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Antibiotic use before chemotherapy: a risk factor for developing neutropenic colitis in children with leukemia
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Patrick’s pharmacoepidemiology project
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BACKGROUND: It has been shown that the use of antimicrobials is a determinant that favors intestinal dysbiosis. The objective of this study is to establish the association between the previous use of antimicrobials and the development of neutropenic colitis (NC). METHODS: A case-control study was carried out with subjects diagnosed with acute lymphoblastic leukemia from 2004 to July 2013. They were identified by cross-referencing the databases from the computing area and the records from the pediatric hematology section. Cases were children with neutropenia and fever, abdominal distension and pain, diarrhea or constipation, and ultrasonography or computed tomography showing an intestinal wall thickness of >/=4 mm. Controls were children with acute lymphoblastic leukemia with neutropenia and fever, with or without gastrointestinal symptomatology, but without images of NC. RESULTS: Thirty-eight cases and 75 controls were included. The factors associated with the development of NC were severe neutropenia (odds ratio [OR], 12.4; 95% confidence interval [CI], 3-51; P=0.00001), the use of antimicrobials for >10 days, within the month previous to the appearance of NC (OR, 12.4; 95% CI, 3-51; P=0.00001), and use of doxorubicin (OR, 5.43, 95% CI, 2.1-13.8, P=0.00004). In particular, the risk of developing CN was 3.46 (95% CI, 0.88-14; P=0.04) when ceftriaxone was used. CONCLUSIONS: The use of antimicrobials during >10 days before the administration of chemotherapy is a risk factor for developing NC, along with other factors previously studied
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0 |
Novel approaches to the management of myeloma
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MSTS 2018 - Femur Mets and MM
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Standard therapy for multiple myeloma, which accounts for 10% of all hematologic malignancies, has been autologous stem cell transplantation (ASCT), alkylator-based chemotherapy, and corticosteroids. Several advances have been made in the treatment of multiple myeloma over the past decade, especially the arrival of new, active agents such as thalidomide (Thalomid), bortezomib (Velcade), and lenalidomide (Revlimid). These have shown significant clinical activity as single agents. Trials are ongoing to incorporate these new agents into the various stages of treatment and to combine them with other effective treatment modalities, including ASCT.
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0 |
Inhibition of Nrf2/HO-1 signaling leads to increased activation of the NLRP3 inflammasome in osteoarthritis
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AMP (Acute Meniscal Pathology)
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INTRODUCTION: Osteoarthritis (OA) is an inflammatory disease of the joints that causes progressive disability in the elderly. Reactive oxygen species (ROS) play an important role in OA development; they may activate the NLRP3 inflammasome, thereby inducing the secretion of proinflammatory IL-1beta and IL-18, leading to the aggravation of the downstream inflammatory response. Nrf2 is a key transcription factor that regulates the expression of antioxidant enzymes that protect against oxidative stress and tissue damage. We aimed to explore the underlying mechanism of OA development by investigating NLRP3, ASC, Nrf2, and HO-1 expression in synovia and their regulatory networks in OA.
METHODS: Human total knee replacement samples were subjected to histology and micro-CT analysis to determine the pathological changes in the cartilage and subchondral bone and to assess the expression of inflammation-related markers in the synovial tissue by immunohistochemistry (IHC), qRT-PCR, and Western blot. To investigate these pathological changes in an OA animal model, adult Sprague-Dawley rats were subjected to anterior cruciate ligament transection and medial meniscectomy. Articular cartilage and subchondral bone changes and synovial tissue were also determined by the same methods used for the human samples. Finally, SW982 cells were stimulated with lipopolysaccharide (LPS) as an in vitro inflammatory cell model. The correlation between NLRP3 and Nrf2 expression was confirmed by knocking down NLRP3 or Nrf2.
RESULTS: Cartilage destruction and subchondral bone sclerosis were found in the OA patients and OA model rats. Significantly increased expression levels of NLRP3, ASC, Nrf2, and HO-1 were found in the synovial tissue from OA patients. NLRP3, ASC, Nrf2, and HO-1 expression in the synovium was also upregulated in the OA group compared with the sham group. Furthermore, the NLRP3, Nrf2, HO-1, IL-1beta, and IL-18 expression in LPS-treated SW982 cells was increased in a dose-dependent manner. As expected, the expression of NLRP3 was upregulated, and the expression of IL-1beta and IL-18 was downregulated after Nrf2 silencing. However, knocking down NLRP3 did not affect the expression of Nrf2.
CONCLUSIONS: ROS-induced oxidative stress may be the main cause of NLRP3 inflammasome activation and subsequent release of downstream factors during OA development. Nrf2/HO-1 signaling could be a key pathway for the activation of the NLRP3 inflammasome, which may contribute to the progression of OA. Herein, we discovered a novel role of Nrf2/HO-1 signaling in the production of NLRP3, which may facilitate the prevention and treatment of OA.
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0 |
Location of metastatic breast carcinoma by a monoclonal antibody chelate labelled with indium-111
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MSTS 2018 - Femur Mets and MM
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The ability of a radiolabelled monoclonal antibody, LICR-LON-M8 (M8), to locate metastatic breast carcinomas has been investigated. The scans generated by M8, either when labelled with radioiodine, or when conjugated with diethylenetriamine-pentaacetic acid (DTPA) and labelled with radioactive indium (111In), have been compared with X-rays and 99mTc-methyl diphosphonate (MDP) bone scans. All 10 patients with skeletal metastases had positive 111In-DTPA-M8 scans and the overall correlation with X-rays and MDP scans was good but varied with the region studied. By contrast, radioiodinated M8 did not detect metastases at any site. The discrepancies between 111In-DTPA-M8 images and conventional techniques may be related to the different stages in the evolution and development of the lesion at which the various techniques detect bone metastases.
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0 |
Brake response time before and after total knee arthroplasty: a prospective cohort study
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Surgical Management of Osteoarthritis of the Knee CPG
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BACKGROUND: Although the numbers of total knee arthroplasty (TKA) are increasing, there is only a small number of studies investigating driving safety after TKA. The parameter 'Brake Response Time (BRT)' is one of the most important criteria for driving safety and was therefore chosen for investigation.The present study was conducted to test the hypotheses that patients with right- or left-sided TKA show a significant increase in BRT from pre-operative (pre-op, 1 day before surgery) to post-operative (post-op, 2 weeks post surgery), and a significant decrease in BRT from post-op to the follow-up investigation (FU, 8 weeks post surgery). Additionally, it was hypothesized that the BRT of patients after TKA is significantly higher than that of healthy controls. METHODS: 31 of 70 consecutive patients (mean age 65.7 +/- 10.2 years) receiving TKA were tested for their BRT pre-op, post-op and at FU. BRT was assessed using a custom-made driving simulator. We used normative BRT data from 31 healthy controls for comparison. RESULTS: There were no significant increases between pre-op and post-op BRT values for patients who had undergone left- or right-sided TKA. Even the proportion of patients above a BRT threshold of 700 ms was not significantly increased postop. Controls had a BRT which was significantly better than the BRT of patients with right- or left-sided TKA at all three time points. CONCLUSION: The present study showed a small and insignificant postoperative increase in the BRT of patients who had undergone right- or left-sided TKA. Therefore, we believe it is not justified to impair the patient's quality of social and occupational life post-surgery by imposing restrictions on driving motor vehicles beyond an interval of two weeks after surgery
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0 |
Influence of medial and lateral hamstring strengthening exercises in women with osteoarthritis knee: A randomized trail
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OAK 3 - Non-arthroplasty tx of OAK
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OA is a progressive degenerative disease that affects the joint cartilage, subchondral bone, and the synovial joint capsule. It has a multifactorial etiology and affects approximately 60% of individuals older than 50 years of age2. The knee is the most common weight-bearing joint affected by OA with the disease predominantly affecting the medial compartment of the tibiofemoral joint2. Patients with OA frequently report symptoms of knee pain and stiffness as well as difficulty with activities of daily living such as walking, stair climbing and housekeeping. Many forces acting in the knee joint cause biomechanical imbalance due to the joint loading which cause early degeneration of the joint which leads to OA knee18. The method of experimental study design was used, 30 OA knee patients aged between 40 and 60 were selected. Group A (n=15) receive both medial and lateral hamstring strengthening exercise and group B (n=9) receive only lateral hamstring strengthening. The outcome measures numeric pain rating scale (NPRS), WOMAC disability index scale, Q angle measurement with X-ray (Kelgren Lawrence method), maximum isometric voluntary contraction (MIVC) of pre and post measurements were done and statistical data was analysed. The study results states that there is a high significant difference in NRPS, WOMAC, Maximum Isometric Voluntary Contraction in group B compared with group A. The findings of the present study support the use of lateral hamstring strengthening exercise is effective in women with osteoarthritis knee.
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0 |
Reduced hospital stay and narcotic consumption, and improved mobilization with local and intraarticular infiltration after hip arthroplasty: a randomized clinical trial of an intraarticular technique versus epidural infusion in 80 patients
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AAHKS (4) Acetaminophen
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BACKGROUND: Epidural analgesia gives excellent pain relief but is associated with substantial side effects. We compared wound infiltration combined with intraarticular injection of local anesthetics for pain relief after total hip arthroplasty (THA) with the well-established practice of epidural infusion.
METHODS: 80 patients undergoing elective THA under spinal block were randomly assigned to receive either (1) continuous epidural infusion (group E) or (2) infiltration around the hip joint with a mixture of 100 mL ropivacaine 2 mg/mL, 1 mL ketorolac 30 mg/mL, and 1 mL epinephrine 0.5 mg/mL at the conclusion of surgery combined with one postoperative intraarticular injection of the same substances through an intraarticular catheter (group A).
RESULTS: Narcotic consumption was significantly reduced in group A compared to group E (p = 0.004). Pain levels at rest and during mobilization were similar in both groups but significantly reduced in group A after cessation of treatment. Length of stay was reduced by 2 days (36%) in group A compared to group E (p < 0.001).
INTERPRETATION: Wound infiltration combined with 1 intraarticular injection can be recommended for patients undergoing THA. Further studies of dosage (high/low) and duration of intraarticular treatment are warranted.
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0 |
Progressive hemiosteoporosis on the paretic side and increased bone mineral density in the nonparetic arm the first year after severe stroke
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Management of Hip Fractures in the Elderly
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Fractures are a common and serious complication after stroke and the risk of hip fractures among stroke patients is 2 to 4 times greater than among other elderly people. The aim of this study was to investigate prospectively the change in bone mineral density (BMD) after severe stroke and to study the association between motor impairment, disability and the development of hemiosteoporosis. The study comprised 24 stroke patients, with no persistent paresis from previous strokes or previous osteoporotic fractures, included 1 month after stroke onset. BMD, motor function, ambulation and activities of daily living (ADL) were assessed at 1, 4, 7 and 12 months after stroke onset. At inclusion, the patients' BMD was normal for their age. During the study, there was a significant loss of BMD in the total body (-2.0%; p < 0.05), but not in the head or spine. BMD differed significantly between the paretic and the non-paretic arm at inclusion (-4.8%; p < 0.001). Decrease in BMD was most pronounced in the affected humerus (-17.4%; p < 0.001) and proximal femur (-12.2%; p < 0.01). BMD decreased significantly in both lower extremities during follow-up, but the losses were more pronounced on the paretic side (p < 0.01). In the nonaffected ultradistal radius there was a significant increase in BMD from inclusion to the end of the study (+5.8%; p < 0.01). There was no pattern in the bone losses correlating with presumptive risk factors for hemiosteoporosis such as motor function, ability to perform ADL or ambulation. Two patients had fractures at follow-up, both on the paretic side. Loss of bone mineral density in the paretic extremities is thus pronounced and progressive during the first year after stroke, indicating that loss of BMD is probably an important risk factor for post-stroke fractures. Surprisingly, BMD in the nonaffected arm increased significantly during the first year after stroke, most likely due to increased physical activity, and perhaps a redistribution of bone minerals from the paretic extremities
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1 |
Platelet-Rich Plasma for Sport-Active Patients with Knee Osteoarthritis: Limited Return to Sport
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PRP (Platelet-Rich Plasma)
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Objective: To evaluate a cohort of sport-active patients suffering from cartilage degeneration and OA, in terms of clinical outcome and return to sport (RTS) after platelet-rich plasma (PRP) injective treatment.
Design: This study included forty-seven sport-active patients <=50 years old with unilateral symptomatic knee cartilage degeneration or OA. Patients received 3 PRP injections and were prospectively evaluated at baseline and then at 2, 6, 12, and 24 months follow-up by IKDC subjective EQ-VAS, and Tegner scores. Furthermore, patients were asked about their RTS, in terms of return to any sport level or to their activity level before symptoms onset.
Results: IKDC subjective score improved significantly at all follow-ups, changing from 59.2 +/- 13.6 to 70.6 +/- 13 at 12 months and to 76.7 +/- 12.5 at 24 months (p < 0.0005). A similar outcome was observed with the EQ-VAS score. Tegner score improved from 3.6 +/- 1.4 to 4.8 +/- 0.9 at 24 months (p < 0.0005). A similar outcome was observed with the EQ-VAS score. Tegner score improved from 3.6 +/- 1.4 to 4.8 +/- 0.9 at 24 months (p < 0.0005). A similar outcome was observed with the EQ-VAS score. Tegner score improved from 3.6 +/- 1.4 to 4.8 +/- 0.9 at 24 months (p < 0.0005). A similar outcome was observed with the EQ-VAS score. Tegner score improved from 3.6 +/- 1.4 to 4.8 +/- 0.9 at 24 months (.
Conclusions: Sport-active patients affected by knee OA can benefit from PRP injections, with pain and function improvement over time. However, results are less satisfactory in terms of RTS since only half can achieve the same sport level as before the onset of symptoms. Patients undergoing PRP treatment should be made aware of their low chances to go back to high-impact sport activities.
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0 |
Bilateral axillary masses mimicking as accessory breast with multiple fibroadenoma and bilateral gigantomastia in HIV-positive patient
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Reduction Mammoplasty for Female Breast Hypertrophy
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Accessory breast is a rare entity that can present as asymptomatic masses or can cause symptoms like heaviness, pain, restriction of arm movement and limitation in daily pursuits with allied apprehension and anxiety for the patient. We present a case of bilateral axillary masses mimicking as accessory breast with multiple fibroadenoma in a 28 years, nulliparous, Indian woman who is HIV positive, which proves to be a diagnostic dilemma. Excisional biopsy was diagnostic. The rarity of such cases imposes challenges on the management in terms of diagnosis, prognosis and therapeutic options.
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0 |
Indoor wayfinding: developing a functional interface for individuals with cognitive impairments
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Upper Eyelid and Brow Surgery
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PURPOSE: Assistive technology for wayfinding will significantly improve the quality of life for many individuals with cognitive impairments. The user interface of such a system is as crucial as the underlying implementation and localisation technology. We studied the user interface of an indoor navigation system for individuals with cognitive impairments. METHOD: We built a system using the Wizard-of-Oz technique that let us experiment with many guidance strategies and interface modalities. Through user studies, we evaluated various configurations of the user interface for accuracy of route completion, time to completion, and user preferences. We used a counter-balanced design that included different modalities (images, audio, and text) and different routes. RESULTS: We found that although users were able to use all types of modalities to find their way indoors, they varied significantly in their preferred modalities. We also found that timing of directions requires careful attention, as does providing users with confirmation messages at appropriate times. CONCLUSIONS: Our findings suggest that the ability to adapt indoor wayfinding devices for specific users' preferences and needs will be particularly important.
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0 |
Tibial plateau fractures: four years review at B & B Hospital
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DoD SSI (Surgical Site Infections)
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BACKGROUND: Tibial plateau fractures involve the articular surface of the tibia resulting from a combination of axial loading with varus or valgus stress. Inadequate and inappropriate treatment may result in significant functional loss.
OBJECTIVE: The purpose of this study was to determine the outcome of our treatment modalities and to compare with the results of comparable studies.
METHODS: The results of treatment of 81 knees were reviewed over the period of five years (1997 to 2002). There were 62 men and 18 women, with an average age of 37 years (15 years to 75 years) at the time of initial evaluation. One patient had bilateral involvement. Fractures were classified according to Schatzker. Seven patients were treated conservatively. Sixteen patients (17 knees, one had bilateral involvement) were operated with closed reduction and percutaneous cannulated screws fixation. Thirty one patients' required open reduction and internal fixation with cannulated screws. Fifteen fractures were plated, and in eleven cases, external fixators were used. Follow up period ranged from six months to three years.
RESULTS: Results were graded as excellent, good, fair and poor on the basis of functional outcome. Forty three (54%) patients (44 knees) had excellent, twenty two (26%) had good, five (6%) had fair and ten (14%) had poor results. Poor results were associated with high energy fractures, late presentation, and inadequate physiotherapy follow up. Eight patients (10%) had complications. One had common peroneal nerve palsy, six had wound infection and one patient demonstrated early arthritic changes.
CONCLUSION: Tibial plateau fracture is a challenging fracture to manage. Restoration of articular congruity and early range of motion should be the primary goal. Proper and adequate preoperative planning is mandatory. Well maintained articular congruity with stable fixation helps early mobilization and better functional outcome.
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0 |
Correlationship of Cathepsin D and Topoisomerase Ii Alpha with Nuclear Grading in Breast Cancers
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MSTS 2018 - Femur Mets and MM
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56 cases of infiltrating duct carcinoma of the breast were studied for the expression of cathepsin D and topoisomerase II alpha. The results were correlated with the morphological differentiation, as determined by the Nottingham's modification of the Bloom-Richardson system. Cathepsin D posltivity in tumour cells and stromal cells was seen in 44.6% and 55.4% cases respectively, whereas topoisomerase II alpha positivity was seen in 33.9% cases. In grade II tumours cathepsin D in tumour cells and stromal cells was 44.4% and 47.2% respectively, as compared to 27.8% posltivity for topoisomerase II alpha. The corresponding figures for grade III tumours were 50.0%, 79.6% and 64.3 % respectively. As grade I comprised only 3 cases no statistical correlation could be observed. It is evident that with increase in tumour grade there is a statistical increase in expression of cathepsin D, a lysosomal acidle protease-implicated in the process of tumour invasion and metastasis, and of topoisomerase II alpha, a marker of rapid cell proliferation and aneuploidy.
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0 |
Treatment of lower extremity long bone nonunion with expandable intramedullary nailing and autologous bone grafting
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DoD SSI (Surgical Site Infections)
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BACKGROUND: Nonunion of long bones in lower limbs is a common complication of orthopedic trauma that can be extremely debilitating. This retrospective study describes our experience using expandable intramedullary nails and autologous bone grafting in treating lower limb long bone nonunion with bone defects.
METHODS: Nineteen patients (mean age 38.9 years, range 18-61) with lower limb long bone nonunion and defects caused by femoral or tibial fracture types were as follows: A2 (3 femoral, 1 tibial), A3 (1 femoral, 2 tibial), B2 (3 femoral, 4 tibial), and B3 (1 femoral, 4 tibial). Expandable intramedullary nailing and autologous bone (iliac and/or fibular) grafting were used for the treatment. Postoperative bone healing as determined by analysis of standard anteroposterior and lateral X-ray films every 4 weeks. Complications were noted.
RESULTS: The average number of previous surgeries was 1.9 (range 1-4). The mean duration from original injury to treatment was 17.6 months (range 9-40 months). Femoral shaft nonunion healed on average of 26.5 weeks (range 16-60 weeks) after surgery, while tibial shaft nonunion healed on average of 23.6 weeks (range 12-40 weeks) after surgery. Class I healing occurred in all but two patients who experienced chronic postoperative osteomyelitis and delayed wound healing, respectively. Two patients complained of postoperative donor site pain.
CONCLUSIONS: The use of expandable intramedullary nails and autologous bone grafts was an effective method for repair of nonunion of lower limb fractures combining with bone defects with minimal complications.
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0 |
YM-150, a Factor Xa inhibitor for the prevention of venous thromboembolism and coronary artery disease
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PJI DX Updated Search
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The oral Factor Xa inhibitor YM-150 is being developed by Astellas Pharma Inc for the prevention of venous thromboembolism (VTE) in patients undergoing surgery and for coronary artery disease. In preclinical thrombosis models, as well as in phase II clinical trials in patients undergoing primary hip replacement surgery, YM-150 was safe and exhibited antithrombotic effects. Patients treated with YM-150 demonstrated a dose-related response in phase II trials, and preclinical studies suggested that efficacy was not diminished in the presence of food. At the time of publication, several phase II, II/III and III trials were ongoing or recruiting patients. In phase II trials the efficacy of YM-150 in the prevention of VTE was comparable with that observed after treatment with the active control, enoxaparin sodium. The phase III trials would assess the efficacy of YM-150 in the prevention of VTE in a larger number of patients. é Thomson Reuters (Scientific) Ltd. é Thomson Reuters (Scientific) Ltd
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0 |
Anatomic tumor location influences the success of contemporary limb-sparing surgery and radiation among adults with soft tissue sarcomas of the extremities
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DoD LSA (Limb Salvage vs Amputation)
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Purpose: To examine the influence of anatomic location in the upper extremity (UE) vs. lower extremity (LE) on the presentation and outcomes of adult soft tissue sarcomas (STS). Methods and Materials: From 2001 to 2008, 118 patients underwent limb-sparing surgery (LSS) and external beam radiotherapy (RT) with curative intent for nonrecurrent extremity STS. RT was delivered preoperatively in 96 and postoperatively in 22 patients. Lesions arose in the UE in 28 and in the LE in 90 patients. Patients with UE lesions had smaller tumors (4.5 vs. 9.0 cm, p < 0.01), were more likely to undergo a prior excision (43 vs. 22%, p = 0.03), to have close or positive margins after resection (71 vs. 49%, p = 0.04), and to undergo postoperative RT (32 vs. 14%, p = 0.04). Results: Five-year actuarial local recurrence-free and distant metastasis-free survival rates for the entire group were 85 and 74%, with no difference observed between the UE and LE cohorts. Five-year actuarial probability of wound reoperation rates were 4 vs. 29% (p < 0.01) in the UE and LE respectively. Thigh lesions accounted for 84% of the required wound reoperations. The distribution of tumors within the anterior, medial, and posterior thigh compartments was 51%, 26%, and 23%. Subset analysis by compartment showed no difference in the probability of wound reoperation between the anterior and medial/posterior compartments (29 vs. 30%, p = 0.68). Neurolysis was performed during resection in (15%, 5%, and 67%, p < 0.01) of tumors in the anterior, medial, and posterior compartments. Conclusions: Tumors in the UE and LE differ significantly with respect to size and management details. The anatomy of the UE poses technical impediments to an R0 resection. Thigh tumors are associated with higher wound reoperation rates. Tumor resection in the posterior thigh compartment is more likely to result in nerve injury. A better understanding of the inherent differences between tumors in various extremity sites will assist in individualizing treatment. © 2012 Elsevier Inc.
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Current concepts in diagnosis and management of periprosthetic infection
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PJI DX Updated Search
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Infection remains a devastating complication of total joint arthroplasty. There have been many significant advances to help identify and reduce the risks of infection over the years. However, when an infection occurs, the management can be complex. This article reviews some of the basic treatment strategies for infected prosthetic replacements
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0 |
MRI of the medial meniscus in patients over 40 years of age with osteoarthritic knees
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AMP (Acute Meniscal Pathology)
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MRI was performed for 171 medial menisci of 147 patients, ranging in age from 40 to 86 years (mean 66.6 years), who showed clinical signs in the medial compartment. We classified the MRI findings of the medial menisci using the modified grading system of Crues et al. (Radiology 1987;164:445- 448) [1], and their grade 3B into three types based on the shape of the meniscus at the menisco-capsular junction as follows; a blunted change with intrameniscal signal as type 1, flattened and/or herniated as type 2, and a diffuse swelling on the joint surface sometimes obscure as if shredded as type 3. Their mean age was lower in grades 1 and 3A, and higher in grades 2 and 3B. Their mean clinical evaluation score according to the Japanese Orthopaedic Association was higher in grades 1 and 3A, and lower in grades 2 and 3B. In grade 3B, type 1 showed similar MRI findings and had similar patient background to those in grade 2. The MRI of the medial menisci in the osteoarthritic knee of those aged 40 years or more showed characteristic shapes, especially at the menisco-capsular junction, that were correlated to patient age and to the clinical severity of the osteoarthritis. We concluded that the MRI findings of the medial meniscus were usefully divided into six groups: groups 1-3 with clear edges and groups 4-6 with diffuse edges.
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0 |
Long-term survivorship of a monoblock long cementless stem in revision total hip arthroplasty
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Hip Fx in the Elderly 2019
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PURPOSE: The purpose of this study was to assess the clinical outcomes, complications, and survival of a long cementless titanium femoral stem in revision total hip arthroplasty (THA) at a minimum five year follow-up.
METHODS: Between 2000 and 2010, 114 patients (116 hips), with a mean age of 68 +/- 12 years, underwent revision THA using a KAR R stem (DePuy, Leeds, UK). The main reasons for revision were aseptic loosening (82%), periprosthetic joint infections (PJI) (11%), and periprosthetic fractures (6%). Mean follow-up was ten +/- three years (range, 5-16). Harris Hip Score (HHS), Oxford Hip Score (OHS), and Postel-Merle d'Aubigne (PMA) score were recorded. Radiographic analysis assessed stem osseointegration and subsidence. Survival was analyzed using the Kaplan-Meier (KM) method and cumulative incidence function (CIF).
RESULTS: Post-operative HHS was 83 +/- 15 (range, 35-99) and OHS was 37 +/- 8 (range, 8-48). PMA score significantly increased from 12 +/- 2 (range, 5-18) pre-operatively to 14.6 +/- 2 (range, 9-18) post-operatively (p = 0.0004). The radiographic Engh score was 15 +/- 8 (range, 7-22). Stem subsidence was observed in two cases (3%). At ten years, five stems had been revised, three for infections and two for periprosthetic fractures. Using the KM method, ten year survival free of stem revision for aseptic loosening was 100%, free of revision for any reason 95%, and free of any re-operation 81%.
CONCLUSIONS: The present study reported satisfactory outcomes and survival of a long tapered unlocked cementless femoral stem in revision THA at a minimum follow-up of five years.
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0 |
Prevalence of Fracture Risk Factors in Postmenopausal Women Enrolled in the POSSIBLE US Treatment Cohort
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Hip Fx in the Elderly 2019
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Subject- and physician-reported data from 4,429 postmenopausal women receiving osteoporosis treatment in the Prospective Observational Scientific Study Investigating Bone Loss Experience (POSSIBLE US) were used to assess the prevalence of risk factors (RFs) and on-study fracture. RFs assessed at study entry were age >70 years; fracture since age 50; minimum T-score (hip/spine) <=-2.5 at diagnosis; body mass index <18.5 kg/m(2); rheumatoid arthritis; parental history of hip fracture; current smoking; and recent oral glucocorticoid use. Data were collected with semiannual self-administered questionnaires. Results were stratified by physician-reported osteoporosis/osteopenia diagnosis. Low T-score and age >70 years were the most common RFs in the osteoporosis group, and age >70 years and prior fracture were the most common risk factors in the osteopenia group. Multiple RFs were more common than a single RF in osteoporotic women (54.2% versus 34.6%; P < 0.0001) but not osteopenic women (13.8% versus 33.6%; P < 0.0001). Women with multiple RFs had more on-study osteoporosis-related fractures than women with a single RF (osteoporosis group: 9.9% versus 6.2%; P = 0.0092; osteopenia group: 11.2% versus 4.7%; P < 0.0001). In postmenopausal women receiving osteoporosis treatment, multiple RFs increased fracture risk. RFs, in addition to bone mineral density, can help identify candidates for osteoporosis treatment.
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0 |
Patellofemoral Instability: Evaluation by Magnetic Resonance Imaging
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AMP (Acute Meniscal Pathology)
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OBJECTIVE: To determine the contribution of magnetic resonance imaging (MRI) in evaluating patelofemoral instability.
METHODS: 39 patients (45 knees) with patellar instability underwent knee magnetic resonance images between October 2009 and July 2011, at the Rede Lab's D'Or, in the city of Rio de Janeiro, State of Rio de Janeiro, were included. MRI were analyzed for the presence of bone, hyaline cartilage and soft-tissue abnormalities, as well as anatomic variants that may contribute to chronic patellar instability.
RESULTS: The authors found, of the 45 knees analysed, bone changes in 44%, cartilaginous injuries in 64%, disruption of the medial patellofemoral ligament (MPFL) in 29% and joint morphology abnormalities in 73% patients. Meniscal tears were also identified in 2 (4%) patients and fibular fracture in one (2%) patient.
CONCLUSION: MRI allowed the detection of predisposing factors that may contribute to the development of patellofemoral instability and the diagnosis of bone, hyaline cartilage, ligamentous and meniscal abnormalities.
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0 |
Primary Candida guilliermondii Infection of the Knee in a Patient without Predisposing Factors
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Surgical Management of Osteoarthritis of the Knee CPG
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Isolated primary candidal infection of joint is extremely rare, with only a few reported cases. It occurs as a result of accidental implantations of fungus during traumatic procedures, such as surgery, and is usually reported in patients with predisposing factors such as immunosuppression, malignancy, and drug abuse. If left untreated, irreversible deformity and pain with severe osteoarticular destruction occur. Thus, early diagnosis and treatment are important. This paper presents a case of 72-year-old man with primary C. guilliermondii infection of knee joint without predisposing factors and previous traumatic procedures, who was misdiagnosed with advanced degenerative osteoarthritis. Our case is the second case of primary C. guilliermondii arthritis of knee to be reported in the English-language literature and the first to be successfully treated with total knee arthroplasty following IV amphotericin B and oral fluconazole. Primary candidal infection of joint is generally asymptomatic or involves only mild pain and swelling in the affected knee. Thus, although the majority of knee joint infections are of a pyogenic or tuberculous origin, if a patient complains of mild pain and swelling in the knee and has mild signs of infection, the possibility of fungal infection should be considered
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0 |
Treatment With Helical Blade Cephalomedullary Nail for Two-Part Basicervical Proximal Femoral Fracture in Elderly Patients: A Retrospective Observational Study
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Hip Fx in the Elderly 2019
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Background: Basicervical proximal femoral fracture is a known subtype of extracapsular fracture and is mechanically unstable, especially for the rotational direction, which may lead to implant failure. A cephalomedullary nail (CMN) is widely used for the fixation of unstable extracapsular fracture; however, its application for basicervical fracture remains controversial. Helical blade CMN is proven to have more rotational stability than traditional lag screw implants and potentially advantageous in the treatment of basicervical fracture. The aim of this study is to assess the effectiveness of helical blade CMN for basicervical fracture in elderly patients.
Methods: We conducted a retrospective review of 500 consecutive extracapsular fracture patients treated surgically between January 2005 and February 2015. Patients who had trochanteric extension or multifragment fracture were excluded. Sixteen cases of 2-part basicervical proximal femoral fracture were identified. All patients were treated with the same single helical blade CMN system (DePuy Synthes PFNA-II). Implant-related complications were recorded.
Results: Two patients dropped out during follow-up and 14 patients were included in the analysis. The average follow-up period was 21.9 months. No major complication was observed. The patients were subcategorized into 2 groups: nondisplaced (displacement <2 mm at any point of the fracture line) or displaced. Excessive telescoping was observed in 2 patients, both of whom were in the displaced fracture group. The overall implant-related complication rate was 14.2% (2/16).
Conclusion: Internal fixation with the helical blade CMN system can be considered as a treatment option for 2-part basicervical proximal femoral fracture in elderly patients.
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0 |
Perineal hygiene in patients with pelvic fractures
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DoD SSI (Surgical Site Infections)
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At the tertiary referral Orthopaedic Unit of St. Georges Hospital, it was noted that there was an unacceptably high number of soiled perinea in patients transferred from Base Hospitals. This not only exposed the patients to increased infection [Jepsen O. The effectiveness of preoperative skin preparations: an integrated review of the literature. AORN J 1993;58:477-82; and Nix D, Ermer-Seltun J. A review of perineal skin care protocols and skin barrier product use. Ostomy Wound Manage 2004;50:59-67] but was also undignified and unacceptable for them. We decided to audit the problem with a view to finding out why this was happening and to improve the situation. A 2-year study was carried out over three distinct phases (phase 1: February-June 2004, phase 2: July-November 2004, phase 3: February-November 2005). Observations of soiling were recorded in a questionnaire by the surgeon prior to surgery. Key system and clinical guidelines were implemented during the second phase, and the audit process was repeated. The percentage of clean perinea in phase 1 was 32%, phase 2 68% and phase 3 99.5% indicating a clear improvement in the overall system.
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1 |
Pre-operative analgesia for patients with femoral neck fractures using a modified fascia iliaca block technique
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Management of Hip Fractures in the Elderly
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Adequate pre-operative analgesia for elderly patients with femoral neck fractures is difficult to assess and is often an overseen aspect of their care. We aimed to assess the efficacy of fascia iliaca blocks inserted via plexus blockade catheters in the pre-operative period. Our simple technique allowed the block to be administered safely without the need for a nerve stimulator. We assessed the effectiveness of the block with a novel objective sitting score and by assessing the degree of passive hip flexion that could be achieved comfortably. Visual analogue scores were also used. We studied 30 consecutive patients, regardless of their mental state. One hour following the block, there was a significant improvement in the sitting scores as well as the passive hip flexion (mean increase 44 degrees ). Visual analogue scores also score improved significantly from 7.2 to 4.6 (S.D. 2.4) in the 18 patients without cognitive impairment. We conclude that fascia iliaca blocks can provide significant benefit in the pre-operative period and allow patients to sit up more comfortably while they await surgery
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0 |
Elective Tracheostomy During Mechanical Ventilation in Patients Affected by COVID-19: Preliminary Case Series From Lombardy, Italy
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Coronavirus Disease 2019 (COVID-19)
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The COVID-19 outbreak poses continued struggles due to the unprecedented number of patients admitted to intensive care units and the overwhelming need for mechanical ventilation. We report a preliminary case series of 32 patients with COVID-19 who underwent elective tracheostomies after a mean intubation period of 15 days (range, 9-21 days). The procedure was performed with percutaneous (10 cases) and open (22 cases) surgical techniques. Neither procedure-related complications nor viral transmission to health care workers was observed. Our preliminary experience supports the safety of tracheostomy, provided that appropriate protocols are strictly followed. The postoperative care is still debated, and, prudentially, our protocol includes tracheal tube change not before 2 weeks after tracheostomy, with cuff deflation and decannulation deferred until confirmation of negative SARS-CoV-2 test results. This is the first case series to report on such a rapidly evolving issue and might represent a source of information for clinicians worldwide who will soon be facing the same challenges.
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0 |
Safety of total hip replacement following an intra-articular steroid hip injection--an audit
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PJI DX Updated Search
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The aim of this study was to determine the deep infection rates in patients who underwent a total hip replacement after having had a prior diagnostic steroid injection into the same hip. We identified and reviewed the case notes, relevant radiographs and microbiology reports of all patients who underwent a total hip replacement after a diagnostic steroid hip injection in our unit from 1 January 2007 to 31 April 2009. There were 40 patients. (10 males and 30 females) Their mean age was 68.4 (52-82) years. The mean time interval from the injection to the joint replacement was 6.2 (2-23) months. The mean follow-up was 23.2 (11-37) months. None of the patients in the study group developed a deep infection during this followup period. Diagnostic intra articular steroid and local anaesthetic injection prior to total hip replacement appears to be safe
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0 |
Prevalence of vertebral fractures in French women older than 75 years from the EPIDOS study
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Management of Hip Fractures in the Elderly
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The aim of this study was to ascertain the prevalence and severity of vertebral fractures in French elderly women. We used spinal radiographs collected during the baseline examination of the Epidemiologie de l'Osteoporose (EPIDOS) study, a multicentric prospective study of risk factors for hip fracture. A total of 7598 ambulatory women volunteers were recruited in the EPIDOS cohort using large population-based listings such as voter-registration lists. A subsample of 770 participants were selected for spinal radiographs using a systematic selection procedure. Anteroposterior and lateral radiographs of the thoracic and lumbar spine were reviewed by two trained rheumatologists using the semiquantitative (SQ) method described by Genant et al. [J. Bone Miner Res. 8 (1993) 1137]. Vertebral deformities that could be related to causes other than osteoporosis (i.e., Scheuermann's disease or osteoarthritis) were disregarded. The final analysis was made over 745 women after excluding 25 women whose spine radiographs were incomplete or of poor quality. The sample average age was 80.1 +/- 3.4 years. Vertebral fractures were found in 170 women: 22.8% (95% CI, 19.8-25.8%). A single, two, three, or more vertebral fractures were seen in 99 (58.2%), 43 (25.3%), and 28 (16.5%) of the 170 affected women, respectively. The prevalence of vertebral fractures increased with age from 19.0% (95% CI, 14.9-23.1%) among women 75-79 years old to 21.9% (95% CI, 17.3-26.5%) among those 80-84 years old and to 41.4%(95% CI, 31.0-51.7%) among those 85 years of age and over (Chi-square test for trend P < 0.00016). A significant correlation was found also between the number of vertebral fractures per woman and age (r = 0.108, P = 0.003) and between the spinal fracture index and age (r = 0.105, P = 0.004). We conclude that the prevalence of vertebral fractures is high in French ambulatory elderly women, which confirms the results of previous studies conducted in various Caucasian and Asian populations
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0 |
Study to Evaluate The Analgesic Efficacy and Safety of Intravenous Paracetamol in Subjects With Postoperative Pain After Total Hip Arthroplasty
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AAHKS (4) Acetaminophen
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The main purpose is to evaluate the analgesic efficacy of 1g of intravenous (Iv) paracetamol versus i.v. placebo, administered every 6h, as measured by the reduction of the 24â?hour cumulative dose of the opioid tramadol in the treatment of postoperative pain following total hip arthroplasty.
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0 |
Open-wedge high tibial osteotomy in patients with discoid lateral meniscus
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AMP (Acute Meniscal Pathology)
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BACKGROUND: There are concerns about the progression of the lateral osteoarthritis (OA) should be taken into account when high tibial osteotomy (HTO) is performed in patients with discoid lateral meniscus (LM). This study evaluated the clinical results of HTO in patients with discoid LM and elucidated factors affecting the results.
METHODS: This study evaluated 32 female patients with varus deformity and medial OA. Patients with discoid LM (8 patients) or without discoid LM (24 patients) underwent open-wedge HTO. The mean age was 53.5 years and the mean follow-up period was 35 months. Clinical results, including the Hospital for Special Surgery (HSS) score, Knee Society knee score (KS) and function score (FS), were evaluated. The progression of OA in the lateral compartment was also evaluated. Finally, we evaluated the factors affecting the clinical results and OA progression in the lateral compartment.
RESULTS: Between two groups, all clinical scores were not different (p = 0.964, 0.963, and 0.559, respectively). Three of eight patients (37.5%) in the discoid group developed OA in the lateral compartment, whereas 2 of 24 patients (8.3%) in the control group developed such; however, this was not significantly different (p = 0.085). In discoid group, patients with undercorrection has higher KS relative to patients with acceptable correction (p = 0.044). Other clinical results and OA change in the lateral compartment were not affected by evaluated factors.
CONCLUSIONS: Patients who underwent open-wedge HTO showed the satisfactory clinical results and lateral OA progression regardless of the presence or absence discoid LM. However, when discoid LM was present, patients with undercorrection showed higher KS in comparison with patients with acceptable correction.
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0 |
The role of Sirt6 in osteoarthritis and its effect on macrophage polarization
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AMP (Acute Meniscal Pathology)
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Osteoarthritis (OA), the commonest arthritis type, features irreversible cartilage loss and synovitis. It was reported that macrophages have an important function in synovial inflammation, and our team revealed that the amounts of Sirt6, a nicotinamide adenine dinucleotide (NAD)<sup>+</sup>-dependent histone deacetylase, decrease during synovial inflammation and osteoarthritis. This work aimed to examine the anti-inflammatory properties of Sirt6 in synovial inflammation. Firstly, we compared Sirt6 amounts in acute meniscus injury and OA human knee synovial tissue samples by immunofluorescence and immunoblot. Secondly, Sirt6's suppressive effects on inflammatory markers and macrophage polarization were evaluated. Finally, OA mice were histologically evaluated, and serum inflammatory factors were detected for assessing the impact of Sirt6 overexpression on the mouse synovium. We found significantly lower interleukin-4 (IL-4) amounts and M2 polarization in OA patients compared with control individuals. The expression of Sirt6 was lower in RAW264.7 cells of the lipopolysaccharides (LPS) + interferon-gamma (IFN-gamma) group compared with the phosphate buffer saline (PBS) group, but higher than in the IL-4 group. The polarization of macrophages affected Sirt6 expression, which was reduced and elevated in M1 and M2 macrophages, respectively. Sirt6 inhibition could promote the release of proinflammatory cytokines by macrophages in the synovial membrane, induce M1 polarization in macrophages and inhibit M2 polarization in vitro, and Sirt6 overexpression alleviated osteoarthritis in vivo. These data strongly suggested that Sirt6 could inhibit synovial inflammation. Thus, this study provides a novel therapeutic target in osteoarthritis.
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0 |
One stage carotid artery resection: reconstruction in radiated head and neck carcinoma
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MSTS 2018 - Femur Mets and MM
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PURPOSE: Management of the carotid artery involved with metastatic squamous cell carcinoma continues to be a topic of much discussion. Early reports, for the most part, focused on the sequel of ligation and the development of various tests to predict patient tolerance for the procedure. More recent alternatives have described resection reconstruction in multistage procedures. By using immediate reconstruction with autogenous arterial grafting, carotid artery resection can be accomplished in patients with radiation failure in a single stage. This technique can be used without the addition of myocutaneous flaps, controlled fistulas, or intracranial surgery advocated for usage with alternative techniques.
PATIENTS AND METHODS: Immediate reconstruction after resection of the carotid artery with superficial femoral arterial graft is described.
RESULTS: In a series of 18 high-risk patients with radiation failure, the artery was successfully resected and reconstructed in 1 stage without any neurologic or vascular complications. The technique has been associated with prolonged survival in selected patients.
CONCLUSION: Carotid artery resection and immediate reconstruction can be performed in high-risk radiation failure patients with acceptable complications, and is associated with prolonged survival in selected cases.
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0 |
Meniscal Repair: a Randomized Prospective Trial of FAST-FIX vs. Meniscal Suturing
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OAK 3 - Non-arthroplasty tx of OAK
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In this prospective, randomized, trial subjects will be randomly assigned to the insideâ?out group or the FasTâ?Fix group and will be followed for at least 24 months. Primary outcome is the difference between groups in the disease specific quality of life assessment â? The Western Ontario Meniscal Evaluation Tool. Secondary outcome measures include range of motion, functional outcome scores, surgical time, complication rate, meniscal retear and differences between groups in postâ?operative pain. The data collector will be blinded to patients' intervention group. Secondary outcome measures include range of motion, functional outcome scores, diseaseâ?specific quality of life outcome scores and the standard knee clinical examination. Study Population: The investigators will assess all patients presenting with suspected meniscal tears. Those meeting the inclusion/exclusion criteria will be asked to sign an informed consent. Subjects who have successfully been screened and are slated to be randomized into the study must have a preâ?operative visit within 12 months of their scheduled surgery. Routine knee xâ?rays will be performed on all patients to rule out extensive degenerative changes, loose bodies, fractures, osteochondritis dissecans and other lesions. Treatment Protocols: Intervention group assignment will take place at the time of surgery, once the patient has undergone the initial arthroscopy and a diagnosis of a repairable meniscal tear has been confirmed. Patients will be stratified for surgeon and for concurrent ACL reconstruction. They will then be randomized to one of the two treatment groups. Meniscal repair is a day surgery procedure performed under general anaesthesia and tourniquet control as required. Prior to the repair, synovial abrasion and debridement of scar tissue will be carried out to promote vascular ingrowth. FasTâ?Fix Technique A suture that is preâ?attached to a Tâ?bar is placed across the meniscal tear via a sheathed needle. A small obturator pushes the "T" out of the needle engaging the outer rim of the meniscus in the synovial recess. The suture tails are tied arthroscopically, stabilizing the tear. Insideâ?Out Suturing Technique Repairs of the medial meniscus will be carried out with the knee in 10â?30° flexion. This allows both preservation of the posterior capsular recess and full knee extension once the repair is complete. A vertical incision is made posterior to the medial collateral ligament. The deep fascia is incised and the posteromedial capsule visualized. The lateral meniscus is repaired through a vertical incision posterior to the lateral collateral ligament made with the knee flexed 90°. The iliotibial band is split in line with its fibers at the level of the joint line. The biceps femoris and lateral gastrocnemius tendon are retracted posteriorly, protecting the common peroneal nerve and exposing the capsule and popliteus tendon. Vertical sutures will be placed in at 5mm intervals along the tear. Sutures are tied over the capsule once ligamentous reconstruction, if necessary, is completed. This is done with the knee in full extension. Assessments: Patients will be assessed preâ?operatively and by a blinded research assistant at 3, 6, 12, and 24 months. A tubiâ?grip will cover the operative knee in order that the data collector may be blinded to treatment group. Effusion and jointâ?line tenderness will be assessed by the physician prior to the data collector's appraisal. The viability of the meniscal repair will be based on the clinical examination. The absence of effusion, jointâ?line tenderness and locking all correlate well with a healed meniscus. The International Knee Documentation Form, the Western Ontario Meniscal Evaluation Tool and the Lysholm score, validated measures for knee problems will be utilized. Patients will be asked to complete a pain journal for a period of 2 weeks following their surgery.
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0 |
Shared decision making in patients with osteoarthritis of the hip and knee: results of a randomized controlled trial
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Surgical Management of Osteoarthritis of the Knee CPG
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BACKGROUND: Despite evidence that shared decision-making tools for treatment decisions improve decision quality and patient engagement, they are not commonly employed in orthopaedic practice. The purpose of this study was to evaluate the impact of decision and communication aids on patient knowledge, efficiency of decision making, treatment choice, and patient and surgeon experience in patients with osteoarthritis of the hip or knee. METHODS: One hundred and twenty-three patients who were considered medically appropriate for hip or knee replacement were randomized to either a shared decision-making intervention or usual care. Patients in the intervention group received a digital video disc and booklet describing the natural history and treatment alternatives for hip and knee osteoarthritis and developed a structured list of questions for their surgeon in consultation with a health coach. Patients in the control group received information about the surgeon's practice. Both groups reported their knowledge and stage in decision making and their treatment choice, satisfaction, and communication with their surgeon. Surgeons reported the appropriateness of patient questions and their satisfaction with the visit. The primary outcome measure tracked whether patients reached an informed decision during their first visit. Statistical analyses were performed to evaluate differences between groups. RESULTS: Significantly more patients in the intervention group (58%) reached an informed decision during the first visit compared with the control group (33%) (p = 0.005). The intervention group reported higher confidence in knowing what questions to ask their doctor (p = 0.0034). After the appointment, there was no significant difference between groups in the percentage of patients choosing surgery (p = 0.48). Surgeons rated the number and appropriateness of patient questions higher in the intervention group (p < 0.0001), reported higher satisfaction with the efficiency of the intervention group visits (p < 0.0001), and were more satisfied overall with the intervention group visits (p < 0.0001). CONCLUSIONS: Decision and communication aids used in orthopaedic practice had benefits for both patients and surgeons. These findings could be important in facilitating adoption of shared decision-making tools into routine orthopaedic practice
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0 |
Salvage for intramedullary nailing breakage after operative treatment of trochanteric fractures
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Hip Fx in the Elderly 2019
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BACKGROUND: Trochanteric fractures are one of the most common fractures in elderly people. The use of intramedullary nails is an option for their treatment, especially in unstable patterns. Nail breakage is a rarely reported complication. The aim of this study was to determine the prevalence of nail breakage in our center. Secondary objectives are to show the management of this complication in our institution as well as the technical problems, complications and final outcomes of these patients in our hands.
MATERIAL AND METHODS: In a retrospective case series review between 2010 and 2015, we analyzed 1481 patients with trochanteric and subtrochanteric fractures who had been treated by cephalomedullary nailing in our centre. 13 patients with nail breakage were identified.
RESULTS: The percentage failure rate in our institution is 0.87%. 9 (69.2%) patients were women and 4 (3.8%) were men, with a mean age of 74.6 years (range 47-90). In all cases the mechanism of injury was a simple fall from standing height. Initial fracture types were: 1 case of AO/OTA 31A1, 6 cases of AO/OTA 31A2 and 6 cases of AO/OTA 31A3. Only 3 cases had a good overall reduction with a correct TAD, an optimal femoral neck-shaft angle and absence of fracture gaps >5 mm after surgery. The average time from the first surgery to the diagnosis of implant breakage was 333 days (range 70-1460), 11 months. Breakage occurred at the nail junction with the lag screw in 11 cases and in the distal nail aperture in 2 cases.
CONCLUSIONS: An insufficient reduction with varus and fracture gaps >5 mm, the use of short nails in unstable patterns with subtrochanteric involvement and patients with certain comorbidities are facts observed that can contribute to the development of delayed or nonunion with subsequent nail breakage. Different salvage treatments, conversion to hip arthroplasty or revision osteosynthesis, may be considered but we think that prevention has to be the best treatment.
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0 |
Treatment of chronic refractory osteomyelitis with adjunctive hyperbaric oxygen
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DoD SSI (Surgical Site Infections)
|
Twenty-eight consecutive patients with chronic refractory osteomyelitis uncomplicated by persistent segmental bone defect, fracture nonunion, septic arthritis, total joint arthroplasty, or major systemic disease (immune deficiency, malignancy, diabetes mellitus, malnutrition, or renal or hepatic failure) were treated from January, 1980 through December, 1985 to evaluate the potential benefits of hyperbaric oxygen therapy. Patients were classified by a staging system that took into account the bone involved; subchondral, periarticular bone involvement; extent of bone involvement; quality of soft tissue envelope and vascular supply; and general health status of the patient. Using this staging system, patients were assigned to either hyperbaric oxygen therapy or control status after their initial debridement. A regimen of hyperbaric oxygen therapy consisting of 100% oxygen, two atmospheres pressure, two hour duration, one dive per day, six dives per week was used in 14 of the 28 patients. Hyperbaric oxygen had no effect on length of hospitalization, rapidity of wound repair, initial clinical outcome, or recurrence of infection noted to date in this patient population.
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0 |
MR imaging of lipoma arborescens and the associated lesions
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AMP (Acute Meniscal Pathology)
|
OBJECTIVE: To describe the typical features of lipoma arborescens on MR imaging with pathologic correlation and to evaluate the associated lesions within the joints.
DESIGN AND PATIENTS: The MR imaging findings of 32 patients with the diagnosis of lipoma arborescens of the knee (n=32) and shoulder (n=1) were reviewed. The diagnosis of lipoma arborescens was confirmed by the histologic findings in 12 cases and the other 21 cases were diagnosed by the characteristic MR imaging features. One patient had bilateral lipoma arborescens of the knee joint.
RESULTS: MR imaging showed a typical pattern of villous lipomatous proliferation of the synovium in all cases, as a diffuse pattern in 79% (26/33) of cases and as a dominant mass-like lesion in 21% (7/33) of cases. The associated MR pathology in the knee was (n=32): joint effusion (100%), degenerative changes (87%), meniscal tear (72%), synovial cysts (38%), bone erosions (25%), chondromatosis (13%), patellar subluxation (6%) and discoid meniscus (3%). In all cases except two there was associated pathology of the knee. MR imaging showed an associated rotator cuff tear in the lipoma arborescens of the shoulder.
CONCLUSION: The characteristic MR features of lipoma arborescens allows an accurate diagnosis of this rare lesion, which is almost always associated with other chronic pathology of the joint in the elderly.
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0 |
The impact of a novel preventive care service on the incidence of hip fractures among the elderly
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HipFx Supplemental Cost Analysis
|
Objective: We wanted to determine the impact of a novel preventive care service (PCS) employing home visits by non-physician experts on the incidence of hip fractures among the elderly. Methods: We estimated an ARMA model for the time series of hip fractures in the Hoganas municipality in Sweden for the years 1987-2008. By means of intervention analysis and out of sample forecasts, we estimated the short- and long-term impact of the novel preventive care service. Results: We found that there is a statistically significant short-term impact of the PCS with about 8.27 fewer incidents of hip fracture. This corresponds to a long-term effect of about 3.74 fewer incidents of hip fracture per year. Conclusion: Since we found a statistically highly significant impact, we concluded that there was an effect on the number of hip fractures. Considering the magnitude of the effect, we found that the examined preventive care service is an economically efficient measure. (copyright) 2010 Springer-Verlag
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1 |
A method to select patients for vertical scar or inverted-T pattern breast reduction
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Reduction Mammoplasty for Female Breast Hypertrophy
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Vertical scar breast reduction (VSBR) is an increasingly popular technique but can carry a high complication and revision rate. We evaluate our complication rate when selecting patients for VSBR or inverted-T breast reductions (ITBR). We looked at 133 consecutive primary bilateral breast reductions performed by a single consultant from 1998 to 2003 (23 incomplete records). VSBR (82 breasts) and ITBR (120 breasts) were performed, with glandular or superomedial pedicle transposition of the nipple-areola complex (NAC), or free nipple grafts (FNG) (18 breasts). The pattern of skin excision chosen was determined by the degree of skin shrinking required to achieve the correct vertical height of the new breast. If the measurement from the inframammary fold to the lower border of the new areola position was < 18 cm the patient underwent VSBR. We assessed complication and revision rates in each group. The complication rate (haematoma, infection, delayed healing, nipple/fat necrosis) in VSBR was 11%, in ITBR 23% (P<0.05). Revision rate was 2.4% in the VSBR and 3.3% in ITBR group. The VSBR had no problem scars, while the ITBR produced problem scars in 16% of operated breasts (P<0.001). We feel it is possible to reduce skin to 40-50% of its original length. Attempting a greater degree of shrinkage produces a high rate of revision surgery. We suggest a method of selection of technique by a reproducible measurement of the vertical skin reduction to produce a low complication rate and low revision rate.
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0 |
Effect of oral clodronate on bone pain. A controlled study in patients with metastic prostatic cancer
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MSTS 2018 - Femur Mets and MM
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Although osteosclerotic metastases are characteristic of prostatic carcinoma, bone resorption is also accelerated. Since clodronate inhibits bone resorption and relieves bone pain, we have given it to patients with painful bone disease from prostatic cancer after failure of hormonal therapy. All patients received estramustine phosphate orally. Simultaneously they were randomly allocated to clodronate (36) and placebo (39) groups. Clodronate was given by mouth. The dose was 3.2 g for the first month, thereafter 1.6 g. Pain relief was more distinct in the clodronate group where one third of patients were totally free of bone pain. The use of analgesics stopped in 38% of patients on clodronate and in 18% on placebo which effect probably belongs to estramustine phosphate. Serum calcium concentration decreased more markedly in the clodronate group. Clodronate dose of 3.2 g seemed to be more potent than that of 1.6 g. Side effects were uncommon and occurred equally in both groups. No significant differences were seen in median survival or survival rates between the groups.
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0 |
Extracorporeal photochemotherapy in the treatment of severe graft-versus-host disease
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Reconstruction After Skin Cancer
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Advances in posttransplant immunosuppression have to the present not been able to prevent the development of graft-versus-host disease (GVHD) in patients given related or unrelated stem cell grafts for cure of hematologic diseases. Patients with GVHD not responding to first line therapy with corticosteroids remain at high risk of death due to severe infections or organ failure. Extracorporeal exposure of peripheral blood mononuclear cells to the photosensitizing agent 8-methoxypsoralen and ultraviolet A radiation has been shown to be effective in treatment of selected T-cell mediated diseases, including cutaneous T-cell lymphoma and rejection after organ transplantation. Extracorporeal photochemotherapy (ECP) is also a safe and efficacious adjunct therapy for both acute and chronic extensive GVHD with skin and visceral involvement and resistance to conventional immunosuppressive therapy. A multicenter randomized study should help define the impact of ECP in the treatment of GVHD and overall survival of these patients.
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0 |
FRAX Update
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Pediatric Supracondylar Humerus Fracture 2020 Review
|
The fracture risk assessment tool, FRAX, was released in 2008 and provides country-specific algorithms for estimating individualized 10-year probability of hip and major osteoporotic fracture (hip, clinical spine, distal forearm, and proximal humerus). Since its release, models are now available for 63 countries, covering 79% of the world population. The website receives approximately 3 million visits annually. Following independent validation, FRAX has been incorporated into more than 80 guidelines worldwide. However, the application of FRAX in guidelines has been heterogeneous with the adoption of several different approaches to setting intervention thresholds. The relationship between FRAX and efficacy of intervention has been explored and is expected to influence treatment guidelines in the future. A more unified approach to setting intervention thresholds with FRAX is a research priority.
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0 |
Distal Humeral Fractures in Adults
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The Treatment of Pediatric Supracondylar Humerus Fractures AUC
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Distal humeral fractures in adults often pose a challenge to the orthopaedic surgeon. Preoperative planning, minimal devitalization of bone and soft tissue, and adherence to the prerequisites of biomechanical fixation are all important elements in effecting the desired end result. The chevron modification of the olecranon osteotomy affords excellent surgical exposure of the joint surface for fractures with an intra-articular component. When two plates are used to fix the lateral and medial distal humeral columns, it is best to orient them so that, when looked at in cross section, they are at right angles to each other. The achievement and maintenance of an anatomic reduction secure enough to permit early functional, pain-free motion of the elbow can be best ensured by open reduction and internal fixation with careful attention to detail
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0 |
Glomus tumour following a total knee replacement: a case report
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Surgical Management of Osteoarthritis of the Knee CPG
|
Pain following total knee replacement (TKR) is a common problem and cause of poor satisfaction amongst patients. We report on a glomus tumour causing pain on the anterolateral aspect of the knee, 2 years after an otherwise successful total knee replacement for osteoarthritis. The tumour was treated by excision biopsy under general anaesthesia and the diagnosis confirmed by histopathological examination. The removal of the tumour relieved the pain and the patient regained good function. We conclude that a thorough clinical assessment of a patient with a painful knee following TKR is essential to detect and treat coincidental painful pathology
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0 |
Early revisions of the Femoro-Patella Vialla joint replacement
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Surgical Management of Osteoarthritis of the Knee CPG
|
The aim of this study was to review the early outcome of the Femoro-Patella Vialla (FPV) joint replacement. A total of 48 consecutive FPVs were implanted between December 2007 and June 2011. Case-note analysis was performed to evaluate the indications, operative histology, operative findings, post-operative complications and reasons for revision. The mean age of the patients was 63.3 years (48.2 to 81.0) and the mean follow-up was 25.0 months (6.1 to 48.9). Revision was performed in seven (14.6%) at a mean of 21.7 months, and there was one re-revision. Persistent pain was observed in three further patients who remain unrevised. The reasons for revision were pain due to progressive tibiofemoral disease in five, inflammatory arthritis in one, and patellar fracture following trauma in one. No failures were related to the implant or the technique. Trochlear dysplasia was associated with a significantly lower rate of revision (5.9% vs 35.7%, p = 0.017) and a lower incidence of revision or persistent pain (11.8% vs 42.9%, p = 0.045). Focal patellofemoral osteoarthritis secondary to trochlear dysplasia should be considered the best indication for patellofemoral replacement. Standardised radiological imaging, with MRI to exclude overt tibiofemoral disease should be part of the pre-operative assessment, especially for the non-dysplastic knee
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0 |
In vivo evaluation of the effect of intramedullary nail microtopography on the development of local infection in rabbits
|
PJI DX Updated Search
|
BACKGROUND AND AIM: Fractures of the tibia and femoral diaphysis are commonly repaired by intramedullary (IM) nails, which are currently composed of either electropolished stainless steel (EPSS) or standard, non-polished titanium-aluminum-niobium (TAN). Once the fracture has fully healed, removal of IM nails is common, but the strong adhesion of bone to standard TAN complicates removal. Polishing the surface of TAN IM nails has been shown to reduce bony adhesion and ease implant removal without compromising fixation. Polished TAN nails are, therefore, expected to have significant clinical benefit in situations where the device is to be removed. The aim of the present study was to determine the effect of polishing TAN IM nails on susceptibility to infection in an animal model. MATERIALS AND METHODS: Solid IM nails (Synthes, Betlach, Switzerland) composed of standard TAN were compared with polished equivalents and also to clinically available EPSS nails. The surface chemical and topographical properties of the materials were assessed by X-ray photon spectroscopy (XPS), white light profilometry, and scanning electron microscopy (SEM). An in vivo infection study was performed using a clinical isolate of Staphylococcus aureus that was characterized with respect to various virulence factors. RESULTS: Polishing TAN IM nails caused no significant change to the chemistry of the nails, but the topography of the polished TAN nails was significantly smoother than standard TAN nails. In the infection study, the rank order based on descending infectious dose 50 (ID(50)) was: standard TAN, polished TAN, and finally EPSS. The ID(50) values did not differ greatly between any of the groups. CONCLUSIONS: Polishing the surface TAN IM nails was not found to influence the susceptibility to infection in our animal model
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0 |
Quantitative ultrasound and bone densitometry to evaluate the risk of nonspine fractures: a prospective study
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Distal Radius Fractures
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The ability of quantitative ultrasound (QUS) to estimate the risk of osteoporotic fractures was evaluated in a prospective study over a mean time of 5.47 years in 254 postmenopausal women (mean age 58.06+/-7.67 years). Baseline measurements of ultrasound transmission velocity (UTV) and bone mineral density (BMD) were taken at the distal radius (DR). UTV was also measured at the patella (P). Fifty nonspine fractures due to minor trauma were detected during annual check-ups with an incidence of 3.59/year. Fractures occurred in older women with a lower BMD and QUS. Using Cox regression analysis the relative risk (RR) per 1 standard deviation (SD) decrease in the unadjusted QUS and BMD measurements was: BMD-DR = 3.56, 95% confidence interval (CI) 1.57-8.09; 95% CI 2.08-9.68. The relationship between BMD and QUS variables and fracture risk persisted after adjusting for potential confounders apart from previous fractures, giving the following RR: BMD-DR = 2.99, 95% CI 1.06-8.41; UTV-DR = 3.69, 95% CI 1.18-11.49; UTV-P = 3.89, 95% CI 1.53-9.90. Correcting also for previous fractures, only UTV-P remained an effective predictor of fracture risk even after QUS measurement correction for BMD. Wrist fractures were best related to BMD-DR (RR 7.33, 95% CI 1.43-37.50) and UTV-DR (RR 10.94, 95% CI 1.10-108.45), while hip and ankle fractures were significantly associated only with UTV-P (hip: RR 32.14, 95% CI 1.83-562.80; ankle: RR 17.60, 95% CI 1.78-173.79). The combined use of BMD and QUS is a better predictor of fracture risk than either technique used separately. Comparison of the areas under the receiver operating characteristic (ROC) curves did not show differences in the ability of BMD and QUS to correctly distinguish fractures. In conclusion, QUS predicts fracture risk in osteoporotic women at least as well as BMD. UTV-DR and BMD-DR are good predictors of wrist fractures, while UTV-P is strongly related to hip and ankle fractures. QUS and BMD combined improve the diagnostic ability of each technique individually.
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0 |
Interpersonal stressors and resources as predictors of parental adaptation following pediatric traumatic injury
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DoD PRF (Psychosocial RF)
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The authors examined the relationship of preinjury interpersonal resources and stressors to parental adaptation following pediatric traumatic brain injury (TBI) and orthopedic injury. Parents of children with severe TBI (n = 53), moderate TBI (n = 56), and orthopedic injuries (n = 80) were assessed soon after injury, 6 and 12 months after the initial evaluation, and at an extended follow-up with a mean of 4 years postinjury. General linear model analyses provide support for both main and moderating effects of stressors and resources on parental adjustment. Support from friends and spouse was associated with less psychological distress, whereas family and spouse stressors were associated with greater distress. The results also reveal a marked decline in injury-related stress over follow-up for families in the severe TBI group who reported a combination of high stressors and high resources. The decline suggests that interpersonal resources attenuated long-term family burden because of severe TBI. The findings are discussed in terms of their implications for intervention following TBI.
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1 |
Antibiotic Prophylaxis in Adults With Open Tibial Fractures: What Is the Evidence for Duration of Administration? A Systematic Review
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DoD SSI (Surgical Site Infections)
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Open tibial fractures are common injuries after high-energy trauma such as road traffic accidents. Infection is one of the main complications of open fractures. Broad-spectrum antibiotics have been used for prophylaxis and treatment of infection in these fractures. The duration of antibiotic prophylaxis remains controversial, especially for the different types and grades of open fractures. No complete review, to date, has been performed of published studies to demonstrate the wide variety of duration of antibiotic use in practice to prevent infection, especially in open tibial fractures. The purpose of the present study was to review the evidence in the current data regarding the duration of prophylactic antibiotic administration in open tibial fractures and to identify the optimum duration of administration of antibiotics to minimize the risk of infection in these fractures. We reviewed and evaluated all published clinical trials claiming or cited elsewhere as being authoritative regarding the duration of prophylactic antibiotic use in open tibial fracture management. A large number of studies reported antibiotic prophylaxis in open fractures; however, only 8 met the inclusion criteria set out for our review. Only 1 randomized, double-blind, prospective study examined the duration of prophylactic antibiotic administration in open tibial fractures. That study suggested a short course of antibiotics is as effective as a long course in infection prophylaxis. The results of the present review highlight the need for a rigorous randomized, double-blind, multicenter trial to establish an agreed protocol for the optimal length of prophylactic antibiotic administration in open tibial fractures.
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1 |
Viscosupplementation with hylan G-F 20: a 26-week controlled trial of efficacy and safety in the osteoarthritic knee
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OAK 3 - Non-arthroplasty tx of OAK
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Hylan Gâ?F 20, which is derived from hyaluronan, is a highly purified, elastoviscous fluid with rheologic properties similar to those of synovial fluid in the knee joints of healthy young persons. The efficacy and safety of viscosupplementation with hylan Gâ?F 20 were evaluated in a multicenter, doubleâ?masked clinical study in patients with chronic idiopathic osteoarthritis (OA) of the knee of 1 to 30 years' duration. Three intraâ?articular injections of 2 mL hylan Gâ?F 20 were administered 1 week apart to 57 knees. The control group (60 knees) received 2 mL of physiologic buffered saline solution at the same intervals. Patients were predominantly female (65%), with a mean age of 62 years and mean weight of 76 kg. Using a visual analogue scale, patients assessed the following clinical variables: pain during weightâ?bearing, pain at rest during the night, reduction of pain during the most painful movement of the knee, and treatment success. Evaluators also assessed patients' loss of activity while performing difficult daily tasks and treatment success. There was dramatic early improvement in all six variables with hylan Gâ?F 20 beginning after the first injection; the improvement continued through the study end points. The differences between hylan Gâ?F 20 and saline treatment were statistically significant for all outcome measures. In the hylan Gâ?F 20 group, 39% to 56% of patients were free or nearly free of weightâ?bearing pain 10 to 24 weeks after the last injection. Treatment with saline was less effective, with fewer than 13% of patients free or nearly free of weightâ?bearing pain. Use of rescue therapy was significantly greater in the saline group than in the hylan Gâ?F 20 group. No adverse events were observed in the injected joint after hylan Gâ?F 20 treatment. These results demonstrate that hylan Gâ?F 20 is effective and well tolerated in the management of chronic idiopathic OA.
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1 |
Differences Regarding Branded HA in Italy, Part 2: Data from Clinical Studies on Knee, Hip, Shoulder, Ankle, Temporomandibular Joint, Vertebral Facets, and Carpometacarpal Joint
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OAK 3 - Non-arthroplasty tx of OAK
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OBJECTIVES: The aim of the current study is to collect scientific data on all branded hyaluronic acid (HA) products in Italy that are in use for intra-articular (IA) injection in osteoarthritis (OA) compared with that reported in the leaflet.
METHODS: An extensive literature research was performed for all articles reporting data on the IA use of HA in OA. Selected studies were taken into consideration only if they are related to products based on HAs that are currently marketed in Italy with the specific joint indication for IA use in patients affected by OA.
RESULTS: Sixty-two HA products are marketed in Italy: 30 products are indicated for the knee but only 8 were proved with some efficacy; 9 products were effective for the hip but only 6 had hip indication; 7 products proved to be effective for the shoulder but only 3 had the indication; 5 products proved effective for the ankle but only one had the indication; 6 products were effective for the temporomandibular joint but only 2 had the indication; only 2 proved effective for vertebral facet joints but only 1 had the indication; and 5 products proved effective for the carpometacarpal joint but only 2 had the indication.
CONCLUSIONS: There are only a few products with some evidences, while the majority of products remain without proof. Clinicians and regulators should request postmarketing studies from pharmaceuticals to corroborate with that reported in the leaflet and to gather more data, allowing the clinicians to choose the adequate product for the patient.
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0 |
Advances in breast surgery, 2002-2012
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Reduction Mammoplasty for Female Breast Hypertrophy
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The past 40 years have brought dramatic changes in breast cancer treatments, resulting in a 30% reduction in breast cancer mortality. This is largely the result of new concepts tested in a steady stream of large, well-designed, coordinated clinical trials. Early trials showed that extended surgery ("local therapy") does not improve mortality over less aggressive surgery. Trials conducted in the 1970s and 1980s clearly showed that radical surgery involving removal of the breast provides no outcome advantage over breast-conserving therapy (BCT). One concern with BCT has been a higher rate of local recurrence compared with mastectomy, with initial studies before the routine use of systemic therapy reporting rates of 10% to 20% with BCT. Modern series define a risk of local recurrence after BCT of 2% to 5%, about the same as with mastectomy. The improvement is partly due to improved standards in surgery, radiation oncology, and pathology. However, it is primarily due to the use of systemic endocrine and chemotherapy. BCT is appropriate for most women with breast cancer. This article explores the advancements in breast surgery over the past 10 years.
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0 |
Dorzolamide versus pilocarpine as adjunctive therapies to timolol: a comparison of patient preference and impact on daily life
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Upper Eyelid and Brow Surgery
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The purpose of this study was to compare 2% dorzolamide three times daily with 2% pilocarpine four times daily to determine patient preference, tolerability, and impact on daily life in patients concurrently receiving 0.5% timolol twice daily for treatment of elevated intraocular pressure (IOP). Seventy-five patients were enrolled in this 4-week, randomized, two-period, crossover study. The Comparison of Ophthalmic Medications for Tolerability questionnaire was used to assess patient preference and perception of side effects and activity limitations resulting from the study medications. IOP measurements were obtained 2 hours after drops were instilled and visual field tests were performed at baseline and at the end of each crossover period. Significantly more patients receiving pilocarpine than dorzolamide reported adverse experiences and discontinued the drug because of these adverse experiences. Similarly, patients reported more interference with their daily life because of side effects and activity limitations when receiving pilocarpine. Vision difficulties, accommodation difficulties, and brow ache were reported more often and were considered more bothersome by patients receiving pilocarpine. Bitter/unusual taste was reported more frequently and was considered more bothersome by patients receiving dorzolamide. Patients also reported missing fewer doses and were more satisfied with their medication when receiving dorzolamide. All of these changes were considered statistically significant. IOP control was not significantly different with either dorzolamide or pilocarpine. However, patients experienced a significant worsening of the mean defect of automated visual field examinations when receiving pilocarpine. At the end of the study, among patients with a preference, dorzolamide was preferred to pilocarpine by a ratio of more than 9:1. Overall, 81.9% of patients preferred dorzolamide. Thus dorzolamide demonstrated better tolerability and less adverse impact on daily life than pilocarpine.
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0 |
Total hip replacement for patients with active tuberculosis of the hip: a systematic review and pooled analysis
|
PJI DX Updated Search
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The timing of total hip replacement (THR) in patients with active tuberculosis (TB) of the hip is controversial, because of the potential risk of reactivation of infection. There is little information about the outcome of THR in these patients. We conducted a systematic review of published studies that evaluated the outcome of THR in patients with active TB of the hip. A review of multiple databases referenced articles published between 1950 and 2012. A total of six articles were identified, comprising 65 patients. TB was confirmed histologically in all patients. The mean follow-up was 53.2 months (24 to 108). Antituberculosis treatment continued post-operatively for between six and 15 months, after debridement and THR. One non-compliant patient had reactivation of infection. At the final follow-up the mean Harris hip score was 91.7 (56 to 98). We conclude that THR in patients with active TB of the hip is a safe procedure, providing symptomatic relief and functional improvement if undertaken in association with extensive debridement and appropriate antituberculosis treatment
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0 |
Local Infiltration of Tranexamic Acid (TXA) in Liposuction: A Single-Surgeon Outcomes Analysis and Considerations for Minimizing Postoperative Donor Site Ecchymosis
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Panniculectomy & Abdominoplasty CPG
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BACKGROUND: Tranexamic acid (TXA) has gained increasing recognition in plastic surgery as a dependable adjunct capable of minimizing blood loss, ecchymosis, and edema. To date, there have been limited data on the utilization of TXA to mitigate liposuction donor site ecchymosis. OBJECTIVES: The authors sought to investigate whether infiltration of TXA into liposuction donor sites safely reduces postoperative ecchymosis. METHODS: A single-surgeon retrospective cohort study was performed to analyze patients undergoing autologous fat transfer for breast reconstruction between 2016 and 2019. Following lipoaspiration, patients in the intervention group received 75 mL of TXA (3 g in NaCl 0.9%) infiltrated into the liposuction donor sites, whereas the historical controls did not. Patient demographics, degree of ecchymosis, surgical complications, and thromboembolic events were examined. A blinded assessment of postoperative photographs of the donor sites was performed. RESULTS: Overall, 120 autologous fat grafting procedures were reviewed. Sixty patients received TXA, whereas 60 patients did not. Patient demographics and comorbidities were similar among the groups. No difference existed between groups regarding donor site locations, tumescent volume, lipoaspirate volume, or time to postoperative photograph. Ten blinded evaluators completed the assessment. The median bruising score of patients who received TXA was significantly lower than that of patients who did not (1.6/10 vs 2.3/10, P = 0.01). Postoperative complications were similar among the groups. Adverse effects of TXA were not observed. CONCLUSIONS: Patients who received local infiltration of TXA into the liposuction donor sites were found to have less donor site ecchymosis than patients who did not. Further prospective randomized studies are warranted.
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1 |
DermACELL: a novel and biocompatible acellular dermal matrix in tissue expander and implant-based breast reconstruction
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Acellular Dermal Matrix
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BACKGROUND: Acellular dermal matrices present a new alternative to supporting expanders and implants for breast reconstruction in breast cancer patients following mastectomy. However, some studies have suggested that acellular dermal matrix may increase the complication rates in certain clinical settings. DermACELL acellular dermal matrix offers advanced processing in order to attempt to decrease bio-intolerance and complications. METHODS: Ten consecutive patients that presented for breast reconstruction and were candidates for tissue expanders underwent the procedure with the use of an acellular dermal matrix. The patients underwent postoperative expansion/adjuvant cancer therapy, then tissue expander exchange for permanent silicone breast prostheses. Patients were followed through the postoperative course to assess complication outcomes. Histologic evaluation of host integration into the dermal matrix was also assessed. RESULTS: Of the ten patients, eight completed reconstruction while two patients failed reconstruction. The failures were related to chronic seromas and infection. Histology analysis confirms rapid integration of mesenchymal cells into the matrix compared to other acellular dermal matrices. CONCLUSIONS: Based on our observations, DermACELL is an appropriate adjunct to reconstruction with expanders. Histological analysis of vascularization and recellularization support the ready incorporation of DermACELL into host tissue. Level of Evidence: Level IV, therapeutic study.
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0 |
Endoscopic brow lifts über alles
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Upper Eyelid and Brow Surgery
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Innumerable approaches to the ptotic brow and forehead have been described in the past. Over the last twenty-five years, we have used all these techniques in cosmetic and reconstructive patients. We have used the endoscopic brow lift technique since 1995. While no one technique is applicable to all patients, the endoscopic brow lift, with appropriate modifications for individual patients, can be used effectively for most patients with brow ptosis. We present the nuances of this technique and show several different fixation methods we have found useful. Copyright © 2006 Informa Healthcare.
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0 |
Clinical Outcomes of Venous Thromboembolism in Patients with and without Cancer: The SWIss Venous ThromboEmbolism Registry (SWIVTER)
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MSTS 2022 - Metastatic Disease of the Humerus
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Background The association between cancer and venous thromboembolism (VTE) in producing adverse clinical outcomes requires further investigation. Methods In the Swiss Venous ThromboEmbolism Registry (SWIVTER), we compared adverse clinical outcomes between 493 patients with cancer-associated VTE and 1,569 VTE patients without cancer, and identified independent predictors of 90-day mortality. Results Among cancer patients, 351 (71%) had active disease at the time of VTE diagnosis and 232 (47%) had metastatic disease. Cancer patients more frequently had asymptomatic VTE (13 vs. 4%; p < 0.001), iliofemoral deep vein thrombosis (42 vs. 32%; p = 0.017), and upper extremity deep vein thrombosis (16 vs. 7%; p < 0.001). Cancer was associated with an increased risk of cumulative 90-day mortality (13.0 vs. 2.2%; hazard ratio [HR], 6.27; 95% confidence interval [CI], 4.13-9.50; p < 0.001), recurrent VTE (4.7 vs. 2.3%; HR, 2.05; 95% CI, 1.21-3.45; p = 0.007), and bleeding requiring medical attention (5.7 vs. 3.3%; HR, 1.80; 95% CI, 1.13-2.86; p = 0.013). Among cancer patients, the strongest factor associated with mortality was metastatic disease (HR, 4.86; 95% CI, 2.68-8.81; p < 0.001), whereas it was pulmonary embolism among noncancer patients (HR, 4.96; 95% CI, 1.50-16.45; p = 0.009). Symptomatic as compared with asymptomatic VTE predicted neither mortality (12.6 vs. 15.9%; HR, 0.76; 95% CI, 0.39-1.49; p = 0.42) nor recurrent VTE (4.7 vs. 4.8%; HR, 0.98; 95% CI, 0.29-3.31; p = 0.98) in cancer patients. Conclusion In SWIVTER, early mortality of cancer-associated VTE was mainly driven by the extent of cancer disease and not by VTE symptoms or severity.
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0 |
Biofeedback to promote movement symmetry after total knee arthroplasty: A feasibility study
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OAK 3 - Non-arthroplasty tx of OAK
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STUDY DESIGN: Prospective analysis of a longitudinal cohort with an embedded comparison group at a single time point.OBJECTIVES: To determine the feasibility and effectiveness of an outpatient rehabilitation protocol that includes movement symmetry biofeedback on functional and biomechanical outcomes after total knee arthroplasty (TKA).BACKGROUND: TKA reduces pain and improves functional ability, but many patients experience strength deficits and movement abnormalities in the operated limb, despite outpatient rehabilitation. These asymmetries increase load on the nonoperated limb, and greater asymmetry is related to worse functional outcomes.METHODS: Biomechanical and functional metrics were assessed 2 to 3 weeks prior to TKA, at discharge from outpatient physical therapy, and 6 months after TKA in 11 patients (9 men, 2 women; mean ± SD age, 61.4 ± 5.8 years; body mass index, 33.1 ± 5.4 kg/m2) who received 6 to 8 weeks of outpatient physical therapy that included specialized symmetry training. Six-month outcomes were compared to a control group, matched by age, body mass index, and sex (9 men, 2 women; mean ± SD age, 61.8 ± 5 years; body mass index, 34.3 ± 5.1 kg/m2), that did not receive specialized symmetry retraining.RESULTS: Of the 11 patients who received added symmetry training, 9 demonstrated clinically meaningful improvements that exceeded the minimal detectable change for all performance-based functional tests at 6 months post-TKA compared to pre-TKA. Six months after TKA, when walking, patients who underwent symmetry retraining had greater knee extension during midstance and had mean sagittal knee moments that were more symmetrical, biphasic, and more representative of normal knee kinetics compared to patients who did not undergo symmetry training. No patients experienced adverse events as the result of the protocol.CONCLUSION: Adding symmetry retraining to postoperative protocols is clinically viable, safe, and may have additional benefits compared to rehabilitation protocols that focus on range of motion, strength, and return to independence. Copyright ©2013 Journal of Orthopaedic & Sports Physical Therapy®.
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0 |
The effects of therapeutic touch on patients with osteoarthritis of the knee
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Surgical Management of Osteoarthritis of the Knee CPG
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BACKGROUND: The purpose of this study was to determine if therapeutic touch, an alternative medicine modality, is effective in the treatment of osteoarthritis of the knee. METHODS: A single-blinded randomized control trial was conducted in a family practice center of a community hospital family practice residency program in Pennsylvania. The patients were between the ages of 40 and 80, had been given a diagnosis of osteoarthritis of at least one knee, had not had knee replacement, and had no other connective tissue disease. The patients were randomized to therapeutic touch, mock therapeutic touch, or standard care. The main outcome measures were pain and its impact, general well-being, and health status measured by standardized, validated instruments, as well as the qualitative measurement of a Depth interview. RESULTS: Twenty-five patients completed the study. The treatment group had significantly decreased pain and improved function as compared with the placebo and control groups. The qualitative Depth interview confirmed this result. CONCLUSION: Despite the small numbers, significant differences were found in improvement in function and pain for patients receiving therapeutic touch. A larger study is needed to confirm these results. Alternative therapies can neither be accepted nor rejected without being subjected to the scientific method
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0 |
Treatment of earthquake-related craniofacial injuries aboard the USNS Comfort during Operation Unified Response
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Upper Eyelid and Brow Surgery
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BACKGROUND: Craniofacial injuries secondary to earthquake-related trauma are uncommonly reported and can pose a significant reconstructive challenge. The objective of this study is to report and analyze earthquake-related craniofacial injury reconstruction and the disaster relief capabilities of a U.S. Navy hospital ship. METHODS: A review of earthquake-related injuries treated over 40 days requiring craniofacial reconstruction onboard a U.S. Navy hospital ship was performed. RESULTS: From January 20 to February 28, 2010 (40 days), 869 patients were admitted to the USNS Comfort. Thirty-three patients (4 percent) treated by the craniofacial service underwent 93 craniofacial surgical procedures. Average patient hospitalization time was 17 days (range, 5 to 38 days). The fractures treated included nine mandibles, 12 zygomaticomaxillary-orbital complexes, 16 orbital floors, eight Le Fort, four naso-orbitoethmoid, and two cranial vault fractures. The soft-tissue injuries treated were two heminasal avulsions, two traumatic cleft lips, and eight other complex facial lacerations. Short-term complications included wound dehiscence (6 percent) and postoperative malocclusion (6 percent). There were no postsurgical wound infections, visual field changes, or mortality. CONCLUSIONS: Complex craniofacial surgery services can be safely delivered onboard a United States Navy hospital ship for devastating injuries caused by natural disasters. Although craniofacial injuries represented a small percentage of the total patients admitted to our hospital ship, the survivors of facial injury required complex and multiple procedures to achieve optimal results. Despite heavy wound contamination and the intrinsic delay in presentation associated with mass casualty triage, facial fractures can be treated adequately and with low morbidity and mortality.
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0 |
UniSpacer arthroplasty of the knee
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Surgical Management of Osteoarthritis of the Knee CPG
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BACKGROUND: The operative treatment of medial compartment knee arthritis is controversial. The purpose of the present study was to report the experience of a single surgeon with the UniSpacer arthroplasty for the treatment of isolated medial compartment arthritis of the knee. METHODS: From April 2002 through November 2002, thirty-seven UniSpacer arthroplasties were performed in thirty-four patients for the treatment of arthritis that primarily involved the medial compartment of the knee. The Ahlback radiographic evaluation scale was used to grade the severity of arthritis; the mean preoperative score was 2.6 points for the medial compartment and 0.5 point for both the lateral and patellofemoral compartments. The study group included eighteen women (nineteen knees) and sixteen men (eighteen knees) who had a mean age of fifty-five years (range, forty-two to seventy-five years) at the time of surgery. Twelve patients had had a previous arthroscopic meniscectomy. The mean preoperative Knee Society function score was 60 points (range, 40 to 80 points), and the mean preoperative Knee Society objective score was 62 points (range, 40 to 76 points). RESULTS: After a mean duration of follow-up of twenty-six months (range, twenty-four to twenty-nine months), there were no excellent, ten good, fifteen fair, and twelve poor results. The mean postoperative total function score was 69 points (range, 40 to 82 points), and the mean Knee Society objective score was 72 points (range, 45 to 88 points). Six of the twelve poor results were in knees that had dislocation of the UniSpacer. All twelve knees were revised to a total knee arthroplasty. CONCLUSIONS: On the basis of this experience, we do not recommend UniSpacer arthroplasty for the treatment of degenerative arthritis of the medial compartment of the knee
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0 |
Osteonecrosis of the knee and related conditions
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Surgical Management of Osteoarthritis of the Knee CPG
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Osteonecrosis (ON) of the knee is a progressive disease that often leads to subchondral collapse and disabling arthritis. Recent studies have identified three distinct pathologic entities, all of which were previously described as knee ON: secondary ON, spontaneous ON of the knee, and postarthroscopic ON. Radiographic and clinical assessment is useful for differentiating these conditions, predicting disease progression, and distinguishing these conditions from other knee pathologies. The etiology, pathology, and pathogenesis of secondary ON of the knee are similar to those found at other sites (eg, hip, shoulder). Spontaneous ON is a disorder of unknown etiology. Postarthroscopic ON has been described as an infrequent but potentially destructive complication. Various treatment modalities (eg, core decompression, bone grafting, high tibial osteotomy, arthroplasty), have been used with varying degrees of success for each type of ON. Secondary ON frequently progresses to end-stage disease, and early surgical intervention is recommended. Initial management of spontaneous ON of the knee and postarthroscopic ON is typically nonsurgical, with observation for clinical or radiographic progression
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Towards a definition of Ancient Rare Diseases (ARD): Presenting a complex case of probable Legg-Calvé-Perthes Disease from the North Caucasian Bronze Age (2200-1650 cal BCE)
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Osteochondritis Dissecans 2020 Review
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OBJECTIVE: This study discusses the challenges and possibilities of establishing a definition for Ancient Rare Diseases (ARD) in a probable case of Legg-Calvé-Perthes Disease (LCPD) from the Bronze Age cemetery Kudachurt 14, situated in the Northern Caucasus. MATERIALS: We investigated the skeletal remains of a male aged 35-45 years at death. For comparison we examined other males buried at Kudachurt 14 (n = 24) and reviewed 22 LCPD cases from the paleopathological literature. METHODS: We use macroscopic as well as osteometric examination methods and imaging techniques. RESULTS: The morphology of the left hip joint corresponds to skeletal characteristics for LCPD. Co-occurring osteochondrosis dissecans, femoral anteversion, and atrophy of the left femoral shaft suggest a complex disease course. CONCLUSIONS: Modern criteria of rare diseases applied on ancient skeletal remains are either non-transferable or require completion. We conclude that rarity is dynamic, etiological uncertainty has to be accepted, and the respective socioeconomic context is crucial. Degree of disability and level of sociomedical investment are not defining criteria for ARD. SIGNIFICANCE: Dating 2200-1650 cal BCE, this study currently presents the earliest case of probable LCPD. This is the first attempt to transform modern characteristics of rare diseases for establishing a paleopathological concept of ARD. LIMITATIONS: As this study is limited to LCPD, our conclusions are not directly applicable to other ARD in question. SUGGESTIONS FOR FURTHER RESEARCH: More focused paleopathological research on skeletal populations from different cultures and time periods is needed, enabling an evolutionary perspective on the comparability of ancient, modern and future rare diseases.
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0 |
Surgical treatment of grade I central chondrosarcoma
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MSTS 2022 - Metastatic Disease of the Humerus
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UNLABELLED: The grade of chondrosarcoma relates to the likelihood of local recurrence and metastases. Many Grade I chondrosarcomas behave benignly if aggressively, and the question arises regarding whether wide resection is essential to control the disease. We therefore asked whether intralesional surgery also could be extended to Grade I chondrosarcomas without an increase in recurrence. We retrospectively reviewed 31 patients with Grade I chondrosarcomas of the limbs. The minimum followup was 66 months (mean, 157 months; range, 66-296 months). None of the 16 patients treated by resection had recurrences during the followup and two of the 15 patients with intralesional excision had recurrences, both of which resolved with resection of the site involved by the recurrence without progression of the disease. The Musculoskeletal Tumor Society scores averaged 72% in patients treated with wide resection compared with 89% in the 15 patients treated by intralesional surgery. The two recurrences occurred in patients whose radiographs showed thinning of the cortex combined with bone enlargement and marked endosteal scalloping; histologic examination in these two patients also showed a correlation between radiographic aggressiveness and the presence of myxoid areas and hypercellularity.
LEVEL OF EVIDENCE: Level II, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.
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1 |
Supracondylar femoral fractures in the frail elderly. Fractures in need of treatment
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DoD LSA (Limb Salvage vs Amputation)
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The investigators of this study reviewed 112 consecutive frail elderly patients with supracondylar femoral fractures to evaluate primarily functional outcomes to optimize initial treatment of these challenging patients. A high 1-year mortality rate (22%) and significant decrease in function and quality of life occurred in frail elderly patients who sustained supracondylar femoral fractures. No statistical relationship could be found among preinjury function, age, cognitive function, type of fracture, treatment, and overall results. Nine percent of patients required late above-knee amputation in the involved extremity because of displacement of the fracture or infection or both. Optimal treatment for this type of patient remains elusive. Primary above-knee amputation may be the preferred treatment in patients who are this severely affected.
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0 |
Electrical Stimulation for Relief of Musculoskeletal Pain
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AMP (Acute Meniscal Pathology)
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In brief: This is a general discussion of the history, applications, and contraindications of transcutaneous neural stimulation (TNS) as well as a brief description of a study of its use after knee surgery. TNS can be used for pain relief after surgery and in conjunction with other physical modalities to decrease joint stiffness and regain strength faster after sports injuries. Patients who used TNS after arthrotomy meniscectomies and total knee arthroplasties had shorter hospital stays and needed less narcotic pain relief after surgery. In the author's experience, people with acute pain respond much better to TNS than people with chronic pain.
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Clinical results of Hi-tech Knee II total knee arthroplasty in patients with rheumatoid athritis: 5- to 12-year follow-up
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PJI DX Updated Search
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BACKGROUND: Total knee arthroplasty (TKA) is a common form of treatment to relieve pain and improve function in cases of rheumatoid arthritis (RA). Good clinical outcomes have been reported with a variety of TKA prostheses. The cementless Hi-Tech Knee II cruciate-retaining (CR)-type prosthesis, which has 6 fins at the anterior of the femoral component, posterior cruciate ligament (PCL) retention, flat-on-flat surface component geometry, all-polyethylene patella, strong initial fixation by the center screw of the tibial base plate, 10 layers of titanium alloy fiber mesh, and direct compression molded ultra high molecular weight polyethylene (UHMWPE), is appropriate for TKA in the Japanese knee.The present study was performed to evaluate the clinical results of primary TKA in RA using the cementless Hi-Tech Knee II CR-type prosthesis. MATERIALS AND METHODS: We performed 32 consecutive primary TKAs using cementless Hi-Tech Knee II CR-type prosthesis in 31 RA patients. The average follow-up period was 8 years 3 months. Clinical evaluations were performed according to the American Knee Society (KS) system, knee score, function score, radiographic evaluation, and complications. RESULTS: The mean postoperative maximum flexion angle was 115.6 degrees , and the KS knee score and function score improved to 88 and 70 after surgery, respectively. Complications, such as infection, occurred in 1 patient and revision surgery was performed. There were no cases of loosening in this cohort, and prosthesis survival rate was 96.9% at 12 years postoperatively. CONCLUSION: These results suggest that TKA using the cementless Hi-Tech Knee II CR-type prosthesis is a very effective form of treatment in RA patients at 5 to 12 years postoperatively. Further long-term follow-up studies are required to determine the ultimate utility of this type of prosthesis
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Technique for Insertion of the Conventus Cage for Distal Radial Fracture Fixation
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Distal Radius Fractures
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Introduction: Use of the intramedullary Conventus DRS Cage and fragment-specific screw fixation of distal radial fractures minimizes soft-tissue trauma, leading to earlier and improved wrist and finger motion while reducing traditional complications seen with internal fixation of distal radial fractures.
Indications & Contraindications:
Step 1 Reduce the Fracture: Reduce the fracture with closed or, if necessary, open methods to achieve anatomic restoration of articular congruity, radial inclination, radial length, volar tilt, and coronal shift.
Step 2 Provisionally Stabilize the Fracture: Provisionally stabilize the reduced fracture for insertion of the cage and fragment-specific screws with either longitudinal finger-trap traction or longitudinal Kirschner wires.
Step 3 Prepare for Cage Fixation: Prepare the distal part of the radius for cavity preparation and insertion of the Conventus DRS Cage.
Step 4 Insert the Conventus DRS Cage: Insert the previously chosen small or large Conventus DRS Cage.
Step 5 Fix the Fracture Fragments: Anatomically fix the fracture fragments to the cage and radial shaft.
Step 6 Confirm Fracture Stability: Move the wrist through a full range of motion while assessing fluoroscopically whether the fracture has been stabilized with the cage-and-screw construct.
Step 7 Close the Wound: Close the skin incision and cutdown wounds and apply dressings.
Results: The Conventus DRS Cage has been used for treatment of distal radial fractures in the U.S. for >3 years.
Pitfalls & Challenges:
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0 |
Dermatan sulphate in methoxy polyethylene glycol-polylactide-co-glycolic acid scaffolds upregulates fibronectin gene expression but has no effect on in vivo osteochondral repair
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Osteochondritis Dissecans 2020 Review
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PURPOSE: The purpose of the study was to investigate the effect of dermatan sulphate (DS) addition to biodegradable methoxy polyethylene glycol (MPEG) substituted polylactide-co-glycolic acid (PLGA) scaffolds for cartilage repair in vitro and in vivo. METHODS: Human chondrocytes from eight patients undergoing anterior cruciate ligament reconstruction were isolated and cultured in 5% oxygen on MPEG-PLGA scaffolds±DS for one, three, seven and 14 days. Analyses were performed using quantitative gene expression analysis for chondrogenic and cell attachment markers. An osteochondral drill hole defect was created in the intertrochlear groove of the distal femur in 20 New Zealand white rabbits (defects n=20). When bleeding was observed, the defects were treated with MPEG-PLGA scaffolds±DS. Twelve weeks after surgery the rabbits were sacrificed and the defects were analysed using histological grading with O'Driscoll scoring. RESULTS: DS addition to MPEG-PLGA scaffolds resulted in a significant upregulation of fibronectin gene expression on day 1. No differences were observed in chondrogenic gene expression. There were no differences between the two groups in histological grading (+DS 10.3 and -DS 9.6). CONCLUSIONS: Upregulation of fibronectin in vitro indicating early cell-scaffold interaction and attachment did not result in improved cartilage repair in an osteochondral defect model in rabbits.
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0 |
Antibiotic prophylaxis in breast reduction surgery: A systematic review and meta-analysis
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Reduction Mammoplasty for Female Breast Hypertrophy
|
Objective To determine the effectiveness and harm of using antibiotic prophylaxis versus placebo or no intervention in patients undergoing breast reduction surgery to prevent surgical site infection. Materials and methods A search strategy was conducted in the MEDLINE, CENTRAL, EMBASE, and LILACS databases. Searches were also conducted in other databases and unpublished literature. Clinical trials were included without language restrictions. The risk of bias was evaluated with the Cochrane Collaboration's tool. An analysis of fixed effects was conducted. The primary outcome was surgical site infection. The secondary outcomes were delayed wound healing and adverse effects. The measure of the effect was the risk difference (RD) with a 95% confidence interval (CI). The planned interventions were antibiotic prophylaxis versus placebo/no intervention. Results Five articles were included in the qualitative and quantitative analysis. A total of 584 patients were included from the five studies. A low risk of bias was shown for most of the study items. The overall RD for surgical site infection was â??0.08 (95% CI â??0.14â??â??0.03), favoring antibiotic prophylaxis compared with placebo. Conclusion Antibiotic prophylaxis lowers the incidence of surgical site infection in breast reduction surgery compared with placebo or no intervention.
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0 |
Serial changes in serum vitamin K1, triglyceride, cholesterol, osteocalcin and 25-hydroxyvitamin D3 in patients after hip replacement for fractured neck of femur or osteoarthritis
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Management of Hip Fractures in the Elderly
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Serum vitamin K1 concentrations were measured at presentation (just before surgery) and then at weekly intervals for 3 weeks in two groups of elderly patients requiring either hemiarthroplasty for fractured neck of femur (FON, n = 13) or total hip replacement for osteoarthritis of the hip (OA, n = 16). In comparison with healthy elderly volunteers (n = 25), serum vitamin K1 concentrations were significantly lower in both groups at presentation, and fell significantly within 24 h after surgery to concentrations approaching non-detectable, subsequently returning to pre-operative values within 3 weeks. Serum vitamin K1 tended to be lower in the fracture group both before and after operation, although calculation of a vitamin K1-triglyceride ratio reduced the apparent difference as triglyceride concentrations were lower in the fracture group. Osteocalcin concentrations were similar and fell significantly after operation in both groups, returning to pre-operative levels within 7 days. No differences in the two forms of osteocalcin (carboxylated and undercarboxylated) were observed either before or after operation in either group. 25-Hydroxyvitamin D3 concentrations were not significantly different between the two groups at any time. Vitamin K1 status may be lower than desirable in certain groups of the elderly population, and supplementation should be considered as prophylactic therapy
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0 |
Median innervated hypothenar muscle: anomalous branch of median nerve in the carpal tunnel
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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A hypothenar motor branch of the median nerve in the carpal tunnel was observed and its motor function was documented by direct intraoperative nerve stimulation in two patients having carpal tunnel releases. The hypothenar branch left the median nerve at the midcarpal tunnel area. It crossed the tunnel superficial to the flexor tendons and penetrated the transverse carpal ligament ulnarly to innervate the abductor digiti quinti. Such branching of the median nerve at this level has not been reported previously. Good visualization of the carpal tunnel and careful dissection of its content even in the so called safe zone ulnar to long axis of palmaris longus tendon is recommended
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0 |
The influence of initial target effect-site concentrations of propofol on the similarity of effect-sites concentrations at loss and return of consciousness in elderly female patients with the Diprifusor system
|
Surgical Management of Osteoarthritis of the Knee CPG
|
Background : Whether effect-site concentrations of propofol (Cep) at loss of consciousness and return of consciousness (LOC and ROC, respectively) in elderly women using Diprifusor are similar is unclear. We investigated whether differences in initial target Cep (Ctarget) alter similarities between Cep values at LOC and ROC. Materials and Methods: In this study, female patients (n = 58, age = 72.5 (plus or minus) 1.1 years) undergoing knee arthroplasty were administered propofol with Diprifusor. Cep at LOC and ROC were estimated for different Ctarget values (3.0-4.5 (mu)mg/ml). Pearson's correlation coefficient analysis and simple regression were performed to assess the relationship between Cep at LOC and ROC for each Ctarget. Differences in correlation coefficients of regression lines obtained from each Ctarget group were determined using the t-test. Results: The different Ctarget groups did not show significant differences in total propofol levels and in Cep values at LOC or ROC. However, Cep at ROC was significantly higher than Cep at LOC when Ctarget was 4.0 and 4.5 (mu)g/ml, whereas these Cep values were not significantly different in low Ctarget groups. Strong positive correlations were observed between Cep at LOC and ROC for all Ctarget groups. Regression coefficients for the different Ctarget groups were not significantly different. Compared to low ((less-than or equal to)3.5 (mu)g/ml) Ctarget groups, high Ctarget groups showed significantly shorter time until LOC. Induction quality was not significantly different among the groups. Conclusions: In elderly women, Cep values at LOC are strong predictors of Cep at ROC when Ctarget is 3.0-4.5 (mu)g/ml. High Ctarget groups ((greater-than or equal to)4.0 (mu)g/ml) exhibited shorter induction times with normal cardiovascular stability
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0 |
Logistic regression and machine learning predicted patient mortality from large sets of diagnosis codes comparably
|
Hip Fx in the Elderly 2019
|
Objective: The objective of the study was to compare the performance of logistic regression and boosted trees for predicting patient mortality from large sets of diagnosis codes in electronic healthcare records. Study Design and Setting: We analyzed national hospital records and official death records for patients with myocardial infarction (n = 200,119), hip fracture (n = 169,646), or colorectal cancer surgery (n = 56,515) in England in 2015–2017. One-year mortality was predicted from patient age, sex, and socioeconomic status, and 202 to 257 International Classification of Diseases 10th Revision codes recorded in the preceding year or not (binary predictors). Performance measures included the c-statistic, scaled Brier score, and several measures of calibration. Results: One-year mortality was 17.2% (34,520) after myocardial infarction, 27.2% (46,115) after hip fracture, and 9.3% (5,273) after colorectal surgery. Optimism-adjusted c-statistics for the logistic regression models were 0.884 (95% confidence interval [CI]: 0.882, 0.886), 0.798 (0.796, 0.800), and 0.811 (0.805, 0.817). The equivalent c-statistics for the boosted tree models were 0.891 (95% CI: 0.889, 0.892), 0.804 (0.802, 0.806), and 0.803 (0.797, 0.809). Model performance was also similar when measured using scaled Brier scores. All models were well calibrated overall. Conclusion: In large datasets of electronic healthcare records, logistic regression and boosted tree models of numerous diagnosis codes predicted patient mortality comparably.
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0 |
Knee complaints in patients with normal arthroscopic findings
|
AMP (Acute Meniscal Pathology)
|
Clinical follow-up was obtained in 96 patients with knee complaints but normal arthroscopic findings (mean observation time, 10 months). About one-third had no symptoms at follow-up; in another third there was improvement; in the remaining third there were unchanged or worsened symptoms, and a clinical re-examination indicated that alterations in the soft tissues around the knee might explain the worsening. However, 10 patients in the last group had not only significant worsening of the knee symptoms but also severe complaints in other regions of the body and a psychosomatic factor was suspected. Most of the patients with symptoms at follow-up had significant wasting of the quadriceps muscles. Energetic exercises seem important even in patients with normal arthroscopic findings.
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0 |
From lymph to fat: complete reduction of lymphoedema
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Panniculectomy & Abdominoplasty CPG
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Liposuction for late-stage lymphoedema remains a controversial technique. While it is clear that conservative therapies such as combined decongestive therapy (CDT) and controlled compression therapy (CCT) should be tried in the first instance, options for the treatment of late-stage lymphoedema that is not responding to treatment is not so clear. Liposuction has been used for many years to treat lipodystrophy. Some results have been far from optimal; however, improvements in technique, patient preparation and patient follow-up have led to a greater and a wider acceptance of liposuction as a treatment for lymphoedema. This paper outlines the benefits of using liposuction and presents the evidence to support its use.
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0 |
Vacuum-assisted minimally invasive surgery-An innovative method for the operative treatment of gynecomastia
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Panniculectomy & Abdominoplasty CPG
|
BACKGROUND: Gynecomastia is the most common benign enlargement of the mammary gland and adipose tissue in males. Because a feminine-looking chest contour can bring severe psychologic burden to patients, subcutaneous mastectomy has become the standard treatment for this condition. Conventional open surgery causes conspicuous scarring that may affect the appearance of the breast. We provide a novel surgical operative for the treatment of gynecomastia. METHOD: With approval from our institutional ethics committee and written informed consent, 22 patients with 33 abnormally hyperplastic breasts were enrolled at The First Affiliated Hospital with Nanjing Medical University between June 2016 and September 2018. Vacuum-assisted minimally invasive surgery was performed under general anesthesia. Patients were followed up with physical examination and ultrasonography. RESULT: Vacuum-assisted minimally invasive mastectomy was performed successfully in all cases, with no residual glands or adipose tissue observed on ultrasonography. The operation had a mean duration of 73.5 minutes per side, ranging from 40 to 102 minutes. An average of 320 specimens were excised from each side with mean blood loss of 34 mL. Of these 33 operative sides, 2 complications occurred, but satisfactory chest contour was attained eventually in all patients. All patients were satisfied with their cosmetic outcome, graded as excellent by 22 patients (100%). Redundant skin was observed in 1 patient at 1 month postoperatively, whose breast, defined as graded III, was the largest before operation. CONCLUSION: Vacuum-assisted, minimally invasive mastectomy is a feasible approach for the treatment of gynecomastia with acceptable complications.
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Ipsilateral obturator type of hip dislocation with fracture shaft femur in a child: A case report and literature review
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Pediatric Diaphyseal Femur Fractures 2020 Review
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The incidence of traumatic hip dislocations in children is rising in this fast developing world along with increasing numbers of high-velocity road traffic accidents. Anterior dislocation of the hip has a lower incidence compared with posterior dislocation of the hip. We encountered a rare case of the obturator type of anteriorly dislocated hip associated with ipsilateral fracture of the shaft femur in an 11-year-old child. This is a highly unusual injury combination and the mechanism of injury is obscure. Only two similar cases have been reported in the English literature to date. Closed reduction of the hip using a hitherto undescribed technique and an intramedullary interlocking nail was performed in this case. At 6 months of follow-up, the fracture shaft femur has united and the child is bearing full weight on the limb.
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1 |
American Society of Clinical Oncology guideline on the role of bisphosphonates in breast cancer
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MSTS 2018 - Femur Mets and MM
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Purpose: To determine clinical practice guidelines for the use of bisphosphonates in the prevention and treatment of bone metastases in breast cancer and their role relative to other therapies for this condition. Methods: An expert multidisciplinary panel reviewed pertinent information from the published literature and meeting abstracts through May 1999. Additional data collected as part of randomized trials and submitted to the United States Food and Drug Administration were also reviewed, and investigators were contacted for more recent information. Values for levels of evidence and grade of recommendation were assigned by expert reviewers and approved by the panel. Expert consensus was used if there were insufficient published data. The panel addressed which patients to treat and when in their course of disease, specific drug delivery issues, duration of therapy, management of bony metastases with other therapies, and the public policy implications. The guideline underwent external review by selected physicians, members of the American Society of Clinical Oncology (ASCO) Health Services Research Committee, and the ASCO Board of Directors. Results: Bisphosphonates have not had an impact on the most reliable cancer end point:, overall survival. The benefits have been reductions in skeletal complications, ie, pathologic fractures, surgery for fracture or impending fracture, radiation, spinal cord compression, and hypercalcemia. Intravenous (IV) pamidronate 90 mg delivered over 1 to 2 hours every 3 to 4 weeks is recommended in patients with metastatic breast cancer who have imaging evidence of lytic destruction of bone and who are concurrently receiving systemic therapy with hormonal therapy or chemotherapy. For women with only an abnormal bone scan but without bony destruction by imaging studies or localized pain, there is insufficient evidence to suggest starting biphosphonates. Starting bisphosphonates in patients out evidence of bony metastasis, even in the presence of other extraskeletal metastases, is not recommended. Studies of bisphosphonates in the adjuvant setting have yielded inconsistent results. Starting bisphosphonates in patients at any stage of their nonosseous disease, outside of clinical trials, despite a high risk for future bone metastasis, is currently not recommended. Oral bisphosphonates are one of several options which can be used for preservation of bone density in premenopausal patients with treatment-induced menopause. The panel suggests that, once initiated, IV bisphosphonates be continued until evidence of substantial decline in a patient's general performance status. The Panel stresses that clinical judgment must guide what is a substantial decline. There is no evidence addressing the consequences of stopping bisphosphonates after one or more adverse skeletal events. Symptoms in the spine, pelvis, or femur require careful evaluation for spinal cord compression and pathologic fracture before bisphosphonate use and if symptoms recur, persist, or worsen during therapy. The panel recommends that current standards of care for cancer pain, analgesics and local radiation therapy, not be displaced by bisphosphonates. IV pamidronate is recommended in women with pain caused by osteolytic metastasis to relieve pain when used concurrently with systemic chemotherapy and/or hormonal therapy, since it was associated with a modest pain control benefit in controlled trials. Conclusion: Bisphosphonates provide a meaningful supportive but not life-prolonging benefit to many patients with bone metastases from cancer. Further research is warranted to identify clinical predictors of when to start and stop therapy, to integrate their use with other treatments for bone metastases, to identify their role in the adjuvant setting in preventing bone metastases, and to better determine their cast-benefit consequences. (C) 2000 by American Society of Clinical Oncology.
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Ultrasound properties of articular cartilage in the tibio-femoral joint in knee osteoarthritis: relation to clinical assessment (International Cartilage Repair Society grade)
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AMP (Acute Meniscal Pathology)
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INTRODUCTION: There is a lack of data relating the macroscopic appearance of cartilage to its ultrasound properties. The purpose of the present study was to evaluate degenerated cartilage and healthy-looking cartilage using an ultrasound system.
METHODS: Ultrasound properties--signal intensity (a measure of superficial cartilage integrity), echo duration (a parameter related to the surface irregularity) and the interval between signals (that is, time of flight--which is related to the thickness and ultrasound speed of cartilage)--of 20 knees were measured at seven sites: the lateral femoral condyle (site A, anterior; site B, posterior), the medial condyle (site C), the lateral tibial plateau (site D, center; site E, under the meniscus) and the medial tibial plateau (site F, anterior; site G, posterior). The sites were evaluated macroscopically and classed using the International Cartilage Repair Society (ICRS) grading system.
RESULTS: The signal intensity of grade 0 cartilage was significantly greater than the intensities of grade 1, grade 2 or grade 3 cartilage. Signal intensity decreased with increasing ICRS grades. The signal intensity was greater at site B than at site C, site D, site F and site G. The signal intensity of grade 0 was greater at site B than at site E. The echo duration did not differ between the grades and between the sites. The interval between signals of grade 3 was less than the intervals of grade 0, grade 1 or grade 2. The interval between signals at site C was less than the intervals at site A, site B, site D, and site E.
CONCLUSION: Site-specific differences in signal intensity suggest that a superficial collagen network may be maintained in cartilage of the lateral condyle but may deteriorate in cartilage of the medial condyle and the medial tibial plateau in varus knee osteoarthritis. Signal intensity may be helpful to differentiate ICRS grades, especially grade 0 cartilage from grade 1 cartilage.
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Knowledge and reported practice of antibiotic prescription by dentists for common oral problems
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Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures
|
OBJECTIVE: To assess the knowledge and reported practice in relation to antibiotic prescribing regarding common oral problems by dentists in Karachi, Pakistan. STUDY DESIGN: Cross-sectional survey. PLACE AND DURATION OF STUDY: Three Dental Colleges of Karachi, from July to December 2010. METHODOLOGY: The cross-sectional study was conducted in Karachi, Pakistan in the Outpatient Departments (OPD) of three dental colleges. Inclusion criteria were full time employed dentists working in their respective OPDs (n = 100). The dentists were asked to fill a questionnaire. The questionnaire included (i) general information, (ii) perception and knowledge of antibiotic resistance, (iii) reported management of oral problems, (iv) perceptions about oral infections and (v) perceptions of how people perceive oral problems. To assess dentists ability to relate knowledge to practice regarding the management of the most common oral problems, written simulated case scenarios with related questions were also included. Scores were given for each correct answer. RESULTS: The response rate was 85%. Of the total respondents, 65 (76%) were under the age of 30 years, 53 (62%) were males and 32 (38%) females. Out of 85 respondents 53% (n = 45) reported prescribing of antibiotics 4-5 times a week, 87% (n = 74) prescribe antibiotics based upon symptoms and 64% (n = 54) prescribed antibiotics in abscess condition. The total score for all four scenarios showed that nearly two thirds (61%) of all respondents scored sub-optimally. CONCLUSION: A substantial number of dentists had suboptimal knowledge regarding antibiotic use. This might lead to the provision of suboptimal care of patients with dental infections. Therefore, continuing education, training and supervision are recommended to improve the quality of dental management
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0 |
Subtrochanteric femoral fractures
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Management of Hip Fractures in the Elderly
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Femoral fractures in the subtrochanteric and proximal shaft regions require special management because of the great stresses inflicted on the area. Stability is best achieved with intramedullary fixation when there is adequate control of both proximal and distal fragments. Intertrochanteric fractures with small subtrochanteric components can often be adequately fixed with strong nail plate or screw plate devices. When the major fracture is subtrochanteric, an intramedullary device should be used to permit stability of the bone by impaction. Experience with a special device composed of an intramedullary rod and triflanged nail indicates that this appliance performs well in the fixation of subtrochanteric fractures
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0 |
The treatment of fracture-dislocation of the hip by total hip arthroplasty
|
Management of Hip Fractures in the Elderly
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Five patients with chronic and subacute unreduced fracture-dislocation of the hip were treated successfully by total hip arthroplasty. The regimen developed was as follows: The first stage, in general, consisted of removal of the head of the femur and reduction and internal fixation of the acetabular fragments. Surgery to the sciatic nerve, if necessary, was done at this time. This was followed by total hip arthroplasty in five to eight weeks as a second stage. If severe fracture of the acetabulum occurred with dislocation of the hip, and the hip could be reduced, total hip arthroplasty could be done in one stage, either soon after the injury or at a later time. Such a procedure restores almost normal function to a hip that otherwise may remain painful and stiff because of traumatic arthritis and disturbed anatomical relationships of the acetabulum to the femoral head, and may save the patient much time and suffering
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0 |
Head and neck replacement endoprosthesis for pathologic proximal femoral lesions
|
Management of Hip Fractures in the Elderly
|
Records of 28 patients with pathologic lesions in the proximal femur treated by implantation of a femoral head and neck replacement prosthesis between 1984 and 1995 were reviewed. Mean clinical followup was 47.8 months in the eight living patients and 15.8 months in the 20 patients who had died. The underlying diagnosis was metastatic disease or myeloma in 22 patients. The most frequently occurring indication for implantation of this device was a pathologic fracture in 26 patients (18 displaced, eight impending), followed by resection and reconstruction in two patients. All femoral components were cemented: 23 were bipolar hemiarthroplasties and five were total hip arthroplasties. Implant survivorship was good (93%), with only two prostheses removed during the followup period, both for infection. However, radiographic analysis revealed increasing lucencies with time, particularly in the most proximal zones, resulting in radiographic failure in an additional case. Deep infection occurred in three cases, leading to resection arthroplasty in two patients. Periprosthetic fractures occurred in three cases, but only one occurred intraoperatively. Despite a high complication rate, the good implant survival during the shortened life span of these patients supports the continued use of femoral head and neck replacement prostheses in this population
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1 |
The Value of Early Mobilization and Physiotherapy Following Wrist Fractures Treated by Volar Plating
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Distal Radius Fractures
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A prospective, randomized study investigating the possible benefits of immediate mobilization and frequent physiotherapy following a wrist fracture treated by volar plating. The current study will test the following null hypothesis: There is no significant difference between patients who receive a cast for the first 2 weeks postoperatively and then instructions in home exercises and patients who receive a cast for 2â?3 days postoperatively and then have frequent sessions with a physiotherapist following volar locked plating for a extraarticular distal radius fracture, as evaluated by selfâ?reported satisfaction after 3 months.
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0 |
Failure of a properly positioned tantalum rod for treatment of early femoral head necrosis and conversion to total hip arthroplasty
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AAHKS (2) Corticosteroids
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Background: Conventional core decompression (CD) is a well-known procedure for treatment of avascular necrosis of the femoral head. Weight bearing is usually restricted in the early postoperative weeks to avoid the risk of fracture. Theoretically, a properly positioned implantation of the new tantalum rod after reaming of the necrotic area has the advantages of decompression, supports the remaining bone to avoid collapse, lowers the risk of subtrochanteric fracture, and allows for early weight bearing. The objective of this study was to evaluate the role of the tantalum rod in the management of early avascular necrosis. Patients and methods: Twenty patients with a mean age of 30.4Â years were treated with CD and implantation of a tantalum rod. The cases were evaluated radiologically by x-rays, CT, and MRI. Sixteen cases were idiopathic while four patients were corticosteroid induced. Using the Steinberg classification system, Fifteen hips were stage II and five hips stage III. Postoperative CT was done in all cases to ensure proper position of the cases. Results: Clinical and radiographic evaluation was carried out preoperatively then at 3, 12, and 24Â months postoperatively. The average preoperative Harris Hip Score (HHS) was 42.5 and improved to 80.7 at 3Â months with two cases of persistent pain and unsatisfactory results with conversion to total hip arthroplasty (THA) in the first 6Â months. At 1Â year, the average HHS was deteriorated to 76.1 of the remaining 18 cases. At 2Â years endpoint follow-up, five cases already converted to THA, another seven cases had a deterioration of the HHS score, and only 40Â % of the cases had satisfactory results. Conclusion: Implantation of a porous tantalum metal rod for early-stage osteonecrosis of the femoral head did not add a significant advantage to core decompression alone even with the proper position in relation to the necrotic area. We had to convert to total hip arthroplasty in 60Â % of the cases.
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Evaluation of a shape memory staple (Qual R) in radial shortening osteotomy in Kienbock's disease: A retrospective study of 30 cases
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Distal Radius Fractures
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The QUAL R (Memometal, Stryker) device is a shape memory staple used for bone fixation during distal radius shortening osteotomy in the context of Kienbock's disease. The present study is a retrospective, single-center and multisurgeon study of 30 patients with a mean follow-up of 8 years. Clinical criteria (range of motion (ROM), strength, pain and functional score) and radiographic data (ulnar variance, distal radius articular surface inclination, Lichtman stage, carpal height and bone healing) were evaluated pre- and post-operatively. We found satisfactory results with the mean grip strength of 22 kg/F before surgery and 24 kg/F after surgery. The mean ROM was 88degree preoperatively and 82degree postoperatively and the mean ulnar deviation was 23degree preoperatively and 21degree post-operatively. There was no change in radial deviation and pronation-supination after surgery. The average ulnar variance was 1 mm before surgery and 0.2 mm after surgery. The inclination of the distal radius articular surface on lateral and anteroposterior views and the mean carpal height were similar to the pre-operative ones. There was no delay in bone healing. The mean pain score was 2 at rest on a visual analogue scale after surgery. Seven patients experienced an increase in their Lichtman stage at the follow-up, and two patients were waiting for conversion to a non-conservative surgical treatment. Seven staples were removed postoperatively. Seventy-eight percent of patients returned to work after 3 months on average. Seventy-five percent of patients were at least satisfied with the outcome of their surgery. The QUAL R staple is a reliable option for fixation during shortening osteotomy of the radius in Kienbock's disease. Copyright © 2019 SFCM. Published by Elsevier Masson SAS. All rights reserved.
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0 |
Distal Femoral Fresh Osteochondral Allografts: Follow-up at a Mean of Twenty-two Years
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DoD LSA (Limb Salvage vs Amputation)
|
BACKGROUND: Osteochondral defects of the knee in young, active patients represent a challenge to the orthopaedic surgeon. Our study examined long-term outcomes of the use of fresh allograft for posttraumatic osteochondral and osteochondritis dissecans defects in the distal aspect of the femur. METHODS: We reviewed the cases of sixty-three patients who underwent osteochondral allograft transplantation to the distal aspect of the femur between 1972 and 1995. Five patients who resided out of the country were lost to follow-up. Indications for the allograft procedure were an age of less than fifty years and a unipolar posttraumatic osteochondral or osteochondritis dissecans defect in the distal aspect of the femur that was larger than 3 cm in diameter and 1 cm in depth. RESULTS: Fifty-eight patients ages eleven to forty-eight years at the time of surgery (mean age, twenty-eight years) were followed for a mean of 21.8 years (range, fifteen to thirty-two years). Thirteen of the fifty-eight cases required further surgery; three underwent graft removal, nine were converted to total knee arthroplasty, and one underwent multiple debridements followed by above-the-knee amputation. Three patients died during the study due to unrelated causes. A Kaplan-Meier analysis of graft survival showed rates of 91%, 84%, 69%, and 59% at ten, fifteen, twenty, and twenty-five years, respectively. Patients with surviving grafts had good function, with a mean modified Hospital for Special Surgery (HSS) score of 86 at fifteen years or more following the allograft transplant surgery. Late osteoarthritic degeneration on radiographs was associated with lower HSS scores and poorer clinical outcomes. CONCLUSIONS: Fresh osteochondral allograft was found to provide a long-term solution for large articular cartilage defects in the distal aspect of the femur in young, active patients. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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0 |
Ultra low-dose naloxone and tramadol/acetaminophen in elderly patients undergoing joint replacement surgery: a pilot study
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AAHKS (8) Anesthetic Infiltration
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OBJECTIVE: A pilot study was conducted to assess whether both the rationale and feasibility exist for future randomized clinical trials to evaluate the combined use of naloxone infusion and tramadol/acetaminophen as opioid-sparing drugs in elderly patients undergoing lower extremity joint replacement surgery.
DESIGN: Ten patients 70 years of age or older undergoing either total knee (n=7) or total hip (n=3) arthroplasty were treated prospectively. Each patient received two tablets of tramadol/acetaminophen (Tramacet; Janssen-Ortho Inc, Canada) preoperatively and every 6 h postoperatively, as well as a naloxone infusion started preoperatively at 0.25 microg/kg/h and continued up to 48 h postoperatively. In addition, standard intraoperative care was provided with 0.2 mg of intrathecal morphine, 1.4 mL of 0.75% bupivacaine, and an intra-articular infiltration of 100 mL of 0.3% ropivacaine and 30 mg of ketorolac, as well as standard postoperative morphine via patient-controlled analgesia orders and celecoxib 200 mg twice daily for five days.
OUTCOME MEASURES: Compared with seven historical controls, also 70 years of age or older, who had undergone either a total knee (n=4) or total hip (n=3) arthroplasty, postoperative opioid use was reduced by 80%. Except for transient nausea and vomiting in 40% and 20% of patients, respectively, the 10 patients on tramadol/acetaminophen and naloxone tolerated the new regimen without difficulty.
CONCLUSION: Consequently, a randomized, double-blinded clinical trial comparing standard therapy versus standard therapy plus these two drugs seems warranted. In such a trial, it would require approximately 20 subjects per treatment arm to detect a 80% decrease in morphine use.
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0 |
Comparison of T2 relaxation times of articular cartilage of the knee in elite professional football players and age-and BMI-matched amateur athletes
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OAK 3 - Non-arthroplasty tx of OAK
|
OBJECTIVE: Recent investigation has underlined the potential of quantitative MR imaging to be used as a complementary tool for the diagnosis of cartilage degeneration at an early state. The presented study analyses T2* relaxation times of articular cartilage of the knee in professional athletes and compares the results to age- and BMI (Body Mass Index)-matched healthy amateur athletes.
MATERIALS AND METHODS: 22 professional football players and 22 age- and BMI-matched individuals were underwent knee Magnetic Resonance Imaging (MRI) at 3T including qualitative and quantitative analysis. Qualitative analysis included e.g. meniscal tears, joint effusion and bone edema. For quantitative analysis T2* (22 ET: 4.6-53.6ms) measurements in 3D data acquisition were performed. Deep and superficial layers of 22 predefined cartilage segments were analysed. All data sets were postprocessed using a dedicated software tool. Statistical analysis included Student t-test, confidence intervals and a random effects model.
RESULTS: In both groups, T2* relaxation times were significantly higher in the superficial compared to the deep layers (p<0.001). Professional athletes had significantly higher relaxation times in eight superficial and three deep cartilage layers in the predefined cartilage segments (p<0.05). Highly significant differences were found in the weight-bearing segments of the lateral superficial femoral condyle (p<0.001).
CONCLUSION: Elevated T2* values in cartilage layers of professional football players compared to amateur athletes were noted. The effects seem to predominate in superficial cartilage layers.
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1 |
Septic arthritis after arthroscopic anterior cruciate ligament reconstruction
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Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures
|
INTRODUCTION: A retrospective review of postoperative infected anterior cruciate ligament (ACL) reconstruction was done on 472 consecutive cases in one institution. The purpose was to assess the incidence, diagnosis, treatment and outcome factors. MATERIALS AND METHODS: Out of 472 arthroscopic-assisted ACL reconstructions performed between 1999 and 2002, 7 (1%) postoperative deep intra-articular infections were detected. Seven males with a mean age of 23 years (range, 19 to 30 years) formed the study group; 3 had undergone prior knee surgery. RESULTS: Four patients had acute infection (<2 weeks), 3 had subacute infection (2 weeks to 2 months) and none had late infection (>2 months). All were admitted within 24 hours of onset of symptoms and underwent immediate arthroscopic lavage, incision and drainage of abscess, debridement with graft retention and intravenous (8 to 31 days) followed by oral (4 to 6 weeks) antibiotics. Staphylococcus aureus was present in 4 patients, Peptostreptococcus in 3, Klebsiella in 1, and Enterobacter in 1. The patients underwent an average of 1.4 arthroscopic procedures (range, 1 to 3 procedures), with an average hospital stay of 17.3 days per patient. All were evaluated at an average of 11.7 months (range, 5 to 26 months). In all cases, the infection resolved with stable knees and with all grafts and implants retained. Although rare, early diagnosis and prompt treatment of infection can result in successful eradication without sacrificing the graft
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Distress, suicidal thoughts, and social support among homeless adults
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DoD PRF (Psychosocial RF)
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Influences on psychological distress and suicidal thoughts are evaluated with a sample of 218 sheltered homeless adults. Levels of distress and suicidal thoughts are much higher than in the general population, and are comparable to those found by Rossi (1989). Perceived social support lessens distress and suicidal thoughts directly and also buffers homeless persons from the distress associated with traumatic experiences. There is little indication of a mediating (intervening) role of social support. Distress and suicidal thoughts are also associated with increased health problems; homeless history and sociodemographic characteristics are less important as predictors. Distress itself increases suicidal thoughts--directly, and also in interaction with low levels of social support. We conclude that distress among homeless persons is explained by the same types of influences as those that account for distress among the general population--the gravity of homeless persons' economic situation does not preclude sensitivity to the benefits of social support.
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0 |
Hamulus fracture
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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Fracture of the hook of the hamate is a rare problem. However, the emergency physician must have the clinical sophistication to recognize hypothenar and dorso-ulnar wrist tenderness, to evaluate ulnar nerve function, to order a carpal tunnel view, and to initiate appropriate referral in order to eliminate symptoms, disability, and possible delayed complications
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0 |
Prevention of hip fractures: drug therapy
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Management of Hip Fractures in the Elderly
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Drug therapy to prevent hip fractures may be considered for postmenopausal women with low bone mass and elderly people with risk factors for hip fracture. As most hip fractures occur 25 years or more after menopause, drug therapy may have to be prescribed for many years to be effective. A preventative drug should be effective, safe, and without side effects. Estrogen therapy decreases bone loss and hip fracture incident, but the effect wears off when treatment is stopped. The positive effect of estrogens on cardiovascular disease should be balanced against the increased risk of breast cancer with long-term use. The newer bisphosphonates are potent inhibitors of bone resorption and decrease bone loss substantially. Again, the effect may wear off after the drug is stopped. The bisphosphonates appear to be safe, but long-term data are lacking. Calcium and/or vitamin D may prevent bone loss in late postmenopausal women and elderly people. The combination was shown to prevent hip fractures and other peripheral fractures in elderly nursing home residents. No single drug will be used more than 10-15 years. Therefore, a public health strategy should be developed with a logical sequence of drug and nondrug interventions for the successful prevention of hip fractures
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0 |
Translation, cross-cultural adaptation and validation of the Turkish version of the Lower Extremity Functional Scale on patients with knee injuries
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OAK 3 - Non-arthroplasty tx of OAK
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Introduction: The Lower Extremity Functional Scale is a widely used questionnaire to evaluate the functional impairment in lower extremities. To date, the Lower Extremity Functional Scale has not been translated into Turkish. The aim of this study is to translate and culturally adapt the Lower Extremity Functional Scale into a Turkish version, and evaluate the psychometric properties of this version in patients with knee injuries. Materials and methods: The translation of the English version of the Lower Extremity Functional Scale into a Turkish version was performed using standard guidelines. Validity and reliability of Turkish version were tested in 134 patients with knee injuries. Association level between other outcomes measures (Kujala Patellofemoral Score, the Western Ontario and McMaster Universities Osteoarthritis Index, Lysholm Knee Scoring Scale and a Visual Analog Scale) and Turkish version of the Lower Extremity Functional Scale was analyzed to assess validation. Participants completed the questionnaire at baseline and after 2 days to test reliability. Results: The Turkish version of the Lower Extremity Functional Scale was showed a high degree of internal consistency (Cronbach α = 0.93). ICCs were 0.96 and no floor or ceiling effects. The Lower Extremity Functional Scale had a high level of association with the Kujala Patellofemoral Score (r = 0.82), Lysholm Knee Scoring Scale (r = 0.80) and the Western Ontario and McMaster Universities Osteoarthritis Index scores (r = 0.69) (all, p < 0.05). Conclusion: The Turkish version of the Lower Extremity Functional Scale is a valid and reliable questionnaire that can be used to evaluate functional status in Turkish speaking patients with different knee disorders. Level of evidence: III.
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A prospective cohort study of the clinical presentation of non-traumatic osteonecrosis of the femoral head: spine and knee symptoms as clinical presentation of hip osteonecrosis
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AAHKS (2) Corticosteroids
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PURPOSE: To study the clinical presentation of femoral head osteonecrosis (ONFH). Publications dedicated to this aspect of ONFH are rare. Our aim was to systematically collect and describe the clinical data.
METHODS: A prospective survey was conducted in a cohort of ONFH recruited from a dedicated clinic for osteonecrosis. The history of symptoms, medical management, and physical findings were obtained from 88 patients suffering from 125 ONFH. Subgroups were formed: bilateral versus unilateral ONFH, radiological stages 1-2 (pre-fractured) versus fractured stage 3 versus stage 4.
RESULTS: ONFH was bilateral in 63 %, especially in corticosteroid users and in sickle-cell cases. These patients were younger but had similar BMIs compared to the unilateral cases. The pain was mechanical in 79 % of hips and inflammatory in 21 %. Acute pain at the onset was present in 55 % of hips. The localization of this pain was variable, including in the groin, the buttocks, or diffused in the lower limbs. A limp was present in 50 % of the patients, only when one hip was painful. The physical examination of the hip was normal in 31 %, especially in stages 1-2 (55 %). The diagnosis delay was 12 months, with inadequate medical management in 51 % of patients.
CONCLUSIONS: In ONFH cases, no typical clinical pattern was found. The clinical presentation was very variable, sometimes having spine or knee symptoms with a normal physical examination of the hip. ONFH should be systematically suspected in cases of onset of pain in the pelvis, buttocks, groin, and lower limbs.
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0 |
Hand strengths in carpal tunnel syndrome
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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The purpose of this study was to determine whether a measurable decrease in isokinetic (dynamic) and isometric (static) hand strengths occurs in carpal tunnel syndrome (CTS) patients. Eighteen CTS patients and 20 healthy controls were included in the study. Isokinetic (eccentric and concentric) and isometric grip and pinch strengths were measured with a Biodex System 3 dynamometer (Biodex Medical System, Inc. New York). All strength measurements, except isometric and isokinetic (concentric/eccentric) three-point pinch and isokinetic (concentric) tip pinch, revealed statistically significant differences between CTS patients and controls. Measurable decrease in hand strengths may exist in CTS despite normal manual assessments. Although both isokinetic (dynamic) and isometric (static) dynamometers are capable of detecting this decrease, neither technique seems better than the other
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1 |
Displaced femoral neck fractures in the elderly: hemiarthroplasty versus total hip arthroplasty
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Management of Hip Fractures in the Elderly
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The incidence of femoral neck fracture among the elderly in the United States is expected to increase dramatically because of the anticipated explosion in the population aged 65 years and older, increased life expectancy, and the rising incidence of osteoporosis. The resulting public health implications may be significant, with annual hospital admissions resulting from hip fracture projected to increase to 700,000 by 2050, and with annual spending on hip fracture care expected to exceed 15 billion dollars within a few years. The decision to perform internal fixation, unipolar hemiarthroplasty, bipolar hemiarthroplasty, or THA must be based on patient mental status, living arrangement, level of independence and activity, and bone and joint quality
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0 |
Acute aquatic treadmill exercise improves gait and pain in people with knee osteoarthritis
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OAK 3 - Non-arthroplasty tx of OAK
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OBJECTIVE: To examine the acute effects of aquatic and land treadmill exercise on gait kinematics as well as the level of disease-specific and movement-related pain for individuals with osteoarthritis.
DESIGN: Quasi-experimental crossover design.
SETTING: Biomechanics laboratory.
PARTICIPANTS: Participants (N=14; age, 43-64y) diagnosed with osteoarthritis at the knee (n=12), osteoarthritis at the knee and ankle (n=1), or osteoarthritis at the knee and hip (n=1).
INTERVENTIONS: Participants performed 3 exercise sessions separated by at least 24 hours in 1 week for each mode of exercise (aquatic treadmill and land treadmill).
MAIN OUTCOME MEASURES: Gait kinematics and pain were measured before and after each intervention.
RESULTS: The angular velocity gain score during stance for left knee extension was improved by 38% after aquatic treadmill exercise (P=.004). Similarly, during swing, the gain scores for angular velocity were also greater for left knee internal rotation and extension by 65% and 20%, respectively (P=.004, P=.008, respectively). During stance, the joint angle gain score for left hip flexion was 7.23% greater after land exercise (P=.007). During swing, the angular velocity gain score for right hip extension was significantly greater for aquatic exercise by 28% (P=.01). Only the joint angle gain score for left ankle abduction during stance was significantly higher after land exercise (4.72%, P=.003). No other joint angle gain scores for either stance or swing were significantly different for either condition (P=.06-.96). Perceived pain was 100% greater after land than aquatic treadmill exercise (P=.02). Step rate and step length were not different between conditions (P=.31-.92).
CONCLUSIONS: An acute training period on an aquatic treadmill positively influenced joint angular velocity and arthritis-related joint pain. Acute aquatic treadmill exercise may be useful as a conservative treatment to improve angular speed of the lower-extremity joints and pain related to osteoarthritis.
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