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Facilitation of pain sensitization in knee osteoarthritis and persistent post-operative pain: a cross-sectional study

Surgical Management of Osteoarthritis of the Knee CPG

BACKGROUND: Around 20% of patients with osteoarthritis (OA) have chronic post-operative pain after total knee arthroplasty (TKA) and often undergo revision surgery with unfavourable pain outcome. This study compared sensitization in pain patients with knee OA and after revision TKA (re-TKA). METHODS: Median pressure pain thresholds (PPTs) assessed from the most affected knee (localized sensitization) were used to subgroup 53 patients with OA pain and 20 patients with pain after re-TKA: group 1: OA and high-knee PPT; group 2: OA and low-knee PPT; group 3: re-TKA and high-knee PPT; group 4: re-TKA and low-knee PPT. Clinical pain intensity was assessed using a visual analogue scale (VAS). Bilateral PPTs were measured from the lower leg and forearm (spreading sensitization). Furthermore, the pain intensities evoked by 10 repeated pressure pain stimuli (temporal summation) at the knee and lower leg were assessed on an electronic VAS. RESULTS: The mean clinical pain intensity was not significantly different between groups. The PPTs from both lower leg and forearm were significantly lower in group 4 compared to groups 1, 2, and 3 and in groups 2 and 3 compared to group 1 (p < 0.05). Temporal summations from the knee and lower leg were significantly facilitated in groups 3 and 4 compared to groups 1 and 2 (p < 0.05). CONCLUSIONS: Despite similar pain intensities, facilitated temporal summation is worse in re-TKA than in OA and patients with high local knee hyperalgesia show more prominent spreading sensitization. The study suggests that sensitization should be considered in knee OA especially before re-TKA

Infrapatellar fat pad of patients with end-stage osteoarthritis inhibits catabolic mediators in cartilage

Surgical Management of Osteoarthritis of the Knee CPG

OBJECTIVE: Adipose tissue is known to release inflammatory cytokines and growth factors. In this exploratory study, the authors examined whether the infrapatellar fat pad (IPFP) closely located to cartilage in the knee joint can affect cartilage metabolism. In addition, the authors analysed whether the macrophage types present in IPFP could explain the effect on cartilage. METHODS: IPFP explants obtained during total knee replacement of 29 patients with osteoarthritis (OA) were used to make fat-conditioned medium (FCM). Explants of bovine cartilage were cultured with or without FCM. Nitric oxide (NO) and glycosaminoglycan release and gene expression of matrix-degrading enzymes in cartilage were analysed. To stimulate catabolic processes in the cartilage, the authors added interleukin 1beta, and the effect of six FCMs was evaluated. The presence of different types of macrophages (CD68+, CD86+ and CD206+) in OA IPFPs was compared with subcutaneous adipose tissue samples and IPFP samples from patients with an anterior cruciate ligament rupture. RESULTS: FCM alone reduced NO and glycosaminoglycan release and matrix metalloproteinase (MMP)1 gene expression by the cartilage. Moreover, when catabolic conditions were enhanced with interleukin 1beta, FCM inhibited NO production as well as MMP1 and MMP3 gene expression and increased collagen type II gene expression. Significantly more CD206+ cells were present in OA IPFP samples than in subcutaneous fat or anterior cruciate ligament IPFP samples. CONCLUSION: In contrast to the authors' expectations, medium conditioned by end-stage OA IPFP inhibited catabolic processes in cartilage. CD206+ cells present in the IPFPs used for making the FCM might have contributed to the inhibition of catabolic processes in the cartilage

Functional outcomes and survivorship of distal femoral osteotomy with cartilage restoration of the knee

AMP (Acute Meniscal Pathology)

Introduction: Few studies have reported on functional outcome and survivorship of simultaneous distal femoral osteotomy (DFO) and cartilage restoration techniques, including lateral femoral condyle osteochondral allograft transplantation (OCA). Objectives: The purpose of this investigation is therefore to evaluate short-term outcomes, mid-term outcomes, and satisfaction in patients receiving OCA and DFO. Methods: A registry of consecutive patients undergoing DFO with concomitant OCA between 2004 and 2017 was retrospectively reviewed. Patient records meeting inclusion criteria were reviewed to collect baseline demographic data; both pre- and postoperative radiographs were reviewed. Patients were contacted to complete postoperative outcome questionnaires. Subsequent surgical history and patient satisfaction were also assessed. The postoperative outcomes obtained were compared to prospectively collected preoperative outcome scores. Outcomes were compared using paired t-testing, with statistical significance defined as P<.05. Results: A total of 24 patients were identified, of which 17 (70.8%) completed follow-up at a mean of 7.13 years (range, 2-14.2 years) after surgery. At final follow-up, there were significant improvements in IKDC (P <.001), Lysholm (P =.001), and 4 of the KOOS subscales (ADL, P =.001; Pain, P <.001; QOL, P <.001; Sport, P =.001). Two patients (10.5%) were considered treatment failures (one revision OCA and one graft debridement) at an average 1.48 years postoperatively. No patients underwent subsequent knee arthroplasty. All patients reported satisfaction with the surgery at final follow-up. Conclusion: In young, active patients with valgus deformity and lateral chondral defects of the knee, DFO with concomitant OCA can significantly improve functional scores compared to baseline at a minimum of 2 years after surgery.

Magnetic resonance imaging of focal articular cartilage lesions

AMP (Acute Meniscal Pathology)

Lesions of the articular cartilage now are recognized as a common, often treatable source of joint disability. Magnetic resonance imaging (MRI) of articular cartilage is a sensitive, noninvasive method for the detection of focal articular cartilage lesions. Advancement in imaging technology now allows for high spatial resolution acquisitions that are able to identify most cartilage lesions, and these acquisitions can be incorporated into everyday clinical imaging protocols. Thus, screening for cartilage abnormalities can be accomplished, along with routine evaluation for ligament and meniscal abnormalities. Familiarity with the appearances of normal cartilage and the full spectrum of cartilage lesions will aid in specific diagnoses. Grading and sizing of cartilage lesions and any underlying bony abnormalities on MRI can help the surgeon in treatment planning; however, some significant cartilage lesions can be difficult to identify and grade by MRI. [References: 59]

Objective analysis of lateral elbow exposure with the extensor digitorum communis split compared with the kocher interval

Distal Radius Fractures

Background: The most widely used surgical approach to treat radial head fractures is through the Kocher interval. However, the extensor digitorum communis (EDC) splitting approach is thought to allow easier access to the anterior half of the radial head, which is more commonly fractured. The aim of this cadaveric study was to compare the osseous and articular surface areas visible through the EDC split and the Kocher interval. Methods: Four approaches were used in fresh frozen cadaveric upper extremities: EDC splitting (n = 6), modified Kocher (n = 6), extended EDC splitting (n = 6), and extended modified Kocher (n = 4). For each approach, the osseous and articular surface areas visualized were outlined with use of a burr. Each elbow was then stripped of soft tissue and a digitized threedimensional model was created with use of a surface scanning system. The visible surface area obtained with each approach was mapped and quantified with use of the markings created with the burr. Results: The EDCsplitting approach provided greater exposure of the anterior half of the radial head (median, 100%) compared with the modified Kocher approach (68%, p < 0.05). The extended modified Kocher and extended EDC splitting approaches provided comparable visualization of the distal aspect of the humerus, capitellum, radial head, and coronoid process. Conclusions: The results suggest that the EDC splitting approach provides more reliable visualization of the anterior half of the radial head whileminimizing soft-tissue dissection and reducing the risk of iatrogenic injury to the lateral ulnar collateral ligament. Copyright © 2014 By The Journal of Bone and Joint Surgery, Incorporated.

Ultra minimally invasive sonographically guided carpal tunnel release: an external pilot study

Diagnosis and Treatment of Carpal Tunnel Syndrome CPG

BACKGROUND: Authors have reported better outcomes, by reducing surgical dissection for carpal tunnel syndromes requiring surgery. Recently, a new sonographically guided technique for ultra minimally invasive (Ultra-MIS) carpal tunnel release (CTR) through 1mm incision has been described. HYPOTHESIS: We hypothesized that a clinical trial for comparing Ultra-MIS versus Mini-open Carpal Tunnel Release (Mini-OCTR) was feasible. MATERIALS AND METHODS: To test our hypothesis, we conducted a pilot study for studying Ultra-MIS versus Mini-OCTR respectively performed through a 1mm or a 2 cm incision. We defined success if primary feasibility objectives (safety and efficacy) as well as secondary feasibility objectives (recruitment rates, compliance, completion, treatment blinding, personnel resources and sample size calculation for the clinical trial) could be matched. Score for Quick-DASH questionnaire at final follow-up was studied as the primary variable for the clinical trial. Turnover times were studied for assessing learning curve stability. RESULTS: Forty patients were allotted. Primary and secondary feasibility objectives were matched with the following occurrences: 70.2% of eligible patients finally recruited; 4.2% of randomization refusals; 26.6 patients/month recruited; 100% patients receiving a blinded treatment; 97.5% compliance and 100% completion. A sample size of 91 patients was calculated for clinical trial validation. At final follow-up, preliminary results for Quick-Dash substantially favored Ultra-MIS over Mini-OCTR (average 14.54 versus 7.39) and complication rates were lower for Ultra-MIS (5% versus 20%). A stable learning curve was observed for both groups. CONCLUSIONS: The clinical trial is feasible. There is currently no evidence to contraindicate nor withhold the use of Ultra-MIS for CTR. LEVEL OF EVIDENCE: III

Imaging the knee

AMP (Acute Meniscal Pathology)

• Plain films are adequate for most cases of uncomplicated arthropathies and trauma. • For suspected internal derangement MRI is the optimum technique. Routine plain films are not indicated. • Ultrasound is ideal for initial examination of periarticular swellings and tendon disorders • MRI or CT arthrography is the best method of assessing the post-operative meniscus. © 2003 The British Institute of Radiology.

Comparison of the effectiveness of medicinal leech and TENS therapy in the treatment of primary osteoarthritis of the knee : A randomized controlled trial

OAK 3 - Non-arthroplasty tx of OAK

OBJECTIVES: The aim of this study was to evaluate the effects of leech therapy in the treatment of knee osteoarthritis in terms of duration of effectiveness and symptom relief and to compare these results with transcutaneous electrical nerve stimulation (TENS) therapy. MATERIAL AND METHODS: This study was designed as a prospective, single center, randomized, single-blind and parallel group study. A total of 90 patients were included in the study, 46 in the leech group and 44 in the TENS group. Primary outcome measures were changes of the pain scores in visual analogue scale (VAS) and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) on the measurements day 0, 21 and 180. Secondary outcome measures were the changes in the sub-groups of the WOMAC scores. Five leeches were applied to the affected knee, once every week for 3 weeks. RESULTS: The VAS pain score showed a similar decrease in both groups in the evaluation on day 21 (p < 0.001). The course of the change of the VAS pain score in both groups was similar in the comparisons between groups. Long-term benefits of the TENS therapy group were slightly more than the leech therapy group. All the sub-scores of WOMAC in both therapy groups showed a similar decrease (p = 0.819). Throughout the study this decrease was statistically significant in both groups (p < 0.001). CONCLUSION: Leech therapy relieves symptoms in patients with osteoarthritis of the knee and is as effective as TENS therapy in the management of osteoarthritis of the knee. This treatment has the potential of being an additional or alternative therapy for the non-surgical management of osteoarthritis of the knee.

Benzodiazepine use and hip fractures in the elderly: who is at greatest risk?

Management of Hip Fractures in the Elderly

BACKGROUND: It remains unclear whether benzodiazepine use increases hip fracture incidence. We studied this relationship in a large cohort, controlling for multiple potential confounders. METHODS: We analyzed 42 months of New Jersey Medicaid health care claims data for all enrollees. Each eligible person-day was assigned to categories of benzodiazepine exposure and categories of other predictors, based on prior and current medication dispensing and diagnosis information. Hip fractures were identified based on hospital claims with primary discharge diagnosis International Classification of Diseases, Ninth Revision (ICD-9) codes 820.xx. RESULTS: Cohort members (n = 125 203) contributed 194 071 person-years and had 2312 eligible hip fractures. After adjustment for age, sex, race, Medicaid nursing home residence, exposure to other psychoactive medications, including antiparkinsonian medications, diagnoses of epilepsy and dementia, and hospitalization in the previous 6 months, the incidence rate of hip fracture was significantly higher compared with no benzodiazepine use for exposure to any benzodiazepine (incidence rate ratio [IRR], 1.24; 95% confidence interval [CI], 1.06-1.44), to a short half-life, high-potency benzodiazepine (IRR, 1.27; 95% CI, 1.01-1.59), during the first 2 weeks after starting a benzodiazepine (IRR, 2.05; 95% CI, 1.28-3.28), during the second 2 weeks after starting a benzodiazepine (IRR, 1.88; 95% CI, 1.15-3.07), and for continued use (IRR, 1.18; 95% CI, 1.03-1.35). CONCLUSIONS: The incidence of hip fracture appears to be associated with benzodiazepine use. Contrary to several previous studies, short half-life benzodiazepines are not safer than long half-life benzodiazepines. Hip fracture risk is highest during the first 2 weeks after starting a benzodiazepine and declines thereafter

GAPN postacute care coordination improves hip fracture outcomes

Management of Hip Fractures in the Elderly

We tested the effectiveness of a nursing intervention model to improve health, function, and return-home outcomes in elders with hip fracture via a 2-year randomized clinical trial. Thirty three elders (age > 65 years) were tracked from hospital discharge to 12 months postfracture. The treatment group had a gerontologic advanced practice nurse as postacute care coordinator for 6 months who intervened with each elder regardless of the postacute care setting, making biweekly visits and/or phone calls. The coordinator assessed health and function, and informed elders, families, long-term care staff, and physicians of the patient's progress. The control group had care based on postacute facility protocols. Nonnormal distribution of data led to nonparametric analysis using Freidman's test with post hoc comparisons (Mann-Whitney U tests, Bonferroni adjustment). The treatment group had better function at 12 months on several activities and instrumental activities of daily living, and no differences in health, depression, or living situation

The effect of psychological interventions on the prevention of chronic pain in adults: A systematic review protocol

DoD PRF (Psychosocial RF)

Background: Numerous psychological risk and protective factors have been identified as contributing to or preventing the development of the prevalent issue of chronic pain. Systematic reviews of studies on psychological interventions that tackle these factors have shown limited effects on chronic pain. Therefore, implementing psychological interventions before pain becomes chronic has been put forward. However, the efficacy of such interventions in preventing the transition from acute to chronic pain has not yet been systematically assessed. Methods: The aims of this systematic review are to assess the effects of psychological interventions applied in the acute pain phase on pain severity as well as on physical, psychological, and social functions at 3months and beyond. Randomized controlled trials including psychological intervention as a treatment of primary interest and participants with pain of less than 3months duration will be considered. The following comparisons will be undertaken: psychological interventions with (1) standard treatment, (2) information, (3) waiting-list, and (4) active treatment. The primary outcome will be pain severity using indicators such the presence or absence of pain and self-report measures such as the numeric pain intensity rating scale. Secondary outcomes will include pain-related disability, mood, coping with pain, quality of life, health care utilization, and work capability. A systematic review of English and French articles in MEDLINE, Embase, PsycINFO, CINAHL, and the Cochrane Central Register of Controlled Trials will be conducted without date restriction. Extracted data will include demographics and clinical characteristics, sample size, intervention and control group types, assessment tools used, time interval of measurement, fidelity of the intervention, and attrition rate. Standardized mean differences (SMD) and risk ratios with 95% confidence intervals (CI) will be used to assess treatment effects. Discussion: This systematic review is the first in examining the effects of psychological interventions implemented in the acute pain phase with the objective of preventing chronic pain. Results of this systematic review could provide information on psychological intervention characteristics that are most helpful for individuals with pain and guidance as to when such interventions should be applied in the continuum of care. Systematic review registration: PROSPERO CRD42016049312

Early discharge of hip fracture patients from hospital: transfer of costs from hospital to nursing home

HipFx Supplemental Cost Analysis

Hip fracture patients occupy more and more hospital beds. One of the strategies for coping with this problem is early discharge from the hospital to institutions with rehabilitation facilities. We studied whether early discharge affects outcome and costs. 208 elderly patients with a hip fracture were followed up to 4 months after the fracture. First, a group of 102 patients stayed in our hospital for the usual period (median 18 days). Then, 106 patients were assigned to a group for early discharge (median 11 days). We measured disabilities, health-related quality of life and cognition at 1 week, 1, and 4 months after hospitalization. To calculate total societal costs, inpatient days, the efforts of professionals in- and outside institutions, and interventions/examinations were recorded during this 4-month period. At 4 months, we found no differences in mortality, ADL level, complications, quality of life, and type of residence. More patients in the early discharge group were discharged to nursing homes with rehabilitation facilities (76% versus 53%), but the median total stay in hospital and nursing home was the same (26 days). Early discharge from hospital did not substantially reduce the total costs (conventional management Euro 15,338 per patient and early discharge Euro 14,281 per patient), but merely shifted them from the hospital to the nursing home

Quality of post-anesthetic care in a hospital without a Post-Anesthetic Care Unit: A clinical audit

Management of Hip Fractures in the Elderly

Aim. The majority of Italian hospitals are not equipped with a Post-Anesthetic Care Unit. The aim of this study is to evaluate whether it is possible to guarantee post-anesthetic care according to current international quality and safety standards in the absence of such a structure. Methods. Our hospital is not equipped with a Post-Anesthetic Care Unit and post-anesthetic assistance is assured by the anesthetist and anesthetic nurse themselves. In order to evaluate the quality of the post-anesthetic care a Recovery Chart was devised and strict discharge criteria defined: Recovery Score (modified Aldrete's score) (greater-than or equal to)7; systolic blood pressure within 20% of the preoperative values; nausea/vomiting and shivering absent; pain absent/mild. A retrospective audit was conducted in 2 orthopedic operating rooms from January 10, 2000 to January 31, 2001 in order to evaluate major complications, observance of discharge criteria, postanesthetic care time. Results. Incidence of complications was 2.6%. Observance of discharge criteria was 74%. In 26% of cases (69/261 cases) discharge criteria were not completely respected: 14 cases with unstable vital parameters; 46 cases with pain not under control; 6 cases with nausea/vomiting; 3 cases with shivering. In these cases monitoring and treatment was continued on the ward according to the anesthetist's prescriptions. None of these patients died or suffered major complications because of a quick discharge to the ward. Mean post-anesthetic care time was 40(plus or minus)18 minutes (median 35 minutes). Conclusion. Where the Post- Anaesthetic Care Unit is not available it is virtually impossible to guarantee post-anesthetic care according to current international quality and safety standards, because production pressure can lead the anesthetist to discharge the patient to the ward before he/she is completely stabilized. In these cases the anesthetist must accurately prescribe the necessary postoperative monitoring and treatment (analgesics, antiemetics, fluids, etc.) that must be continued in the surgical ward to guarantee the patient's safety, but it must be underlined that the surgical ward is not the appropriate place to carry on immediate post-anesthetic care

Non-invasive raman spectroscopic detection of carotenoids in human skin

Panniculectomy & Abdominoplasty CPG

Carotenoids are thought to play a significant part in the skin's anti-oxidant defense system, and may help prevent malignancy. Inability to measure skin carotenoid content readily has, however, made it difficult to establish the relationship between carotenoid concentration and the occurrence of cutaneous malignancy. We have measured in vivo carotenoid concentration using a noninvasive optical method, Raman spectroscopy. To validate our instrumentation, abdominoplasty skin was evaluated by both Raman spectroscopy and high-performance liquid chromatography determination for carotenoid content. Evaluation of the Raman signal in specific carotenoid solutions was also performed. Precision of Raman measurements within skin sites, within subjects, and between subjects was measured. Sensitivity of the method was evaluated as a function of anatomical region and the distribution of carotenoids within the stratum corneum. Lastly, we evaluated the Raman signal in actinic keratosis and basal cell carcinoma lesions and perilesional skin and compared this with region-matched sites in healthy subjects. Our results indicate that the Raman scattering method reflects the presence of carotenoids in human skin and is highly reproducible. Evaluation of five anatomical regions demonstrated significant differences in carotenoid concentration by body region with the highest carotenoid concentration noted in the palm. Comparison of carotenoid concentrations in basal cell carcinomas, actinic keratosis, and their perilesional skin demonstrate a significantly lower carotenoid concentration than in region-matched skin of healthy subjects. These results represent the first evidence that carotenoid concentration in the skin correlate with the presence or absence of skin cancer and precancerous lesions.

Delayed treatment of type 3 supracondylar humerus fractures in children

DoD SSI (Surgical Site Infections)

A retrospective review of 158 type 3 supracondylar humerus fractures was undertaken to determine whether any correlation exists between an increased time from injury to surgery and four unfavorable results: a longer operative time, an increase in hospital stay, an increase in the need to open the fracture, or an increase in unsatisfactory outcomes. The average age of the patients was 5.0 years. Five children had nerve injury on initial examination, and no arm was poorly perfused. The average time from injury to evaluation in the emergency department was 9.8 hours and the average time from the emergency department to surgery was 11.5 hours. The average total time from injury to surgical treatment was 21.3 hours. The patients were in the hospital between 1 to 6 days. The average operative time was 53 minutes. Thirty patients had unsatisfactory results, defined as a pin infection, more than 15 degrees loss of motion in any plane, loss of normal carrying angle, neuropraxia, or retained hardware. There was no correlation between an increase in time to surgical intervention and longer operative time or need to open the fracture site, nor was there an indication that the delay to surgical treatment resulted in a longer hospital stay or an increase in unsatisfactory results.

Changes in knee joint load indices from before to 12 months after arthroscopic partial meniscectomy: a prospective cohort study

AMP (Acute Meniscal Pathology)

OBJECTIVE: Patients undergoing arthroscopic partial meniscectomy (APM) are at increased risk of knee osteoarthritis (OA). Meniscal damage and/or surgery may alter knee joint loading to increase OA risk. We investigated changes in knee joint loading following medial APM surgery, compared with the contra-lateral leg. METHODS: We estimated indices of knee joint loading (external peak knee adduction moment (KAM), KAM impulse and peak knee flexion moment (KFM)) normalized to body size (i.e., body mass (BM) and height (HT)) using 3D gait analysis in 23 patients (17 men, mean (SD) 46.2 (6.4) years, BMI 25.8 (3.4) kg/m(2)) without radiographic knee OA before and 12 months after medial APM. Static alignment was assessed by radiography and self-reported outcomes by Knee injury and Osteoarthritis Outcome Score (KOOS). RESULTS: Peak KAM and KAM impulse increased in the APM leg compared to the contra-lateral leg from before to 12 months after surgery (change difference: 0.38 Nm/BM*HT% 95% CI 0.01 to 0.76 (P = 0.049) and 0.20 Nm*s/BM*HT% 95% CI 0.10 to 0.30 (P < 0.001)). Patients self-reported improvements on all KOOS subscales (KOOS pain improvement: 22.8 95% CI 14.5 to 31.0 (P < 0.01)). CONCLUSIONS: A relative increase in indices of medial compartment loading was observed in the leg undergoing APM compared with the contra-lateral leg from before to 12 months after surgery. This increase may contribute to the elevated risk of knee OA in these patients. Randomized trials including a non-surgical control group are needed to determine if changes in joint loading following APM are caused by surgery or by changes in symptoms.

Expert consensus on Pulmonary Function Testing during the epidemic of Corona Virus Disease 2019

Coronavirus Disease 2019 (COVID-19)

Corona virus disease 2019 (COVID-19) is mainly transmitted by respiratory droplets and close contact. Pulmonary function testing procedures have been associated with an increasing risk of COVID-19 transmission among patients/subjects and medical staffs. Effective prevention and control strategies must be compulsorily implemented to prevent nosocomial infection. This recommendation is intended to be followed by healthcare workers (HCWs) of pulmonary function testing laboratory when COVID-19 is in epidemic. Based on the features of pulmonary function testing, precaution principles and strategies are developed in three aspects of management for HCWs, operating procedure, environment and equipment. Indications of pulmonary function testing should be followed strictly. It is strongly recommended to suspend the test for the confirmed or suspected cases of COVID-19 during the contagious stage, and to postpone the test for other patients if it is not imperative. Medical personnel should mandatorily adhere to the standard stratification of precaution measures. Patients/Subjects should be isolated in a separate area for testing. Disposable in-line filters must be used during pulmonary function testing. Cleaning and disinfection procedures for environment and equipment in pulmonary function testing laboratory should be paid more attention. æ?°å??å? ç?¶ç??æ¯?è?ºç??ï¼?COVID-19ï¼?主要é??è¿?å?¼å¸é?é£?沫传æ?­å?å¯?å??æ?¥è§¦ä¼ æ?­ã??è?ºå??è?½æ£?æ?¥å¯å¢?å? å?»å?¡äººå??å??å?æ£?è??å?ç??COVID-19ä¼ æ?­ç??é£?é?©ï¼?å¿?须严 æ ¼æ?§è¡?æ??æ??ç??é¢?é?²å??æ?§å?¶æ?ªæ?½ä»¥é?²æ­¢é?¢å??æ??æ??ã??为äº?æ??导è?ºå??è?½æ£?æ?¥å®¤å?»å?¡äººå??å?好é?²æ?§å·¥ä½?ï¼?æ?¬æ??å¼?ç»?å?è?ºå??è?½æ£?æ?¥ç??ç?¹ç?¹ï¼?å?¶è®¢äº?å½?å?ç?«æ??ä¸?è?ºå??è?½æ£?æ?¥å?¨å?»å?¡ 人å??管ç?ã?æ£?æ?¥æµç¨?管ç?å??æ£?æ?¥ç?¯å¢?ç?©å?ç®¡ç?3个æ?¹é¢ç??要æ±?å?注æ?äº?项ã??主要强è°?å?¨ç?«æ??流è¡?æ??é?´ï¼?å¿?须严格æ??握è?ºå??è?½æ£?æ?¥ç??é??åº?证ï¼?强ç??建议COVID-1 9ç¡®è¯?ç??ä¾?æ??ç??ä¼¼ç??ä¾?å?¨ä¼ æ??æ??å??æ??ç¼?æ£?æ?¥ï¼?å?¶ä»?ç??æ?£å¦?é?ç??æ??æ?¥é??ä¹?æ??ç¼?æ£?æ?¥ï¼?è?ºå??è?½å®¤å?»å?¡äººå??åº?严格æ?§è¡?æ ?å??å??级é?²æ?¤æ?ªæ?½ï¼?å?è¯?è??åº?å?¨å?ç?¬å?ºå??è¿?è¡?é??离æ£? æ?¥ï¼?æ£?æ?¥æ?¶å¿?须使ç?¨ä¸?次æ?§å?¼å¸è¿?滤å?¨ï¼?并é?è§?è?ºå??è?½æ£?æ?¥ç?¯å¢?å??设å¤?ç??æ¸?洁æ¶?æ¯?ã??.

Surgery for incarcerated hernia: short-term outcome with or without mesh

PJI DX Updated Search

BACKGROUND: Incarcerated hernias represent about 5-15 % of all operated hernias. Tension-free mesh is the preferred technique for elective surgery due to low recurrence rates. There is however currently no consensus on the use of mesh for the treatment of incarcerated hernias, especially in case of bowel resection. AIM: The aims of this study were (i) to report our current practice for the treatment of incarcerated hernias, (ii) to identify risk factors for postoperative complications, and (iii) to assess the safety of mesh placement in potentially infected surgical fields. METHODS: This retrospective study included 166 consecutive patients who underwent emergency surgery for incarcerated hernia between January 2007 and January 2012 in two university hospitals. Demographics, surgical details, and short-term outcome were collected. Univariate analysis was employed to identify risk factors for overall, infectious, and major complications. RESULTS: Eighty-four patients (50.6 %) presented inguinal hernias, 43 femoral (25.9 %), 37 umbilical hernias (22.3 %), and 2 mixed hernias (1.2 %), respectively. Mesh was placed in 64 patients (38.5 %), including 5 patients with concomitant bowel resection. Overall morbidity occurred in 56 patients (32.7 %), and 8 patients (4.8 %) developed surgical site infections (SSI). Univariate risk factors for overall complications were ASA grade 3/4 (P = 0.03), diabetes (P = 0.05), cardiopathy (P = 0.001), aspirin use (P = 0.023), and bowel resection (P = 0.001) which was also the only identified risk factor for SSI (P = 0.03). In multivariate analysis, only bowel incarceration was associated with a higher rate of major morbidity (OR = 14.04; P = 0.01). CONCLUSION: Morbidity after surgery for incarcerated hernia remains high and depends on comorbidities and surgical presentation. The use of mesh could become current practice even in case of bowel resection

Unusual complication associated with femoral intramedullary alignment guide in total knee arthroplasty

Surgical Management of Osteoarthritis of the Knee CPG

The few reported complications related to the use of a femoral intramedullary alignment guide in total knee arthroplasty include increase in perioperative bleeding and fat embolism. We report 3 patients suffering from an unusual complication, concerning trapping of the tibial locking pin inside the intramedullary canal of the femur secondary to the use of an intramedullary alignment guide. Methods of retrieving the locking pin from the medullary canal are discussed

Unipedal standing exercise and hip bone mineral density in postmenopausal women: A randomized controlled trial

Management of Hip Fractures in the Elderly

The aim of this study was to test the effect of unipedal standing exercise on bone mineral density (BMD) of the hip in postmenopausal women. Japanese postmenopausal women (n = 94) were assigned at random to an exercise or control group (no exercise). The 6-month exercise program consisted of standing on a single foot for 1 min per leg 3 times per day. BMD of the hip was measured by dual-energy X-ray absorptiometry. There was no significant difference in age and baseline hip BMD between the exercise group (n = 49) and control group (n = 45). Exercise did not improve hip BMD compared with the control group. Stepwise regression analysis identified old age as a significant determinant (p = 0.034) of increased hip total BMD at 6 months after exercise. In 31 participants aged (greater-than or equal to) 70 years, the exercise group (n = 20) showed significant increase in the values of hip BMD at the areas of total (p = 0.008), intertrochanteric (p = 0.023), and Ward's triangle (p = 0.032). The same parameters were decreased in the control group (n = 11). The percent changes in hip BMD of the exercise group were not significantly different from those of the control group either in the participants with low baseline hip total BMD (<80% of the young adult mean) or high baseline hip total BMD ((greater-than or equal to)80% of the young adult mean). In conclusion, unipedal standing exercise for 6 months did not improve hip BMD in Japanese postmenopausal women. Effect of exercise on hip total BMD was age dependent. In participants aged (greater-than or equal to)70 years, the exercise significantly increased hip total BMD. (copyright) 2009 The Japanese Society for Bone and Mineral Research and Springer

Genetic contributions to pain: A review of findings in humans

Diagnosis and Treatment of Carpal Tunnel Syndrome CPG

Pain represents the major motivating factor for which individuals seek healthcare, and pain responses are characterized by substantial inter-individual differences. Increasing evidence suggests that genetic factors contribute significantly to individual differences in responses to both clinical and experimental pain. The purpose of this review article was to summarize the current literature regarding genetic contributions to pain, highlighting findings relevant to oral pain where available. A brief discussion of methodologic considerations is followed by a review of findings regarding genetic influences on clinical pain. Next, the literature examining genetic contributions to experimental pain responses is presented, emphasizing genetic associations that have been replicated in multiple cohorts. It is hoped that an enhanced understanding of genetic contributions to pain responses will ultimately improve diagnosis and treatment of clinical pain conditions. (copyright) 2008 The Authors

Objective integrated assessment of functional outcomes in reduction mammaplasty

Reduction Mammoplasty for Female Breast Hypertrophy

BACKGROUND: The aim of our study was an objective integrated assessment of the functional outcomes of reduction mammaplasty. METHODS: The study involved 17 women undergoing reduction mammaplasty from March 2009 to June 2011. Each patient was assessed before surgery and 2 months postoperatively with the original association of 4 subjective and objective assessment methods: a physiatric clinical examination, the Roland Morris Disability Questionnaire, the Berg Balance Scale, and a static force platform analysis. RESULTS: All of the tests proved multiple statistically significant associated outcomes demonstrating a significant improvement in the functional status following reduction mammaplasty. Surgical correction of breast hypertrophy could achieve both spinal pain relief and recovery of performance status in everyday life tasks, owing to a muscular postural functional rearrangement with a consistent antigravity muscle activity sparing. Pain reduction in turn could reduce the antalgic stiffness and improved the spinal range of motion. In our sample, the improvement of the spinal range of motion in flexion matched a similar improvement in extension. Recovery of a more favorable postural pattern with reduction of the anterior imbalance was demonstrated by the static force stabilometry. Therefore, postoperatively, all of our patients narrowed the gap between the actual body barycenter and the ideal one. The static force platform assessment also consistently confirmed the effectiveness of an accurate clinical examination of functional impairment from breast hypertrophy. CONCLUSIONS: The static force platform assessment might help the clinician to support the diagnosis of functional impairment from a breast hypertrophy with objectively based data.

Mobilization of human immature hematopoietic progenitors through combinatory use of bortezomib and immunomodulatory drugs

MSTS 2018 - Femur Mets and MM

Combination use of the proteasome inhibitor bortezomib and the immunomodulatory drugs lenalidomide or thalidomide has provided superior outcomes in multiple myeloma over their single use; however, these combinations can produce significant toxicities. Unexpectedly, we found a small but significant increase in the population of immature granulocytes and erythrocytes/megakaryocytes in peripheral blood in 16 of 22 patients (73%) treated with dexamethasone in combination with bortezomib and immunomodulatory drugs (triplet), but not in any of 25 patients treated with either bortezomib or immunomodulatory drugs with dexamethasone (doublet). These immature cells gradually increased to a peak level (mean 2.6% per white blood cells) with triplet therapy, and disappeared immediately after therapy cessation. The numbers of circulating CD34⁺ cells and colony-forming cells derived from peripheral blood mononuclear cells increased after triplet therapy compared with those in patients treated by either bortezomib or immunomodulatory drugs plus dexamethasone. Furthermore, triplet regimen downregulated the expression of CXCR4, a chemokine receptor essential for bone marrow retention, on CD34⁺ cells, suggesting an unexpected effect on normal hematopoietic stem/progenitor cells through the reduced interaction with the bone marrow microenvironment. Our observations suggest that combination use should be carefully evaluated to exert synergistic anti-myeloma effects while avoiding unexpected adverse events.

Reconstruction with endoprosthesis in gonarthrosis: a report of 111 consecutive cases operated upon from 1973 through 1977

Surgical Management of Osteoarthritis of the Knee CPG

The results of reconstruction with 3 standard knee joint endoprostheses in advanced gonarthrosis are reported prospectively for 111 consecutive cases operated upon during the years 1973 through 1977 according to a consecutive, precise routine. High tibial osteotomy was indicated in the early stages of the disease, i.e., roentgenographic Grades I and II. In advanced gonarthrosis constituting Grades III to V, unicompartmental reconstruction with hemiprosthesis was performed in 68% of the cases, while 26% needed a stablizing total surface prosthesis and 6% a hinge prosthesis. This differentiation is important in view of the better results achieved in the category of hemiprosthetic reconstructions compared with those of the 2 latter categories. In the total series, 96% of the patients were satisfied or improved correlating with the clinical assessments made at regular clinical and roentgenological examinations 1 to 5 years after the operation; there were 99% in the hemiprosthetic group and 93% in the group having total surface replacement. In the former group of patients, wear of the tibial component was detected in 3%, while loosening occurred in 6 and 11%, respectively. The rates of primary deep infection were 1 and 3%, respectively, and, in addition, 7% (3 cases) in the latter group showed the occurrence of late deep infection. Relief of pain, correction of deformity and a range of movement of 90 degrees or more, were the most significant results. Strict indications and operative techniques should be used according to the different stages of gonarthrosis

External Fixation Versus Volar Locking Plate for Unstable Dorsally Displaced Distal Radius Fractures-A 3-Year Follow-Up of a Randomized Controlled Study

Distal Radius Fractures

PURPOSE: To determine if a volar locking plate (VLP) is superior to external fixation (EF) 3 years after surgery for unstable, dorsally displaced, distal radius fractures caused by low-energy injury in patients 50 to 74 years of age. METHODS: During 2009 to 2013, 140 patients with an unstable dorsally displaced distal radius fracture were randomized to either VLP or EF. One hundred eighteen patients (EF 56, VLP 62) were available for a 3-year follow-up. The primary outcome was the Disabilities of the Arm, Shoulder, and Hand (DASH) score at 3 years. Secondary outcomes were Patient-Related Wrist Evaluation (PRWE) score, EuroQol-5 Dimensions (EQ-5D) score, range of motion (ROM), grip strength, and radiological signs of osteoarthritis (OA) at 3 years. Moreover, reoperations and minor complications during the first 3 years were recorded. RESULTS: There were no differences regarding DASH, PRWE, EQ-5D, ROM or grip strength. The reoperation rate was 21% (13 of 62) in the VLP group compared with 14% (8 of 56) in the EF group. The OA rate was 42% (25 of 59) in the VLP group compared with 28% (15 of 53) in the EF group. CONCLUSIONS: Three years after surgery for unstable dorsally displaced distal radius fractures, the clinical and radiological results for VLP and EF were comparable. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic II.

Superficial liposuction: a new application of the technique for aged and flaccid skin

Panniculectomy & Abdominoplasty CPG

From 1982 to 1991, 2500 patients underwent liposuction to thin the superficial areolar layer of fat. The patients were of all ages and had different types of skin. From the results the author concludes that the new superficial liposculpting, based on the controlled scar retraction of the thin cutaneous adipose flap remaining after the treatment, allows for very good results even in very flaccid and aged skin. A digital molding of the residual fat also improves the contouring. So-called "cellulite" is finally meliorated.

International variations in hip fracture probabilities: implications for risk assessment

Management of Hip Fractures in the Elderly

It is recommended that intervention thresholds should be based on absolute fracture risk, but there is a large variation in hip fracture incidence from different regions of the world. The aim of this study was to examine heterogeneity of hip fracture probability in different regions from recent estimates of hip fracture incidence and mortality to adjust intervention thresholds. Ten-year probabilities of hip fracture were computed in men and women at 10-year intervals from the age of 50 years and lifetime risks at the age of 50 years from the hazard functions of hip fracture and death. Lifetime risk at the age of 50 years varied from 1% in women from Turkey to 28.5% in women from Sweden. High lifetime risks in women were associated with high lifetime risks in men (r = 0.83). There also were significant correlations of 10-year risk at any age between men and women. Ten-year probability was standardized to that of men and women from Sweden (set at 1.0). There was a 15-fold range in 10-year probability from 1.24 in Norway to 0.08 in Chile. Countries were categorized by 10-year probabilities comprising very high risk (Norway, Iceland, Sweden, Denmark, and the United States), high risk (China [Taiwan [TW]], Germany, Switzerland, Finland, Greece, Canada, The Netherlands, Hungary, Singapore, Italy, United Kingdom, Kuwait, Australia, and Portugal), medium risk (China [Hong Kong [HK]], France, Japan, Spain, Argentina, and China), and low risk (Turkey, Korea, Venezuela, and Chile). The categorization of hip fracture probabilities can be used to adjust intervention thresholds based on age, sex, and relative risk from a reference population such as Sweden

Growth hormone deficiency in the transition period: Body composition and gonad function

Diagnosis and Treatment of Carpal Tunnel Syndrome CPG

Recombinant GH therapy is normally administered to GH-deficient children in order to achieve a satisfactory height - the main target during childhood and adolescence. However, the role of GH does not end once final height has been reached, but continues during the so-called transition period. In this phase of life, the body undergoes several changes, both physical and psychological, that culminate in adulthood. During this period, GH has a part in numerous metabolic functions. These include the lipid profile, where it increases HDL and reduces LDL, with the global effect of cardiovascular protection. It also has important effects on body composition (improved muscle strength and lean body mass and reduced body fat), the achievement of proper peak bone density, and gonad maturation. Retesting during the transition period, involving measurement of IGF-I plus a provocative test (insulin tolerance test or GHRH + arginine test), is thus necessary to establish any persistent GH deficiency requiring additional replacement therapy. The close cooperation of the medical professionals involved in the patient's transition from a pediatric to an adult endocrinologist is essential. The aim of this review is to point out the main aspects of GH treatment on body composition, metabolic and gonad functions in the transition period. (copyright)2011, Editrice Kurtis

Bone loss after initiation of androgen deprivation therapy in patients with prostate cancer

Management of Hip Fractures in the Elderly

CONTEXT: Although androgen deprivation therapy (ADT) for prostate cancer is associated with bone loss, little is known about when this bone loss occurs. OBJECTIVE: We postulated that men on ADT would experience the greatest bone loss acutely after initiation of ADT. DESIGN AND SETTING: We conducted a 12-month prospective study at an academic medical center. PATIENTS OR OTHER PARTICIPANTS: We studied 152 men with prostate cancer (30 with acute ADT, < 6 months; 50 with chronic ADT, > or = 6 months; and 72 with no ADT) and 43 healthy age-matched controls. MAIN OUTCOME MEASURES: We assessed bone mineral density (BMD) of the hip, wrist, total body, and spine; body composition; and markers of bone turnover. RESULTS: After 12 months, men receiving acute ADT had a significant reduction in BMD of 2.5 +/- 0.6% at the total hip, 2.4 +/- 1.0% at the trochanter, 2.6 +/- 0.5% at the total radius, 3.3 +/- 0.5% at the total body, and 4.0 +/- 1.5% at the posteroanterior spine (all P < 0.05). Men with chronic ADT had a 2.0 +/- 0.6% reduction in BMD at the total radius (P < 0.05). Healthy controls and men with prostate cancer not receiving ADT had no significant reduction in BMD. Both use and duration of ADT were associated with change in bone mass at the hip (P < 0.05). Men receiving acute ADT had a 10.4 +/- 1.7% increase in total body fat and a 3.5 +/- 0.5% reduction in total body lean mass at 12 months, whereas body composition did not change in men with prostate cancer on chronic ADT or in healthy controls (P < 0.05). Markers of bone formation and resorption were elevated in men receiving acute ADT after 6 and 12 months compared with the other men with prostate cancer and controls (P < 0.05). Men in the highest tertile of bone turnover markers at 6 months had the greatest loss of bone density at 12 months. CONCLUSIONS: Men with prostate cancer who are initiating ADT have a 5- to 10-fold increased loss of bone density at multiple skeletal sites compared with either healthy controls or men with prostate cancer who are not on ADT, placing them at increased risk of fracture. Bone loss is maximal in the first year after initiation of ADT, suggesting initiation of early preventive therapy

Clinical issues in the prevention of dental-induced endocarditis and prosthetic joint infection

Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures

No issue in medicine or dentistry is the subject of more misunderstanding than the prevention of infective endocarditis and late prosthetic joint infections. To resolve some of the confusion, national medical groups have published guidelines for the prevention of these infections, including the use of antibiotic prophylaxis for certain dental procedures and certain at-risk patients. While these guidelines are helpful, there still are clinicians who either do not recommend antibiotics when indicated or recommend antibiotics without indication. An understanding of these issues helps to prevent not only the infections but also the adverse antibiotic effects and associated legal problems. The learning objective of this article is to to educate clinicians on the prevention of dental-induced endocarditis and prosthetic joint infections

The Effect of Early Progressive Resistive Exercise Therapy on Balance Control of Patients with Total Knee Arthroplasty

OAK 3 - Non-arthroplasty tx of OAK

Background and Purpose: Although total knee arthroplasty (TKA) is a common treatment for severe osteoarthritis, high risks of fall and balance loss are the main complications of this procedure. While multiple rehabilitation protocols have been suggested for TKA, efficacy of early resistive exercise therapy aimed at improving balance has not yet been thoroughly investigated. Methods: In this double-blind randomized controlled trial study, 40 patients with severe osteoarthritis, sampled by a simple convenient method, were randomly assigned into either "control" group or "early resistive exercise" group. After TKA surgery, both groups attended a routine rehabilitation program while the experimental group received extra early resistive exercises. Static, semidynamic, and dynamic balance were assessed by the Sharpened Romberg (SRBT), Star Excursion (SEBT), and Berg (BBT) balance tests prior to surgery, after the rehabilitation process (seventh week), and at a 2-week later follow-up time (ninth week). Results: At the end of the seventh and ninth weeks, in both groups all 3 balance scores were significantly enhanced comparing the baseline scores (P <.001). The experimental group had significantly higher scores than the control group in SRBT, SEBT, and BBT after the intervention and at the follow-up time (P <.001). Discussion and Conclusions: The findings of this study showed that rehabilitation following TKA is accompanied by balance (static, semidynamic, and dynamic) improvement, and this improvement is greater among patients participating in an early resistive exercise regimen. Early progressive resistive exercise in addition to routine physical therapy may lead to better balance performance than routine physical therapy and might be incorporated into the postoperative physical therapy of these patients. Further studies with longer follow-up periods are needed to confirm these results.

Analysis of the prognostic factors of extensive disease small-cell lung cancer patients in tokushima university hospital

MSTS 2018 - Femur Mets and MM

Background: Small-cell lung cancer (SCLC) presents aggressive clinical behavior, and its prognosis is still poor. Previously, performance status (PS), or the existence of brain, bone, or liver metastasis were reported to be unfavorable prognostic factors. Given the recent progress of treatment modalities such as radiotherapy techniques and bone modifying agents, the prognostic factors might be different from previous findings. Therefore, we analyzed the prognostic factors of extensive disease SCLC (ED-SCLC) in recent years. Methods: ED-SCLC patients treated in Tokushima University Hospital between 2010 and 2016 were analyzed. Log-rank test and the Cox proportional hazards regression model was used in univariate and multivariate analysis, respectively. Results: Totally, 79 patients were analyzed. In the univariate analysis, age, PS, interstitial pneumonia (IP), liver metastasis, pleural dissemination, neutrophil counts, hypoalbuminemia, hypercalcemia and several liver and biliary enzymes were identified as poor prognostic factors. In the multivariate analysis, age, PS, IP, and liver and biliary enzymes were identified. Moreover, the PS in patients with liver metastasis was significantly worsened. Conclusions: In this study, we newly demonstrated that IP was a significant poor prognostic factor of ED-SCLC. Although liver metastasis was not extracted in multivariate analysis, it may have an impact on the prognosis of ED-SCLC.

Torticollis and hip dislocation

Developmental Dysplasia of the Hip CPG

Reports in the literature suggest that there is an association between two childhood disorders: torticollis, an easily recognized clinical deformity, and developmental dislocation or dysplasia of the hip, an occult disorder. The identification of the obvious disease, torticollis, may prompt a search for the occult disease, developmental dislocation of the hip. If the association of these two disorders is common, it may be justified to expend resources to diagnose the occult disorder in all cases in which the more obviously noticed disorder is recognized. The reported association varies between 2 and 29%. We retrospectively reviewed 70 patients with the diagnosis of congenital muscular torticollis to determine the incidence of hip dislocation or subluxation in these patients. Fifty-four patients had radiographs of their hips. Forty-one patients were available for follow-up at an average of age 3+4 years. Six patients were noted to have hip subluxation or dislocation, all at presentation. Of these, four had been referred for diagnosed hip disease, whereas two were referred for torticollis, and the hip disease was then diagnosed by the pediatric orthopaedist. No patient had abnormal radiographs or physical findings at follow-up. We conclude that the rate of hip disease in those with torticollis is approximately 8% and is lower than the 20% often quoted

Latarjet, Bristow, and Eden-Hybinette procedures for anterior shoulder dislocation: systematic review and quantitative synthesis of the literature

Glenohumeral Joint OA

PURPOSE: The aim of this study was to evaluate clinical outcome, rate of recurrence, complications, and rate of postoperative osteoarthritis in patients with anterior shoulder instability managed with Latarjet, Bristow, or Eden-Hybinette procedures. METHODS: A systematic review of the literature on management of anterior dislocation of the shoulder with glenoid bony procedures was performed. A comprehensive search of PubMed, MEDLINE, CINAHL, Cochrane, EMBASE, and Google Scholar databases using various combinations of the keywords "shoulder," "dislocation," "treatment," "Latarjet," "Bristow," "bone loss," "Eden-Hybinette," "iliac," "bone," "block," "clinical," "outcome," and "Bankart." The following data were extracted: demographics, bone defects and other lesions, type of surgery, outcome measurement, range of motion (ROM), recurrence of instability, complications, and osteoarthritis. A quantitative synthesis of all comparative studies was performed to compare bone block procedures and Bankart repair in terms of postoperative recurrence of instability and osteoarthritis. RESULTS: Forty-six studies were included and 3,211 shoulders were evaluated. The mean value of the Coleman Methodology Score (CMS) was 65 points. Preoperatively, the injuries detected most were glenoid bone loss and Bankart lesions. The Eden-Hybinette procedure had the highest rate of postoperative osteoarthritis and recurrence. Pooled results from comparative studies showed that the bone block procedures were associated with a lower rate of recurrence when compared with Bankart repair (odds ratio [OR], 0.45; 95% confidence interval [CI], 0.28 to 0.74; P = .002), whereas there was no significant difference between the 2 groups in terms of postoperative osteoarthritis (P = .79). CONCLUSIONS: The open Bristow-Latarjet procedure continues to be a valid surgical option to treat patients with anterior shoulder instability. Bone block procedures were associated with a lower rate of recurrence when compared with the Bankart repair. The Eden-Hybinette procedure has clinical outcomes very similar to the Bristow-Latarjet technique but has a higher rate of postoperative osteoarthritis and recurrence. An arthroscopic Bristow-Latarjet procedure seems to be better in terms of prevention of recurrence and rehabilitation, but randomized studies are needed to reach definitive conclusions. LEVEL OF EVIDENCE: Level IV, systematic review of Level II, III, and IV studies.

Epidemiological burden of postmenopausal osteoporosis in Italy from 2010 to 2020: estimations from a disease model

HipFx Supplemental Cost Analysis

The article describes the adaptation of a model to estimate the burden of postmenopausal osteoporosis in women aged 50 years and over in Italy between 2010 and 2020. For this purpose, a validated postmenopausal osteoporosis disease model developed for Sweden was adapted to Italy. For each year of the study, the 'incident cohort' (women experiencing a first osteoporotic fracture) was identified and run through a Markov model using 1-year cycles until 2020. Health states were based on the number of fractures and deaths. Fracture by site (hip, clinical vertebral, non-hip non-vertebral) was tracked for each health state. Transition probabilities reflected fracture site-specific risk of death and subsequent fractures. Model inputs specific to Italy included population size and life tables from 1970 to 2020, incidence of hip fracture and BMD by age in the general population (mean and standard deviation). The model estimated that the number of postmenopausal osteoporotic women would increase from 3.3 million to 3.7 million between 2010 and 2020 (+14.3%). Assuming unchanged incidence rates by age group over time, the model predicted the overall number of osteoporotic fractures to increase from 285.0 to 335.8 thousand fractures between 2010 and 2020 (+17.8%). The estimated expected increases in hip, vertebral and non-hip non-vertebral fractures were 22.3, 17.2 and 16.3%, respectively. Due to demographic changes, the burden of fractures is expected to increase markedly by 2020

The effect of endoskeleton on antibiotic impregnated cement spacer for treating deep hip infection

DoD SSI (Surgical Site Infections)

BACKGROUNDS: A two-stage revision arthroplasty was suggested optimal treatment for deep infections in hip joint. The effect of endoskeleton of cement spacers on the interim function and infection control remains unclear. METHODS: From Jan. 2004 to Dec. 2007, we collected a prospective cohort of consecutive 34 patients who treated with two-stage revision total hip arthroplasty for deep infection of hip joint. In group 1, fifteen patients were treated by a novel design augmented with hip compression screw while nineteen patients were treated by traditional design in group 2. RESULTS: No fracture of cement spacer occurred in group 1 while 6 cases developed spacer failure in group 2. (p < 0.05) There were significant differences in bodily pain and general health perception between groups (p < 0.05). CONCLUSIONS: Patients being treated for deep infection of hip joint using cement spacer augmented with stronger endoskeleton have lower pain levels and better joint function between stages.

Total knee arthroplasty fixation. Comparison of the early results of paired cemented versus uncemented porous coated anatomic knee prostheses

Surgical Management of Osteoarthritis of the Knee CPG

The results of 18 matched pairs of Porous Coated Anatomic knee prostheses were studied to compare the early clinical and functional performance of cemented versus uncemented fixation with an average five-year follow-up period for both. The knee score improved from a preoperative average of 35 points to a postoperative average of 90 points in the cemented group, and from 38 points to 93 points in the uncemented group. In particular, the individual pain scores and the range-of-motion values were well matched at the three-, six-, and 12-month follow-up visits and showed a steady improvement. Subjectively, all patients were pleased with the results of surgery; one-third preferred the cemented side, one-third preferred the uncemented side, and one-third found no difference in the performance of either knee. The clinical and functional performance of knee prostheses in patients who had one cemented knee and one uncemented knee were comparable and possibly unrelated to the type of fixation method

A classification and grading system for Barton fractures

Distal Radius Fractures

PURPOSE: We described a morphological classification and grading system for volar Barton fractures. METHODS: We divided these fractures into four types: typical Barton, ulna Barton, radial Barton, comminuted Barton. Moreover, we graded the fractures into two degrees: simple split and split-depression. We retrospectively reviewed all wrist radiographs showing Barton fractures in our hospital between January 2013 and January 2015. We identified 100 cases whose records and radiographs were reviewed and included 36 men and 64 women with a mean age of 50 years (15-78). The morphological classification was applied to the 100 cases by three reviewers on two occasions using the Kappa statistic. RESULTS: The inter- and intra-observer reliability of the morphological classification was 0.71-0.80 and 0.68-0.88, respectively. The distribution of typical, ulna, radial and comminuted Barton type fractures was 69 %, 7 %, 5 % and 19 %, respectively. Grade 2 fractures accounted for 49 % in our series. CONCLUSIONS: This classification and grading system of Barton fractures is likely to have implications in terms of pathophysiology and surgical technique.

Long-term outcome and risk factors of proximal femoral fracture in uncemented and cemented total hip arthroplasty in 2551 hips

Management of Hip Fractures in the Elderly

Proximal femoral fractures are relatively common during total hip arthroplasty. The purposes of this study were to identify risk factors associated with femoral fractures and determine their effect on femoral stem survivorship. A total of 2551 hips were examined with up to 16 years of follow-up (mean, 6.8 years). Seventy-five percent of the stems were cemented. The incidence of proximal femoral fracture was 2.3% (59 hips). Risk factors associated with fractures include anterolateral approach, uncemented femoral fixation, and female sex (P < .01). Cerclage wiring was the most common treatment. After a fracture, femoral component survivorship was 95.8% for uncemented stems and 91.7% for cemented stems. In the absence of fracture, stem survivorship was 98.6% for cemented stems and 100% for circumferentially coated tapered titanium uncemented stems

Femoral nerve block for patient undergoing total knee arthroplasty: Prospective, randomized, double-blinded study evaluating analgesic effect of perineural fentanyl additive to local anesthetics

AAHKS (9/10) Regional Nerve Blocks

BACKGROUND: The existence of peripheral opioid receptors and its effectiveness in peripheral nerve block remain controversial. The aim of this prospective, randomized, double-blinded study was to examine the analgesic effects of adding fentanyl to ropivacaine for continuous femoral nerve block (CFNB) using patient-controlled analgesia after total knee arthroplasty (TKA). METHODS: The patients were divided into 2 groups, each with n = 40 in ropivacaine (R) group and n = 42 in R with fentanyl (R + F) group. After operation, the patients in each group received R + F and R alone via a femoral nerve catheter, respectively. We assessed the visual analog scale (VAS) pain immediately before administration (baseline) and at 15, 30, and 60 minutes on postanesthesia care unit (PACU), and resting and ambulatory VAS score up to 24 hours. RESULTS: Overall, the average VAS scores in the R + F group were slightly lower than those of the R group. However, the VAS score differences between groups were not statistically significant, except for 30 minutes (P = 0.009) in PACU. R group showed higher supplemental analgesics consumption in average compared with R + F group, but not significant. CONCLUSION: Additional fentanyl did not show prominent enhancement of analgesic effect in the field of CFNB after TKA.

Retrospective, multicenter, observational study of 112 surgically treated cases of humerus metastasis

Pediatric Supracondylar Humerus Fracture 2020 Review

INTRODUCTION: The humerus is the second most common site for metastasis in the peripheral skeleton. These humeral metastases (HM) occur in the midshaft in 42% to 61% of cases and theproximal humerus in 32% to 45% of cases. They are often secondary to primary breast (17-31%), kidney (13-15%) or lung (11-24%) cancer. The optimal surgical treatment between intramedullary (IM) procedures, fixation or arthroplasty is still being debated. HYPOTHESIS: We hypothesized that fixation and/or arthroplasty are safe and effective options for controlling pain and improving the patients' function. MATERIALS AND METHODS: Between 2004 and 2016, 11 French hospitals included 112 continuous cases of HM in 54 men (49%) and 57 women (51%). The average age was 63.7±13.4 years (30-94). The HM occurred in the context of primary breast (30%), lung (23%) or kidney (21%) cancers. The HM was proximal in 35% of cases, midshaft in 59% and distal in 7% of cases. Surgery was required in 69% of patients because of a pathological fracture. The surgical procedure consisted of bundle pinning, plate fixation, arthroplasty or locked IM nailing in 6%, 11%, 14% and 69% of patients, respectively. RESULTS: Seven patients (6%) had to be reoperated due to surgical site complications including two infections and four fractures (periprosthetic or away from implant). Twelve patients (11%) experienced a general complication. The overall survival was 16.7 months, which was negatively and significantly impacted by the occurrence of a fracture, a diaphyseal location and the type of primary cancer. At the final assessment, 75% had normal or subnormal function and more than 90% were pain-free or had less pain. The final function was not related to the occurrence of a fracture or etiology of the metastasis. In epiphyseal and metaphyseal HM, there was a trend to better function after shoulder arthroplasty than after plate fixation or IM nailing. CONCLUSIONS: Our initial hypothesis was confirmed. Our findings were consistent with those of other published studies. Based on our findings, we recommend using static locked IM nailing with cementoplasty for mid-shaft lesions and modular arthroplasty for destructive epiphyseal or metaphyso-epiphyseal lesions. The criteria for assessing humeral fracture risk should be updated to allow the introduction of a preventative procedure, which contributes to better survival. LEVEL OF EVIDENCE: IV, retrospective study.

PR11-364P22.2/ATF3 protein interaction mediates IL-1beta-induced catabolic effects in cartilage tissue and chondrocytes

AMP (Acute Meniscal Pathology)

Osteoarthritis (OA) is a degenerative joint disease which lacks effective medical treatment due to ill-defined molecular mechanisms underlying the pathology. Inflammation is a key factor that induces and aggravates OA. Therefore, the current study aims to explore roles of the dysregulated long non-coding RNAs in the pro-inflammatory cytokine IL-1beta-mediated catabolic effects in cartilage tissue and chondrocytes. We identified RP11-364P22.2 as dysregulated in OA patient-derived cartilage tissues and highly responsive to IL-1beta stimulus. RNA pull-down coupled with mass spectrometry demonstrated that RP11-364P22.2 physically binds to activating transcription factor 3 (ATF3) and thus increases the protein stability and facilitates its nuclear translocation. Loss- and gain-of-function assays indicated that the interaction between RP11-364P22.2 and ATF3 is indispensable for the detrimental effects of IL-1beta including growth inhibition, apoptosis induction as well as degradation of the key chondrocyte structural proteins of type II collage and Aggrecan and synthesis of the extracellular matrix-degrading enzyme MMP13 in chondrocytes. In vivo, depletion of the RP11-364P22.2 effector ATF3 drastically prevented OA development in the rats with surgical destabilization of the medial meniscus (DMM). These results highlight the important roles of lncRNAs in the pathogenesis of OA and indicate the RP11-364P22.2/ATF3 regulatory axis as a potential therapeutic target of inflammation-induced OA.

MRI of the wrist

Diagnosis and Treatment of Carpal Tunnel Syndrome CPG

In the past, the diagnostic imaging algorithm for evaluating the painful wrist included initial plain radiographic examination followed by arthrography, tomography, bone scintigraphy, or computed tomography. In recent years, magnetic resonance imaging (MRI) has been proven efficacious for diagnosing a number of maladies of the bones, ligaments, and soft tissues. MRI can be of aid in evaluation of carpal instability, disorders of the triangular fibrocartilage, ulnar impaction syndrome, distal radioulnar joint (DRUJ) instability, fracture, avascular necrosis (AVN), tendinopathy, nerve entrapment syndromes, synovial abnormalities, and soft tissue masses

Early postoperative cartilage evaluation by magnetic resonance imaging using T2 mapping after arthroscopic partial medial meniscectomy

AMP (Acute Meniscal Pathology)

PURPOSE: This study was performed to quantitatively evaluate postoperative changes in cartilage by T2 mapping after arthroscopic partial medial meniscectomy. MATERIAL AND METHODS: The study enrolled 17 patients with 20 knees that underwent arthroscopic partial medial meniscectomy. MRI was performed preoperatively and at six months postoperatively, with subjects evaluated by T2 mapping of the central part of the medial condyle of the femur in the sagittal plane. Regions of interest (ROIs) were set at 10 points between the point of intersection of the anatomical axis of the femur and the articular surface of the medial condyle and posterior area approximately 90 degrees to the anatomical axis. Pre- and postoperative T2 values at each ROI were evaluated. RESULTS: Postoperative T2 values were significantly longer than preoperative values at approximately 20, 30, 40, and 50 degrees to the anatomical axis of the femur. The maximum change between pre- and postoperative T2 values was +6.65% at 30 degrees to the anatomical axis. CONCLUSIONS: Mechanical stress at positions approximately 20, 30, 40, and 50 degrees relative to the anatomical axis of the femur increased soon after arthroscopic medial meniscectomy. These findings indicate the start of degeneration, via disorganization of collagen arrays, of the articular cartilage and increased water content.

The suspension (Frost) suture: experience and applications

Upper Eyelid and Brow Surgery

BACKGROUND: The Frost suture is a well-known surgical technique for providing upward tension on the lower lid to prevent or correct ectropion after surgical interventions in the periorbital area. Despite its relatively common use, comprehensive information on executing this technique is not readily available. OBJECTIVE: To review eyelid anatomy, indications, and proper technique for performing the Frost suture, as well as potential complications. MATERIALS AND METHODS: A review of the literature on Frost sutures was performed. Cadaveric dissection was performed to demonstrate placement of the Frost suture. RESULTS AND CONCLUSION: The Frost suture is a useful method to reduce the risk of ectropion after surgery near the lower eyelid. Downward pull on the lid can occur with normal wound contracture even if ectropion is not present with the initial repair, reinforcing the need for preventive measures. Potential complications of this technique include superficial skin erosion of the upper lid, corneal abrasion, and blockage of the field of vision while the suture is in place.

Corrective osteotomy through fracture site and internal fixation with headless screws for type I (Hahn-Steinthal) capitellar malunion

The Treatment of Pediatric Supracondylar Humerus Fractures AUC

A 20-year-old woman presented 6 months after an initial injury to her left elbow with pain and restricted movements. She was diagnosed with a type I malunited (Hahn-Steinthal) type of capitellum fracture through radiographic studies. Classically, the treatment has been excision of the fragment, which carries a risk of valgus instability of the elbow and late osteoarthrosis. We report a case of malunited type I capitellum fracture, for which corrective osteotomy through fracture site, open reduction and internal fixation was done 6 months following missed trauma. At 24 months follow-up the capitellum fracture had united and the patient has a stable elbow and excellent range of motion. Our case demonstrates that for type I malunited capitellum fractures corrective osteotomy through fracture site and internal fixation rather than excision of the fragment in young can result in successful union and stable elbow. Copyright 2013 BMJ Publishing Group. All rights reserved

Automatic identification algorithm of meniscus tear based on radiomics of knee MRI

AMP (Acute Meniscal Pathology)

OBJECTIVE: To establish a classification model based on knee MRI radiomics, realize automatic identification of meniscus tear, and provide reference for accurate diagnosis of meniscus injury. METHODS: A total of 228 patients (246 knees) with meniscus injury who were admitted between July 2018 and March 2021 were selected as the research objects. There were 146 males and 82 females; the age ranged from 9 to 76 years, with a median age of 53 years. There were 210 cases of meniscus injury in one knee and 18 cases in both knees. All the patients were confirmed by arthroscopy, among which 117 knees with meniscus tear and 129 knees with meniscus non-tear injury. The proton density weighted-spectral attenuated inversion recovery (PDW-SPAIR) sequence images of sagittal MRI were collected, and two doctors performed radiomics studies. The 246 knees were randomly divided into training group and testing group according to the ratio of 7:3. First, ITK-SNAP3.6.0 software was used to extract the region of interest (ROI) of the meniscus and radiomic features. After retaining the radiomic features with intraclass correlation coefficient (ICC)>0.8, the max-relevance and min-redundancy (mRMR) and least absolute shrinkage and selection operator (LASSO) were used for filtering the features to establish an automatic identification model of meniscus tear. The receiver operator characteristic curve (ROC) and the corresponding area under the ROC curve (AUC) was obtained; the model performance was comprehensively evaluated by calculating the accuracy, sensitivity, and specificity. RESULTS: A total of 1 316-dimensional radiomic features were extracted from the meniscus ROI, and the ICC within the group and ICC between the groups of the 981-dimensional radiomic features were both greater than 0.80. The redundant information in the 981-dimensional radiomic features was eliminated by mRMR, and the 20-dimensional radiomic features were retained. The optimal feature subset was further selected by LASSO, and 8-dimensional radiomic features were selected. The average ICC within the group and the average ICC between the groups were 0.942 and 0.920, respectively. The AUC of the training group was 0.889±0.036 [95% CI (0.845, 0.942), P<0.001], and the accuracy, sensitivity, and specificity were 0.873, 0.869, and 0.842, respectively; the AUC of the testing group was 0.876±0.036 [95% CI (0.875, 0.984), P<0.001], and the accuracy, sensitivity, and specificity were 0.862, 0.851, and 0.845, respectively. CONCLUSION: The model established by the radiomics method has good automatic identification performance of meniscus tear.

High survival of dome pelvic osteotomy in patients with early osteoarthritis from hip dysplasia hip

PJI DX Updated Search

Background: The Chiari osteotomy reportedly has a 60% to 91% survival rate at a minimum 20 years followup. The dome pelvic osteotomy (DPO) has the advantage of allowing a larger weightbearing surface, and congruity in the sagittal plane presumably would reduce the joint contact stress and perhaps increase longevity. Questions/purposes: We determined: (1) the survival after DPO at a minimum 25-year followup, (2) patient function, (3) acetabular coverage, and (4) factors influencing conversion to THA. Methods: We retrospectively reviewed 50 patients (59 hips) with developmental dysplasia of the hip (DDH) treated with DPO. The preoperative radiographic stages were graded as prearthritis (18 hips), early osteoarthritis (25 hips), and advanced osteoarthritis (16 hips). We performed a Kaplan-Meier survival analysis with THA conversion as the end point. We determined various radiographic parameters reflecting coverage, and compared demographic information for hips without and with THA conversion using multivariate logistic regression analysis. The minimum followup was 25 years (mean, 27.5 years; range, 25-32 years). Results: Survival for all hips was 63.6% (95% CI, 51-76) at 27.5 years and that for hips with prearthritis and early osteoarthritis before the surgery was 79.1% (95% CI, 63-91). Twenty-one hips (36%) had undergone THAs at a mean 18.3 years (range, 2.5-25 years). At the last followup, pain, walking ability, and acetabular coverage improved. We identified four factors predicting THA conversion: greater age, presence of a preoperative Trendelenburg sign, higher preoperative radiographic osteoarthritis grade, and smaller postoperative acetabular head index (AHI) predicted conversion to THA. Conclusions: DPO is a reasonable treatment option for patients with DDH and prearthritis or early osteoarthritis, with high survival at greater than 25 years. Level of Evidence: Level IV, prognostic study. See the Guidelines for Authors for a complete description of levels of evidence. © 2012 The Association of Bone and Joint Surgeons®

A morphological study on femoral heads in human hip joint osteoarthrosis

Management of Hip Fractures in the Elderly

Several pathogenetical and clinical interpretation of osteoarthritic modifications are given in the literature. In this work we tried to compare in humans macroscopic, structural and ultrastructural observations on eight osteoarthritic with four femural heads from control patients. The sample for Light Microscopy and Scanning Electron Microscopy observations came from selected regions of the femural head, which included both cartilage and bone tissue of loaded and unloaded regions. The cartilage showed superficial lesions, such as erosions and fissures, and deep lesions that included matrix alterations and chondrocyte proliferation. In relation to the thickening of the subchondral bone we noticed an irregular bone-cartilage surface with signs of bone tissue proliferation. The trabeculae appeared thickened in loaded zones and rarefied in unloaded ones. Cavities were sometimes present at different depths in cancellous bone. Our observations allow us to conclude that cartilage lesions are precocious, diffusely located and relatively independent of the considered zone of the femural head, while bone tissue alterations seem evenly sited and chronologically subsequent. The cavities in the cancellous bone could produce load modifications and consequent bone deformity

Cleidocranial Dysplasia Spectrum Disorder GeneReviews R

Dental Implant Infection

CLINICAL CHARACTERISTICS: Cleidocranial dysplasia (CCD) spectrum disorder is a skeletal dysplasia that represents a clinical continuum ranging from classic CCD (triad of delayed closure of the cranial sutures, hypoplastic or aplastic clavicles, and dental abnormalities), to mild CCD, to isolated dental anomalies without other skeletal features. Individuals with classic CCD spectrum disorder typically have abnormally large, wide-open fontanelles at birth that may remain open throughout life. Clavicular hypoplasia can result in narrow, sloping shoulders that can be opposed at the midline. Moderate short stature may be observed, with most affected individuals being shorter than their unaffected sibs. Dental anomalies may include delayed eruption of secondary dentition, failure to shed the primary teeth, and supernumerary teeth. Individuals with CCD spectrum disorder are at increased risk of developing recurrent sinus infections, recurrent ear infections leading to conductive hearing loss, and upper airway obstruction. Intelligence is typically normal., DIAGNOSIS/TESTING: The diagnosis of CCD spectrum disorder is established in an individual with typical clinical and radiographic findings and/or a heterozygous pathogenic variant in RUNX2 identified by molecular genetic testing., MANAGEMENT: Treatment of manifestations: If the cranial vault defect is significant, the head needs protection from blunt trauma; helmets may be used for high-risk activities. Surgical cosmesis for depressed forehead or lengthening of hypoplastic clavicles can be considered. Careful planning of anesthetic management due to craniofacial and dental abnormalities. Consultation with an otolaryngologist to assist in securing the airway. Consideration of alternative anesthetic approaches, including neuraxial block, taking into account possible spine abnormalities. If bone density is below normal, treatment with calcium and vitamin D supplementation. Dental procedures to address retention of primary dentition, presence of supernumerary teeth, and non-eruption of secondary dentition. Such procedures may include prosthetic replacements, removal of the supernumerary teeth followed by surgical repositioning of the secondary teeth, and a combination of surgical and orthodontic measures for actively erupting and aligning the impacted secondary teeth. Speech therapy as needed. Aggressive treatment of sinus and middle ear infections; consideration of tympanostomy tubes for recurrent middle ear infections; regular immunizations including influenza. Sleep study in those with manifestations of obstructive sleep apnea; surgical intervention may be required for upper airway obstruction. Surveillance: Monitor children for orthopedic complications, dental abnormalities, sinus and ear infections, upper airway obstruction, hearing loss, and speech issues. DXA scan to assess bone mineral density beginning in early adolescence and every five to ten years thereafter. Agents/circumstances to avoid: Helmets and protective devices should be worn when participating in high-risk activities. Pregnancy management: Monitor affected women during pregnancy for cephalopelvic disproportion., GENETIC COUNSELING: CCD spectrum disorder is inherited in an autosomal dominant manner. The proportion of individuals with CCD spectrum disorder caused by a de novo pathogenic variant is high. Each child of an individual with CCD spectrum disorder has a 50% chance of inheriting the RUNX2 pathogenic variant. Once the RUNX2 pathogenic variant has been identified in an affected family member, prenatal and preimplantation genetic testing for CCD spectrum disorder are possible. Copyright © 1993-2023, University of Washington, Seattle. GeneReviews is a registered trademark of the University of Washington, Seattle. All rights reserved.

Faster recovery without the use of a tourniquet in total knee arthroplasty

AAHKS (4) Acetaminophen

Background and purpose - Tourniquet application is still a common practice in total knee arthroplasty (TKA) surgery despite being associated with several adverse effects. We evaluated the effects of tourniquet use on functional and clinical outcome and on knee range of motion (ROM). Patients and methods - 70 patients who underwent TKA were randomized into a tourniquet group (n = 35) and a non-tourniquet group (n = 35). All operations were performed by the same surgeon and follow-up was for 1 year. Primary outcomes were functional and clinical outcomes, as evaluated by KOOS and knee ROM. Secondary outcomes were intraoperative blood loss, surgical time and visibility, postoperative pain, analgesic consumption, and transfusion requirements. Results - Patients in the non-tourniquet group showed a better outcome in all KOOS subscores and better early knee ROM from surgery to week 8. No difference was detected at the 6- and 12-month follow-ups. Postoperative pain and analgesic consumption were less when a tourniquet was not used. Surgical time and visibility were similar between groups. Intraoperative blood loss was greater when not using a tourniquet, but no postoperative transfusions were required. Interpretation - This study shows that TKA without the use of a tourniquet results in faster recovery in terms of better functional outcome and improved knee ROM. Furthermore, reduced pain and analgesic use were registered and no intraoperative difficulties were encountered. © Copyright: Nordic Orthopaedic Federation.

The early results of metal-on-metal hip resurfacing: A prospective study at a minimum two-year follow-up

Management of Hip Fractures in the Elderly

Hip resurfacing has recently been offered as an attractive alternative to conventional total hip arthroplasty. This report evaluated the short-term functional outcome and longevity of a newer generation resurfacing device and includes the results of 228 consecutive hip resurfacings in 209 patients at a minimum of two-year follow-up. All resurfacings were performed by a single surgeon using a posterior approach. Excluding infections, there were only three failures (1.3%). The overall survival at 4.6 years was 96.9%. The survival of resurfacing in this study was comparable to that of other published studies of hip resurfacing. Surface hip arthroplasty appears to be an effective alternative to conventional total hip arthroplasty in patients suffering from osteoarthritis

A prospective investigation of long-term cognitive impairment and psychological distress in moderately versus severely injured trauma intensive care unit survivors without intracranial hemorrhage

DoD PRF (Psychosocial RF)

BACKGROUND: The primary objective was to prospectively determine the 12-month prevalence of cognitive impairment and psychologic difficulties in moderately versus severely injured adult trauma intensive care unit (TICU) survivors without intracranial hemorrhage. METHODS: We conducted a prospective cohort study in which patients were followed for 1 year after hospital discharge. A total of 173 patients from the Vanderbilt TICU who had an Injury Severity Score (ISS) of >15 (indicative of moderately severe trauma) were enrolled between July 2006 and June 2007. Patients were screened for delirium on a daily basis in the TICU by study personnel via the confusion assessment method of the ICU, and preexisting cognitive impairment was assessed through a surrogate-based evaluation using the short form of the Informant Questionnaire for Cognitive Decline in the Elderly. Of these patients, 108 were evaluated 1 year after hospital discharge with a comprehensive battery of neuropsychological tests and depression and posttraumatic stress disorder (PTSD) instruments. Cognitive impairment was defined as having two neuropsychological test scores 1.5 SD below the mean or one neuropsychological test score 2 SD below the mean. RESULTS: Fifty-nine patients (55%) demonstrated cognitive impairment at 12-month follow-up, with three of these patients (5.5%) having preexisting impairment. Clinically significant symptoms of depression and PTSD occurred in 40% and 26% of patients, respectively. No significant differences in cognitive impairment (59% vs. 50%), depressive symptoms (35% vs. 44%), and symptoms of PTSD (22% vs. 28%) were identified between moderately (ISS 15-25) and severely (ISS>25) injured TICU survivors, respectively (all p>0.05). In addition, multivariate logistic regression analysis found that moderately injured trauma patients had a similar rate of cognitive impairment when compared with those with severe injury at 12-month follow-up (p=0.25). CONCLUSION: Long-term cognitive impairment is highly prevalent in TICU survivors without intracranial hemorrhage as are psychologic difficulties. Injury severity, concussion status, and delirium duration were not risk factors for the development of neuropsychological deficits in this cohort. Individuals with moderately severe injuries seem to be as likely as their more severely injured counterparts to experience marked cognitive impairment and psychologic difficulties; thus, screening efforts should focus on this potentially overlooked patient group.

Pain intensity and Patients' acceptance of surgical complication risks with lumbar fusion

DoD SSI (Surgical Site Infections)

STUDY DESIGN.: Cross-sectional study with prospective recruitment. OBJECTIVE.: To determine the relationship of pain intensity (back and leg) on patients' acceptance of surgical complication risks when deciding whether or not to undergo lumbar spinal fusion. SUMMARY OF BACKGROUND DATA.: To formulate informed decisions regarding lumbar fusion surgery, preoperative discussions should include a review of the risk of complications balanced with the likelihood of symptom relief. Pain intensity has the potential to influence a patient's decision to consent to lumbar fusion. We hypothesized that pain intensity is associated with a patient's acceptance of surgical complication risks. METHODS.: Patients being seen for the first time by a spine surgeon for treatment of a nontraumatic or non-neoplastic spinal disorder completed a structured questionnaire. It posed 24 scenarios, each presenting a combination of risks of 3 complications (nerve damage, wound infection, and nonunion) and probabilities of symptom relief. For each scenario, the patient indicated whether he or she would or would not consent to a fusion for low back pain (LBP). The sum of the scenarios in which the patient responded that he or she would elect surgery was calculated to represent acceptance of surgical complication risks. A variety of other data were also recorded, including age, sex, education level, race, history of nonspinal surgery, duration of pain, and history of spinal injections. Data were analyzed using bivariate and multivariate regression analyses. RESULTS.: The mean number of scenarios accepted by 118 enrolled subjects was 10.2 (median, 8; SD, 8.5; range, 0-24, or 42.5% of scenarios). In general, subjects were more likely to accept scenarios with lower risks and higher efficacy. Spearman rank correlation estimates demonstrated a moderate association between the LBP intensity and acceptance of surgical complication risks (r = 0.37, P = 0.0001) whereas leg pain intensity had a weak but positive correlation (r = 0.19, P = 0.04). In bivariate analyses, a history of spinal injections was strongly associated with patients' acceptance of surgical complication risks and willingness to proceed with surgery (54.5% of scenarios accepted for those who had a history of spinal injections vs. 27.6% for those with no history of spinal injections, P = 0.0001). White patients were more willing to accept surgery (45.9% of scenarios) than non-white patients (28.4%, P = 0.03). With the available numbers, age, sex, history of nonspinal surgery, education, and the duration of pain demonstrated no clear association with acceptance of surgical complication risks. Although education overall was not an influential factor, more educated males had greater risk tolerance than less educated males whereas more educated females had less risk tolerance than less educated females (P = 0.023). In multivariate analysis, LBP intensity remained a highly statistically significant correlate (P = 0.001) of the proportion of scenarios accepted, as did a history of spinal injections (P = 0.001) and being white (0.03). CONCLUSION.: The current investigation indicates that the intensity of LBP is the most influential factor affecting a patient's decision to accept risk of complication and symptom persistence when considering lumbar fusion. This relationship has not been previously shown for any surgical procedure. These data could potentially change the manner in which patients are counseled to make informed choices about spinal surgery. With growing interest in adverse events and complications, these data could be important in establishing guidelines for patient-directed surgical decision making. Copyright © 2013 Lippincott Williams & Wilkins.

Salter-Harris I fractures of the distal radius misdiagnosed as wrist sprain

Distal Radius Fractures

Over a period of 5 years, 65 children under 12 years of age were diagnosed as having 'wrist sprain' at the American University of Beirut Medical Center, Emergency Department. Thirty-eight children were reevaluated; 33 patients (86.8%) were diagnosed as having a Salter-Harris I fracture of the distal radius that necessitated further treatment to relieve symptoms and allow early wrist function. The diagnosis of 'wrist sprain' is often inadequate in establishing a proper treatment regimen. Rather, by taking a careful history, performing an exacting examination, and utilizing appropriate diagnostic aids, an accurate diagnosis of wrist injury can be established. (C) 2000 Elsevier Science Inc.

Ewing's sarcoma: Experience with 12 cases

MSTS 2018 - Femur Mets and MM

Twelve patients with localized Ewing's sarcoma were treated between 1980-1990 at the Istanbul School of Medicine, Department of Pediatric Oncology-Hematology, Oncology Research and Treatment Center and Our Children Leukemia Foundation. There were 8 boys and 4 girls, with a mean age of 8.1 (range 3-17) years. The tumors were in the femur in 3 patients, in the humerus and rib in 2 patients each and in the tibia, radius, vertebra, clavicula and pelvis in 1 patient each. Chemotherapy alone was applied in 2 patients, 1 patient had chemotherapy and radiotherapy. The remaining 9 cases were treated with chemotherapy and radiotherapy (during the chemotherapy). The chemotherapy protocols were: VAC (n = 5), VACA (n = 3), IVAD (n = 3) and T.9 (n = 1). One patient died from the disease itself. Remissions were achieved in the other 11 patients. After 5 to 95 months (mean: 22 months) 7 patients had relapsed (4 had local and 3 had distant metastases). Three patients were not able to be followed, 3 died due to additional problems (infection, cardiotoxicity). The best prognosis was achieved when Ewing's sarcoma initiated in the long bones, with less than 100 ml tumor volumes and patients were under 5 years old. There were no significant differences among chemotherapy protocols.

Review of Spinal cord injury in the child and young adult

DoD PRF (Psychosocial RF)

Reviews the book, Spinal Cord Injury in the Child and Young Adult edited by L. C. Vogel, K. Zebracki, R. R. Betz and M. J. Mulcahey (2014). The current volume is an expansion of the first published work The Child With a Spinal Cord Injury (American Academy of Orthopedic Surgeons, Rosemont, IL, 1996). The focus of the book expands the topics to encompass the International Classification of Functioning, Disability and Health paradigm. The main sections include early management, unique pediatric considerations, medical management, neuromuscular, and psychosocial issues. (PsycINFO Database Record (c) 2016 APA, all rights reserved)

Revision Total Hip Arthroplasty after Ceramic Bearing Fractures in Patients Under 60-years Old; Mid-term Results

Hip Fx in the Elderly 2019

Purpose: Although advances in technology have reduced the risk of ceramic implant fractures in total hip arthroplasty, these injuries do occur and their treatment remains challenging. There is a lack of studies reporting on the effectiveness of ceramic components in revision hip arthroplasty after ceramic bearing fracture. The aim of this study is to evaluate clinical and radiologic outcomes of revision surgery with ceramic-on-ceramic components after ceramic bearing fractures in young (i.e., under 60 years old) and active patients. Materials and Methods: Eight patients who, from May 2004 to November 2011, underwent ceramic-on-ceramic revision surgery following a ceramic component fracture and had more than 6 years follow up were enrolled in this study. All eight patients were male with mean ages at first and revision surgeries of 39 years (range, 31-50 years) and 43.8 years (range, 33-60 years), respectively. There were 6 and 2 cases of ceramic liner and ceramic head fractures, respectively. The average time from the first operation to revision surgery was 54.3 months (range, 9-120 months), and the average follow up period was 9.7 years (range, 6-13.3 years). Results: At the last follow up, all patients showed improvement in Harris hip score and pain relief and there were no cases of loosening or osteolysis. Conclusion: Revision total hip arthroplasty using ceramic-on-ceramic components after ceramic component fracture is a feasible and appropriate surgical option in young and active patients.

Osteoarthritis of the wrist following Colles' fracture: A primary or secondary phenomenon?

Distal Radius Fractures

Both wrists and hands of 51 patients, who had sustained unilateral Colles' fracture 10 years previously, were examined radiologically for osteoarthritis (OA). Twenty-nine demonstrated OA, which in only five was confined to the injured wrist. The prevalence of OA was comparable in both injured and uninjured wrists. Radiocarpal and radioulnar OA correlated with carpometacarpal OA in the same hand (p < 0.001). Polyarticular interphalangeal OA (indicating primary OA) was present in 16 patients (31%), and was closely associated with radiocarpal OA and radiocarpal with radioulnar OA in the previously fracture wrist.

Factors associated with long-term functional and psychological outcomes in persons with moderate to severe traumatic brain injury

DoD PRF (Psychosocial RF)

OBJECTIVE: To examine factors impacting long-term functional and psychological outcomes in persons with moderate-severe traumatic brain injury. METHODS: A prospective cross-sectional study (n=103) assessed the long-term (up to 5 years) impact of traumatic brain injury on participants' current activity and restriction in participation using validated questionnaires. RESULTS: Participants' median age was 49.5 years (interquartile range (IQR) 20.4-23.8), the majority were male (77%), and 49% had some form of previous rehabilitation. The common causes of traumatic brain injury were falls (42%) and motor vehicle accidents (27%). Traumatic brain injury-related symptoms were: pain/headache (47%), dizziness (36%), bladder/bowel impairment (34%), and sensory-perceptual deficits (34%). Participants reported minimal change in their physical function and cognition (Functional Assessment Measure: motor (median 102, IQR 93-111) and cognition (median 89, IQR 78-95)). Participants were well-adjusted to community-living; however, they reported high levels of depression. Factors significantly associated with poorer current level of functioning/well-being included: older age (>=60 years), presence of traumatic brain injury-related symptoms, a lack of previous rehabilitation and those classified in "severe disability categories" at admission. Caregivers reported high levels of strain and burden (55%). CONCLUSION: Cognitive and psychosocial problems are more commonly reported than physical disability in the longer-term. A greater focus on participation and ageing with disability in these persons is needed.

Deep vein harvest: predicting need for fasciotomy

DOD - Acute Comp Syndrome CPG

OBJECTIVE: Deep thigh veins, including the superficial femoral, superficial femoropopliteal, and profunda femoris veins, are versatile autogenous conduits for arterial reconstruction. Although late venous complications are unusual, deep vein harvest may induce severe venous hypertension and predispose the limb to acute compartment syndrome. The purpose of this study was to define the frequency of fasciotomy in patients undergoing deep vein harvest and to identify clinical predictors of the need for fasciotomy after deep vein harvest. METHODS: Over 9 years, 162 patients underwent arterial reconstruction with deep vein harvested from 264 limbs. Indications for deep vein harvest included aortofemoral reconstruction in 127 patients, brachiocephalic arterial reconstruction in 22 patients, and visceral arterial reconstruction in 13 patients. RESULTS: Fasciotomy was performed in 47 of 264 limbs (17.8%) after deep vein harvest. The prevalence of fasciotomy after deep vein harvest was 20.6% for patients requiring aortofemoral reconstruction, whereas no patients underwent fasciotomy after deep vein harvest for mesenteric or brachiocephalic arterial reconstruction (P =.0068). Fasciotomy was performed in 20.7% of limbs after complete deep vein harvest to a level below the adductor hiatus, but no fasciotomies were performed in patients undergoing subtotal deep vein harvest, ending above the adductor hiatus (P =.0023). The mean preoperative ankle-brachial index (ABI) was significantly lower in limbs requiring fasciotomy (ABI, 0.39 +/- 0.05), compared with patients who did not require fasciotomy (ABI, 0.79 +/- 0.02; P <.0001). Fasciotomy was performed in 76.0% of limbs undergoing concurrent ipsilateral greater saphenous vein (GSV) and deep vein harvest, compared with 11.7% of patients undergoing deep vein harvest alone (P <.0001). The mean volume of intraoperative fluid administered to patients requiring fasciotomy was almost 50% higher than the fluid resuscitation received by patients who did not require fasciotomy (9.6 +/- 1.2 L vs 6.5 +/- 0.6 L; P <.0001). Logistic regression analysis determined that lower preoperative ABI (odds ratio [OR], 60.1; 95% confidence interval [CI], 12.5-289.3; P <.0001) and concurrent harvest of the ipsilateral GSV (OR, 9.9; 95% CI, 3.1-31.3; P <.0001) were predictors of the need for fasciotomy. CONCLUSIONS: One in four patients undergoing deep vein harvest for aortofemoral reconstruction may be expected to develop acute compartment syndrome and require fasciotomy. The risk appears to be greatest in patients with severe lower extremity ischemia and in patients undergoing simultaneous GSV and deep vein harvest. Prophylactic fasciotomy may be appropriate in patients with both risk factors, but vigilance for the development of compartment syndrome after deep vein harvest is required in all patients undergoing deep vein harvest for aortofemoral reconstruction.

Osteonecrosis of the myeloma patients treated with bisphosphonates

MSTS 2018 - Femur Mets and MM

Osteonecrosis of the jaw (ONJ) has been reported as uncommon but well recognised complication associated with bisphosphonate treatment. Multiple Myeloma (MM) is the pathology most frequently associated with ONJ in the medical and dental papers published over the last years (45% of the ONJ published cases). ONJ appears to be time-dependent with higher risk after long-term use of intravenous (i.v.) nitrogen containing bisphosphonates (eg, pamidronate, zoledronate) in older MM patients. The most frequent site of ONJ is the mandible and previous dental procedures may be a precipitating factor. Most of the ONJ cases presented clinical evidence of bone exposure and pain. There was no significant association between the occurrence of ONJ and the presence of osteolytic lesions, disease status and the use of thalidomide. Different treatments have been proposed, associated or not: medical therapy (eg, antimicrobial oral rinses, antibiotic and antimicotic), surgical therapy (eg, curettage or sequestrectomy) showing low healing rates and uncertain impact on the prognosis and on the outcome.

Isolated limb infusion with melphalan and dactinomycin for regional melanoma and soft-tissue sarcoma of the extremity: Final report of a phase II clinical trial

DOD - Acute Comp Syndrome CPG

Isolated limb infusion (ILI) is a minimally invasive technique of delivering regional chemotherapy in patients with advanced melanoma or soft-tissue sarcoma of the limb. We report the final results of the first clinical trial of ILI in North America (NCT00004250). Eligible patients had recurrent melanoma or unresectable soft-tissue sarcoma of the limb. Angiographic catheters were positioned just above the knee or elbow of the extremity. General anesthesia was performed, a proximal tourniquet inflated, and a normothermic, low flow, hypoxic infusion of melphalan and dactinomycin circulated through the involved limb for 20'min. Tumor response and morbidity were assessed using standard criteria. Thirty-seven patients were accrued to the trial and 44 ILIs were performed (eight patients had two ILIs); one patient was not treated. Of the 32 evaluable patients, 17 (53%) had a significant response at 3 months: 25% of patients had a complete response and 28% of patients had a partial response. The median duration of complete response was 1 year (5-32 months). Morbidity was acceptable, with peak erythema, edema, and pain experienced at 2 weeks and considered 'moderate' in most patients. No patients developed compartment syndrome or required amputation because of ILI. ILI is well tolerated. More than half of the treated patients experienced a complete or partial response. © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins.

Audit-induced change reduces complications of the Ganz trochanteric flip approach

Management of Hip Fractures in the Elderly

INTRODUCTION: The Ganz trochanteric flip approach aims to avoid the potential risk of avascular necrosis in hip conserving surgery and may reduce the risk of femoral neck fractures, neck thinning and femoral head implant migration in hip resurfacing. Our initial audit revealed the complications of non-union and trochanteric screw irritation to be associated with this approach. We, therefore, modified our selection criteria and re-audited our results. SUBJECTS AND METHODS: The initial audit (IA) ran between January 2003 and November 2007 after which an age limit of 50 years was recommended. The re-audit (RA) ran between November 2007 and December 2008 where one of the senior authors stopped using the approach in the over 50 year age group whilst the other senior author continued on selected patients over 50 years. RESULTS: There were 545 hips in the IA and 152 hips in the RA group. The incidence of non-union decreased in the RA after the change of selection criteria (6.2% [IA] vs 1.3% [RA]). In both audit groups, the incidence of non-union increased with age, and in the RA no non-unions were observed under the age of 50 years. The incidence of screw irritation and the necessity for removal remained relatively unchanged (20.7% [IA] vs 28.3% [RA]) with a combined incidence of 22.4%. CONCLUSIONS: The trochanteric flip approach to the hip can be used safely with an acceptable complication rate in young adult impingement and resurfacing surgery. Caution must, however, be exercised in patients over 50 years of age as they have a higher incidence of trochanteric non-union. In addition, all patients should be consented for the possibility of screw removal as a second procedure

Impact of Juvenile Idiopathic Arthritis Associated Uveitis in Early Adulthood

Upper Eyelid and Brow Surgery

BACKGROUND: Typically juvenile idiopathic arthritis (JIA)-associated uveitis (further referred as 'JIA-uveitis') has its onset in childhood, but some patients suffer its, sometimes visual threatening, complications or ongoing disease activity in adulthood. The objective of this study was to analyze uveitis activity, complications and visual prognosis in adulthood. METHODS: In this multicenter study, 67 adult patients (129 affected eyes) with JIA-uveitis were retrospectively studied for best corrected visual acuity, visual fields, uveitis activity, topical/systemic treatments, ocular complications, and ocular surgeries during their 18th, 22nd and 30th year of life. Because treatment strategies changed after the year 1990, outcomes were stratified for onset of uveitis before and after 1990. RESULTS: Sixty-two of all 67 included patients (93%) had bilateral uveitis. During their 18th life year, 4/52 patients (8%) had complete remission, 28/52 (54%) had uveitis activity and 37/51 patients (73%) were on systemic immunomodulatory treatment. Bilateral visual impairment or legal blindness occurred in 2/51 patients (4%); unilateral visual impairment or legal blindness occurred in 17/51 patients (33%) aged 18 years. The visual prognosis appeared to be slightly better for patients with uveitis onset after the year 1990 (for uveitis onset before 1990 (n = 7) four patients (58%) and for uveitis onset after 1990 (n = 44) 13 patients (30%) were either visual impaired or blind). At least one ocular surgery was performed in 10/24 patients (42%) between their 18th and 22nd year of life. CONCLUSIONS: Bilateral visual outcome in early adulthood in patients with JIA-uveitis appears to be fairly good, although one third of the patients developed one visually impaired or blind eye. However, a fair amount of the patients suffered from ongoing uveitis activity and needed ongoing treatment as well as surgical interventions. Awareness of these findings is important for ophthalmologists and rheumatologists treating patients with JIA-uveitis, as well as for the patients themselves.

Impact of a Postoperative Intervention Educational Program on the Quality of Life of Patients with Hip Fracture: A Randomized, Open-Label Controlled Trial

Hip Fx in the Elderly 2019

The objective of this study was to determine the impact of a postoperative educational intervention program on the health-related quality of life (HRQoL) of patients with hip fracture using a controlled clinical trial in a randomized, multicenter study. In total, 102 patients (45.5%) from trauma units at the two University Hospitals of the province of Caceres received the educational program, whereas 122 (54.5%) did not. Patients were consecutively included in either an intervention or a control group. Patients from the intervention group received an educational program during admission and the postoperative period. Patients from the control group did not receive any educational program. These patients were managed according to routine protocols. The patients were predominantly female (76.3%), aged 84.6 years (SD 6.1). All dimensions in both groups at 12 months showed a significant decrease with respect to baseline, except for bodily pain in both groups (p = 0.447; p = 0.827) and social functioning in the intervention group (p = 0.268). Patients receiving the educational program showed higher levels in the dimensions of the Mental Component Summary (MCS-12) (p = 0.043), vitality (p = 0.010), and social functioning (p < 0.001), as well as in the dimensions of the SF-12 health survey questionnaire of HRQoL 12 months after surgery. In conclusion, our study of the intervention group showed that there were significant improvements in MCS-12, vitality, and social function dimensions compared to the control group.

Choice of surgical approach for capitellar fractures based on pathoanatomy of fractures: outcomes of surgical management

Pediatric Supracondylar Humerus Fracture 2020 Review

The understanding of the anatomic configuration of the fractures of the capitellum has enhanced in the last few years, and the classification of these fractures continues to evolve. It is essential to tailor the surgical approaches to these fractures based on the state-of-the-art classifications. Thirty-three patients with fractures of the capitellum were included in this retrospective study. The mean age of the patients was 37.9 years, and the mean follow-up period was 24.6 months. Seventeen patients had Bryan-Morrey type I fracture, three had type II fracture, two had type III fracture and eleven had type IV fracture. Of the 11 patients with Bryan-Morrey type 4 fracture, 5 patients belonged to Dubberley 2A and 3A category and 6 patients belonged to Dubberley 2B and 3B category. Bryan-Morrey type 1, 2 and 3 fractures were approached via extended lateral approach. Bryan-Morrey type 4 was further classified using the Dubberley classification. Dubberley 2A and 3A fractures were approached via the anterolateral approach, and Dubberley 2B and 3B fractures were approached via the posterior transolecranon approach. Fracture united in all patients. Three patients showed slight delay in union, but union was achieved eventually. Two patients had avascular necrosis of the capitellar fragment. The mean range of flexion/extension was 133° (SD ± 8.0°), and pronation/supination was 151° (SD ± 6.7°). The mean Mayo Elbow Performance Index at final follow-up was 80.9 (SD ± 13.9). Based on the MEPI score, 14 patients had excellent, 10 patients had good, 6 patients had fair and 3 patients had poor results (Dubberley type 3B fractures). Correct choice of surgical approach facilitates the accuracy of reduction and fixation of these difficult fractures. It also helps to minimize the requirement of two-incision approach. Anterolateral approach is an excellent approach for Dubberley 2A and 3A fractures. LEVEL OF EVIDENCE: Level IV.

Postoperative pain after hip fracture is procedure specific

AAHKS (8) Anesthetic Infiltration

Background. Hip fracture patients experience high pain levels during postoperative rehabilitation. The role of surgical technique on postoperative pain has not been evaluated previously. Methods. One hundred and seventeen hip fracture patients were included in a descriptive prospective study. All patients received continuous epidural analgesia and were treated according to a standardized perioperative rehabilitation programme. Resting pain, pain on hip flexion, and walking were measured during daily physiotherapy sessions on a verbal five-point rating scale during the first four postoperative days. Patients were stratified into four groups according to surgical procedure: screws or pins, arthroplasty, dynamic hip screw (DHS), and intra-medullary hip screw (IMHS). Results. Cumulated pain levels were significantly different between surgical procedures both for hip flexion (P=0.002) and for walking (P=0.02) with highest dynamic pain levels for patients who had either DHSs or IMHSs compared with arthroplasty or parallel implants. There were significant negative correlations between ambulatory capacity assessed by the cumulated ambulation score and both the dynamic cumulated pain scores on hip flexion (r=-0.43, P<0.001) and walking (r=-0.36, P=0.004). Conclusions. Postoperative pain levels after surgery for hip fracture are dependent on the surgical procedure, which should be taken into account in future studies of analgesia and rehabilitation. © The Board of Management and Trustees of the British Journal of Anaesthesia 2009. All rights reserved.

Bactericidal micron-thin sol-gel films prevent pin tract and periprosthetic infection

PJI DX Updated Search

Orthopedic injuries constitute the majority of wounds sustained by U.S. soldiers in recent conflicts. The risk of infection is considerable with fracture fixation devices. In this pilot study, we examined the use of unique bactericidal micron-thin sol-gel films on fracture fixation devices and their ability to prevent and eradicate infections. External fixation was studied with micron-thin sol-gel coated percutaneous pins releasing triclosan and inserted medially into rabbit tibiae. A total of 11 rabbits received percutaneous pins that were either uncoated or sol-gel/triclosan coated. Internal fracture fixation was also studied using sol-gel coated intramedullary (IM) nails releasing vancomycin in the intramedullary tibiae. Six sheep received IM nails that were coated with a sol-gel film that either contained vancomycin or did not contain vancomycin. All animals were challenged with Staphylococcus aureus around the implant. Animals were euthanized at 1 month postoperative. Rabbits receiving triclosan/sol-gel coated percutaneous pins did not show signs of infection. Uncoated percutaneous pins had a significantly higher infection rate. In the sheep study, there were no radiographic signs of osteomyelitis with vancomycin/sol-gel coated IM nails, in contrast to the observations in the control cohort. Hence, the nanostructured sol-gel controlled release technology offers the promise of a reliable and continuous delivery system of bactericidals from orthopedic devices to prevent and treat infection

Advances in segmental endoprosthetic reconstruction for extremity tumors: a review of contemporary designs and techniques

PJI DX Updated Search

BACKGROUND: Improved understanding and advances in treatment regimens have led to increased longevity among patients diagnosed with extremity soft tissue sarcomas. Limb salvage techniques and implants have improved and continue to evolve to accommodate the increasing demands and survival of these patients. METHODS: The current report is a review of the literature for recent advancements in techniques, implant design, and outcomes in the field of limb salvage therapy using segmental megaprostheses for the treatment of extremity sarcomas. We report on our experience in this field utilizing a classification system of failure mechanisms to outline to discuss current controversies in management. RESULTS: Five mechanisms of failure have been identified: soft-tissue failure, aseptic loosening, structural failure, infection, and tumor progression. Infection was the most common mode of failure in our series, accounting for 34% of cases. Soft-tissue failure occurred most commonly in the joints that depend heavily on periarticular muscles and ligaments for stability due to their high degree of functional range of motion. We observed a 28% soft-tissue failure rate about the shoulder and hip, aseptic loosening accounted for 19% of implant failures, and structural failure was seen in 17% of cases. Seventeen percent of cases failed due to tumor progression, an etiology that is defined by biological factors, surgical technique, and adjuvant therapies. CONCLUSIONS: Surgical techniques and megaprosthesis designs are constantly changing in order to meet the challenge of increasing functional demands and longevity in this unique patient population. A classification system defined by treatment failure etiologies provides the framework for discussion of current controversies in limb salvage therapy as well as a guide for advancement and potential solutions in this challenging arena

Alendronate in the treatment of primary hyperparathyroid-related osteoporosis: A 2-year study

Management of Hip Fractures in the Elderly

We investigated the effect of alendronate on calcium, PTH, and bone mineral density in 27 female and 5 male patients with primary hyperparathyroidism. The treatment group [n = 14; T score (less-than or equal to) -2.5 SD at the femoral neck (FN) or T (less-than or equal to) -1.0 SD plus previous nonvertebral fracture] was given alendronate 10 mg/d for 24 months. The second group (n = 18; T score > -2.5 SD at the FN) was untreated. Biochemistry was repeated at 1.5, 3, 6, 12, 18, and 24 months, and dual-energy x-ray absorptiometry at 12 and 24 months. There were no significant between-group baseline differences in calcium, creatinine, or PTH. Alendronate-treated patients gained bone at all sites [lumbar spine (LS), 1 yr gain, +7.3 (plus or minus) 1.7%; P < 0.001; 2 yr, +7.3 (plus or minus) 3.1%; P = 0.04). Untreated patients gained bone at the LS over 2 yr (+4.0 (plus or minus) 1.8%; P = 0.03) but lost bone elsewhere. Calcium fell nonsignificantly in the alendronate group between baseline (2.84 (plus or minus) 0.12 mmol/liter) and 6 wk (2.76 (plus or minus) 0.09 mmol/liter), with a nonsignificant rise in PTH (baseline, 103.5 (plus or minus) 14.6 ng/liter; 6 wk, 116.7 (plus or minus) 15.6 ng/liter). By 3 months, values had reverted to baseline. In primary hyperparathyroidism, alendronate is well tolerated and significantly improves bone mineral density at the LS (with lesser gains at FN and radius), especially within the first year of treatment. Short-term changes in calcium and PTH resolve by 3 months

Prognostic Factors for the Clinical Outcome after Microfracture Treatment of Chondral and Osteochondral Defects in the Knee Joint: A Systematic Review

Osteochondritis Dissecans 2020 Review

OBJECTIVE: The objective of this study is to establish which patient and lesion characteristics are related to the clinical outcome after microfracture of cartilage defects in the knee. STUDY DESIGN: Systematic review. METHODS: After preregistration, PubMed, Embase, and Cochrane were searched for studies that analyzed prognostic factors for the outcome of microfracture treatment in the knee. The criteria for inclusion were outcome measured using Patient-Reported Outcome Measures (PROMs), a clinical study with =10 participants receiving microfracture, and a minimal follow-up period of 1 year. RESULTS: For none of the investigated prognostic factors, effect size reporting was sufficiently homogeneous to conduct a meta-analysis. However, a majority of the included studies identified higher age, larger lesion size, longer preoperative symptom duration, and previous surgery on the ipsilateral knee, especially meniscectomy and anterior cruciate ligament reconstruction, as factors that are reported to be correlated to a less favorable outcome. A lesion location that does not include the trochlea or the patellofemoral joint and is not weightbearing, a nondegenerative mechanism of injury, and a single lesion were reported as factors that predict a favorable outcome. As to gender, body mass index, preoperative activity level, smoking, and concomitant knee surgery, the included articles were inconclusive or no effect was reported. CONCLUSIONS: Several factors correlated with the clinical result after microfracture treatment. However, the information on the effect sizes of the influence on clinical outcome is incomplete due to poor reporting. Large-scale registries or pooling of homogeneous, well-reported data is needed to work toward prognostic models. That would be an important step toward personalized treatment.

Cost effectiveness of denosumab compared with oral bisphosphonates in the treatment of post-menopausal osteoporotic women in Belgium

HipFx Supplemental Cost Analysis

Background: Denosumab has recently been shown to be well tolerated, to increase bone mineral density (BMD) and to significantly reduce the risk of hip, vertebral and non-vertebral fractures in the FREEDOM (Fracture REduction Evaluation of Denosumab in Osteoporosis every 6 Months) trial. It is becoming increasingly important to evaluate not only the therapeutic value of a new drug but also the cost effectiveness compared with the most relevant treatment alternatives. Objective: The objective of this study was to estimate the cost effectiveness of denosumab compared with oral bisphosphonates (branded and generic drugs) in the treatment of post-menopausal osteoporotic women in Belgium. Methods: Cost effectiveness of 3 years of treatment with denosumab was compared with branded risedronate and branded and generic alendronate using an updated version of a previously validated Markov microsimulation model. The model was populated with relevant cost, adherence and epidemiological data for Belgium from a payer perspective and the results were presented as costs per QALY gained ((euro), year 2009 values). Analyses were performed in populations (aged (greater-than or equal to)60 years) in which osteoporosis medications are currently reimbursed in many European countries, i.e. those with BMD T-score of -2.5 or less or prevalent vertebral fracture. Patients receiving denosumab were assumed to have a 46% lower risk of discontinuation than those receiving oral bisphosphonates, and the effect of denosumab after treatment cessation was assumed to decline linearly to zero over a maximum of 1 year. Results: Denosumab was cost effective compared with all other therapies, assuming a willingness to pay of (euro)40 000 per QALY gained. In particular, denosumab was found to be cost effective compared with branded alendronate and risedronate at a threshold value of (euro)30 000 per QALY and denosumab was dominant (i.e. lower cost and greater effectiveness) compared with risedronate from the age of 70 years in women with a T-score of -2.5 or less and no prior fractures. The cost effectiveness of denosumab compared with generic alendronate was estimated at (euro)38 514, (euro)22 220 and (euro)27 862 per QALY for women aged 60, 70 and 80 years, respectively, with T-scores of -2.5 or less. The equivalent values were (euro)37 167, (euro)19 718 and (euro)19 638 per QALY for women with prevalent vertebral fractures. Conclusion: This study suggests, on the basis of currently available data, that denosumab is a cost-effective strategy compared with oral bisphosphonates (including generic alendronate) for the treatment of post-menopausal osteoporotic women, aged (greater-than or equal to)60 years in Belgium. Denosumab therefore appears to have the potential to become a first-line treatment for post-menopausal women with osteoporosis. However, further studies would be required to evaluate the long-term safety and adherence of denosumab in real-world clinical practice as well as head-to-head effectiveness compared with oral bisphosphonates. (copyright) 2011 Adis Data Information BV. All rights reserved

Assessing late-onset stress symptomatology among aging male combat veterans

DoD PRF (Psychosocial RF)

This study's goal was to develop a measure of late-onset stress symptomatology (LOSS). LOSS is a phenomenon observed in aging combat veterans who (a) were exposed to highly stressful combat events in their early adult years, (b) have functioned successfully throughout midlife with no history of chronic stress-related disorders, but (c) begin to register increased combat-related thoughts, feelings, and reminiscences commensurate with the changes and challenges of aging. Several samples of older male combat veterans from World War II, the Korean Conflict, and the Vietnam War served as participants. We developed a LOSS Scale that demonstrated a high degree of internal consistency reliability (coefficient alpha = 0.97). Scores were stable over brief intervals but were sensitive to developmental change over an extended period. Factor analysis suggested a single LOSS factor. Bivariate associations between LOSS score and other variables (e.g., indicators of contemporary life stressors, resilience, quality of life) were consistent with hypotheses, and there was support for the incremental validity of LOSS vis-a-vis posttraumatic stress symptoms and symptoms of general distress. Discussion of the potential uses of the scale, future directions for psychometric research, and suggestions for generalizing the LOSS construct to other trauma populations are provided.

Workplace managersâ?? view of the role of co-workers in return-to-work

DoD PRF (Psychosocial RF)

Purpose: Theoretical and empirical research findings attest to the workplace being a social environment in which co-workers have a critical influence on the employment outcomes and return-to-work (RTW) success of other employees. However, co-workers do not have a formal role in RTW planning. The aim of this study was to explore how managers responsible for developing and implementing RTW procedures view the role of co-workers in this process. Method: An exploratory qualitative pilot study was conducted in Canada. Participants (1 male; 13 females; mean experience in RTW = 11.8 years) were workplace (n = 8) or RTW managers (n = 6) with direct oversight of RTW plans. The participants were recruited via invitation from a research institute and were drawn from three different provinces. Data were gathered via open-ended questions and were coded and subject to thematic analysis. Findings: Three key themes were identified: (1) Managers view RTW as having little relevance to co-workers but expect them to cooperate with the arrangements; (2) Formal procedures are inadequate when psychosocial barriers to work resumption are present, so managers use informal strategies to engage co-workersâ?? emotional and social support; and (3) Managers have difficulty integrating RTW procedures with other legal obligations, such as privacy and confidentiality requirements. Conclusion: Existing arrangements for the development and implementation of RTW are sufficient most of the time, but may be inadequate when an injured worker presents with psychosocial barriers to work resumption. Implications for Rehabilitation: (i) Standard RTW arrangements can be inadequate when a RTW plan requires active co-worker support. (ii) Privacy and confidentiality provisions can result in managers using informal procedures for information exchange and to engage co-workers. (iii) The use of risk management strategiesâ??assessment, consultation and communicationâ??could be used to include co-workers when workplace issues threaten the success of a RTW plan. (PsycINFO Database Record (c) 2016 APA, all rights reserved)

An evaluation of the cutaneous distribution after obturator nerve block

AAHKS (9/10) Regional Nerve Blocks

UNLABELLED: In 1973, Winnie et al. introduced the inguinal paravascular three-in-one block, which allegedly provides anesthesia of three nerves--the femoral, lateral cutaneous femoral, and obturator nerves--with a single injection. This concept was undisputed until the success of the obturator nerve block was reassessed by using evidence of adductor weakness rather than cutaneous sensory blockade, the latter being variable in its distribution and often absent. We performed this study, therefore, to evaluate the area of sensory loss produced by direct injection of local anesthetic around the obturator nerve. A selective obturator nerve block with 7 mL of 0.75% ropivacaine was performed in 30 patients scheduled for knee surgery. Sensory deficit and adductor strength were evaluated for 30 min by using sensory tests (cold and light-touch perception) and the pressure generated by the patient's squeezing a blood pressure cuff placed between the knees. Subsequently, a three-in-one block was performed, and the sensory deficit was reassessed. The obturator nerve block was successful in 100% of cases. The strength of adductors decreased by 77% +/- 17% (mean +/- SD). In 17 patients (57%), there was no cutaneous contribution of the obturator nerve. The remaining 7 patients (23%) had an area of hypoesthesia (cold sensation was blunt but still present) on the superior part of the popliteal fossa, and the other 6 (20%) had sensory deficit located at the medial aspect of the thigh. The three-in-one block resulted in blockade of the lateral aspect of the thigh in 87% of cases, whereas the anteromedial aspect was always anesthetized. By use of magnetic resonance imaging in eight volunteers, we demonstrated that the obturator nerve has already divided into its two branches at the site of local anesthetic injection. However, the injection of blue dye after having simulated the technique in five cadavers showed that the fluid regularly spread to both branches. We conclude that after three-in-one block, a femoral nerve block may have been assessed as an obturator nerve block in 100% of cases when testing the cutaneous distribution of the obturator nerve on the medial aspect of the thigh. IMPLICATIONS: Previous studies reporting an incidence of obturator nerve block after three-in-one block may have mistaken a femoral nerve block for an obturator nerve block in 100% of cases when the cutaneous distribution of the obturator nerve was assessed on the medial aspect of the thigh. The only way to effectively evaluate obturator nerve function is to assess adductor strength.

Osteonecrosis of the knee: review

Osteochondritis Dissecans 2020 Review

Osteonecrosis is a devastating disease that can lead to end-stage arthritis of various joint including the knee. There are three categories of osteonecrosis that affect the knee: spontaneous osteonecrosis of the knee (SONK), secondary, and post-arthroscopic. Regardless of osteonecrosis categories, the treatment of this disease aims to halt further progression or delay the onset of end-stage arthritis of the knee. However, once substantial joint surface collapse has occurred or there are sign of degenerative arthritis, joint arthroplasty is the most appropriate treatment option. Currently, the non-operative treatment options consist of observation, non-steroidal anti-inflammatory drugs (NSAIDs), protected weight bearing, and analgesia as needed. Operative interventions include joint preserving surgery, unilateral knee arthroplasty (UKA), or total knee arthroplasty (TKA) depending on the extent and type of disease. Joint preserving procedures (i.e., arthroscopy, core decompression, osteochondral autograft, and bone grafting) are usually attempted in pre-collapse and some post-collapse lesions, when the articular cartilage is generally intact with only the underlying subchondral bone being affected. Conversely, after severe subchondral collapse has occurred, procedures that attempt to salvage the joint are rarely successful and joint arthroplasty are necessary to relieve pain. The purpose of this article is to highlight the recent evidence concerning the treatment options across the spectrum of management of osteonecrosis of the knee including lesion observation, medications, joint preserving techniques, and total joint arthroplasties.

Demystifying medical complexities

Dental Implant Infection

Although dentists often fear treating medically complex patients, in many cases this fear may be based not on scientific facts but rather on a "mythology" of the dangers of dentistry. Dentistry is a remarkably safe profession, even for most medically complex patients. The myths of endocarditis, artificial joint infections, local anesthetics and vasoconstrictors, dental surgery in anticoagulated patients and patients on antiplatelet drugs, and antibiotic interference with oral contraceptives are discussed. Although dental treatment is not usually a risk factor for endocarditis, practitioners should consult the 1997 American Heart Association statement for recommendations for endocarditis prevention. Most artificial joint patients should not receive antibiotic prophylaxis. Local anesthetics and vasoconstrictors can be used safely in most medically complex patients. Neither continuous anticoagulation nor antiplatelet medications should be withdrawn for dental surgery. Scientific studies have failed to document an interaction between antibiotics used in dentistry and oral contraceptives.

A universal snap-fit endoprosthesis for the treatment of subcapital fractures of the femur: a preliminary report

Management of Hip Fractures in the Elderly

A new endoprosthesis for the treatment of subcapital fractures is described. It is hemispherical with a high density polyethylene (HDP) core which is snap-fitted onto a Charnley-type femoral prosthesis. The aim is to prevent acetabular erosion by its virtual lack of movement of the cartilage-metal interface. If this should occur then conversion to a total hip is readily performed without removing the femoral stem. So far 14 have been inserted without any complications. In fact, they are easily mobilized with very little pain

Managing the medically compromised geriatric patient

Dental Implant Infection

Demographic trends indicate that dentists will be treating more dentate geriatric patients, many of whom will be medically compromised. This article emphasizes the effect advancing age may have on the identification and management of common medical problems. In particular, cardiovascular disease, (ischemic heart disease, hypertension, prevention of infective endocarditis), diabetes, and arthritis (prosthetic joints) were reviewed. The prevalence of all these diseases increases with age and many geriatric patients have undiagnosed cardiac disease or diabetes. Knowledge of the pathophysiology of these common systemic diseases will be increasingly important to dentists in the future.

Detection of malignant soft tissue tumors in bone imaging

MSTS 2018 - Femur Mets and MM

A total of 2530 consecutive bone scans were examined to evaluate the number and the type of soft tissue neoplasms detected with bone-seeking phosphonates. Sixty-eight primary or secondary soft tissue neoplasms of 63 patients accumulated 99mTc -methylene diphosphonate and 2 accumulated 99mTc -diphosphonate, and one metastasis was seen as a nonactive 'cold' focus in the urinary bladder. The localization of tumors was: 19 in the lung, 15 in the liver, 11 in the kidney, 10 in the peritoneal cavity or ascites, 5 in the large bowel, 4 in the vascular or lymphatic system, 3 in the connective tissue or muscles, 2 in the ovary, 1 in the urinary bladder, and 1 in the brain. Our results differ in many respects from those reported in the literature. The causes of the differences are discussed.

Bisphosphonate therapy for skeletal malignancies and metastases: impact on jaw bones and prosthodontic concerns

MSTS 2018 - Femur Mets and MM

Healthy jawbones ensure better tooth anchorage and the ability to masticate and maintain metabolism. This is achieved by a delicate balance between bone formation and resorption in response to functional demands. An imbalance in the expression of receptor activator of nuclear factor kappa-B (RANK) ligand (RANKL) and osteoprotegerin (OPG) or osteoclastogenesis inhibitory factor (OCIF) is believed to be the underlying mechanism of osteolysis in metastases, multiple myelomas, and cancer therapy-induced bone loss in patients. Considered mainly as bone-specific agents to treat postmenopausal osteoporosis, bisphosphonates, in combination with certain chemotherapeutic agents have proved to be effective in prevention of tumor formation and metastatic osteolysis in bone tissue. Osteonecrosis of the jaws associated with them has, however, been of grave concern to the prosthodontist, as it predisposes patients to a bone-deficient basal seat for dental prostheses. This manuscript reviews available information over the past 13 years on possible mechanisms of bone loss, bisphosphonate-induced osteonecrosis of jaw bones, and prosthodontic concerns.

Associations of parity, breast-feeding, and birth control pills with lumbar spine and femoral neck bone densities

Management of Hip Fractures in the Elderly

The relationships between parity, breast-feeding, and the use of birth control pills and the bone densities of the lumbar spine and the femoral neck, measured by dual-photon densitometry, were studied in normal women. Femoral neck density was found to decrease by 1.1% per live-birth, whereas lumbar spine density showed no significant association with parity. Breast-feeding was found to increase lumbar spine density by 1.5% per breast-fed child, whereas femoral neck density was not significantly correlated. No significant relationships between the use of birth control pills and the bone densities were found

Effects of Liposomal Bupivacaine With Adductor Canal Block on Pain and Functional Outcomes in Patients Undergoing Total Knee Arthroplasty

AAHKS (8) Anesthetic Infiltration

BACKGROUND: Liposomal bupivacaine (LB) has an extended duration of action compared to bupivacaine and may allow patients to reach physical therapy (PT) goals faster than traditional methods. OBJECTIVE: To determine the effect of a periarticular LB mixture with adductor canal blockade (ACB) on postoperative opioid requirements, pain scores, and functional outcomes in patients undergoing primary unilateral total knee arthroplasty. METHODS: A retrospective chart review was performed; 86 patients received the LB mixture + ACB, and 86 historical controls received nonliposomal bupivacaine and femoral nerve block (FNB). RESULTS: There was no effect of group on mean postoperative pain scores (P = 0.144). There was an effect of group on equivalent morphine dose (P = 0.008). Pain scores and morphine doses changed over time in both groups, but there was no time-group interaction. Compared with controls, patients in the LB mixture group were more likely to require minimal assistance or better when going from a sitting to a standing position by postoperative day 1 (POD; 99% vs 81%, P = 0.0001) and POD 2 (90% vs 77%, P = 0.0212). There were no differences between groups with regard to discharge disposition or safety outcomes. Use did not affect LOS for patients discharged to an extended care facility but did reduce LOS for those discharged home. CONCLUSIONS: The LB mixture was effective in reducing opioid use and improving functional outcomes compared with historical controls.

Childhood adversity, social support, and telomere length among perinatal women

DoD PRF (Psychosocial RF)

Adverse perinatal health outcomes are heightened among women with psychosocial risk factors, including childhood adversity and a lack of social support. Biological aging could be one pathway by which such outcomes occur. However, data examining links between psychosocial factors and indicators of biological aging among perinatal women are limited. The current study examined the associations of childhood socioeconomic status (SES), childhood trauma, and current social support with telomere length in peripheral blood mononuclear cells (PBMCs) in a sample of 81 women assessed in early, mid, and late pregnancy as well as 7-11 weeks postpartum. Childhood SES was defined as perceived childhood social class and parental educational attainment. Measures included the Childhood Trauma Questionnaire, Center for Epidemiologic Studies-Depression Scale, Multidimensional Scale of Perceived Social Support, and average telomere length in PBMCs. Per a linear mixed model, telomere length did not change across pregnancy and postpartum visits; thus, subsequent analyses defined telomere length as the average across all available timepoints. ANCOVAs showed group differences by perceived childhood social class, maternal and paternal educational attainment, and current family social support, with lower values corresponding with shorter telomeres, after adjustment for possible confounds. No effects of childhood trauma or social support from significant others or friends on telomere length were observed. Findings demonstrate that while current SES was not related to telomeres, low childhood SES, independent of current SES, and low family social support were distinct risk factors for cellular aging in women. These data have relevance for understanding potential mechanisms by which early life deprivation of socioeconomic and relationship resources affect maternal health. In turn, this has potential significance for intergenerational transmission of telomere length. The predictive value of markers of biological versus chronological age on birth outcomes warrants investigation.

Cardiovascular disease predicts complications following bilateral total knee arthroplasty under a single anesthetic

Surgical Management of Osteoarthritis of the Knee CPG

INTRODUCTION: This study evaluated the rate of perioperative complications of single anesthetic bilateral total knee arthroplasties (TKA) compared with staged procedures. METHODS: The records of all single anesthetic bilateral TKA performed between 1997 and 2007 at one large community hospital and one university hospital were retrospectively reviewed. Complete demographic data, preoperative co-morbidities and complications for 156 patients were compared to a matched staged bilateral TKA (n=78) cohort. RESULTS: In the single anesthetic bilateral TKA cohort, cardiovascular disease predicted postoperative myocardial (p<0.01, Odds Ratio - 67.6), need for ICU admission (p<0.01, Odds Ratio - 88.8), and days spent in ICU (p<0.01), while cardiovascular disease did not significantly predict postoperative MI in the staged bilateral (p=0.99, OR - 0). CONCLUSION: Patients with cardiovascular disease are at higher risk for perioperative MI after single anesthetic bilateral TKA

Spectrum of common and uncommon causes of knee joint hyaline cartilage degeneration and their key imaging features

Osteochondritis Dissecans 2020 Review

Hyaline cartilage lining the surfaces of diarthrodial joints is an important construct for transmission of load and to reduce friction between the bones. Normal wear and tear accounts for about 3–5 percent knee cartilage loss ever year in otherwise healthy people after the age of 30 years. Several conditions and diseases lead to premature cartilage degeneration. Standardized description of cartilage loss, detailed evaluation of the joint health and determining the underlying etiology of cartilage loss are important for effective reporting, multidisciplinary communications and patient management. In this article, the authors discuss normal and abnormal imaging appearances of the hyaline cartilage of knee with focus on using controlled terminology and MRI classifications. The reader will benefit and learn key MR imaging features of a spectrum of common and uncommon conditions and diseases affecting the knee cartilage, such as trauma, secondary injury associated with meniscus and ligament injury related instability, arthritis, ischemia, idiopathic, and hereditary conditions including Matrix metalloproteinase-2 (MMP-2) mutations and mucopolysaccharidosis type IX disease with illustrative case examples.

The operative management of displaced intra-articular fractures of the calcaneum: a two-centre study using a defined protocol

DoD SSI (Surgical Site Infections)

The management of intra-articular calcaneal fractures remains controversial with strong arguments supporting both conservative and operative management. This study assesses the results of open reduction and internal fixation (ORIF) of displaced intra-articular fractures of the calcaneum in two independent centres where the indications for operative management had been strictly defined.Forty-seven patients (51 fractures) who had sustained such injuries underwent an ORIF performed by one of the senior surgeons using the technique described by Eastwood et al. [JBJS 75-B(1993)189] All of the fractures were assessed by plain X-ray and CT scan and graded according to the Sanders classification [Clin. Orthop. 290(1993)97]. Patients were assessed at a minimum of 2 years post-surgery both clinically and with a standardised questionnaire based on that described by Kerr et al. [Injury 27(1996)35]. The mean age at operation was 42 and 50 years for the two centres, and the mean follow-up was 44 months. Seventy-six per cent of the patients were male. Eighty-eight per cent of the injuries were due to a fall from a height. Fifteen patients had contralateral foot/ankle injuries. Thirty-four of 46 patients were in employment at the time of the injury, 24 of these were in physical jobs and 20 sustained their injury whilst at work.Overall, the satisfaction rate was 90%. Ninety-four per cent of patients in work returned to work at a median of 6 months. Bilateral injuries were associated with a significantly poorer outcome as were those with heel pad pain. Delay to operation greater than 14 days was associated with a higher infection rate. Smoking was not related to infection rate.

Speckle tracking ultrasound for assessment of the relative motion of flexor tendon and subsynovial connective tissue in the human carpal tunnel

Diagnosis and Treatment of Carpal Tunnel Syndrome CPG

The objective of this study was to compare tissue Doppler imaging and speckle tracking ultrasound to assess the relative motion of flexor tendon and surrounding subsynovial connective tissue (SSCT). Twenty normal human wrists were imaged with an ultrasound scanner. The two ultrasound methods measured the excursion and maximum velocity of the tendon and SSCT while subjects gripped three different sized acrylic tubes and these were correlated with tendon excursions estimated from finger joint angle changes. The maximum velocity ratio (=SSCT/tendon velocity) and the shear index (=[(Tendon excursion-SSCT excursion)/Tendon excursion]x100%) were calculated. The intraclass correlation coefficient was higher for joint angle/speckle tracking tendon excursion (0.642) than for joint angle/tissue Doppler excursion (0.377). The speckle tracking method could also discriminate differences in maximum velocity ratio and shear index for different tube sizes. We conclude that speckle tracking may be useful in assessing the relative motion of tendon and SSCT

Employment outcome four years after a severe traumatic brain injury: results of the Paris severe traumatic brain injury study

DoD PRF (Psychosocial RF)

OBJECTIVE: To describe employment outcome four years after a severe traumatic brain injury by the assessment of individual patients' preinjury sociodemographic data, injury-related and postinjury factors. DESIGN: A prospective, multicenter inception cohort of 133 adult patients in the Paris area (France) who had received a severe traumatic brain injury were followed up postinjury at one and four years. Sociodemographic data, factors related to injury severity and one-year functional and cognitive outcomes were prospectively collected. METHODS: The main outcome measure was employment status. Potential predictors of employment status were assessed by univariate and multivariate analysis. RESULTS: At the four-year follow-up, 38% of patients were in paid employment. The following factors were independent predictors of unemployment: being unemployed or studying before traumatic brain injury, traumatic brain injury severity (i.e., a lower Glasgow Coma Scale score upon admission and a longer stay in intensive care) and a lower one-year Glasgow Outcome Scale-Extended score. CONCLUSION: This study confirmed the low rate of long-term employment amongst patients after a severe traumatic brain injury. The results illustrated the multiple determinants of employment outcome and suggested that students who had received a traumatic brain injury were particularly likely to be unemployed, thus we propose that they may require specific support to help them find work. Implications for rehabilitation Traumatic brain injury is a leading cause of persistent disablity and can associate cognitive, emotional, physical and sensory impairments, which often result in quality-of-life reduction and job loss. Predictors of post-traumatic brain injury unemployment and job loss remains unclear in the particular population of severe traumatic brain injury patients. The present study highlights the post-traumatic brain injury student population require a close follow-up and vocational rehabilitation. The study suggests that return to work post-severe traumatic brain injury is frequently unstable and workers often experience difficulties that caregivers have to consider.

Total Knee Arthroplasty in Patients With Juvenile Idiopathic Arthritis

Surgical Management of Osteoarthritis of the Knee CPG

BACKGROUND: Total knee arthroplasty (TKA) for juvenile idiopathic arthritis is rare but is nonetheless indicated for many patients with this disease. Few reports exist on the results of TKA in patients with juvenile idiopathic arthritis. QUESTIONS/PURPOSES: It was sought to determine (1) survivorship and (2) functional outcomes of TKAs in patients with juvenile idiopathic arthritis. METHODS: Results were combined from patients treated by experienced surgeons at five hospitals between 1979 and 2011. Two hundred nineteen patients (349 TKAs) were identified and contacted to survey their outcomes at a minimum followup of 2 years (mean, 12 +/- 8 years; range, 2-33 years). The average age at surgery was 28.9 +/- 9.7 years (range, 11-58 years). Data on revision surgery and ability to perform daily activities were collected. RESULTS: The 10-year survivorship was 95%, decreasing to 82% by 20 years. At latest followup, 31 of 349 TKAs (8.9%) had been revised for either polyethylene failure or loosening (18 TKAs), infection (four), stiffness (three), periprosthetic fractures (two), bilateral amputation for vascular reasons (two), patellar resurfacing (one), and instability (one). Walking tolerance was unlimited in 49%, five to 10 blocks in 23%, and less than five blocks in 28%. Eleven percent could not manage stairs, and another 59% depended on railings. A cane was used by 12% and crutches by 7%; 12% were wheelchair-dependent. CONCLUSIONS: TKA survivorship in patients with juvenile idiopathic arthritis was inferior to that typically seen in younger patients with osteoarthritis or even rheumatoid arthritis confirming results of earlier studies with smaller patient numbers. This is especially disconcerting because younger patients require better durability of their TKAs. LEVEL OF EVIDENCE: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence

Steep posterior slope of the medial tibial plateau and anterior cruciate ligament degeneration contribute to medial meniscus posterior root tears in young patients

AMP (Acute Meniscal Pathology)

PURPOSE: Medial meniscus posterior root tears (MMPRTs) occur most frequently in middle-aged and older adults. However, this serious condition can also occur in younger patients. The purpose of this study was to compare anterior cruciate ligament (ACL) degeneration and sagittal medial tibial slope in young adults with and without MMPRT. METHODS: Eighteen healthy volunteers, 18 young patients (20-49 years of age), and 30 middle-aged and older patients (50-70 years of age) with MMPRT repair were included in the study. Sex, body mass index (BMI), femorotibial angle, ACL degeneration, and medial tibial slope angle were compared among the groups. ACL degeneration and medial tibial slope angle were assessed using magnetic resonance imaging. RESULTS: In the healthy volunteer group, the young patient group, and the older patient group, the medial tibial slopes were 3.5degree +/- 1.4degree, 6.1degree +/- 2.7degree, and 7.2degree +/- 1.9degree, respectively, and the ACL degeneration rates were 5.6%, 38.9%, and 43.3%, respectively. Young patients with MMPRT had significantly steeper medial tibial slopes and ACL degeneration compared to those of the healthy volunteers (P < 0.05). The parameters of young patients were similar to those of older patients with MMPRT. In the multivariate logistic regression analysis, BMI, medial tibial slope, and ACL degeneration were significantly associated with MMPRT in young patients. CONCLUSION: BMI, steep medial tibial slope, and ACL degeneration contribute to MMPRT development in younger patients. LEVEL OF EVIDENCE: Level III.

Hemiarthroplasty or total hip arthroplasty for the treatment of a displaced intracapsular fracture in active elderly patients: 12-year follow-up of randomised trial

Hip Fx in the Elderly 2019

AIMS: Our aim was to analyse the long-term functional outcome of two forms of surgical treatment for active patients aged > 70 years with a displaced intracapsular fracture of the femoral neck. Patients were randomised to be treated with either a hemiarthroplasty or a total hip arthroplasty (THA). The outcome five years post-operatively for this cohort has previously been reported. We present the outcome at 12 years post-operatively. PATIENTS AND METHODS: Initially 252 patients with a mean age of 81.1 years (70.2 to 95.6) were included, of whom 205 (81%) were women. A total of 137 were treated with a cemented hemiarthroplasty and 115 with a cemented THA. At long-term follow-up we analysed the modified Harris Hip Score (HHS), post-operative complications and intra-operative data of the patients who were still alive. RESULTS: At a mean follow-up of 12 years (8.23 to 16.17, standard deviation 2.24), 50 patients (20%), 32 in the hemiarthroplasty group and 18 in the THA group, were still alive, of which 47 (94%) were women. There were no significant differences in the mean modified HHS (p = 0.85), mortality (p = 0.13), complications (p = 0.93) or rate of revision surgery (p = 1.0) between the two groups. CONCLUSION: In the treatment of active elderly patients with an intracapsular fracture of the hip there is no difference in the functional outcome between hemiarthroplasty and THA treatments at 12 years post-operatively. Cite this article: Bone Joint J 2017;99-B:250-4.

Microscopic and Macroscopic Fat Embolism: Solving the Puzzle with Case Reports

Panniculectomy & Abdominoplasty CPG

BACKGROUND: The frequency of fat embolism mortality after liposuction has increased. As the only dependable evidence for this problem is that available in the medical literature, a study of clinical case reports is warranted. METHODS: The authors reviewed the medical literature by searching for case reports of fat embolism after liposuction in humans who manifested either of the variants of the condition: microscopic fat embolism or macroscopic fat embolism. The authors performed a literature search of the PubMed and PubMed Central databases from the first case of fat embolism syndrome associated with liposuction reported until March of 2017; keywords Fat Embolism (Fat Embolism Syndrome), Liposuction, and Case (((fat embolism) AND liposuction) AND case) were used. A detailed analysis of the data contained in the clinical case reports was conducted. RESULTS: In total, 39 and 98 articles were found in PubMed and PubMed Central, respectively, using the keywords (((Fat + Embolism) + AND + Liposuction) + AND + Case). After analysis, only 15 reports corresponded to cases of macroscopic or microscopic fat embolism after liposuction, and the basic statistics of the two proposed variants were examined. CONCLUSIONS: This work provides relevant information regarding very important characteristics of microscopic and macroscopic fat embolism. Despite the diagnostic difficulty, clinical diagnosis remains the gold standard for identifying microscopic and macroscopic fat embolism. The establishment of a rapid and timely diagnosis is of great help for appropriate treatment.

Comparison of MRI- and CT-based patient-specific guides for total knee arthroplasty

Surgical Management of Osteoarthritis of the Knee CPG

BACKGROUND: The patient-specific guide for total knee arthroplasty (TKA) is created from the data provided by magnetic resonance imaging (MRI) or computed tomography (CT) scans. It remains unknown which imaging technology is suitable for the patient-specific guide. The purpose of this study was to compare the accuracy of implant positioning and operative times between the two types of patient-specific guides for TKA. METHODS: Forty arthritic knees were divided into two treatment groups using MRI-based (PS-MRI group) or CT-based (PS-CT group) patient-specific guides in this prospective, comparative study. The guide in the PS-MRI group had a cutting slot, whereas that in the PS-CT group only had a pin locator. The operative times were compared between the two groups. The angular error and number of outliers (deviations >3 degrees ) of the implant position using pre- and postoperative CT were investigated in both groups. RESULTS: The mean operative time was significantly shorter in the PS-MRI group (109.2+/-16.5min) than in the PS-CT group (129.5+/-19.4min) (p<0.001). There were no significant differences in the accuracy of the implant position regarding the coronal, sagittal, and axial planes between the groups (p>0.05). CONCLUSIONS: To reduce the operative time, guides with additional functions, such as cutting and positioning, should be used. Both CT- and MRI-based-guides would result in the same accuracy in three planes but high inaccuracy in the sagittal plane. The use of patient-specific guide based on MRI might not be cost-effective. Level of evidence: level 2

Antiepileptic drug use increases rates of bone loss in older women: a prospective study

Management of Hip Fractures in the Elderly

OBJECTIVE: To test the hypothesis that older women with antiepileptic drug (AED) use have increased rates of bone loss. METHODS: AED use was ascertained and calcaneal and hip bone mineral density (BMD) measured in a cohort of 9,704 elderly community-dwelling women enrolled in the Study of Osteoporotic Fractures, and they were followed prospectively for changes in BMD. Current use of AED was assessed by interview, with verification of use from medication containers at baseline and follow-up examinations. Women were classified as continuous users, partial (intermittent) users, or nonusers. Rates of change in BMD were measured at the total hip and two subregions (average 4.4 years between examinations) and at the calcaneus (average 5.7 years between examinations). RESULTS: After adjustment for confounders, the average rate of decline in total hip BMD steadily increased from -0.70%/year in nonusers to -0.87%/year in partial AED users to -1.16%/year in continuous AED users (p value for trend = 0.015). Higher rates of bone loss were also observed among continuous AED users at subregions of the hip and at the calcaneus. In particular, continuous phenytoin users had an adjusted 1.8-fold greater mean rate of loss at the calcaneus compared with nonusers of AED (-2.68 vs -1.46%/year; p < 0.001) and an adjusted 1.7-fold greater mean rate of loss at the total hip compared with nonusers of AED (-1.16 vs -0.70%/year; p = 0.069). CONCLUSIONS: Continuous AED use in elderly women is associated with increased rates of bone loss at the calcaneus and hip. If unabated, the rate of hip bone loss among continuous AED users is sufficient to increase the risk of hip fracture by 29% over 5 years among women age 65 years and older

Prognostic factors affecting anatomic outcome of rotator cuff repair and correlation with functional outcome

Optimizing the Management of Full-Thickness Rotator Cuff Tears

PURPOSE: To analyze the relationship between functional outcomes and postoperative cuff integrity (anatomic outcome), and to reveal the factors affecting outcomes of rotator cuff repair. METHODS: Seventy-eight patients who had undergone repair of full-thickness rotator cuff tear received both computed tomographic arthrography (CTA) and functional evaluation a minimum of 1 year after surgery. The mean follow-up period was 19.6 months (range, 12 to 39 months). Anatomic outcome was evaluated by CTA. Functional outcomes were evaluated by visual analogue scale (VAS) for pain and satisfaction with the operation, Constant score, simple shoulder test (SST), and American Shoulder and Elbow Surgeons (ASES) score. Various clinical and structural factors were included for statistical analysis. RESULTS: All patients displayed significant improvement in all functional evaluations at the final visit. Functional outcome did not correlate with anatomic outcome (P > .05). A few variables did relate to functional outcome: female or old age statistically correlated with the score of SST, and the size of the tear correlated with the ASES score (P < .05). The retear was influenced by age, fatty degeneration of the cuff muscles, and the size of tear. Fatty degeneration of the infraspinatus was the most independent predictor of anatomic outcome on multivariate regression analysis. CONCLUSIONS: Rotator cuff repair brought significant functional improvement. However, the functional outcome did not correlate with the anatomic outcome. The fatty degeneration of the infraspinatus muscle served as an independent predictor of the postoperative integrity of the rotator cuff. LEVEL OF EVIDENCE: Level IV, prognostic case series

Aspiration lipectomy and adipose tissue injection: Pathophysiologic commentary

Panniculectomy & Abdominoplasty CPG

The subcutis, made up of connective and adipose tissue, may consist of one or two layers, depending on the part of the body. The superficial layer, up to 10 mm in thickness, has the function of giving contour. In localizations where one typically sees relatively large fat deposits a padding layer is added to the contour layer, and this may be centimeters in thickness. Aspiration lipectomy should be limited to reducing the padding layer. The advancing cannula perforates the supportive structures in the subcutis and breaks up the fat lobules. Analysis of the aspirated material suggests that residues of fat lobules remain adhering to the chamber walls; it may be assumed that they necrose and are removed by the mechanisms of foreign body reaction. Some stiffening of the reduced subcutis due to ribroproductive processes appears to be inevitable. Implantation of fat fragments obtained through lipectomy offers little biological advantage; at the same time one must expect extensive necrosis of the implanted tissue. With fat cell suspensions, failure to heal seems to be due to inadequatc restoration of the capillary bed. The use of cultured preadipocytes to build up adipose tissue is an attractive idea, but the method is still at the experimental stage.

Soft-tissue reconstruction in orthopedic surgery. Secondary procedures

Panniculectomy & Abdominoplasty CPG

The original consulting microsurgeon should be present to assist in the identification and protection of the vascular pedicle during secondary procedures on microvascular transplants. Flap elevation, trimming, and bone graft placement should be completed during a single tourniquet time, whenever possible. Flaps can easily be resutured on the original bed while the tourniquet is still inflated. Although proximal pedicle transection is possible, it should be avoided by careful planning, because the transplanted tissue cannot be predictably expected to survive, especially with muscle transplants. The distal muscle should be transected only in situations in which the muscle inset is extremely complex. Transection in the extramuscular portion of the main pedicle may require prompt microsurgical repair in immature muscle transplants. The safest approach is to avoid the pedicle whenever additional secondary procedures are necessary following free microvascular tissue transplantation. Placement of vascular pedicles such that the anterior crest of the tibia is avoided if the Ilizarov technique is required permit uncomplicated distraction osteosynthesis. Simultaneous Ilizarov fixation and microvascular tissue transfer are safe, practical procedures for limb salvage. Placement of the Ilizarov fixator at the time of microvascular transplantation provides stable fixation and eliminates the need for a subsequent anesthetic for fixator placement. This form of stabilization, when performed at the time of microvascular tissue transfer, allows the orthopedic surgeon direct visualization of the fracture site as the fixator is placed and eliminates the need for placement of the fixation device through the transplanted tissue. Tissue expansion or suction lipectomy are sometimes needed to optimize the clinical result.

The advantages of carbon fiber based orthopedic devices in patients who have to undergo radiotherapy

MSTS 2022 - Metastatic Disease of the Humerus

BACKGROUND AND OBJECTIVES: The modern approach to primary and secondary muscular skeletal tumors is multidisciplinary. The right combination of chemotherapy, surgery and radiotherapy (RT) makes obtaining local and distant disease control more likely. When surgery is indicated, radiotherapy often has a fundamental role as an adjuvant treatment; however, the titanium alloy instrumentations interfere with Radiotherapy setting, decreasing its effectiveness. It is common opinion that carbon fiber-reinforced devices are convenient in case of adjuvant RT in muscular skeletal oncology. The aim of the study is to support this intuition with experimental data, verifying the more accurate estimation of the delivered dose during RT, comparing Carbon Fiber-Reinforced PEEK (CFRP) plates with titanium-alloy orthopedic devices in order to evaluate their effects on target volume identification and dose distribution for radiation treatment. METHODS: Phantoms were then irradiated with a linear accelerator Varian 2100 C/D with photon beams of 6 and 15 MV energies. Absorbed dose in the point of interest was verified by EBT3 gafchromic films above and below the two materials. Images from CT simulations were also analyzed in terms of Hounsfield numbers in patients with titanium and carbon fiber orthopedic implants in the spine or in the femur. RESULTS: For a 6 MV photon beam, the doses measured just under the titanium-alloy plate were less than approximately 20% of the value calculated by the TPS. For a 15 MV beam energy, these differences were slightly lower. Using CFRP plate, the difference between measured and calculated doses was within +/-3% for both energies, which was comparable with the statistical uncertainties. In the cases of simulated treatment of humerus titanium implants, the difference varies in range +/- 10% with hot spot of + 10% and cold spot of -15%. CONCLUSIONS: The use of CFRP for orthopedic devices and implants provides a valuable advantage in identifying the target due to the reduction of artifacts. Clear imaging of the soft tissues surrounding the bone is useful and reduces the discrepancies between calculated/delivered and measured doses, generating a more homogeneous dose distribution. Furthermore, there is a significant benefit in detecting the state of disease in CT imaging during the follow-up of treated patients. In-vivo studies are encouraged to verify whether a more effective radiotherapy leads to a decrease in local recurrence and local progression.