muscle groups. Patellar kinesiotaping may provide additional short-term pain relief;however, evidence is insufficient to support its routine use. Surgery is considered a last resort.
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1 |
Factors associated with tumor volume and primary metastases in Ewing tumors: Results from the (EI)CESS studies
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MSTS 2018 - Femur Mets and MM
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Background: Tumor volumes of more than 100 ml and the presence of primary metastases have been identified as determinants of poor prognosis in patients with Ewing tumors. We sought to assess the prevalence of critical tumor size and primary metastases in a large national sample of patients at the time of first diagnosis and to identify factors that are associated with their occurrence. Patients: The present report is based on data of 945 German patients who were enrolled into the (EI)CESS therapy studies between 1980 and 1997. It is assumed that registration of German patients with Ewing tumors under the age of 15 years was almost complete since around 1985. Diagnoses of primary tumors were ascertained exclusively by biopsies. Analyses were restricted to patients with Ewing tumors of bone due to the few occurrences in soft tissues. Methods: Tumor volume data as assessed by radiography, computed tomography or nuclear magnetic imaging were available for 821 patients. The diagnosis of primary metastases was based on thoracic computed tomography or on whole body bone scans in 936 patients. Suspicious lesions had to be confirmed by bone marrow biopsies. We explored how year of first diagnosis, age at first diagnosis, sex, histological subtype and site of the primary tumor related to tumor size and presence of metastases by univariate and multivariate statistical techniques. Results: Sixty-eight percent of the patients (n = 559) had a volume above 100 ml with smaller tumors being more common in childhood than in late adolescence and early adulthood. Extensive volumes were observed in almost 90% of the tumors located in femur and pelvis while they were less common in other sites (P < 0.001). On average, 26% of all patients presented with clinically apparent primary metastases. The detection rate of metastases was markedly higher in patients diagnosed after 1991 (P < 0.001). Primary metastases were also significantly more common for tumors originating in the pelvis and for peripheral neuroectodermal tumors (PNET; P < 0.01). Tumors greater than 100 ml were positively associated with metastatic disease (P < 0.001) Multivariate analyses, which included simultaneously all univariate predictors in s logistic regression model, indicated that most of the observed associations were essentially unconfounded. The adjusted odds ratios (OR) for the presence of tumor volumes â?¥ 100 ml were OR = 1.5 per age rise of 10 years, and OR = 5.8 for pelvis and OR = 7.1 for femur as primary tumor site (all P < 0.001). The presence of metastases was significantly associated with the year of diagnosis (OR = 1.9, after 1991 vs. before 1986, pelvis as site of the primary tumor (OR = 1.8), a PNET (OR = 1.5), and tumor size â?¥ 100 ml (OR = 1.6). Conclusions: In conclusion, we find that the prevalence of established factors for an unfavorable prognosis is disturbingly high among patients diagnosed with Ewing tumors. Recent progress in imaging techniques seems to account for much of the rise in the detection rate of metastases after 1991. We identify age and, in particular, pelvic and femoral site as the major determinants of local tumor extension. Occurrence of primary metastases is independently related to tumor size, pelvic site, and PNET.
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Hip fractures, nocturia, and nocturnal polyuria in the elderly
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Management of Hip Fractures in the Elderly
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This study was undertaken to evaluate the relation between hip fractures and nocturnal micturition habits in elderly men and women. A questionnaire survey was undertaken among 10,216 elderly subjects. The mean (+/-S.D.) ages of the men and women were 73.0+/-6.0 and 72.6+/-6.7 years, respectively. A hip fracture during the past five years had occurred in 97 (3.9%) of the men and 175 (4.6%) of the women and the occurrence increased with increasing age in both sexes. In both men and women nocturnal micturition increased with age. Among men, passing of subjectively large amounts of urine at night was reported to occur never or very seldom in 63.3% and rather seldom, rather often, and very often in 21.9%, 12.7%, and 2.1%, respectively. The corresponding frequencies in women were 65.1%, 17.2%, 13.7%, and 3.9%, respectively. Multiple logistic regression analysis with sex, nocturia, and nocturnal voided volumes as independent variables and occurrence of hip fracture during the last five years as the dependent variable showed that the risk of having had a hip fracture was increased by nocturia three or more episodes versus two or fewer; odds ratio (OR) 1.8, confidence interval (CI) 1.1-3.0, and by large nocturnal urine volumes, very often versus very seldom or never; (OR 3.5; CI 1.8-7.3). One can conclude that in these elderly subjects the risk of hip fractures during a five-year period was increased independently by increased nocturnal micturition and increased nocturnal urine output
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0 |
Prediction of arterial extravasation in pelvic fracture patients with stable hemodynamics using coagulation biomarkers
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Hip Fx in the Elderly 2019
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Background: Determining the presence of an active arterial hemorrhage in the acute phase is important as a treatment strategy in patients with pelvic fracture. The purpose of this study was to evaluate whether coagulation biomarkers could predict arterial extravasation, especially in pelvic fracture patients with stable hemodynamics. Methods: We studied patients with a pelvic fracture who had a systolic blood pressure above 90â??mmHg and lactate level less than 5.0â??mmol/L on hospital arrival. Patients were divided into two groups: those with arterial extravasation on enhanced computed tomography (CT) or angiography (extravasation [+] group) and those without arterial extravasation (extravasation [-] group). Coagulation biomarkers measured on arrival were statistically compared between the two groups. Predictive ability of arterial extravasation using coagulation biomarkers was evaluated by receiver-operating characteristic analyses provided area under the receiver-operating characteristic curves (AUROC) and diagnostic indicators with optimal cutoff point including sensitivity, specificity, positive and negative predictive values, and diagnostic odds ratio (DOR). Results: Sixty patients were analyzed. Fibrin degradation products (FDP), D-dimer, prothrombin time-international normalized ratio (PT-INR), and the ratio of FDP to fibrinogen were significantly higher in the extravasation (+) group than in the extravasation (-) group (FDP, 242â??μg/mL [145-355] vs. 96â??μg/mL [58-153]; D-dimer, 81â??μg/mL [41-140] vs. 39â??μg/mL [21-75]; PT-INR, 1.09 [1.05-1.24] vs. 1.02 [0.98-1.08]; and ratio of FDP to fibrinogen, 1.06 [0.85-2.01] vs. 0.46 [0.25-0.74]). The highest AUROC was with a ratio of FDP to fibrinogen of 0.777 (95% confidence interval, 0.656-0.898), and the highest predictive ability in terms of DOR was with a ratio of FDP to fibrinogen (sensitivity, 0.76; specificity, 0.76; DOR 9.90). Conclusion: Coagulation biomarker could predict of arterial extravasation in pelvic fracture patients with stable hemodynamics.
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1 |
Surgical treatment of displaced intra-articular calcaneal fractures: Is bone grafting necessary?
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DoD SSI (Surgical Site Infections)
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Background: The aim of this retrospective study was to determine the need for bone grafting in the surgical treatment of displaced intra-articular calcaneal fractures. We reviewed 390 cases of displaced intra-articular calcaneal fractures treated with plate osteosynthesis with or without autologous iliac bone grafting, and compared outcomes and complications related to fracture stabilization. Materials and methods: Three hundred ninety patients with displaced intra-articular calcaneal fractures that were treated with plate osteosynthesis from December 2002 to December 2010 were reviewed. Two hundred two patients (group A) were treated by osteosynthesis with autologous bone grafting, and 188 patients (group B) were treated by osteosynthesis without bone grafting. One hundred eighty-one patients with an AO type 73-C1 fracture (Sanders type II), 182 patients with an AO type 73-C2 fracture (Sanders type III), and 27 patients with an AO type 73-C3 fracture (Sanders type IV) were included in this study. Bohler's angle, the crucial angle of Gissane, and calcaneal height in the immediate postoperative period and at the 2-year follow-up were compared. Any change in the subtalar joint status was documented and analyzed. The final outcomes of all patients were evaluated by the AOFAS Ankle-Hindfoot Scale and compared in both groups. Results: The mean full weight-bearing time in group A (with bone grafting) was significantly lower (median 6.2 months, range 2.8-9.2 months) than that in group B (without bone grafting; median 9.8 months, range 6.8-12.2 months). The immediate-postoperative Bohler's angle and that at the 2-year follow-up were significantly higher in group A. The loss of Bohler's angle after 2 years was significantly lower in group A (mean 3.5°; 95 % CI 0.8° -6.2°) than in group B (mean 6.2°; 95 % CI 1.0° -11.2°). The average change in the crucial angle and the average change in calcaneal height were not statistically significant for either group. The infection rate in the bone grafting group was higher, though statistically insignificantly so, than in the nongrafting group (8.3 vs. 6.3 %). No significant difference was found between the groups in terms of the rates of good reduction, postoperative osteoarthritis, and subtalar fusion. Regarding the efficacy outcomes, the mean AOFAS score was lower (mean 76.4 points; 95 % CI 65.8-82.9 points) in group A than in group B (mean, 81.6 points; 95 % CI, 72.3-88.8 points), but this difference was not significant (p > 0.05). Conclusions: Bohler's angle showed improved restoration and the patients returned to full weight-bearing earlier when bone grafting was used in the treatment of intra-articular calcaneal fracture. However, the functional outcomes and complication rates of both groups were similar. © 2012 The Author(s).
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0 |
Imaging of articular cartilage injuries of the lower extremity
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AMP (Acute Meniscal Pathology)
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Imaging has become an important clinical tool in the evaluation of articular cartilage, both in the clinical and research setting. This article reviews the mechanisms of articular cartilage injury in the lower extremities and their implications. Specific examples of acute and chronic repetitive injuries in the hip, knee, and ankle are used to demonstrate the characteristics of articular cartilage lesions on magnetic resonance imaging and multidetector computed tomographic arthrography. Loss of meniscal function in the knee and femoroacetabular impingement in the hip represent sources of repetitive cartilage injury that predispose the joint to osteoarthritis. Acute cartilage injury is exemplified by osteochondral lesions of the talus, which may result in post-traumatic osteoarthritis. Recognition of early cartilage damage and associated lesions may help determine the proper treatment for the patient to delay or prevent progression to osteoarthritis. [References: 145]
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Race/Ethnicity Moderates the Association Between Psychosocial Resilience and Movement-Evoked Pain in Knee Osteoarthritis
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OAK 3 - Non-arthroplasty tx of OAK
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Objective: Racial/ethnic disparities in pain are well-recognized, with non-Hispanic blacks (NHBs) experiencing greater pain severity and pain-related disability than non-Hispanic whites (NHWs). Although numerous risk factors are posited as contributors to these disparities, there is limited research addressing how resilience differentially influences pain and functioning across race/ethnicity. Therefore, this study examined associations between measures of psychosocial resilience, clinical pain, and functional performance among adults with knee osteoarthritis (OA), and assessed the moderating role of race/ethnicity on these relationships. Methods: In a secondary analysis of the Understanding Pain and Limitations in Osteoarthritic Disease (UPLOAD-2) study, 201 individuals with knee OA (NHB = 105, NHW = 96) completed measures of resilience (ie, trait resilience, optimism, positive well-being, social support, positive affect) and clinical pain, as well as a performance-based measure assessing lower-extremity function and movement-evoked pain. Results: Bivariate analyses showed that higher levels of psychosocial resilience were associated with lower clinical pain and disability and more optimal physical functioning. NHBs reported greater pain and disability, poorer lower-extremity function, and higher movement-evoked pain compared with NHWs; however, measures of psychosocial resilience were similar across race/ethnicity. In moderation analyses, higher optimism and positive well-being were protective against movement-evoked pain in NHBs, whereas higher levels of positive affect were associated with greater movement-evoked pain in NHWs. Conclusion: Our findings underscore the importance of psychosocial resilience on OA-related pain and function and highlight the influence of race/ethnicity on the resilience-pain relationship. Treatments aimed at targeting resilience may help mitigate racial/ethnic disparities in pain.
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0 |
The external fixation in the treatment of humeral diaphyseal fractures: Outcomes of 84 cases
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Pediatric Supracondylar Humerus Fracture 2020 Review
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We retrospectively review 84 cases of diaphyseal humeral fractures (24 type A, 38 type B, 22 type C of the AO/OTA classification) treated with external fixation (Hoffmann II frame) between 1995 and 2007. Six of these fractures were complicated with radial nerve palsy. Four cases were open fractures. All reductions were achieved closely or through minimal open approaches. All fractures achieved consolidation with an average of 95 days (range 58-140). The six radial nerve palsies had complete spontaneous recovery. According to the Constant score excellent shoulder function was recorded in 54.6% of the cases, good results in 25%, fair in 13.6% and poor in 6.8%. The elbow function according to the Mayo elbow performance index was excellent in 81.8% of cases, good in 13.6%, fair in 2.3%, and poor in 2.3%. We observed superficial pin tract infections in 12% of the patients. There was no cases of deep infection. External fixation of humeral diaphyseal fractures as recorded in this case series, represents a management option, which allows straightforward fracture reduction and adequate stability, with a short operative time, excellent consolidation rate and good functional results with no major complications secondary to this type of surgery. © 2010 Elsevier Ltd. All rights reserved.
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Systematic percutaneous pinning of displaced extension-type supra-condylar fractures of the humerus in children: A prospective study of 67 patients
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The Treatment of Pediatric Supracondylar Humerus Fractures AUC
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Extension supra-condylar fracture of the humerus is a most common fracture in children. Several treatment regimens have been used in the treatment of displaced supra-condylar humeral fractures. A prospective study was performed including 67 children presenting a displaced supra-condylar humeral fracture. We uniformly treated them by closed reduction under general anaesthesia with fluoroscopic control and two parallel lateral pinnings. The criteria for inclusion were a supra-condylar humeral fracture (gartland type ii and type iii) with posterior displacement in an infant, or in an adolescent less than 16 years old. According to the flynn classification, there were 47 excellent results (70%), 15 good (23%), two fair (3%) and three poor (4%), which means 62 good and excellent results (93%). This percentage fell to 61 and 27% respectively if we considered the humero-ulnar angle. Forearm pronosupination was always normal. Poor results analysis found no relation between them except for the type of the fracture. The humero-ulnar angle seemed to be the pejorative radiological criterion. There was no correlation between type of reduction in ap or lateral x-ray and functional or cosmetic results. Poor fracture reduction induced residual deformity; anatomic reduction is therefore necessary to avoid it. (copyright) Springer-Verlag 2004
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Free vascularized fibular graft reconstruction of large skeletal defects after tumor resection
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DoD LSA (Limb Salvage vs Amputation)
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UNLABELLED: Skeletal reconstruction of large tumor resection defects is challenging. Free vascularized fibular transfer offers the potential for rapid autograft incorporation in limbs compromised by adjuvant chemotherapy or radiation. We retrospectively reviewed 30 patients treated with free vascularized fibular graft reconstruction of large skeletal defects after tumor resections (mean defect length, 14.8 cm). The minimum followup was 2 years (mean, 4.9 years; range, 2-15 years). One patient died with liver and lung metastases at 3 years postoperatively. Loss of limb occurred in one patient. Five patients either had metastatic disease (one patient) or had metastatic disease (four patients) develop after treatment, with a mean time to metastasis of 18 months. The overall complication rate was 16 of 30 (53%), with a reoperation rate of 12 of 30 (40%). Union was attained in all 30 grafts. Primary union was attained in 23 (77%) at a mean of 6 months. Secondary union was achieved in seven (23%) after revision fixation and bone grafting; the mean subsequent time to union was 9.2 months, with an index of 1.33 additional operations per patient. Graft fracture (20%) and infection (10%) were other common complications. Despite a high complication rate, free vascularized fibular graft reconstruction offers a reliable treatment of large skeletal defects after tumor resection without increased risk of limb loss, local recurrence, or tumor metastasis. LEVEL OF EVIDENCE: Level IV, case series. See Guidelines for Authors for a complete description of levels of evidence.
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Magnetic resonance imaging scans are not a reliable tool for predicting symptomatic acromioclavicular arthritis
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Glenohumeral Joint OA
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Background: We investigated whether magnetic resonance imaging (MRI) scans can accurately diagnose arthritis of the acromioclavicular joint (ACJ) because it has recently been suggested that bone marrow oedema on MRI scans is a predictive sign of symptomatic ACJ arthritis.
Methods: The MRI scans of 43 patients (50 shoulders) who underwent ACJ excision for clinically symptomatic ACJ arthritis were compared to a control group of 43 age- and sex-matched patients (48 shoulders) who underwent an MRI scan for investigation of shoulder pain but did not have clinical symptoms or signs of ACJ arthritis. The scans were evaluated by an experienced musculoskeletal radiologist, who was blinded to the examination findings.
Results: Bone marrow oedema was present in only 15 (30%) shoulders in the ACJ excision group, although this was higher than the six shoulders in the asymptomatic group (p = 0.03). Forty-one (82%) shoulders in the symptomatic group had grade III/IV ACJ arthritis compared to 31 (65%) in the asymptomatic group (p = 0.05). However, 44 out of 48 (92%) shoulders in the asymptomatic group had signs of osteoarthritis on MRI scans.
Conclusions: In contrast to recent reports, the present study shows that MRI is not helpful in making the diagnosis of ACJ arthritis. A focused history and clinical examination should remain the mainstay for surgical decision making.
Level of evidence: Level 3.
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Staphylococcus aureus adhesion to titanium oxide surfaces coated with non-functionalized and peptide-functionalized poly(L-lysine)-grafted-poly(ethylene glycol) copolymers
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Dental Implant Infection
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Implanted biomaterials are coated immediately with host plasma constituents, including extracellular matrix (ECM); this reaction may be undesirable in some cases. Poly(L-lysine)-grafted-poly(ethylene glycol) (PLL-g-PEG) has been shown to spontaneously adsorb from aqueous solution onto metal oxide surfaces, effectively reducing the degree of non-specific adsorption of blood and ECM proteins, and decreasing the adhesion of fibroblastic and osteoblastic cells to the coated surfaces. Cell adhesion through specific peptide-integrin receptors could be restored on surfaces coated with PLL-g-PEG functionalized with peptides of the RGD (Arg-Asp-Gly) type. To date, no study has examined the effect of surface modifications by PLL-g-PEG-based polymers on bacterial adhesion. The ability of Staphylococcus aureus to adhere to the ECM and plasma proteins deposited on biomaterials is a significant factor in the pathogenesis of medical-device-related infections. This study describes methods for visualizing and quantifying the adhesion of S. aureus to smooth and rough (chemically etched) titanium surfaces without and with monomolecular coatings of PLL-g-PEG, PLL-g-PEG/PEG-RGD and PLL-g-PEG/PEG-RDG. The different surfaces were exposed to S. aureus cultures for 1-24h and bacteria surface density was evaluated using scanning electron microscopy and fluorescence microscopy. Coating titanium surfaces with any of the three types of copolymers significantly decreased the adhesion of S. aureus to the surfaces by 89-93% for PLL-g-PEG, and 69% for PLL-g-PEG/PEG-RGD. Therefore, surfaces coated with PLL-g-PEG/PEG-RGD have the ability to attach cells such as fibroblasts and osteoblasts while showing reduced S. aureus adhesion, resulting in a selective biointeraction pattern that may be useful for applications in the area of osteosynthesis, orthopaedic and dental implantology.
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Clinical efficacy of intra-articular injections in knee osteoarthritis: A prospective randomized study comparing hyaluronic acid and betamethasone
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OAK Recommendation 9 Articles
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Background: Osteoarthritis (OA) is the most common joint disease and leading cause of disability. Intra-articular (IA) administration of hyaluronic acid (HA) or corticosteroids (CS) have been previously studied, though using insufficient number of patients or short follow-up periods.Objective: We evaluate HA and CS in patients with knee OA in terms of clinical efficacy over 12 months.Methods: We used a prospective, randomized study with parallel groups. Randomized patients received IA injections of HA or betamethasone (BM). The primary outcomes were improvement in pain using Visual Analog Scale and function in the Western Ontario and McMaster University Osteoarthritis Index (Likert scale). Follow-up visits were scheduled at 3 months, 6 months, 9 months, and 12 months.Results: A total of 200 patients were included. Pain was significantly reduced in both groups at the first follow-ups. At 12 months, the mean pain reduction in the HA group was 33.6% (95% CI: 31.1null36.1) compared to 8.2% (95% CI: 5.2null11.1) in BM (P,0.0001). Function improvement was higher in HA through every visit, and mean improvement at 12 months was 47.5% (95% CI: 45.6null49.3) in HA patients vs 13.2% (95% CI: 11.4null14.9) in the BM group (P,0.0001). All patients from both groups achieved the Minimal Clinically Important Improvement (MCII) for both pain and function up to 6 months. At 9 months and 12 months, the MCII figures were higher in HA group with $80% compared to #10% in BM group (P,0.0001). Adverse reactions were rare and related to the administration procedure.Conclusion: Both treatments effectively controlled OA symptoms. BM showed higher short-term effectiveness, while HA showed better long-term effectiveness, maintaining clinical efficacy in a large number of patients 1 year after administration
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CT arthrography of adhesive capsulitis of the shoulderAre MR signs applicable?
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Glenohumeral Joint OA
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Objective To determine if diagnostic signs of adhesive capsulitis (AC) of the shoulder at Magnetic Resonance Imaging (MRI) and arthrography (MRA) are applicable to CT arthrography (CTA). Methods 22 shoulder CTAs with AC were retrospectively reviewed for features described in MR literature. The control group was composed of 83 shoulder CTA divided into four subgroups 1) normal (N = 20), 2) omarthrosis (N = 19), 3) labral injury (N = 23), and 4) rotator cuff tear (N = 21). Two musculoskeletal radiologists assessed the rotator interval (RI) for obliteration, increased width and thickening of coracohumeral ligament (CHL). The width and capsule thickness of the axillary recess were measured. Results The width of the axillary recess was significantly decreased in the AC group (4.6 ± 2.6 mm versus 9.9 ± 4.6 mm, p � 0.0001; sensitivity and specificity of 84% and 80%). Thickness of the medial and lateral walls of the axillary capsule was significantly increased in the AC group (5.9 ± 1.3 mm versus 3.7 ± 1.1 mm, p � 0.0001 and 5.7 ± 1 mm versus 3.5 ± 1.3 mm, p � 0.0001, respectively). CHL thickness was significantly increased in the AC group (4.1 ± 1 mm (p � 0.001)) in comparison to others groups. Obliteration of the RI was statistically significantly more frequent in patients with AC (72.7% (16/22) vs. 12% (10/83), p < 0.0001). Width of the RI did not differ significantly between patients and controls (p � 0.428). Conclusion Decreased axillary width, and thickened axillary capsule are MR signs of AC applicable to CTA. Evaluation of rotator interval seems useful and reproducible only for obliteration.
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The Risk of Falls after Total Knee Arthroplasty with the Use of a Femoral Nerve Block Versus an Adductor Canal Block: A Double-Blinded Randomized Controlled Study
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AAHKS (9/10) Regional Nerve Blocks
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Background: Adductor canal block (ACB) has emerged as an appealing alternative to femoral nerve block (FNB) that produces a predominantly sensory nerve block by anesthetizing the saphenous nerve. Studies have shown greater quadriceps strength preservation with ACB compared with FNB, but no advantage has yet been shown in terms of fall risk. The Tinetti scale is used by physical therapists to assess gait and balance, and total score can estimate a patient's fall risk. We designed this study to test the primary hypothesis that FNB results in a greater proportion of "high fall risk" patients postoperatively using the Tinetti score compared with ACB. Methods: After institutional review board approval, informed written consent to participate in the study was obtained. Patients undergoing primary unilateral total knee arthroplasty were eligible for enrollment in this double-blind, randomized trial. Patients received either an ACB or FNB (20 mL of 0.5% ropivacaine) with catheter placement (8 mL/h of 0.2% ropivacaine) in the setting of multimodal analgesia. Continuous infusion was stopped in the morning of postoperative day (POD)1 before starting physical therapy (PT). On POD1, PT assessed the primary outcome using the Tinetti score for gait and balance. Patients were considered to be at high risk of falling if they scored <19. Secondary outcomes included manual muscle testing of the quadriceps muscle strength, Timed Up and Go (TUG) test, and ambulation distance on POD1 and POD2. The quality of postoperative analgesia and the quality of recovery were assessed with American Pain Society Patient Outcome Questionnaire Revised and Quality of Recovery-9 questionnaire, respectively. Results: Sixty-two patients were enrolled in the study (31 ACB and 31 FNB). No difference was found in the proportion of "high fall risk" patients on POD1 (21/31 in the ACB group versus 24/31 in the FNB group [P = 0.7]; relative risk, 1.14 [95% confidence interval, 0.84-1.56]) or POD2 (7/31 in the ACB versus 14/31 in the FNB group [P = 0.06]; relative risk, 2.0 [95% confidence interval, 0.94-4.27]). The average distance of ambulation during PT and time to up and go were similar on POD1 and POD2. Manual muscle testing grades were significantly higher on POD1 in the ACB group when compared with that in the FNB (P = 0.001) (Wilcoxon-Mann-Whitney odds, 2.25 [95% confidence interval, 1.35-4.26]). There were no other differences in postoperative outcomes. Conclusions: ACB results in greater preservation of quadriceps muscle strength. Although we did not detect a significant reduction in fall risk when compared with FNB, based on the upper limit of the relative risk, it may very well be present. Further study is needed with a larger sample size.
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Acetabular labral tears and cartilage lesions of the hip: Indirect MR arthrographic correlation with arthroscopy - A preliminary study
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Management of Hip Fractures in the Elderly
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OBJECTIVE. The purpose of this study was to assess the diagnostic correlation between indirect MR arthrography, conventional MRI, and arthroscopy in acetabular labral and cartilage lesions of the hip
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0 |
Acetabular Remodeling After a Varus Derotational Osteotomy in Children With Cerebral Palsy
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Developmental Dysplasia of the Hip 2020 Review
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BACKGROUND: The optimal surgical intervention for hip dysplasia in cerebral palsy (CP) is controversial. The purpose of this study was to determine (1) whether an isolated varus derotation osteotomy (VDRO) for the treatment of CP hip dysplasia allows for acetabular remodeling as measured by acetabular depth ratio (ADR), (2) the predictive factors for acetabular remodeling after an isolated VDRO for the treatment of CP hip dysplasia, and (3) to establish the normal ADR in typical children for comparison. METHODS: Eighty-seven CP patients (174 hips) treated with an isolated VDRO between 2003 and 2009 were retrospectively reviewed. The average age at surgery was 4.6 years (range, 2.4 to 10.6 y) and the average follow-up period was 5.1 years (range, 1.1 to 9.9 y). Acetabular remodeling was assessed on radiographs by the ADR. Changes in preoperative and postoperative ADR were analyzed using linear mixed-effects models. Patients were divided into 2 different groups for the postoperative ADR analysis: Gross Motor Function Classification System (GMFCS) levels I, II, and III compared with GMFCS levels IV and V. The progression of ADR versus age was determined in a set of 917 normal children (1834 hips) for comparison. RESULTS: There was a statistically significant increase (improvement) in ADR postsurgically for the collective CP set (P<0.001) and for both GMFCS categories (I/II/III, IV/V: P<0.001). GMFCS level, sex, and intraoperative neck shaft angle (NSA) were determined to be significant predictors for postoperative ADR improvement. GMFCS level was the most significant predictor for an increase in ADR after surgery (P<0.001). Less improvement in ADR was observed in patients of GMFCS levels IV and V compared with patients of GMFCS levels I, II, and III (P<0.001). A lower intraoperative NSA resulted in greater postoperative increase in ADR (P<0.05). CONCLUSIONS: Overall, isolated VDRO allowed for acetabular remodeling in CP hip dysplasia. Acetabular remodeling was increased in patients of GMFCS levels I, II, and III compared with patients of GMFCS levels IV and V. Increased varization at the time of VDRO improved acetabular remodeling. This study recommends considering GMFCS level and intraoperative NSA during surgical planning for CP hip dysplasia.
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Recanalized umbilical vein as a conduit for mesenterico/porto-Rex bypass for patients with extrahepatic portal vein obstruction
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DOD - Acute Comp Syndrome CPG
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PURPOSE: Mesenterico-left portal vein (meso-Rex) bypass is as an effective modality for restoring intrahepatic portal perfusion in patients with extrahepatic portal vein obstruction. Achieving sufficient patency is difficult with end-to-side anastomosis of a bypass graft to a small or hypoplastic left portal vein in the Rex recessus. Here, we describe the use of a recanalized umbilical vein in the round ligament as a conduit for bypass construction in two patients.
METHODS: Case 1 was an 11-year-old boy diagnosed with rupture of the esophageal varices and hypersplenism due to congenital extrahepatic portal hypertension. Because of persistent hypersplenism and thrombocytopenia, he underwent meso-Rex bypassing with a left iliac vein graft interposed between the umbilical vein and the superior mesenteric vein. Case 2 was a neonate with a large hepatic tumor (mesenchymal hamartoma) that developed abdominal compartment syndrome at birth. The tumor was removed by right hepatectomy with excision of the portal vein bifurcation at 3 days of age. Porto-Rex bypassing was accomplished by end-to-end anastomosis between the portal vein trunk and the umbilical vein.
RESULTS: Sufficient hepatopetal portal flow through the umbilical vein was achieved in both patients and maintained for over 16 and 13 months, respectively. Although hypersplenism remained in Case 1, intrahepatic portal vein branches gradually widened and the cavernoma in the hepatic hilum disappeared within 2 months. Neither patient had symptoms or signs of portal hypertension at the most recent follow-up.
CONCLUSION: Using the umbilical vein as a vein conduit may facilitate construction of a meso/porto-Rex bypass and restore intrahepatic portal vein perfusion in patients with extrahepatic portal vein obstruction.
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Altered patterns and synthesis of extracellular matrix macromolecules in early osteoarthritis
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Surgical Management of Osteoarthritis of the Knee CPG
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The synthesis and contents of extracellular non-collagenous matrix macromolecules was studied in early and late human osteoarthritic (OA) cartilage obtained at surgery for sarcomas in the lower extremities (normal and early OA) or for total knee replacement (late stage OA). The early OA samples were those that had some fibrillation in the joint by visual examination. One group had fibrillation in the area sampled and the other group had no fibrillation. Cartilage was taken from the same topographical area on the medial femoral condyle in all the samples, labeled with [3H]leucine and [35S]sulfate for 4 h at 37 degrees C and extracted with 4 M guanidine-HCl. Analysis of the extracts showed that the total amount of proteoglycans relative to hydroxyproline content was higher in the early and late OA than in the normal cartilage. These proteoglycans showed a relatively lower [35S]sulfate incorporation into GAG chains and a higher [3H]leucine incorporation. The pattern of newly synthesized proteins was altered similarly in early and late OA. Notably, synthesis of cartilage oligomeric matrix protein (COMP), fibronectin, and cartilage intermediate layer protein (CILP) was increased, also reflected in their abundance as determined by enzyme-linked immunosorbent assay (ELISA). Collagen synthesis appeared significantly increased only in the late stage OA. The observed altered composition and pattern of biosynthesis indicate that the joint undergoes metabolic alterations early in the disease process, even before there is overt fibrillation of the tissue. The early OA samples studied appear to represent two distinct groups of early lesions in different stages of the process of cartilage deterioration as shown by their differences in relative rates of synthesis and abundance of proteins
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Trends and social barriers for inpatient palliative care in patients with metastatic bladder cancer receiving critical care therapies
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MSTS 2022 - Metastatic Disease of the Humerus
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Background: Use of inpatient palliative care (IPC) in the treatment of advanced cancer represents a well-established guideline recommendation. A recent analysis showed that patients with genitourinary cancer benefit from IPC at the second lowest rate among 4 examined primary cancers, namely lung, breast, colorectal, and genitourinary. Based on this observation, temporal trends and predictors of IPC use were examined in patients with metastatic urothelial carcinoma of the bladder (mUCB) receiving critical care therapies (CCTs). Patients and Methods: Patients with mUCB receiving CCTs were identified within the Nationwide Inpatient Sample database (2004-2015). IPC use rates were evaluated in estimated annual percentage change (EAPC) analyses. Multivariable logistic regression models with adjustment for clustering at the hospital level were used. Results: Of 1,944 patients with mUCB receiving CCTs, 191 (9.8%) received IPC. From2004 through 2015, IPC use increased from 0.7% to 25.0%, respectively (EAPC,123.9%; P <001). In analyses stratified according to regions, the highest increase in IPC use was recorded in the Northeast (EAPC, 144.0%), followed by the West (EAPC, 126.8%), South (EAPC,122.9%), and Midwest (EAPC,115.5%). Moreover, the lowest rate of IPC adoption in 2015 was recorded in the Midwest (14.3%). In multivariable logistic regression models, teaching status (odds ratio [OR], 1.97; P <001), more recent diagnosis (2010-2015; OR, 3.89; P <001), and presence of liver metastases (OR, 1.77; P5.02) were associated with higher IPC rates. Conversely, Hispanic race (OR, 0.42; P5.03) and being hospitalized in the Northeast (OR, 0.36; P5.01) were associated with lower rate of IPC adoption. Finally, patients with a primary admission diagnosis that consisted of infection (OR, 2.05; P5.002), cardiovascular disorders (OR, 2.10; P5.03), or pulmonary disorders (OR, 2.81; P5.005) were more likely to receive IPC. Conclusions: The rate of IPC use in patients with mUCB receiving CCTs sharply increased between 2004 and 2015. The presence of liver metastases, infections, or cardiopulmonary disorders as admission diagnoses represented independent predictors of higher IPC use. Conversely, Hispanic race, nonteaching hospital status, and hospitalization in the Midwest were identified as independent predictors of lower IPC use and represent targets for efforts to improve IPC delivery in patients with mUCB receiving CCT.
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Contribution of trochanteric soft tissues to fall force estimates, the factor of risk, and prediction of hip fracture risk
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Management of Hip Fractures in the Elderly
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We compared trochanteric soft tissue thickness, femoral aBMD, and the ratio of fall force to femoral strength (i.e., factor of risk) in 21 postmenopausal women with incident hip fracture and 42 age-matched controls. Reduced trochanteric soft tissue thickness, low femoral aBMD, and increased ratio of fall force to femoral strength (i.e., factor of risk) were associated with increased risk of hip fracture. INTRODUCTION: The contribution of trochanteric soft tissue thickness to hip fracture risk is incompletely understood. A biomechanical approach to assessing hip fracture risk that compares forces applied to the hip during a sideways fall to femoral strength may by improved by incorporating the force-attenuating effects of trochanteric soft tissues. MATERIALS AND METHODS: We determined the relationship between femoral areal BMD (aBMD) and femoral failure load in 49 human cadaveric specimens, 53-99 yr of age. We compared femoral aBMD, trochanteric soft tissue thickness, and the ratio of fall forces to bone strength (i.e., the factor of risk for hip fracture, phi), before and after accounting for the force-attenuating properties of trochanteric soft tissue in 21 postmenopausal women with incident hip fracture and 42 age-matched controls. RESULTS: Femoral aBMD correlated strongly with femoral failure load (r2 = 0.73-0.83). Age, height, and weight did not differ; however, women with hip fracture had lower total femur aBMD (OR = 2.06; 95% CI, 1.19-3.56) and trochanteric soft tissue thickness (OR = 1.82; 95% CI, 1.01, 3.31). Incorporation of trochanteric soft tissue thickness measurements reduced the estimates of fall forces by approximately 50%. After accounting for force-attenuating properties of trochanteric soft tissue, the ratio of fall forces to femoral strength was 50% higher in cases than controls (0.92 +/- 0.44 versus 0.65 +/- 0.50, respectively; p = 0.04). CONCLUSIONS: It is possible to compute a biomechanically based estimate of hip fracture risk by combining estimates of femoral strength based on an empirical relationship between femoral aBMD and bone strength in cadaveric femora, along with estimates of loads applied to the hip during a sideways fall that account for thickness of trochanteric soft tissues. Our findings suggest that trochanteric soft tissue thickness may influence hip fracture risk by attenuating forces applied to the femur during a sideways fall and provide rationale for developing improved measurements of trochanteric soft tissue and for studying a larger cohort to determine whether trochanteric soft tissue thickness contributes to hip fracture risk independently of aBMD
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Cathepsins B, K, and L are regulated by a defined collagen type II peptide via activation of classical protein kinase C and p38 MAP kinase in articular chondrocytes
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Surgical Management of Osteoarthritis of the Knee CPG
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Degradation of the extracellular matrix (ECM) is a prominent feature in osteoarthritis (OA), which is mainly because of the imbalance between anabolic and catabolic processes in chondrocytes resulting in cartilage and bone destruction. Various proteases act in concert to degrade matrix components, e.g. type II collagen, MMPs, ADAMTS, and cathepsins. Protease-generated collagen fragments may foster the destructive process. However, the signaling pathways associated with the action of collagen fragments on chondrocytes have not been clearly defined. The present data demonstrate that the N-terminal telopeptide of collagen type II enhances expression of cathepsins B, K, and L in articular chondrocytes at mRNA, protein, and activity levels, mediated at least in part through extracellular calcium. We also demonstrate that the induction is associated with the activation of protein kinase C and p38 MAP kinase
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Antibiotic-loaded synthetic calcium sulfate beads for prevention of bacterial colonization and biofilm formation in periprosthetic infections
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PJI DX Updated Search
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Periprosthetic infection (PI) causes significant morbidity and mortality after fixation and joint arthroplasty and has been extensively linked to the formation of bacterial biofilms. Poly(methyl methacrylate) (PMMA), as a cement or as beads, is commonly used for antibiotic release to the site of infection but displays variable elution kinetics and also represents a potential nidus for infection, therefore requiring surgical removal once antibiotics have eluted. Absorbable cements have shown improved elution of a wider range of antibiotics and, crucially, complete biodegradation, but limited data exist as to their antimicrobial and antibiofilm efficacy. Synthetic calcium sulfate beads loaded with tobramycin, vancomycin, or vancomycin-tobramycin dual treatment (in a 1:0.24 [wt/wt] ratio) were assessed for their abilities to eradicate planktonic methicillin-resistant Staphylococcus aureus (MRSA) and Staphylococcus epidermidis relative to that of PMMA beads. The ability of the calcium sulfate beads to prevent biofilm formation over multiple days and to eradicate preformed biofilms was studied using a combination of viable cell counts, confocal microscopy, and scanning electron microscopy of the bead surface. Biofilm bacteria displayed a greater tolerance to the antibiotics than their planktonic counterparts. Antibiotic-loaded beads were able to kill planktonic cultures of 10(6) CFU/ml, prevent bacterial colonization, and significantly reduce biofilm formation over multiple days. However, established biofilms were harder to eradicate. These data further demonstrate the difficulty in clearing established biofilms; therefore, early preventive measures are key to reducing the risk of PI. Synthetic calcium sulfate loaded with antibiotics has the potential to reduce or eliminate biofilm formation on adjacent periprosthetic tissue and prosthesis material and, thus, to reduce the rates of periprosthetic infection
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Acetabular fractures: the role of total hip replacement
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PJI DX Updated Search
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Total hip replacement (THR) after acetabular fracture presents unique challenges to the orthopaedic surgeon. The majority of patients can be treated with a standard THR, resulting in a very reasonable outcome. Technical challenges however include infection, residual pelvic deformity, acetabular bone loss with ununited fractures, osteonecrosis of bone fragments, retained metalwork, heterotopic ossification, dealing with the sciatic nerve, and the difficulties of obtaining long-term acetabular component fixation. Indications for an acute THR include young patients with both femoral head and acetabular involvement with severe comminution that cannot be reconstructed, and the elderly, with severe bony comminution. The outcomes of THR for established post-traumatic arthritis include excellent pain relief and functional improvements. The use of modern implants and alternative bearing surfaces should improve outcomes further
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Evaluation of screening schemes for eye disease in a primary care setting
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Upper Eyelid and Brow Surgery
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BACKGROUND AND PURPOSE: Screening in a primary care setting could be an effective method for detection of eye disease. This study was designed to evaluate a questionnaire and a battery of tests for their performance in eye disease screening at a primary care clinic. METHODS: 405 patients aged 40 years or older were interviewed and received a comprehensive eye examination including visual acuity and visual field testing, tonometry, slit-lamp examination, dilated fundus examination and photography. Sensitivity and specificity for the identification of eye disease were calculated for each test and various combinations of tests. RESULTS: A questionnaire-based algorithm for detection of overall eye disease was sufficiently sensitive (90%) but less specific (44%) than an ideal screening test. Distance visual acuity with presenting correction of < or = 20/40 had a sensitivity of 61% and specificity of 72%. A dilated fundus examination had a sensitivity of 79% and specificity of 82%. In screening for glaucoma, tonometry was ineffective (sensitivity = 27% and specificity = 96%), while visual field testing by suprathreshold screening had a sensitivity of 70% and specificity of 67%. Among a variety of combinations, a two-stage strategy with the questionnaire as a first-stage and visual acuity and ophthalmoscopy as second-stage tests provided the best balance of sensitivity (83%) and specificity (76%). CONCLUSION: Among currently available ophthalmic tests, an eye examination including a thorough fundus examination is critical in detection of eye disease. A five-item questionnaire may be useful to identify patients at high risk in primary care practice. More effective tests are needed to improve performance of eye disease screening.
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Trends in hip fracture incidence and in the prescription of antiosteoporosis medications during the same time period in Belgium (2000-2007)
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Management of Hip Fractures in the Elderly
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OBJECTIVE: To examine the secular trend of hip fracture incidence in Belgium between 2000 and 2007 and the concomitant change in the prescriptions of antiosteoporosis medications. METHODS: The incidence of hip fractures and the number of prescriptions were determined using national databases. A logistic regression including years and 5-year age range was performed to assess the secular trend of hip fracture incidence, and Pearson's correlation coefficient was calculated to examine the relationship between hip fracture incidence and the prescriptions of antiosteoporosis medications. RESULTS: The annual number of hip fractures increased in Belgium from 13,512 in 2000 to 14,744 in 2007, with a more marked increased in men (20.4%) than in women (5.7%). The age-adjusted incidence of hip fractures was significantly decreased by 1.12% per year in women, but declined nonsignificantly by 0.34% per year in men. An increase in the prescriptions of antiosteoporosis medications in women was observed during the same time period. CONCLUSION: Despite an increase in the number of hip fractures in Belgium between 2000 and 2007, there was a significant decrease in age-adjusted incidence in women but not in men. Although our results suggest that the decrease may be related to the extent of antiosteoporosis medications, a causal relationship cannot be ascertained and many other factors may have contributed to the decrease in age-adjusted incidence
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Moxibustion for the treatment of osteoarthritis: a systematic review and meta-analysis
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SR for PM on OA of All Extremities
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The aim of this review was to summarise and critically evaluate the evidence from randomised clinical trials (RCTs) of moxibustion as a treatment for patients with osteoarthritis (OA). Twelve databases were searched from their inception through July 2011. RCTs were considered whether they assessed any type of clinical outcome from moxibustion therapy for patients with OA localised to any joints. Two reviewers independently performed the selection of studies, data abstraction and validations. The risk of bias was assessed using the Cochrane criteria. Eight RCTs met our inclusion criteria, and most of them had significant methodological weaknesses. Six RCTs tested the effects of moxibustion against conventional oral drug therapies in patients with knee OA (KOA). Meta-analysis showed favourable effects of moxibustion on the response rate (n = 540; RR, 1.09; 95 % CI 1.03-1.17; P = 0.005; heterogeneity: chi(2) = 5.48, P = 0.36, I (2) = 9 %). Two RCTs tested the effects of moxibustion on response rate after 2 months. The meta-analysis failed to show favourable effects of moxibustion (n = 180; RR, 1.10; 95 % CI 0.97-1.24; P = 0.13; heterogeneity: chi(2) = 0.03, P = 0.87, I (2) = 0 %). In conclusion, consistent results show that moxibustion may be effective in symptom management in patients with KOA. However, because of the number of eligible RCTs and the high risk of bias in the assessment of the available RCTs, the evidence supporting this conclusion is limited
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Tibial plateau fractures in the older patient
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Surgical Management of Osteoarthritis of the Knee CPG
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The epidemiology and management of 151 tibial plateau fractures in patients aged over 60 years of age were reviewed. There were 115 females and 36 males. The usual mode of injury was a simple fall (88 fractures, 58%). The most common pattern of injury observed was the split depression variety, which accounted for 48 (32%) cases, followed by central depression fractures, which occurred in 31 (20%) cases. Non-operative management was used in 103 (68%) of fractures, open reduction and internal fixation in 40 (26%) fractures and external fixation in 8 (5%) fractures. Functional outcome in 67 patients assessed by the Hohl plateau evaluation score was similar in all 3 groups and was more closely related to initial fracture pattern. Forty-six (68%) of these 67 patients had evidence of osteoarthritic change on follow-up radiographs, but only 2 patients in the entire series went on to have a knee replacement. Degenerative change and a mediocre functional outcome are a common occurrence following tibial plateau fractures in patients over 60 years of age
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0 |
Instability and femoral head vitality in fractures of the femoral neck
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Management of Hip Fractures in the Elderly
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Sixteen patients with femoral neck fractures were studied with roentgen-stereophotogrammetric analysis (RSA) and low-field magnetic resonance (MR) imaging in addition to plain roentgenography. In six patients, these results were compared with the results of histopathologic analyses. All fractures were stabilized with two cannulated titanium screws. Evaluation of fracture movement before weight bearing (nine fractures) revealed no or only slight movement (less than 3.4 mm or 4.7 degrees). During weight bearing, two undisplaced fractures were compressed about 5 mm and one 20.3 mm, because of delayed union, which was verified by repeated RSA measurements and MR imaging. The average compression in nine displaced fractures that subsequently healed was 13.3 mm. MR imaging revealed signs of femoral head necrosis in three healed and two unhealed fractures. Segmental or total femoral head necrosis was histologically confirmed in all removed femoral heads, and the fracture areas were shown to be bridged by bone trabeculae to a varying degree. Absence of micromovement six months after fracture implied uncomplicated healing. Fracture stabilization at nine to 12 months postfracture was associated with femoral head necrosis or delayed union in four of six cases. Micromotion after more than one year indicated femoral head necrosis or pseudarthrosis
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1 |
Predicting participation in ultrasound hip screening from message framing
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Developmental Dysplasia of the Hip CPG
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The use of ultrasound (US) screening for developmental dysplasia of the hip (DDH) is an innovation in preventive child health care in the Netherlands. What is not known is whether parents will accept this screening method and will actually participate in it. It is widely known that health behaviors can be influenced by the framing of information. The objective of this study was to examine the influence of a gain- versus loss-framed brochure on parental participation in US screening for DDH. In total, 4150 parents of infants born between August 2007 and December 2008 received either a gain-framed or a loss-framed brochure. Parents could participate in the screening when their infant was 3 months old. The participation rate in the US screening was 74.3%. In contrast to the predictions of prospect theory, the results indicated that parents who had received the gain-framed message were more likely to participate in the screening compared to parents who had received the loss-framed message. This effect may be explained by the low risk perception of parents and by the possibility that the screening was perceived as a health-affirming behavior rather than an illness-detecting behavior. To increase participation rates, it is recommended that parents be informed about the positive aspects of partaking in screening for DDH
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Factor IX replacement to cover total knee replacement surgery in haemophilia B: a single-centre experience, 2000-2010
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PJI DX Updated Search
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Total knee replacement (TKR) is a well recognized treatment for haemophilic arthropathy. Successful haemostasis can be achieved by bolus doses or continuous infusion (CI) using either recombinant (r) or plasma-derived (pd) factor IX (FIX). We retrospectively analysed our experience of factor replacement to cover TKR in haemophilia B patients and explored factors related to FIX use during surgery. Between 2000 and 2010, 13 primary TKRs were performed in 11 haemophilia B patients. Operations were performed by the same surgeon using standard techniques. Median age was 58 years (42-79). An adjusted CI protocol was used for 5 days followed by bolus doses. FIX:C was maintained at 100 IU dL(-1) in the immediate postoperative period. There was no excess haemorrhage. There was no evidence of thrombosis or infection. All patients received mechanical thromboprophylaxis and only one chemical. CI was used in seven cases. Ten patients received pdFIX. Median hospital stay was 14 days (8-17). Median factor usage was 999 IU kg(-1) (768-1248). During CI, factor consumption was 695 IU kg(-1), 691 IU kg(-1) and 495 IU kg(-1) for BeneFix(R), Replenine(R) and Haemonine, respectively. Clearance of both pdFIX and rFIX reduced during CI. All operations were uncomplicated. The decreased clearance in the CI setting reduced the amount of FIX required to maintain a therapeutic level. This reduction was greater with pdFIX and may be related to pharmacokinetic differences between pdFIX and rFIX. Given the excellent safety profile of the pdFIX products, CI of FIX and particularly pdFIX is safe, efficacious and convenient
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Randomized, prospective study of TissuGlu® surgical adhesive in the management of wound drainage following abdominoplasty
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Panniculectomy & Abdominoplasty CPG
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Wound drainage and seroma formation following abdominoplasty remain significant concerns to both surgeons and patients due to the resulting increased need for patient follow-up and delays in returning to normal function. While a number of approaches are used to reduce wound drainage and seroma formation, there is still no definitive solution. A promising strategy to reduce these complications is the development of an effective method for closing dead space between tissue layers in order to achieve improved patient outcomes. We conducted a multicenter, prospective, randomized trial assessing the use of a lysine-derived urethane adhesive (TissuGlu®, Cohera Medical) in patients undergoing abdominoplasty. Twenty patients were randomized to a treatment group and a control group, with the adhesive applied to the abdominal wall prior to closure of the abdominoplasty flap in the treatment group. Control patients underwent an identical procedure but without application of TissuGlu. Outcome measures included time to drain removal, total wound drainage prior to drain removal, and surgical complications. The use of TissuGlu was associated with a trend toward decreased time to drain removal compared to the control group (2.9±1.4 vs. 3.7±1.5 days; P=0.13). Mean total drain volume also tended to be lower in the treatment versus the control group (208.7±138.2 vs. 303.5±240.8 ml; P=0.14). There were no differences in adverse events or complication rates between the two study groups. The application of TissuGlu in abdominoplasty is safe and may decrease wound drainage and the length of time required for postsurgical drains in abdominoplasty patients.
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Dynamic hip screws for unstable intertrochanteric fractures in elderly patients--encouraging results with a cement augmentation technique
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PJI DX Updated Search
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BACKGROUND: Despite the good and reliable results of the dynamic hip screw (DHS) for stable fracture patterns, complications of excessive sliding of the lag screw and inadequate bone anchorage occur frequently in elderly patients with unstable intertrochanteric fractures. Although polymethylmethacrylate (PMMA) bone cement has been widely used as a secondary fixation to facilitate fixation stability, there has been no prospective study on the clinical significance of PMMA cement to prevent these two complications in unstable fracture patterns. METHODS: A prospective study was conducted. The DHS was applied either with or without PMMA cement augmentation in 108 elderly patients. The Arbeitsgemeinschaft fur Osteosynthesefragen/Orthopaedic Trauma Association fracture classification was 31-A2 in 91 patients and 31-A3 in 17 patients. The average age of the patients was 81.9 years (range, 75-96 years). The average follow-up period was 13.9 months (range, 12-30 months). PMMA cement was injected precisely into the proximal fragment with an average amount of 13.7 mL (range, 10-19 mL) in 55 patients. RESULTS: All but six patients (5.6%) had eventual bone union, and the average time to union was 18.1 week (range, 12-36 weeks). Screw sliding, femoral shortening, and varus collapse of the proximal fragment were all significantly reduced in the cemented group at the 1-year follow-up (p < 0.001, p < 0.001, p < 0.001, respectively). The mean hip pain score was 1.9 (range, 1-4) in all 102 patients and was significantly lower in the cemented group (p = 0.008). One patient with a deep infection in the cemented group and five patients with lag screw penetration in the noncemented group received a total hip replacement. All 18 patients with malunion were in the noncemented group. Of these 18 patients, 14 patients (77.8%) had excessive sliding of the lag screw. The overall complication rate was significantly higher in the noncemented group (p < 0.001). CONCLUSIONS: With the meticulous augmentation technique demonstrated in this study, the PMMA cemented DHS proved to have better outcome than a conventional DHS for unstable intertrochanteric fractures in elderly patients. Typical complications related to a conventional DHS device for the treatment of such fractures were successfully prevented
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Health care needs and support for patients undergoing treatment for prosthetic joint infection following hip or knee arthroplasty: A systematic review
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OAK 3 - Non-arthroplasty tx of OAK
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Background: Hip and knee arthroplasty are common interventions for the treatment of joint conditions, most notably osteoarthritis. Although many patients benefit from surgery, approximately 1% of patients develop infection afterwards known as deep prosthetic joint infection (PJI), which often requires further major surgery. Objective: To assess support needs of patients undergoing treatment for PJI following hip or knee arthroplasty and to identify and evaluate what interventions are routinely offered to support such patients. Design: Systematic review Data sources: MEDLINE, EMBASE, Web of Science, PsycINFO, Cinahl, Social Science Citation Index, The Cochrane Library, and reference lists of relevant studies from January 01, 1980 to October 05, 2016. Selection criteria: Observational (prospective or retrospective cohort, nested case-control or case-control) studies, qualitative studies, or clinical trials conducted in patients treated for PJI and/or other major adverse occurrences following hip or knee arthroplasty. Review methods: Data were extracted by two independent investigators and consensus was reached with involvement of a third. Given the heterogeneous nature of study designs, methods, and limited number of studies, a narrative synthesis is presented. Results: Of 4,213 potentially relevant citations, we identified one case-control, one prospective cohort and two qualitative studies for inclusion in the synthesis. Patients report that PJI and treatment had a profoundly negative impact affecting physical, emotional, social and economic aspects of their lives. No study evaluated support interventions. Conclusion: The findings demonstrate that patients undergoing treatment for PJI have extensive physical, psychological, social and economic support needs. The interpretation of study results is limited by variation in study design, outcome measures and the small number of relevant eligible studies. However, our review highlights a lack of evidence about support strategies for patients undergoing treatment for PJI and other adverse occurrences following hip or knee arthroplasty. There is a need to design, implement and evaluate interventions to support these patients. Systematic Review Registration: PROSPERO 2015: CRD42015027175.
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The Effect of Preoperative Administration of Intravenous Tranexamic Acid During Revision Hip Arthroplasty: A Retrospective Study
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Hip Fx in the Elderly 2019
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BACKGROUND: Revision hip arthroplasty poses several challenges, including the management of perioperative blood loss. Recent studies have validated the use of tranexamic acid in primary total hip arthroplasty, showing reduced blood loss and decreased number of allogenic blood transfusions. The effectiveness of tranexamic acid has not been well studied in the revision hip arthroplasty setting.
METHODS: We performed a retrospective review of 1,072 patients who underwent revision hip arthroplasty at our institution from 2008 to 2016. A total of 634 patients met the inclusion criteria, and comparisons were made between 232 consecutive patients without the use of tranexamic acid and 402 consecutive patients with the use of tranexamic acid. Patients were subdivided into 4 groups based on the complexity of revision surgical procedures: (1) major revision, (2) isolated femoral component revision, (3) isolated acetabular component revision, and (4) isolated femoral head and acetabular liner exchange. Within these groups, we compared the demographic data, estimated intraoperative blood loss, perioperative blood units transfused, postoperative hemoglobin drop, and thromboembolic complications between patients receiving either tranexamic acid or no antifibrinolytic therapy.
RESULTS: The primary outcomes of our study (estimated intraoperative blood loss, postoperative hemoglobin drop, and perioperative blood transfusion) were all reduced in patients who received tranexamic acid compared with patients who received no antifibrinolytic therapy. When analyzed on the basis of the complexity of surgical revision, there was a decrease in estimated intraoperative blood loss following tranexamic acid administration in the major revision group (845 compared with 1,095 mL; p < 0.001). The postoperative drop in hemoglobin was lower in the major revision group with tranexamic acid administration (by 8.9 g/L; p < 0.01) and the isolated acetabular component revision group with tranexamic acid administration (by 11.9 g/L; p < 0.001). The need for perioperative blood transfusion was reduced across all revisions treated with tranexamic acid (major revision group, 1.79 compared with 3.33 units, p < 0.001; femoral revision only, 0.97 compared with 2.25 units, p < 0.01; acetabular revision only, 0.73 compared with 1.72 units, p < 0.001; and head and liner exchange, 0.15 compared with 0.89 unit, p < 0.05).
CONCLUSIONS: Based on this study, preoperative administration of intravenous tranexamic acid in revision hip arthroplasty reduces allogenic blood transfusions and perioperative blood loss.
LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Complication rates following open reduction and internal fixation of ankle fractures
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DoD LSA (Limb Salvage vs Amputation)
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BACKGROUND: Ankle fractures are among the most common injuries treated by orthopaedic surgeons. The purpose of the present investigation was to examine the risks of complications after open reduction and internal fixation of ankle fractures in a large population-based study. METHODS: With use of California's discharge database, we identified 57,183 patients who had undergone open reduction and internal fixation of a lateral malleolar, bimalleolar, or trimalleolar ankle fracture as inpatients in the years 1995 through 2005. Short-term complications were examined on the basis of the rates of readmission within ninety days after discharge. The intermediate-term rate of reoperation for ankle fusion or arthroplasty was also analyzed. Logistic regression and proportional hazard regression models were used to determine the strength of the relationships between the rates of complications and fracture type, patient demographics and comorbidities, and hospital characteristics. RESULTS: The overall rate of short-term complications was low, including the rates of pulmonary embolism (0.34%), mortality (1.07%), wound infection (1.44%), amputation (0.16%), and revision open reduction and internal fixation (0.82%). The intermediate-term rates of reoperation were also low, with ankle fusion or ankle replacement being performed in 0.96% of the patients who were observed for five years. Open fractures, age, and medical comorbidities were significant predictors of short-term complications. The presence of complicated diabetes was a particularly strong predictor (odds ratio, 2.30; p < 0.001), as was peripheral vascular disease (odds ratio, 1.65; p < 0.001). The intermediate-term rate of reoperation for ankle fusion or replacement was higher in patients with trimalleolar fractures (hazard ratio, 2.07; p < 0.001) and open fractures (hazard ratio, 5.29; p < 0.001). Treatment at a low-volume hospital was not significantly associated with either the aggregate risk of short-term complications or the risk of intermediate-term reoperation. CONCLUSIONS: By analyzing a large, diverse patient population, the present study clarifies the risks associated with open reduction and internal fixation of ankle fractures. Open injury, diabetes, and peripheral vascular disease were strong risk factors predicting a complicated short-term postoperative course. Fracture type was a strong predictor of reoperation for ankle fusion or replacement. Hospital volume did not play a significant role in the rates of short-term or intermediate-term complications.
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Expression of calcitonin gene-related peptide in medullary thyroid cancer
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MSTS 2018 - Femur Mets and MM
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We studied the expression of calcitonin (CT) and calcitonin gene-related peptide (CGRP) in 18 patients with medullary thyroid cancer (MTC) in the neoplastic (primary or metastatic) tissue by immunohistochemistry and in the plasma by radioimmunoassay. CT immunoreactivity was found in 100% of the primary and metastatic MTC, CGRP was expressed in 66% of the primary tumors and in 73% of the metastases. Both the number of positive cells and the degree of staining were always higher for CT than for CGRP staining. While plasma CT concentrations were always increased in patients with metastases, 3 patients with metastases had undetectable plasma CGRP levels. A positive correlation was found between plasma CT and CGRP levels. These data indicate that CGRP is frequently expressed in MTC sections and that plasma CGRP measurement is an additional marker for MTC, although has no advantage with respect to CT measurements in monitoring the progression of the disease.
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Functional comparison of the dynamic hip screw and the Gamma locking nail in trochanteric hip fractures: a matched-pair study of 268 patients
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Management of Hip Fractures in the Elderly
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The aim of this prospective matched-pair (age, sex, fracture type, residential status, and walking ability at fracture) study was to analyse the short-term outcome after Gamma nail (GN) and dynamic hip screw (DHS) fixation, focusing especially on functional aspects (Standardised Audit of Hip Fractures in Europe [SAHFE] hip fracture follow-up forms), reoperations, and mortality. Both groups consisted of 134 patients. DHS and GN groups did not differ significantly with respect to location of residence at 4 months or returning to the prefracture dwelling (78% vs. 73%, P = 0.224). The change in walking ability at 4 months compared to prefracture situation was better in the DHS group (p = 0.042), although there was no difference in the change of use of walking aids. The frequency of reoperations during the first year was somewhat lower in the DHS group (8.2% vs. 12.7%, p = 0.318). Mortality was lower in the DHS group both at 4 months (6.0% vs. 13.4%, p = 0.061) and 12 months (14.9% vs. 23.9%, p = 0.044). Although walking ability was better and mortality lower in the DHS group, both methods are useful in the treatment of trochanteric femoral fractures
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Revision surgery of reverse shoulder arthroplasty
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Glenohumeral Joint OA
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Background: There is limited knowledge regarding revision of reverse shoulder arthroplasty (RSA). This study assesses reasons for failure in RSA and evaluates the outcomes of revision RSA. Materials and methods: Between 1997 and 2009, 37 patients with RSA had revision surgery. Clinical and radiologic examinations performed preoperatively and at 3 months, at 6 months, and then annually postoperatively were analyzed retrospectively. Patients were reviewed with a minimum 2-year follow-up. Results: The most common causes for RSA revision were prosthetic instability (48%); humeral loosening, derotation, or fracture (21%); and infection (19%). Only 2 patients (3%) had to be reoperated on for glenoid loosening. More than 1 re-intervention was performed in 11 patients (30%) because of recurrence of the same complication or appearance of a new complication. Underestimation of humeral shortening and excessive medialization were common causes of recurrent prosthetic instability. Proximal humeral bone loss was found to be a cause for humeral loosening or derotation. Previous surgery was found as a potential cause of low-grade infection. At a mean follow-up of 34 months, 32 patients (86%) had retained the RSA whereas 2 patients (6%) had undergone conversion to humeral hemiarthroplasty and 3 (8%) to a resection arthroplasty. The mean Constant score in patients who retained the RSA increased from 19 points before revision to 47 points at last follow-up (P < .001). Conclusions: Even if revision may lead to several procedures in the same patient, preservation or replacement of the RSA is largely possible, allowing for a functional shoulder. Full-length scaled radiographs of both humeri are recommended to properly assess humeral shortening and excessive medialization before revision. © 2013 Journal of Shoulder and Elbow Surgery Board of Trustees.
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Measuring functional outcomes in work-related upper extremity disorders. Development and validation of the Upper Extremity Function Scale
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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Questionnaire-based measures of function have been validated extensively in studies of chronic illness and work-related low back pain. These measures have only recently been developed for upper extremity disorders (UEDs), and there is little information on their utility in evaluation of injured workers. We developed the Upper Extremity Function Scale (UEFS), an eight-item, self-administered questionnaire, to measure the impacts of UEDs on function. This instrument was tested in a cohort of 108 patients with work-related UEDs and 165 patients with the carpal tunnel syndrome (CTS); both groups were enrolled in prospective follow-up studies. The UEFS demonstrated excellent psychometric properties, including good internal consistency (Cronbach's alpha > 0.83), relative absence of floor effects, and excellent convergent and discriminant validity, compared with measures of symptom severity and clinical findings. In the CTS group, the UEFS was more responsive to significant improvements over time than clinical measures such as grip and pinch strength. These data support the use of a self-reported functional scale as a measure of outcome in studies of work-related UEDs. Further investigations in working populations are needed to substantiate its utility in workers with UEDs who have not yet sought medical care
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Identification Bracelet Precipitated Acute Compartment Syndrome during Intravenous Infusion in an Obtunded Patient
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DOD - Acute Comp Syndrome CPG
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Acute compartment syndrome is a serious condition requiring immediate medical care. A lack of urgent medical treatment can result in serious complications such as loss of function and even amputation. While the pathophysiology of acute compartment syndrome is well understood, numerous potential causes are still being discovered. A rare cause of acute compartment syndrome is IV infiltration. We present a case of acute compartment syndrome resulting from intravenous infusion due to proximal placement of a patient identification bracelet. We conclude that both routine evaluation for IV infiltration and proximal placement of IV lines are essential for prevention of acute compartment syndrome.
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The role of community screening for developmental dysplasia of the hip at the 8-month baby check
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Developmental Dysplasia of the Hip CPG
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BACKGROUND: Screening for developmental dysplasia of the hip (DDH) after the neonatal period is controversial. Due to recent changes in the screening policy in England & Wales, routine clinical screening for DDH at the 8-month baby check is no longer recommended. RESULTS: This paper looks at the effectiveness of screening for DDH by health visitors in the Flintshire area. A total of 525 8-month baby checks were performed in our area in 2007. Thirty babies were referred to their general practitioner of which six were referred on to a specialist children's orthopaedic surgeon. None of these required treatment for DDH. One patient who was screened by the health visitor but not referred was later diagnosed with DDH. CONCLUSION: Screening for DDH at 8 months using clinical examination by a trained health visitor has a high false-positive rate. This paper therefore supports the current UK National Screening Committee position
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Bone demineralization and vertebral fractures in endogenous cortisol excess: role of disease etiology and gonadal status
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Management of Hip Fractures in the Elderly
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INTRODUCTION: The effects of endogenous cortisol (F) excess on bone mass and vertebral fractures have still not been thoroughly investigated. The aim of this cross-sectional case-control study was to investigate factors influencing bone demineralization and vertebral fractures in different conditions of F excess, i.e. Cushing's disease and adrenal and ectopic Cushing's syndrome. MATERIALS AND METHODS: Eighty consecutive patients and 80 controls were prospectively enrolled: 37 patients (21 females) with pituitary ACTH-secreting adenoma, 18 (14 females) with adrenocortical adenoma, 15 (11 females) with adrenal carcinoma of mixed secretion, and 10 (three females) with ectopic ACTH secretion. The groups had similar age. At diagnosis, bone mineral density (BMD) was determined by the dual-energy x-ray absorptiometry technique at the lumbar spine (L1-L4) and femoral neck; vertebral fractures were investigated by standard spinal radiographs. RESULTS: When comparing the groups with different etiology of F excess, the patients with ectopic ACTH secretion had higher F and lower BMD values than the other subgroups. Morning F (P = 0.03) and testosterone levels (P = 0.04) correlated with lumbar BMD. Vertebral fractures were found in 61 (76%) of the patients, were multiple in 52 (85%) of the cases, and clinically evident in 32 (52%). Only multiple fractures were more frequent in patients with ectopic ACTH hypersecretion (P < 0.05). Lumbar spine BMD was the best predictor of vertebral fractures (P < 0.01). Surprisingly, amenorrheic and eumenorrheic women had similar BMD values and fracture prevalence. CONCLUSION: A high prevalence (76%) of vertebral fracture was revealed, regardless of the etiology of the patients' hypercortisolism. The harmful effects of F excess at the spine were partly counterbalanced by the increased androgen production but were not affected by gonadal status in women
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1 |
Epidural vs. lumbar plexus infusions following total knee arthroplasty: randomized controlled trial
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Surgical Management of Osteoarthritis of the Knee CPG
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BACKGROUND AND OBJECTIVE: Postoperative regional analgesia for total knee replacement can provide excellent pain control and speedy rehabilitation compared with systemic opioid analgesia but the optimal technique to provide best analgesia with minimal adverse effects remains unclear. We carried out an observer-blinded randomized trial of side-directed epidural infusion with lumbar plexus infusion after total knee arthroplasty. METHODS: Sixty patients scheduled for total knee replacement were randomized to receive epidural or lumbar plexus infusions of levobupivacaine and clonidine. Pain, sensory and motor block were assessed at 0, 6, 24 and 48 h postoperatively. Range of knee movement and mobility were assessed on the first and second postoperative days. RESULTS: No significant differences were detected between the epidural and lumbar plexus groups in 24-h pain scores at rest (median visual analogue scale, 30 mm (interquartile range, 10-45) vs. 39 mm (17-51), P = 0.286), and on movement (48 mm (20-66) vs. 60 mm (47-81), P = 0.068). The only statistically significant difference in pain scores in favour of the epidural groups was at 6 h postoperatively (P < 0.001). Median morphine usage in the epidural group was 0 mg (interquartile range, 0-35) compared with 14.5 mg (0-44) in the lumbar plexus group (P = 0.33). Range of movement (epidural: median 70 degrees (interquartile range, 58-75) vs. lumbar plexus: 70 degrees (50-75), P = 0.79) or mobility was similar between groups. Adverse effects were also similar between groups, apart from a higher incidence of bladder catheterization in the epidural group (37.9% vs. 12.5%, P = 0.04). CONCLUSIONS: Lumbar plexus infusion is a reasonable alternative to epidural anaesthesia for total knee arthroplasty
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Long-term Outcomes with Ifosfamide-based Hypofractionated Preoperative Chemoradiotherapy for Extremity Soft Tissue Sarcomas
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DoD SSI (Surgical Site Infections)
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Objectives: The objective of this study was to analyze outcomes for patients with soft tissue sarcoma of the extremities using neoadjuvant ifosfamide-based chemotherapy and hypofractionated reduced dose radiotherapy, followed by limb-sparing surgery. Materials and Methods: An Institutional Review Board (IRB)- approved retrospective review of patients treated at a single institution between 1990 and 2013 was performed. In total, 116 patients were identified who received neoadjuvant ifosfamide-based chemotherapy and 28 Gy in 8 fractions of preoperative radiation (equivalent dose in 2 Gray fractions, 31.5 Gy [a/ß 10] 36.4 Gy [a/ß 3]) followed by limbsparing surgery. Local recurrence (LR), distant failure (DF), and overall survival (OS) were calculated. Univariate and multivariate analysis for LR, DF, and OS were performed using Cox analysis. Statistical significance was set at a P<0.05. Results: Median follow-up was 5.9 years (range, 0.3 to 24 y). Actuarial LR at 3/6 years was 11%/17%, DF at 3/6 years was 25%/35%, and OS at 3/6 years was 82%/67%. On multivariate analysis, only a positive surgical margin was significantly correlated with worse local control (P=0.005; hazard ratio [HR], 18.33; 95% confidence interval (CI), 2.41-139.34). Age over 60 years (P=0.03; HR, 2.34; 95% CI, 1.10- 4.98) and tumor size over 10 cm compared with tumor size = 5 cm (P=0.03; HR, 3.32; 95% CI, 1.15-9.61) were associated with worse OS. Conclusions: Soft tissue extremity sarcoma patients treated using reduced dose hypofractionated preoperative radiotherapy in combination with ifosfamide-based chemotherapy shows acceptable local control and warrants further investigation.
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Effect of levobupivacaine on articular chondrocytes: an in-vitro investigation
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AAHKS (8) Anesthetic Infiltration
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BACKGROUND: Intra-articular injection of local anaesthetics is a technique commonly used to enhance postoperative analgesia following arthroscopic surgery. However, the potential for cartilage damage due to toxicity of intra-articular local anaesthetics is a concern. Most studies indicate that the toxic effect is drug and time dependent.
OBJECTIVES: The objective of this study is to compare the in-vitro chondrotoxic effect of levobupivacaine on human cartilage with saline and bupivacaine.
DESIGN: An experimental study.
SETTING: University hospital.
PARTICIPANTS: Adult patients undergoing knee surgery.
INTERVENTIONS: Human articular cartilage was harvested and removed from five patients during knee replacement surgery. Chondrocytes were cultured and divided into three groups exposed to bupivacaine 0.5%, levobupivacaine 0.5% or physiological saline for 15, 30 or 60 min.
MAIN OUTCOME MEASURES: Viability of human cartilage cells after contact with the different study drugs at different durations of exposure using two techniques: live/dead cell viability flow cytometry analysis and trypan blue exclusion assay.
RESULTS: At 1 h of exposure, chondrocyte mortality in cartilage explants was significantly greater after treatment with levobupivacaine or bupivacaine than with saline (25.9% +/- 14.1, 20.7% +/- 10.4 and 9.6% +/- 5.4, respectively). No differences between groups were found when exposure to the experimental drug was limited to 15 or 30 min.
CONCLUSION: In-vitro 0.5% levobupivacaine is more chondrotoxic than saline in human articular cartilage after 1 h of exposure. Bupivacaine seems to be less chondrotoxic than levobupivacaine. With shorter exposures, no clear chondrotoxic effect was shown.
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Early surgery increases mitochondrial DNA release and lung injury in a model of elderly hip fracture and chronic obstructive pulmonary disease
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Hip Fx Time to Surgery
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Hip fractures are one of the most common injuries in elderly individuals and are associated with a high incidence of complications and mortality. Clinical guidelines recommend early reparative surgery within 24-48 h from hospital admission; however, it is currently unknown whether this principle of early surgery is applicable for patients with hip fracture and chronic obstructive pulmonary disease (COPD). To investigate the systemic inflammatory response and lung injury as a result early surgery in elderly patients with hip fracture and COPD, a COPD model was created, by daily exposure to cigarette smoke, and evaluated. Rats (5 months of age) were exposed to cigarette smoking for 37 weeks to create a COPD group. Rats not exposed to cigarette smoke formed the control group. All rats experienced hip fracture, which was subsequently treated with surgery at 24 h (early fixation; EF) or 72 h (late fixation; LF) after fracture, respectively. Serum mitochondrial DNA (mtDNA), tumor necrosis factor-alpha (TNF-alpha), interleukin (IL)-6 and IL-10 were measured at 2 and 24 h after surgery. Cytokine and myeloperoxidase (MPO) activity in the lung tissue were measured and assessed via bronchoalveolar lavage. The serum mtDNA, IL-6 and IL-10 levels in the control group and in the COPD group increased rapidly at 2 h and peaked at 24 h, while TNF-alpha levels peaked at 2 h and subsequently decreased. Rats that received EF in the COPD group demonstrated a significant increase of TNF-alpha (P<0.001 at 2 h), IL-6 (P<0.001 at 2 and 24 h), IL-10 (P=0.010 at 2 h and P=0.001 at 24 h) and mtDNA (P<0.001 at 24 h) compared with the rats that received LF. LF in experimental rats also significantly reduced the severity of MPO activity (P<0.001 and P=0.001) and permeability (P=0.009 and P=0.018) in pulmonary samples at 2 or 24 h, respectively, compared with EF. However, LF in the control group did not demonstrate a significant advantage at reducing MPO and permeability in serum and pulmonary samples. The present study indicated that early surgery increased mtDNA and cytokine release in a model of elderly hip fracture with COPD, and LF may reduce the severity of the inflammatory response and degree of permeability in pulmonary tissues.
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0 |
Medial Closing-Wedge Distal Femoral Osteotomy: Fixation With Proximal Tibial Locking Plate
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OAK 3 - Non-arthroplasty tx of OAK
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Distal femoral varus osteotomy is a well-established procedure for the treatment of lateral compartment cartilage lesions and degenerative disease, correcting limb alignment and decreasing the progression of the pathology. Surgical techniques can be performed with a lateral opening-wedge or medial closing-wedge correction of the deformity. Fixation methods for lateral opening-wedge osteotomies are widely available, and there are various types of implants that can be used for fixation. However, there are currently only a few options of implants for fixation of a medial closing-wedge osteotomy on the market. This report describes a medial, supracondylar, V-shaped, closing-wedge distal femoral osteotomy using a locked anterolateral proximal tibial locking plate that fits anatomically to the medial side of the distal femur. This is a great option as a stable implant for a medial closing-wedge distal femoral osteotomy.
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Emergency Department Visits Following Joint Replacement Surgery in an Era of Mandatory Bundled Payments
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PJI DX Updated Search
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OBJECTIVES: The Center for Medicare and Medicaid Services (CMS) is actively testing bundled payments models. This study sought to identify relevant details for 90-day post-discharge Emergency Department (ED) visits of Medicare beneficiaries following total joint replacement (TJR) surgery meeting eligibility for a CMS bundled payment program. METHODS: The CMS research identifiable file for the State of Texas for 2011-2012 was used to identify patients who underwent TJR. Qualifying inpatient claims were linked to 90-day post-discharge ED claims. The claims associated with live discharge were divided into three cohorts; elective total hip replacement (THR), emergent (THR) and total knee replacement (TKR). The frequency, distribution, diagnoses, and disposition for these ED visits were identified and stratified by timing within the post-discharge period as well as discharge diagnosis. Visits were correlated with age, gender, joint replaced, and fracture. RESULTS: There were 50,838 TJR surgeries in Texas in 2011-2012 that would have been eligible for inclusion in the CMS defined CJR program. A total of 12,747 ED visits by 9,299 patients occurred in the 90-days post-discharge period. Visits to the ED by patients 85 and older predominated in the case of THR performed secondary to a hip fracture. Patients 65-74 predominated in both elective surgery categories. There were 2370 ED visits within 90 days of 10,786 elective total hip replacements; of which 55.5% were discharged home, 34.6% were hospitalized or transferred and 6.9% were admitted to observation. Of the 3438 ED visits among 8475 emergent hip replacement cases; 22.4% were discharged home, 50.2% were hospitalized or transferred and 5.3% were admitted to observation. Of the 6939 visits among 31,387 knee replacement cases; 61.9% were discharged home, 30.6% were readmitted or transferred, and 7.1% were admitted to observation. The discharge diagnoses varied by volume and timing in the post-discharge period. The most prevalent diagnoses across groups included injury/trauma, physiologic decompensation, cardiopulmonary events, and infection. CONCLUSIONS: ED services are frequent for Medicare total joint replacement bundle-eligible patients within the post-discharge period. ED utilization, discharge diagnosis and disposition varied by age, and elective and emergent surgeries. The ED is an important site for identifying and managing post-operative adverse outcomes. This article is protected by copyright. All rights reserved
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Diagnosis of long head of biceps tendinopathy in rotator cuff tear patients: correlation of imaging and arthroscopy data
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Trial Systematic Review Project
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Introduction: The goal of this prospective study was to assess the reliability of pre-operative cross-sectional imaging for the diagnosis of long head of biceps (LHB) tendinopathy in patients with a rotator cuff tear. Methods: Cross-sectional imaging with MRI or CT arthrography data from 25 patients operated upon because of a rotator cuff tear between 1 October 2015 and 1 April 2016 was analysed by one experienced orthopaedic surgeon, one experienced radiologist and one orthopaedic resident. The analysis consisted of determining whether the LHB was present, the extrinsic tendon abnormalities (dislocation, tendon coverage) and intrinsic abnormalities (fraying, inflammation, degeneration). These findings were then compared to intra-operative arthroscopy findings, which were used as the benchmark. The interobserver correlation between the three different examiners for the cross-sectional imaging analysis as well as the correlation between the imaging and arthroscopy data were determined. Results: The correlation between the imaging and arthroscopy data was the highest (80%) for the determination of LHB dislocation from the bicipital groove. The other diagnostic elements (subluxation, coverage and tendon degeneration) were difficult to discern with preoperative imaging, and correlated poorly with the arthroscopy findings (45% to 65%). The interobserver correlation was moderate to strong for the diagnosis of extrinsic tendon abnormalities. It was low to moderate for intrinsic abnormalities. Conclusion: Except for LHB dislocation, pre-operative imaging is not sufficient to make a reliable diagnosis of LHB tendinopathy. Arthroscopy remains the gold standard for the management of LHB tendinopathy, as diagnosed intra-operatively.
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pH and metal concentration of synovial fluid of osteoarthritic joints and joints with metal replacements
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PJI DX Updated Search
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BACKGROUND: Due to degradation and metal dissolution during articulation of metal joint replacements the chemical periprosthetic environment may change. The aim was to establish whether metal replacements cause the local changes in pH and elevated metal concentrations. METHODS: pH was measured on samples from 167 patients: native hip and knee osteoarthritic joints, joints with hip and knee replacements revised for aseptic or septic reasons. pH of synovial fluid and periprosthetic tissue was measured perioperatively using a microelectrode and pH indicator papers for removed metal components. Metal concentrations were measured in 21 samples using inductively coupled plasma mass spectrometry. RESULTS: The mean pH value of synovial fluid at native osteoarthritic joints (n = 101) was 7.78 +/- 0.38. The mean pH value of synovial fluid at revision aseptic operation (n = 58) was 7.60 +/- 0.31, with statistically significant difference (p = 0.002) compared to native osteoarthritic joints. The mean pH value of synovial fluid at revision septic operation (n = 8) was 7.55 +/- 0.25, with statistically significant difference (p = 0.038) compared to native osteoarthritic joints. Measurements in tissue and at stems were not reliable. In the majority of samples taken at revision increased levels of cobalt and chromium were measured. CONCLUSION: A small but statistically significant difference was observed in the pH of synovial fluid between natural joints with degenerative diseases and joints treated with metal replacements. Based on the increased metal levels we expected the value of pH to be lower, but the influence of metal ions is counteracted by the buffering capacity of human body. (c) 2016 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater, 2016
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Unicompartmental arthroplasty for knee osteoarthritis
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Osteochondritis Dissecans 2020 Review
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This is a protocol for a Cochrane Review (Intervention). The objectives are as follows: To assess the benefits and harms of unicompartmental knee arthroplasty in the treatment of knee osteoarthritis in adults in terms of decreasing pain, increasing knee function, and postponing the need for a total knee arthroplasty.
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Virtual Fracture Clinics in Orthopaedic Surgery - A Systematic Review of Current Evidence
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DoD SSI (Surgical Site Infections)
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AIMS: Approximately 75% of fractures are simple, stable injuries which are often unnecessarily immobilised with subsequent repeated radiographs at numerous fracture clinic visits. In 2014, the Glasgow Fracture Pathway offered an alternative virtual fracture clinic (VFC) pathway with the potential to reduce traditional fracture clinic visits, waiting times and overall costs. Many units have implemented this style of pathway in the non-operative management of simple, undisplaced fractures. This study aims to systematically review the clinical outcomes, patient reported outcomes and cost analyses for VFCs.
MATERIALS AND METHODS: Two independent reviewers performed the literature search based on PRISMA guidelines, utilizing the MEDLINE, EMBASE and COCHRANE Library databases. Studies reporting outcomes following the use of VFC were included. Outcomes analysed were: 1) clinical outcomes, 2) patient reported outcomes, and 3) cost analysis.
RESULTS: Overall, 15 studies involving 11,921 patients with a mean age of 41.1 years and mean follow-up of 12.6 months were included. In total, 65.7% of patients were directly virtually discharged with protocol derived conservative management, with 9.1% using the Helpline and 15.6% contacting their general practitioner for advice or reassurance. A total of 1.2% of patients experienced fracture non-unions and 0.4% required surgical intervention. The overall patient satisfaction rate was 81.0%, with only 1.3% experiencing residual pain at the fracture site. Additionally, the mean cost per patient for VFC was 71, with a mean saving of 53 when compared to traditional clinic models. Subgroup analysis found that for undisplaced fifth metatarsal or radial head/neck fractures, the rates of discharge from VFC to physiotherapy or general practitioners were 81.2% and 93.7% respectively.
DISCUSSION AND CONCLUSION: This study established that there is excellent evidence to support virtual fracture clinic for non-operative management of fifth metatarsal fractures, with moderate evidence for radial head and neck fractures. However, the routine use of virtual fracture clinics is presently not validated for all stable, undisplaced fracture patterns.
LEVEL OF EVIDENCE: IV; Systematic Review of all Levels of Evidence.
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High tibial osteotomy for the treatment of unicompartmental arthritis of the knee
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Surgical Management of Osteoarthritis of the Knee CPG
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Proximal tibial osteotomy can be used to correct varus and valgus deformities in the management of isolated medial or lateral compartment osteoarthritis. Several surgical techniques have been described for achieving this goal, and the relative merits of each have been outlined. Whatever the technique used, the selection of the appropriate patient and the attainment of a precise correction without complications are critical to the success of the procedure. If these goals are met, proximal tibial osteotomy should provide long-term relief of pain and restoration of function in patients who have localized knee osteoarthritis even in carefully selected, highly motivated, older active patients. (copyright) 2005 Elsevier Inc. All rights reserved
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Fresh-stored osteochondral allografts for the treatment of femoral head defects: surgical technique and preliminary results
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Osteochondritis Dissecans 2020 Review
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PURPOSE: The purpose of this study was to present the preliminary clinical and radiographic outcomes of the treatment of femoral head osteochondral defects in eight consecutive symptomatic patients with fresh-stored osteochondral allografts via a trochanteric osteotomy. METHODS: This study included all consecutive patients treated in our department between 2008 and 2010 for worsening pain and mechanical symptoms of femoral head osteochondral defects. Each patient had preoperative routine hip radiographs and a preoperative magnetic resonance imaging study that determined and recorded the defect size and femoral head diameters. Allograft donors were identified through the Multiple Organ Retrieval and Exchange program (Ontario, Canada). RESULTS: The osteochondral defects were secondary to osteochondritis dissecans in four patients, avascular necrosis in three and femoral head fracture without dislocation in one. The patients' average age at surgery was 23.7 (range 17-42), and the average follow-up was 41 months (range 24-54). Follow-up included clinical and radiographic examinations at standard intervals. The average Harris hip scores improved from 57.7 (range 50-65) points preoperatively to 83.9 (range 72-94) points at latest follow-up. Five patients had good-to-excellent clinical outcomes, and one had a fair outcome. One patient was converted to a total hip arthroplasty due to progression of arthritis. Another patient's graft subsided and he underwent a successful repeat transplantation. An additional patient required the removal of the screws transfixing her trochanter due to persistent irritation. CONCLUSIONS: These findings indicate that fresh-stored osteochondral allograft transplantation using a trochanteric slide and surgical dislocation is a viable treatment option for femoral head defects in young patients.
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A Surgeon's Guide to Obtaining Hemorrhage Control in Combat-Related Dismounted Lower Extremity Blast Injuries
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DoD LSA (Limb Salvage vs Amputation)
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The application of lessons learned on the battlefield for timely surgical control of lower extremity hemorrhage secondary to blast injuries to the civilian practice for similar wounding patterns from industrial accidents or terrorist activities is imperative. Although simple cut-down procedures are commonly sufficient for the control of blood vessels for distal extremity traumatic amputations, high-thigh or disarticulation wounding patterns often require more complex surgical methods. The following details both the decision-making process and operative techniques for controlling hemorrhage from lower extremity blast injuries.
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Knee arthrodesis with a press-fit modular intramedullary nail without bone-on-bone fusion after an infected revision TKA
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PJI DX Updated Search
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INTRODUCTION: Knee arthrodesis can be an effective treatment after an infected revision Total Knee Arthroplasty (TKA). The main hypothesis of this study is that a two-stage arthrodesis of the knee using a press-fit, modular intramedullary nail and antibiotic loaded cement, to fill the residual gap between the bone surfaces, prevents an excessive limb shortening, providing satisfactory clinical and functional results even without direct bone-on-bone fusion. MATERIAL AND METHODS: The study included 22 patients who underwent knee arthrodesis between 2004 and 2009 because of recurrent infection following revision-TKA (R-TKA). Clinical and functional evaluations were performed using the Visual Analogue Scale (VAS) and the Lequesne Algofunctional Score. A postoperative clinical and radiographical evaluation of the residual limb-length discrepancy was conducted by three independent observers. RESULTS: VAS and LAS results showed a significant improvement with respect to the preoperative condition. The mean leg length discrepancy was less than 1cm. There were three recurrent infections that needed further surgical treatment. DISCUSSION: This study demonstrated that reinfection after Revision of total knee Arthroplasty can be effectively treated with arthrodesis using a modular intramedullary nail, along with an antibiotic loaded cement spacer and that satisfactory results can be obtained without direct bone-on-bone fusion
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Follow-up of total hip replacement using domestic prosthesis in 33 hips
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Management of Hip Fractures in the Elderly
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BACKGROUND: Total hip replacement has been widely used in the treatment of severer hip diseases in China. However, most of prostheses are designed according to Caucasian osteometric measurements, whether those prostheses are suitable for Orientals is still in dispute. It is emerging to design prostheses for Orientals, there are few reports addressing therapeutic effect after replacement. OBJECTIVE: To follow up the long-term results of total hip replacement using domestic designed dual-assembly total hip prosthesis. METHODS: Totally 30 patients (33 hips) who underwent total hip replacement at the Department of Orthopaedic Surgery, China-Japan Union /Affiliated Hospital of Jilin University, from June 1987 to December 1996, were followed up. The designed dual-assembly total hip prosthesis was produced by Central Iron & Steel Research Institute, which was similar to bipolar prosthesis with a polyethylene acetabular cup. First generation cementing techniques were applied. The average age at the time of the operation was 56.5 years (30-81 years) and the average follow-up period was 8.5 years (5.0-14.4 years). Standard anteroposterior radiographs of the hip and clinical examinations were used to analyze therapeutic efficacy
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Total Knee Replacement TIVA
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AAHKS (4) Acetaminophen
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Preoperative Care Patients will be approached at the preadmission clinic or in the general ward before operation. The anaesthetic techniques will be explained and s/he will be recruited into the study if s/he agrees. Fasting will start 6 hours before surgery for solids and 2 hours clear fluid. All patients will be given oral celebrex 200mg, paracetamol 1g, pregabalin 75mg po, and pantaloc 40mg po two hours before start of anaesthesia. Range of movement of the operating knee, quadriceps function, pain scores of the affecting knee will be assessed on day before operation. Baseline data for health related quality of life, psychological status, and quality of recovery will be obtained using the Chinese Hong Kong version of SF12v2, hospital anxiety and depression scale (HADS) questionnaire, and the Chinese quality of recovery (QoR) score, respectively (10, 11). Anaesthesia and intraoperative care On arrival to the operation theatre, a 18 or 16 gauge intravenous cannula will be inserted. Standard monitoring with pulse oximeter, nonâ?invasive blood pressure, and three lead electrocardiogram will be applied before start of anaesthesia. Nonâ?invasive blood pressure will be checked at least every 5 minutes throughout the operation. Spinal anaesthesia (SA) group Patients in the SA group will receive intrathecal (L4â?5, or L3â?4 if failed at L4â?5) administration of 2.4ml 0.5% heavy bupivicaine using a 25G Whitacare needle. No intrathecal opioid will be given during the procedure. Light sedation will be given during surgery with targetâ?controlled infusion of propofol using the Marsh effect site model (0.3 â?1 mcg/ml). Supplemental oxygen 2L/min will be given via the nasal cannula. General anaesthesia with inhalational anaesthesia (GAS) group Patients receiving inhalational general anaesthesia will be induced with intravenous bolus propofol 1.5â?3mg/kg, remifentanil 1mcg/kg, and rocuronium 0.6mg/kg for induction of general anaesthesia and intubation of the patient. General anesthesia monitoring will be used. Maintenance of general anesthesia would be provided using sevoflurane, together with air and oxygen. FiO2 will be maintained between 35â?50%. Bispectral (BIS) monitoring will be applied and level of anaesthesia will be maintained at a BIS value of between 40â?60. Remifentanil infusion will be given at between 0.1â?0.2mcg/kg/min. This will be titrated to maintain mean arterial blood pressure within 20% of baseline (blood pressure in the ward before surgery will be taken as baseline) and heart rate between 45 to 100 beats per minute. Muscle relaxants can be given as required. Morphine sulphate will be given at a dose of 0.1mg/kg before skin incision. Sevoflurane and remifentanil infusion will be switched off at the end of the procedure. Reversal of muscle relaxation will be achieved using intravenous neostigmine 50mcg/kg and atropine 20mcg/kg after the operation. General anaesthesia with propofol total intravenous anesthesia (TIVA) group Target controlled infusion (TCI) with modified Marsh effect site model (Fresenius Kabi) will be used for induction and maintenance of general anaesthesia. Level of anaesthesia will be titrated to produce a BIS value of between 40â?60. For induction, remifentanil 1mcg/kg and rocuronium 0.6â?1mg/kg will be given intravenously prior to intubation. Sevoflurane will not be given. Air and oxygen will be given, and FiO2 will be kept at between 35â?50%. Similarly to the GAS group, remifentanil will be infused at a rate of between 0.1â?0.2mcg/kg/min and titrated according to the haemodynamic parameters stated for the GAS group. Morphine sulphate will be given at a dose of 0.1mg/kg before skin incision. TCI propofol and remifentanil will be switched off at the end of the procedure. Reversal of muscle relaxation will be achieved as for the GAS group. Intraoperative care for all 3 groups Intravenous antibiotic will be given before skin incision. Hypotension will be managed with intravenous phenylephrine or ephedrine at the discretion of the anaesthesiologist. Hypertension or tachycardia n patients from the TIVA and GAS groups will be managed by titrating the remifentanil infusion up to 0.2mcg/kg. Intravenous antiâ?hypertensive drugs such as betaâ?blockers (eg esmolol, metoprolol), hydralazine, glyceryl trinitrate and phentolamine can be given if hypertension persists. Intraâ?operative fluid 8â?10ml/kg/hr will be infused as maintenance. In addition, fluid replacement will be given for of blood loss. Infusion fluid warmer and thermal blankets will be used with the aim of keeping a core temperature of 35.5â?37.5 degrees Celsius. All patients will be given 4mg of intravenous ondansetron 30 minutes before end of surgery. Local anaesthetic infiltration with 40ml 0.75% ropivacaine, 0.5ml 1:200,000 adrenaline, 40mg triamcinolone in 60ml normal saline over the perisurgical area will be administrated by orthopaedic surgeon after implant insertion and wound closure. Patients will subsequently be transferred to the post anaesthetic care unit (PACU) for monitoring for at least 1 hour. Analgesic modalities and assessment Procedures for all the analgesic modalities are described below: For all the groups Resting numerical rating scale (NRS) pain scores will be checked every 5 minutes in the PACU. In the PACU, 2mg intravenous morphine will be given every 5 minutes until the numerical rating pain score (NRS) is less than 4/10. Patient controlled analgesia (PCA) with morphine will then be given once NRS is less than 4/10. The PCA device will be configured to give 1 mg of bolus dose of morphine with each demand and the lockout duration will be 5 minutes. No background infusion will be given and the maximum dose limit of morphine will be 0.1mg/kg per hour. Intramuscular morphine sulphate at a dose of 0.1mg/kg will be prescribed every 4 hours if necessary for breakthrough beginning from postoperative day (POD) 0. Intravenous 4mg ondansetron every 4 hours as necessary will be prescribed for nausea or/and vomiting. While in the PACU, the respiratory rate, oxygen saturation, Ramsay sedation scores, blood pressure and heart rate will be monitored every 5 minutes. On POD 0, patients will resume oral diet if not contraindicated. Oral paracetamol 1g twice daily, celebrex 200mg twice daily, and pregabalin 75mg once at night will be given to all patients for 7 days. While on PCA morphine, the patient's respiratory rate, SpO2 and sedation score will be monitored every hour. Heart rate and blood pressure will be checked every 4 hours. NRS pain scores at rest, during knee movement, cumulative PCA morphine doses, and number of PCA demands/goods delivered, and side effects (eg nausea, vomiting, dizziness, pruritis) will be recorded every 4 hours. Patients will be assessed by the pain team everyday. Patients will be on PCA morphine for at least 2 days. If NRS pain scores during knee movement on POD 2 is less than 4/10 and morphine consumption is low, PCA morphine will be stopped. PCA morphine will be continued if NRS pain score is equal or greater than 4, or if PCA morphine consumption is high. After cessation of PCA morphine, NRS pain scores at rest and during knee movement, as well as the dose and frequency of rescue analgesia and the incidence of side effects will be charted once a day until discharge. Patient satisfaction with analgesia (0â?10, where 0 is the least satisfaction, and 10 is the most satisfaction) will be assessed daily during hospital stay. Surgical technique/Prosthesis The surgery will be performed by the same surgical team with standardized surgical technique. All the patients will have posterior stabilized knee prosthesis. Tranexamic acid will be given according to protocol. Standardized regimen and technique of local infiltration of analgesic at the end of the surgery will be given as part of the multiâ?modal pain control protocol. Postoperative care and assessment POD 0 mobilization or early mobilization with physiotherapy and occupational therapy rehabilitation is encouraged after operation. Fluid diet will be allowed on POD 0. The surgical team will assess for occurrences of postoperative surgical complica ions, suitability for discharge (good pain control, ambulation, normal bowel function, and ability to eat properly without vomiting. Urinary retention will be documented as well. Time to mobilization and time to soft diet intake will be recorded. Active and passive range of movement of the operated knee, ability to achieve straight leg raising, and other rehabilitation parameters will be assessment by allied health staffs from POD 0 till day of discharge. Sleep disturbance (0â?10, where 0 represents no disturbance and 10 represents the most disturbance possible) and quality of recovery (Chinese QoR) will be assessed during hospital stay (11). Postoperative follow up (3 months, 6 months) Questions about pain that will be asked during the faceâ?toâ?face interview at 3 months, 6 months after surgery are: â? The presence or absence of chronic pain â? Severity of pain if present (NRS pain score): at rest, during movement of the ipslateral knee â? The location of the pain: medial or lateral aspect of knee, scar â? Any analgesic consumption â? Nature of pain: nociceptive, neuropathic. (Presence of neuropathic pain will be assessed using the Identification Pain Questionnaire for Neuropathic Pain (IDâ?NeP). â? Timing of pain occurrence: continuous, related to movement, intermittent. â? Presence of allodynia and/or hyperalgesia â? Any abnormal sensation or loss of sensation over operated side. â? Physical examination will be performed by pain nurse to look for any area of brush allodynia and pinprick hyperalgesia at the ipslateral knee, scar site. â? Health related quality of life (Chinese SF12v2) â? Hospital Anxiety and Depression score (HADS) â? Patient satisfaction with analgesia (0â?10) Other Data collection The following data will be collected during the perioperative period: â? Demographics â? Time of admission â? Intraoperative vital signs (blood pressure, heart rate, oxygen saturation) â? Estimated intraoperative blood loss â? Tourniquet time if any â? Volume of intraoperative fluid/blood infusion â? Duration of surgery and anaesthesia â? Time of discharge If at certain time point after operation, the patients cannot be managed according to the protocol due to any reason such as the development of complication, no further data will be collected. These patients will still be followed up. Intentionâ?toâ?treat analysis will be used. Patients will remain in their initial designated groups for data analysis even if there is a change in surgical or anaesthetic/analgesic management, as long as they have had unilateral total knee replacement.
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Ex-smokers and risk of hip fracture
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Management of Hip Fractures in the Elderly
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OBJECTIVES: The purpose of this study was to examine the reversibility of the effect of smoking on hip fracture incidence rates. METHODS: A 3-year follow-up cohort study was conducted involving 35,767 adults 50 years of age or older. Of these individuals, 421 suffered a hip fracture. RESULTS: Among participants less than 75 years of age, the relative risk (RR) of hip fracture was elevated for ex-smokers, even for those who had quit smoking more than 5 years previously (men: RR = 4.4, 95% confidence interval [CI] = 1.2, 15.3; women: RR = 1.3, 95% CI = 0.6, 3.0), but was not as high as that for current smokers (men: RR = 5.0, 95% CI = 1.5, 16.9; women: RR = 1.9, 95% CI = 1.2, 3.1). CONCLUSIONS: The effect of smoking on risk of hip fracture was not reversed completely 5 years after smoking cessation
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Lateral meniscal slope negatively affects post-operative anterior tibial translation at 1 year after primary anterior cruciate ligament reconstruction
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AMP (Acute Meniscal Pathology)
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PURPOSE: The aim of this study was to assess the correlation between posterior tibial slope and meniscal slope over postoperative anterior tibial translation during the first 18 months after primary anterior cruciate ligament (ACL) reconstruction. The main hypothesis was that PTS and MS would be positively correlated with post-operative ATT-SSD after ACL reconstruction.
METHODS: Patients (28 males and 15 females) with confirmed ACL tears were selected from an in-house registry and included if they were over 16 years old, had primary ACL-reconstruction and healthy contralateral knee. Patients meeting one of the following criteria were excluded: previous knee surgeries, intraarticular fractures, associated ligamentous lesions, previous or concomitant meniscectomy or extraarticular procedures. Lateral posterior tibial slope, medial posterior tibial slope, lateral meniscal slope and medial meniscal slope were measured using preoperative MRIs. The side-to-side-difference in anterior tibial translation was evaluated 9-18 months postoperatively.
RESULTS: Forty-three patients were included, (28 males/15 females; mean age 25 +/- 8 years). Mean postoperative anterior tibial translation was 1.0 +/- 1.1 mm at a mean time of 12 +/- 1 months. Mean slope values were: lateral posterior tibial slope 4.7degree +/- 2.2degree, medial posterior tibial slope 4.0degree +/- 2.8degree, lateral meniscal slope 3.0degree +/- 2.2degree and medial meniscal slope 2.0degree +/- 2.8degree. The anterior tibial translation was significantly correlated with lateral meniscal slope (r = 0.63; p < 0.01). For each 1degree increase in lateral meniscal slope, a 0.3 mm 95% CI [0.2, 0.4] (p < 0.01) increase in anterior tibial translation was observed. A lateral meniscal slope greater or equal to 4.0degree was estimated as optimal threshold for increased risk of abnormal side-to-side difference in postoperative anterior tibial translation (>= 1.2 mm).
CONCLUSION: The lateral meniscal slope was positively correlated to side-to-side difference in anterior tibial translation after primary ACL reconstruction. A lateral meniscal slope greater or equal to 4.0degree was detected as threshold for an increased risk of abnormal side-to-side difference in postoperative anterior tibial translation in patients who underwent primary ACL reconstruction. This confirms that soft tissue slopes have an impact on the outcomes after reconstructive surgery. Level of evidence III.
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Quadriceps neuromuscular function and self-reported functional ability in knee osteoarthritis
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OAK 3 - Non-arthroplasty tx of OAK
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The purposes of this study were to determine 1) the relationships of self-reported function scores in patients with knee osteoarthritis (OA) to both maximal isometric torque and to isotonic power at a variety of loads, and 2) the degree to which muscle volume (MV) or voluntary activation (VA) are associated with torque and power measures in this population. Isometric maximal voluntary contraction (MVC) torque and isotonic power [performed at loads corresponding to 10, 20, 30, 40, and 50% MVC, and a minimal load ("Zero Load")] were measured in 40 participants with knee OA. Functional ability was measured with the Western Ontario and McMaster Osteoarthritis Index (WOMAC) function subscale. MV was determined with magnetic resonance imaging, and VA was measured with the interpolated twitch technique. In general, power measured at lower loads (Zero Load and 10-30% MVC, r(2) = 0.21-0.28, P < 0.05) predicted a greater proportion of the variance in function than MVC torque (r(2) = 0.18, P < 0.05), with power measured at Zero Load showing the strongest association (r(2) = 0. 28, P < 0.05). MV was the strongest predictor of MVC torque and power measures in multiple regression models (r(2) = 0.42-0.72). VA explained only 6% of the variance in MVC torque and was not significantly associated with power at any load (P > 0.05). Quadriceps MVC torque and power are associated with self-reported function in knee OA, but muscle power at lower loads is more predictive of function than MVC torque. The variance in MVC torque and power between participants is due predominantly to differences in MV and has little to do with deficits in VA.
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The collagen changes of Dupuytren's contracture
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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In Dupuytren's contracture there is an increase in the ratio of type III to type I collagen. The objective of this study was to determine if fibroblasts from patients with Dupuytren's contracture have an intrinsic aberration in collagen production or whether local factors govern the collagen changes in Dupuytren's contracture. Using a new collagen micro-method, we found that fibroblasts cultured from palmar fascia affected by Dupuytren's contracture produced similar collagen to fibroblasts derived from the palmar fascia of age- and sex-matched patients with carpal tunnel syndrome. Furthermore, the collagen changes of Dupuytren's contracture could be reproduced in all cell lines by increasing fibroblast density. At high fibroblast density, type I collagen production was inhibited: a finding that could account for the increased types III/I collagen ratio in Dupuytren's contracture. These results suggest that a genetic defect in collagen production is unlikely and that the important phenomenon is an increase in fibroblast density
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0 |
Two-Year Outcomes After Arthroscopic Lateral Meniscus Centralization
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AMP (Acute Meniscal Pathology)
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PURPOSE: To evaluate clinical and radiographic outcomes of arthroscopic centralization for lateral meniscal extrusion.
METHODS: Twenty-one patients who underwent arthroscopic centralization of the lateral meniscus were included. In cases with an extruded lateral meniscus (9 patients) or discoid meniscus (12 patients), the capsule at the margin between the midbody of the lateral meniscus and the capsule was sutured to the lateral edge of the lateral tibial plateau and centralized using suture anchors to reduce or prevent meniscal extrusion. Clinical outcomes included clinical examination findings, Lysholm score, Knee Injury and Osteoarthritis Outcome Score, and subjective rating scales regarding patient satisfaction and sports performance level. Radiographic outcomes included meniscal extrusion width (MEW) on magnetic resonance imaging and lateral joint space width on a standing 45degree flexion posteroanterior view. All clinical and radiographic outcomes were reported pre-operatively and at 2 years post-operatively, whereas MEW was reported at 1 year; outcomes were compared with baseline.
RESULTS: Clinical outcomes were significantly improved at 2 years postoperatively compared with baseline: Lysholm score (97 v 69, P < .0001) and all subscores of the Knee Injury and Osteoarthritis Outcome Score except activities of daily living (pain, 89 v 72, P = .0010; symptoms, 91 v 74, P = .0002; activities of daily living, 94 v 89, P = .091; sport and recreational function, 79 v 42, P = .0028; and quality of life, 78 v 46, P = .0029). Patient satisfaction (84 v 22, P < .0001) and sports performance level (82 v 15, P < .0001) were also improved. At 1 year, MEW was significantly reduced compared with baseline for both the extrusion group (1.0 mm v 5.0 mm, P < .0001) and the discoid group (0.3 mm v 1.6 mm, P = .047). Lateral joint space width increased at 2 years in the extrusion group (5.6 mm v 4.8 mm, P = .041) and was maintained in the discoid group (5.5 mm v 5.4 mm).
CONCLUSIONS: Arthroscopic centralization of the lateral meniscus improved clinical and radiographic outcomes for meniscal extrusion as well as for discoid menisci at 2-year follow-up.
LEVEL OF EVIDENCE: Level IV, therapeutic case series.
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A HIF-regulated VHL-PTP1B-Src signaling axis identifies a therapeutic target in renal cell carcinoma
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MSTS 2018 - Femur Mets and MM
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Metastatic renal cell carcinoma (RCC) is a molecularly heterogeneous disease that is intrinsically resistant to chemotherapy and radiotherapy. Although therapies targeted to the molecules vascular endothelial growth factor and mammalian target of rapamycin have shown clinical effectiveness, their effects are variable and short-lived, underscoring the need for improved treatment strategies for RCC. Here, we used quantitative phosphoproteomics and immunohistochemical profiling of 346 RCC specimens and determined that Src kinase signaling is elevated in RCC cells that retain wild-type von Hippel-Lindau (VHL) protein expression. RCC cell lines and xenografts with wild-type VHL exhibited sensitivity to the Src inhibitor dasatinib, in contrast to cell lines that lacked the VHL protein, which were resistant. Forced expression of hypoxia-inducible factor (HIF) in RCC cells with wild-type VHL diminished Src signaling output by repressing transcription of the Src activator protein tyrosine phosphatase 1B (PTP1B), conferring resistance to dasatinib. Our results suggest that a HIF-regulated VHL-PTP1B-Src signaling pathway determines the sensitivity of RCC to Src inhibitors and that stratification of RCC patients with antibody-based profiling may identify patients likely to respond to Src inhibitors in RCC clinical trials.
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1 |
Intra-articular treatment of knee osteoarthritis: from anti-inflammatories to products of regenerative medicine
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OAK 3 - Non-arthroplasty tx of OAK
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OBJECTIVES: Knee osteoarthritis (OA) is a debilitating condition that may ultimately require total knee arthroplasty (TKA). Non-operative treatments are bracing, oral analgesics, physical therapy, and intra-articular knee injection (IAKI). The objective of this paper is to provide a systematic literature review regarding intra-articular treatment of knee OA and insight into promising new products of regenerative medicine that may eventually have a substantial effect on treatment.
METHODS: A literature search was executed using Medline, Cochrane, and Embase with keywords "knee osteoarthritis" and "injection." Specifically, 45 articles that discussed intra-articular knee injection using corticosteroids, hyaluronic acid, analgesics, local anesthetics, and newer products of regenerative medicine, such as platelet-rich plasma (PRP) and mesenchymal stem cells (MSC), were analyzed. Of these, eleven were level 1, three were level 2, twelve were level 3, two were level 4, and seventeen were level 5 evidence. Papers included animal models.
RESULTS: Local anesthetics have potential side effects and may only be effective for a few hours. Morphine and ketorolac may provide significant pain relief for 24 hours. Corticosteroids may give patients weeks to months of effective analgesia, but complications may occur, such as systemic hyperglycemia, septic arthritis, and joint degradation . Hyaluronic acid is a natural component of synovial fluid, but efficacy with respect to analgesia is controversial. Platelet-rich plasma formulations, autologous conditioned serum, autologous protein solution, and mesenchymal stem cell injections contain anti-inflammatory molecules and have been proposed to attenuate joint destruction or potentially remodel the joint.
CONCLUSIONS: Currently, knee OA treatment does not address the progressively inflammatory environment of the joint. More investigation is needed regarding products of regenerative medicine, but they may ultimately have profound implications in the way knee OA is managed.
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Use of cementless acetabular component with a hook and iliac flanges in revision arthroplasty for massive acetabular defect
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PJI DX Updated Search
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BACKGROUND: Revision hip arthroplasty of massive acetabular defect, severe combined defect, or pelvic discontinuity is challenging. The purpose of this study was to determine the midterm outcome and survivorship of a new revision technique using cementless acetabular cup supplemented with a hook and three iliac flanges in massive acetabular defects. MATERIALS: From January 2000 to June 2004, we revised 17 severe acetabular defects, 14 combined defects and three pelvic discontinuities according to the American Academy of Orthopaedic Surgeons (AAOS) classifications, in which bone stock at the dome was not available to provide support for the cup. These revisions were performed using a cementless porous-coated hemispherical cup with a hook and flanges. RESULTS: One patient (one hip) underwent resection arthroplasty due to infection 1 year after the revision. The remaining 16 hips were evaluated at a mean of 6.8 (range 5-9) years postoperatively. Thirteen acetabular components (81%) showed no migration and were stable with bone ingrowth. Three hips showed progressive medial and upward migration during the 18-24 months after the index revision, after which migration was not progressive. The Merle d'Aubigne hip score was 14.5 (range 12-18) points at the latest follow-up evaluation. Survival rate was 94.4% when revision for any reason was considered as the end point [95% confidence interval (CI) 83.9-100%] and 82.0% (95% CI 62.8-100%) when loosening of the cup was considered as the end point. CONCLUSION: Results of this type of revision were superior to previously reported results of acetabular revisions with the use of various techniques and devices
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Entrapment neuropathies II: carpal tunnel syndrome
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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Diagnostic tests in patients complaining of carpal tunnel syndrome (CTS) are based on physical examination, electrodiagnostic tests (EDTs), and diagnostic imaging. Timely diagnosis helps prevent permanent nerve damage and its sequelae in terms of functional impairment. Imaging provides additional information to that obtained from clinical tests and EDTs. By allowing direct visualization of the compressed median nerve (MN), ultrasound (US) and magnetic resonance imaging can depict the causes for secondary CTS and describe anatomical variants, such as a bifid MN or a persistent median artery of the forearm, as well as space-occupying lesions including tenosynovitis and ganglion cysts. In addition, diagnostic imaging is of value for postoperative patients presenting with persistent symptoms. Finally, US is able to add information for EDT-negative symptomatic patients. Over time, US has increased in its sensitivity and specificity so it can be used as the initial test in patients presenting with clinical symptoms of CTS because it is now equivalent to EDT. The use of US as a screening test may reduce the number of EDT examinations in patients with suspected CTS, providing additional valuable anatomical information
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Difficulty of total hip arthroplasty following open reduction and internal fixation of acetabular fractures
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Hip Fx in the Elderly 2019
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Background: The incidence of posttraumatic arthrosis after acetabular fractures is significant, and patients frequently require secondary total hip arthroplasty. Conversion arthroplasty is more technically difficult, and there is higher risk than with routine primary total hip arthroplasty. The goal of this study was to identify the challenges and risks of secondary total hip arthroplasty compared to primary total hip arthroplasty. Methods: We retrospectively identified 30 patients who underwent secondary total hip arthroplasty after open reduction and internal fixation of an acetabulum fracture and compared them with 20 patients who had undergone primary total hip arthroplasty for degenerative joint disease. Results: Demographic data were similar between groups. Hardware removal was deemed necessary in 21 patients (70%). Allograft was needed for bone defects in 33% of secondary total hip arthroplasty cases, while no primary cases required grafting. Operative time (217.4 vs. 113.7 min, P < 0.01) and estimated blood loss (875.8 vs. 365 mL, P < 0.01) were significantly greater in the secondary arthroplasty group. Early postoperative complications were also higher in the secondary arthroplasty group. Conclusions: Total hip arthroplasty after acetabular fracture open reduction and internal fixation is a more complex procedure due to exposure difficulty, possible implant removal, management of bony deficits, and the potential use of cages and revision components. Experienced surgeons managing these complicated cases must take great care not only in ensuring appropriate technique but also in appropriate patient education regarding increased risk of major and minor complications.
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Results and complications in elderly patients with acetabular fractures
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Hip Fx in the Elderly 2019
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Background: The frequency of acetabular fractures in elderly patients is rising over time. The group presents with underlying challenges including osteoporosis, medical comorbidities, and varying levels of baseline physical and cognitive function. The purposes of this study were to characterize such patients and to determine rates of complications and secondary operations. We propose to identify injury and treatment features associated with optimal recovery. Methods: One hundred and ninety-three patients over the age of 60 with acute acetabular fractures were retrospectively reviewed over 12 yr. Complications, mortality, and secondary operations were documented for 171 patients with complete records and mean 18.5 mo follow-up. Ninety-one were treated operatively. Results: Patients who underwent open reduction and internal fixation had a mean age of 73 yr (vs. 69 yr, P=0.0003) and mean Injury Severity Score of 28.4 (vs. 15.7, P=0.001), consistent with higher-energy injuries and unstable fracture patterns compared to patients treated nonoperatively. Twenty-two percent developed early complications, with a trend toward a higher rate in patients treated surgically (27% compared to 16%, P=0.057). After open reduction and internal fixation, posttraumatic arthrosis and conversion to total hip arthroplasty occurred in 18% and 14%, respectively, compared to 3.8% of patients who had nonoperative care (both P<0.02). Mortality at 1 yr was 9.9% and at 5 yr was 29.5%, increasing with greater age. Conclusions: Additional research into efforts to expedite open reduction and internal fixation in stable patients with unstable fracture patterns may minimize complications by promoting mobility from bed. Further study to define patients better suited for nonoperative management is needed, as is investigation into the role of acute total hip arthroplasty or minimally invasive methods of reduction and fixation.
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Orthopaedic crossfire--can we justify unicondylar arthroplasty as a temporizing procedure? in opposition
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Surgical Management of Osteoarthritis of the Knee CPG
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The indications for unicompartmental arthroplasty are quite specific. Overall, there should be involvement of 1 tibiofemoral compartment, mild malalignment, and ligamentous stability. In a review of 250 osteoarthritic knees, these pathologic findings were present in 19 patients (8%). Technique, despite improvement in instrumentation, still is more demanding than tricompartmental knee arthroplasty, and failure to achieve an optimal arthroplasty occurs more frequently. In the literature, long-term results with unicompartmental arthroplasty have been inferior to tricompartmental arthroplasty. The concept that unicompartmental arthroplasty is a temporizing procedure is not a valid one in that the patient has to undergo another arthroplasty with all the risks of revision arthroplasty surgery. Many of these revision procedures require bone grafting or component augmentation. Tibial osteotomy remains the procedure of choice in younger, active patients with unicompartmental arthritis (in highly selected patients), and tricompartmental arthroplasty is preferred in older, lower demand patients
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Focal knee resurfacing
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Osteochondritis Dissecans 2020 Review
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A significant number of patients suffer from focal articular damage that is neither appropriate for traditional arthroplasty, nor for biological repair. Since 2005, contoured focal resurfacing systems for the femoral condyle have been available that can cater for this specific subgroup of patients. Independent long-term data on these implants have previously been lacking, but are now becoming available. This review will look at: the basic biology of cartilage, the natural progression of focal cartilage disease in the knee, the surgical and non-surgical options available, the indications for focal resurfacing, surgical techniques, which implants are currently available, and the current clinical data with respect to these.
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Not just a talking shop: practitioner perspectives on how communities of practice work to improve outcomes for people experiencing multiple exclusion homelessness
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DoD PRF (Psychosocial RF)
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Within homelessness services recent policy developments have highlighted the need for integration and improved collaborative working and also, the need for "Psychologically Informed Environments" (PIES) in which workers are better equipped to manage the "complex trauma" associated with homelessness. Drawing on the findings of an evaluation of a multi-site development programme, this paper demonstrates how both these policy aspirations might be implemented through a single delivery vehicle (a community of practice). The paper describes how organizational, educational and psychosocial theory was used to inform programme design and reflects on the utility of these approaches in the light of the evaluation findings. It is reported that communities of practice can deliver significant performance gains in terms of building collaborative relationships and opening-up opportunities for interprofessional education and learning. Filling an important knowledge gap, it also suggested how (professional) participation in a community of practice might work to improve outcomes for service users. Most likely we see those outcomes as being linked to tackling exclusion by sustaining the workforce itself, that is in motivating workers to remain engaged and thinking positively in what is an emotionally challenging and stressful job role.
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Five-year relative survival of patients with osteoporotic hip fracture
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Hip Fx in the Elderly 2019
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CONTEXT: Osteoporotic hip fracture is known to be associated with excess mortality. The 1-year mortality rate after hip fracture is known to reach up to ~20%, similar to that of cancer. However, there was no study that compared cancer survival. Recently, relative survival has been used to present a prognosis for a particular disease.
OBJECTIVE: The purpose of this study was to compare the 5-year relative survival after osteoporotic hip fracture with those of general population and cancer patients.
DESIGN, SETTING, AND PATIENTS: We retrospectively reviewed the medical records of 727 patients who were treated for osteoporotic hip fractures from 2003 to 2009.
INTERVENTION: Intervention was hip fracture surgery.
MAIN OUTCOME MEASURE: Five-year relative survival after fracture was estimated and was compared with survival in the general population and in cancer patients. Relative survival of 100% would reflect no excess mortality associated with the hip fracture compared with the general population.
RESULTS: Cumulative mortality was 32.3% at 5 years, and 5-year absolute survival rate was 63.0% (95% confidence interval, 59.0%-66.9%). Five-year relative survival of hip fracture was 93.9% (95% confidence interval 87.5%-99.7%), which was comparable with those of thyroid or breast cancer (99.8% and 91.0%, respectively).
CONCLUSIONS: Our results showed that 5-year relative survival after osteoporotic hip fracture was below those of the general populations and was comparable with some cancers such as thyroid and breast cancer. Therefore, osteoporotic hip fracture should not be overlooked.
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Comparison of lifetime incremental cost:utility ratios of surgery relative to failed medical management for the treatment of hip, knee and spine osteoarthritis modelled using 2-year postsurgical values
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Surgical Management of Osteoarthritis of the Knee CPG
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BACKGROUND: Demand for surgery to treat osteoarthritis (OA) of the hip, knee and spine has risen dramatically. Whereas total hip (THA) and total knee arthroplasty (TKA) have been widely accepted as cost-effective, spine surgeries (decompression, decompression with fusion) to treat degenerative conditions remain underfunded compared with other surgeries. METHODS: An incremental cost-utility analysis comparing decompression and decompression with fusion to THA and TKA, from the perspective of the provincial health insurance system, was based on an observational matched-cohort study of prospectively collected outcomes and retrospectively collected costs. Patient outcomes were measured using short-form (SF)-36 surveys over a 2-year follow-up period. Utility was modelled over the lifetime, and quality-adjusted life years (QALYs) were determined. We calculated the incremental cost per QALY gained by estimating mean incremental lifetime costs and QALYs of surgery compared with medical management of each diagnosis group after discounting costs and QALYs at 3%. Sensitivity analyses were also conducted. RESULTS: The lifetime incremental cost:utility ratios (ICURs) discounted at 3% were $5321 per QALY for THA, $11,275 per QALY for TKA, $2307 per QALY for spinal decompression and $7153 per QALY for spinal decompression with fusion. The sensitivity analyses did not alter the ranking of the lifetime ICURs. CONCLUSION: In appropriately selected patients with leg-dominant symptoms secondary to focal lumbar spinal stenosis who have failed medical management, the lifetime ICUR for surgical treatment of
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In-hospital mortality analysis in patients with proximal femoral fracture operatively treated by hip arthroplasty procedure
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DoD SSI (Surgical Site Infections)
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BACKGROUND/AIM: Hip fracture remains the leading cause of death in trauma among elderly population and is a great burden to national health services. In-patient death analysis is important to evaluate risk factors, make appropriate selection and perform adequate treatment of infections for patients to be operated. The aim of this study was to analyze in-hospital mortality in proximal femoral fracture patients operatively treated with hip arthroplasty procedure.
METHODS: We followed 622 consecutive patients, and collected data about age, gender, the presence of infection preoperatively and postoperatively, American Society of Anesthesiologists (ASA) score, diabetes mellitus and the type of surgical procedure. Postoperative infections included pneumonia, urinary tract infections, surgical site infections and sepsis.
RESULTS: We found a statistically significant influence of preoperative and postoperative infection presence for in-patient mortality with relative risk for lethal outcome of 4.53 (95% CI: 1.44-14.22) for patients with preoperative infection and 7.5 (95% CI: 1.90-29.48) for patients with postoperative infection. We did not confirm a statistically significant influence of age, gender, ASA score, diabetes mellitus or the type of surgical procedure for increased mortality rate.
CONCLUSION: Adequate preoperative selection, risk evaluation and adequate treatment of infections are of the key importance for lowering the risk of death in patients operated due to proximal femoral fracture and treated by hip arthroplasty procedures. Special attention is to be paid for the presence of preoperative and postoperative infections in patients operatively treated due to the risk for increased in-hospital mortality.
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Analgesic consumption after total knee replacement (TKR) in 11 European Hospitals participating in the Pain-Out Project
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Surgical Management of Osteoarthritis of the Knee CPG
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Introduction and aims: Pain after TKR is moderate-severe, regardless of the type of analgesia administered. We have assessed the analgesic requirements during postoperative day 1 after TKR, in 11 European hospitals participating in the PainOut Project (www.pain-out.eu). Patients and methods: Data was obtained from 990 patients on postoperative day 1. Patients completed a self-administered questionnaire about pain, AE and satisfaction; in a different questionnaire the investigators recorded the type of surgery, anaesthesia, analgesia, co-morbidities, etc. All Ethics Committees approved the protocol and patients gave informed consent. Student's t-test, Mann-Whitney's and ANOVA were used. P< 0.05 was considered significant. Results: Mean age was 68.8(plus or minus)10.5 years, being 63.3% women. Postoperatively, 46.9% of patients received morphine (mean dose 17.2(plus or minus)20.1 mg/patient/day; range 168-1) with significant differences between hospitals regarding % of patients (p< 0.001) and dose (p< 0.001). Oxycodone, tramadol and piritramide were administered to 18.4%, 17.6% and 14.8% of patients, at doses of 11.0(plus or minus)6.4, 180.8(plus or minus)103.9, 18.5(plus or minus)12.9 mg/pt/day respectively. Differences between hospitals were observed except for piritramide (p=0.064). Consumption of paracetamol (76.5% of patients, mean dose= 3061.3mg/pt/ day), metamizol (22.5%, 2606.5mg/pt/day) and diclofenac (15.1%, 129.9mg/ pt/day) also showed significant differences between hospitals. Two hospitals similarly (p=0.376) used ketoprofen (27.3%, 123.1mg/pt/day). Each patient received 2.8(plus or minus)1.0 analgesic-drugs (range 1.8-3.6; p< 0.001 between centres); the number of drugs did not influence pain outcomes. Mean score for worst pain (WP) was 6.0(plus or minus)2.9 (range 4.9-8.8; p< 0.001 between hospitals). Patients with WP(greater-than or equal to)4 (74.6%) received 18.0(plus or minus)21.1mg/pt/day morphine, while those with WP < 4 received 13.64(plus or minus)15.20mg/pt/day (p=0.190). Conclusions: Significant differences between hospitals were observed regarding % of patients receiving a certain type of analgesic-drugs and the doses administered. Morphine administration does not correlate with WP. Other factors (type of anaesthesia, nerve blocks, non-pharmacological treatments) must also be taken into account when assessing postoperative pain outcomes
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Patella intraosseous blood flow disturbance during a medial or lateral arthrotomy in total knee arthroplasty: a laser Doppler flowmetry study
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Surgical Management of Osteoarthritis of the Knee CPG
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Patella complications are recognized sequelae of total knee arthroplasty (TKA). Disruption of blood flow to the patella and adjacent soft tissues during surgery may contribute to reduced viability of the bone and patella ligament tissue. The effect on genicular blood flow to the medial and lateral patella was compared for a medial (MA) and lateral arthrotomy (LA) during TKA. Laser Doppler flowmetry was used to measure both baseline and postarthrotomy flow in vivo for 16 primary TKA patients. Flow in the lateral patella was reduced approximately 20% for both MA and LA. Conversely, the use of MA resulted in substantial reduction in flow to the medial patella (53%) compared to the lateral approach (27%). A large standard deviation of scores was evident in all cases. Although there was a tendency for LA to disturb the patellar blood flow less, the difference was not significant. It was concluded that neither approach is superior regarding the blood flow preservation to the patella. Hence, a lateral approach might only have an advantage in knee joints that are likely to need a lateral release in combination with an MA-e.g., a valgus deformity or preoperative patella maltracking
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Total knee arthroplasty treatment of rheumatoid arthritis with severe versus moderate flexion contracture
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Surgical Management of Osteoarthritis of the Knee CPG
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BACKGROUND: This study aims to explore the technique of soft tissue balance and joint tension maintenance in total knee arthroplasty (TKA) for the rheumatoid arthritis (RA) patients with flexion contracture of the knee. METHODS: This retrospective study reviewed flexion contracture deformity of RA patients who underwent primary TKA and ligament and soft tissue balancing. Based on the flexion contracture deformity, the remaining 76 patients available for analysis were divided into two groups, i.e., severe flexion group (SF) and moderate flexion group (MF). RESULTS: There were no intraoperative complications in this study. All patients had improved Knee Society Rating System scores and range of motion. The flexion contracture was completely corrected in MF and SF patients. There were no cases of patellar dislocation, but three cases had mild mediolateral instability in severe flexion group. Four knees (two knees in SF versus two knees in MF) had transient peroneal nerve palsy but recovered after conservative therapy. CONCLUSIONS: TKA can be performed successfully in the RA knees with severe flexion contracture. It is very important in TKA to maintain the joint stability in the condition of severe flexion contracture deformity of the RA knee
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Immediate internal fixation of open, complex tibial plateau fractures: treatment by a standard protocol
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DoD SSI (Surgical Site Infections)
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A retrospective review of 46 consecutive patients with complex (Schatzker V and VI) tibial plateau fractures treated at Harborview Medical Center between 1984 and 1989, disclosed a subset of 14 grade II or III (Gustilo) open injuries. We wished to determine the incidence of infection, union rate, and the number of operations required to achieve a satisfactory result, based on a treatment protocol: alignment and splinting of fracture at the scene of injury if possible, antibiotics administered in the emergency room (ER) and continued for 48 h, and admission of patient to the operating room as quickly as possible for irrigation and thorough debridement of the wound, immediate rigid internal fixation, and delayed primary closure at 5 days. No acute deep infection or radiographic evidence of implant loosening was noted. The final outcome was graded by Hospital for Special Surgery (HSS) Knee Rating Score at an average follow-up of 2 years 7 months. Radiographs were reviewed for reduction and evidence of postoperative change in reduction. The average HSS Functional Score was 81.5, and Knee Score was 84.6. Of 14 limbs, 10 had an excellent radiographic grade that did not change at follow-up, 2 had a satisfactory grade, and 2 had a poor grade.
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Comparison of quadriceps-sparing minimally invasive and medial parapatellar total knee arthroplasty: a 2-year follow-up study
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Surgical Management of Osteoarthritis of the Knee CPG
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BACKGROUND/PURPOSE: Quadriceps-sparing minimally invasive total knee arthroplasty (TKA) has been proposed to limit surgical dissection without compromising surgical outcome. We conducted a prospective and randomized study to compare the outcomes of patients who underwent quadriceps-sparing TKA with the outcomes of those who underwent standard medial parapatellar TKA, after a 2-year follow-up period. METHODS: Eighty primary TKA procedures that were to be performed in 60 osteoarthritis patients were randomly assigned to either a quadriceps-sparing (40 knees) or a standard medial parapatellar (40 knees) group. All surgeries were designed to set the prosthesis with a femoral component alignment of 7 degrees valgus and a tibial component alignment that was perpendicular to the tibial shaft. Surgical time and tourniquet time were recorded. Outcome variables included knee function, as defined by a hospital for special surgery knee score; quadriceps muscle strength, which was measured by an isokinetic dynamometer; pain, as indicated on a visual analog scale; prosthetic position, which was measured on plain radiograph; and range of motion. RESULTS: Patients who underwent the 38 quadriceps-sparing and 37 standard TKA procedures completed the 2-year follow-up period without any infection or revision. The mean surgical time and tourniquet time were significantly longer in the quadriceps-sparing group. The mean peak quadriceps muscle strength, hamstring muscle strength, normalized muscle balance (hamstring/quadriceps ratio), pain score, function score, and range of motion were comparable in both groups at 2 months and 2 years. In the quadriceps-sparing group, both the femoral and the tibial components were significantly more varus-deviated from the expected position. CONCLUSIONS: Patients undergoing quadriceps-sparing and standard medial parapatellar TKA had comparable outcomes for quadriceps muscle strength, hamstring-quadriceps balance, and knee function; however, the quadriceps-sparing TKA was more time consuming surgically and resulted in a less accurate prosthesis position
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Effect of bisphosphonates, denosumab, and radioisotopes on bone pain and quality of life in patients with non-small cell lung cancer and bone metastases: A systematic review
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MSTS 2018 - Femur Mets and MM
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Bone metastases are common in patients with non-small cell lung cancer (NSCLC), often causing pain and a decrease in quality of life (QoL). The effect of bone-Targeted agents is evaluated by reduction in skeletal-related events in which neither pain nor QoL are included. Radioisotopes can be administered for more diffuse bone pain that is not eligible for palliative radiotherapy. The evidence that bone-Targeted agents relieve pain or improve QoL is not solid. We performed a systematic review of the effect of bone-Targeted agents on pain and QoL in patients with NSCLC. Our systematic literature search included original articles or abstracts reporting on bisphosphonates, denosumab, or radioisotopes or combinations thereof in patients with bone metastases (â?¥5 patients with NSCLC), with pain, QoL, or both serving as the primary or secondary end point. Of the twenty-five eligible studies, 13 examined bisphosphonates (one also examined denosumab) and 12 dealt with radioisotopes. None of the randomized studies on bisphosphonates or denosumab evaluated pain and QoL as the primary end point. In the single-Arm studies of bisphosphonates a decrease in pain or analgesic consumption was found for 38% to 77% of patients. QoL was included in five of 13 studies, but improvement was found in only two. No high-level evidence that bisphosphonates or denosumab reduce pain or improve QoL was found. Although the data are limited, radioisotopes seem to reduce pain with a rapid onset of action and duration of response of 1 to 3 months. The evidence that bisphosphonates or denosumab reduce or prevent pain in patients with NSCLC and bone metastases or that they have an influence on QoL is very weak. Radioisotopes can be used to reduce diffuse pain, although there is no high-level evidence supporting such use.
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Liposomal bupivacaine versus traditional bupivacaine for pain control after total hip arthroplasty: A meta-analysis
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AAHKS (8) Anesthetic Infiltration
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BACKGROUND: In the past, the efficacy of local infiltration of liposomal bupivacaine for total hip arthroplasty (THA) patients was in debate. Therefore, this meta-analysis was conducted to determine whether local infiltration of liposomal bupivacaine provides better pain relief after THA.
METHODS: We searched Web of Science, PubMed, Embase, and the Cochrane Library databases to the April 2017. Any studies comparing liposomal bupivacaine and traditional bupivacaine were included in our meta-analysis. The outcomes included visual analog scale (VAS) at 24, 48, and 72 hours, total morphine consumption at 24 hours, and the length of hospital stay. We assessed the pooled data using a random-effect model.
RESULTS: Six studies were finally included in this meta-analysis. Our pooled data analysis demonstrated that liposomal bupivacaine was more effective than the traditional bupivacaine in terms of VAS at 24 hours (P = .018) and the length of hospital stay (P = .000). There was no significant difference in terms of the VAS at 48 and 72 hours and total morphine consumption at 24 hours (P >.05).
CONCLUSION: Compared with the traditional bupivacaine, liposomal bupivacaine shows better pain control at 24 hours and reduces the length of hospital stay after THA. Its economic costs must be assessed in multimodal center randomized controlled trials when being recommended as a long-acting alternative analgesic agent for a THA patient.
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The effect of intra-articular epinephrine lavage on blood loss following total knee arthroplasty
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AAHKS (8) Anesthetic Infiltration
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The purpose of this study was to examine the effects of intra-articular epinephrine lavage on blood loss following total knee arthroplasty (TKA). Our retrospective study involved 189 patients who had primary cemented TKA by 1 of 2 surgeons. Surgeon 1 performed 41 procedures without and 53 with the epinephrine lavage. Surgeon 2 performed 41 procedures without and 54 with the epinephrine lavage. We compared calculated blood loss (CBL) for the patients in all 4 groups. We found no significant differences in CBL among the patients in the 4 patient groups. Our results show that an intra-articular epinephrine lavage does not affect blood loss after TKA.
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Capacity limitations and representational shifts in spatial short-term memory
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Upper Eyelid and Brow Surgery
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Performance was examined in a task requiring the reconstruction of spatial locations. Previous research suggests that it may be necessary to differentiate between memory for smaller and larger numbers of locations (Postma & DeHaan, 1996), at least when locations are presented simultaneously (Igel & Harvey, 1991). Detailed analyses of the characteristics of performance showed that such a differentiation might also be required for sequential presentation. Furthermore the slope of the function relating each successive response to accuracy was greater with 3 than with 6, 8, or 10 locations that did not differ. Participants also reconstructed the arrays as being more proximal than in fact they were; sequential presentation eliminated this distortion when there were three but not when there were more than three locations. These results support the idea that very small numbers of locations are remembered using a specific form of representation, which is unavailable to larger numbers of locations. © 2006 Psychology Press Ltd.
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Pain in arthroscopic knee surgery under local anesthesia
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Surgical Management of Osteoarthritis of the Knee CPG
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BACKGROUND: We evaluated pain during arthroscopic knee surgery performed under local anesthesia, with respect to various types of lesions and specific procedures used. PATIENTS AND METHODS: Arthroscopic surgery was performed on 63 joints (61 patients), with a median age of 49 years. We asked the patients to describe the pain experienced at each step of the procedure, and to compare the level of pain experienced at the time of injection and during the operation, using a visual analog scale (VAS). RESULTS: Pain experienced at the time of injection of the local anesthetic was more severe than the pain experienced during the surgical procedure. Local anesthesia provided good pain control during partial resection of the meniscus, chondroplasty, and removal of free bodies. Patients sometimes experienced more pain during treatment of the suprapatellar pouch, including the plica and the anterior cruciate ligament. INTERPRETATION: Injection of the local anesthetic was usually the most painful phase of the entire procedure. Patients were generally satisfied with the pain control
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Displaced supracondylar fractures of the humerus in children
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The Treatment of Pediatric Supracondylar Humerus Fractures AUC
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We performed an audit of 71 children with consecutive displaced, extension-type supracondylar fractures of the humerus over a period of 30 months. The fractures were classified according to the Wilkins modification of the Gartland system. There were 29 type IIA, 22 type IIB and 20 type III. We assesed the effectiveness of guidelines proposed after a previous four-year review of 83 supracondylar fractures. These recommended that: 1) an experienced surgeon should be responsible for the initial management; 2) closed or open reduction of type-IIB and type-III fractures must be supplemented by stabilisation with Kirschner (K-) wires; and 3) K-wires of adequate thickness (1.6 mm) must be used in a crossed configuration. The guidelines were followed in 52 of the 71 cases. When they were observed there were no reoperations and no malunion. In 19 children in whom they had not been observed more than one-third required further operation and six had a varus deformity. Failure to institute treatment according to the guidelines led to an unsatisfactory result in 11 patients. When they were followed the result of treatment was much better. We have devised a protocol for the management of these difficult injuries
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Rationale, baseline characteristics and methodology of the non-interventional VIVA study in postmenopausal osteoporosis
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Hip Fx in the Elderly 2019
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Background: It is important to understand compliance and persistence with medication use in the clinical practice of osteoporosis treatment. The purpose of this work is to describe the "intravenous ibandronate versus oral alendronate" (VIVA) study, a non-interventional trial to assess the compliance and persistence of osteopenic post-menopausal women with treatment via weekly oral alendronate or intravenous ibandronate (Bonviva®) every three months. Methods: 4477 patients receiving ibandronate 3 mg i. v. quarterly and 1491 patients receiving alendronate 70 mg orally weekly were included in the study. Matched pairs of 901 subjects in each group were also generated. Matching was performed on the basis of age, body mass index, fracture history at study inclusion, prior treatment with bisphosphonates and the number of concomitant disorders. Secondary outcome measures of osteoporosis related fractures, mobility restriction and pain, analgesia, quality of life questionnaires as well as attitudes to medications were assessed. The primary outcome parameters of compliance and persistence will be tracked in these subjects. Results: At baseline, the entire collectives differed significantly on body weight (less in ibandronate group), duration since osteo -porosis diagnosis (longer in ibandronate), and incidence of prior osteoporotic fracture (higher in ibandronate group). The matched-pairs differed only on mobility restriction and quality of life (both worse in ibandronate group). Conclusion: The results from the VIVA study trial will provide scientific rationale for clinical recommendations in the pharmacological treatment of postmenopausal osteoporosis. © Schattauer 2014.
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