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Draining after breast reduction: a randomised controlled inter-patient study
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Reduction Mammoplasty for Female Breast Hypertrophy
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One hundred and seven bilateral breast reductions were prospectively randomised during surgery to receive or not receive wound drains. Fifty-five patients were randomised to have a drain and 52 to not have a drain. There was no statistical difference in the number of complications between the drained and undrained group (P = 0.092; student's t-test for independent observations). Twenty-two of the 55 patients in the drained group had a complication, 12 of the 52 patients in the undrained group had a complication. The hospital stay was significantly shorter (P < 0.001) in the undrained group. The main discomfort score due to the presence of the drains was 5.62, which can be qualified as high. This study demonstrates that breast reduction without postoperative draining does not increase the risk of complications, increases the patient's comfort and significantly reduces hospital stay. © 2008 British Association of Plastic, Reconstructive and Aesthetic Surgeons.
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Open-wedge high tibial osteotomy: comparison between manual and computer-assisted techniques
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OAK 3 - Non-arthroplasty tx of OAK
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PURPOSE: The purpose of our study was to compare clinical and radiological results of two groups of patients treated for medial compartment osteoarthritis of the knee with either conventional or computer-assisted open-wedge high tibial osteotomy (HTO). Goals of surgical treatment were a correction of the mechanical axis between 2degree and 6degree of valgus and a modification of posterior tibial slope between -2degree and +2degree.
METHODS: Twenty-four patients (27 knees) affected by varus knee deformity and operated with HTO were prospectively followed-up. They were randomly divided in two groups, A (11 patients, conventional treatment) and B (13 patients, navigated treatment). The American Knee Society Score and the Modified Cincinnati Rating System Questionnaire were used for clinical assessment. All patients were radiologically evaluated with a comparative lower limb weight-bearing digital radiograph, a standard digital anteroposterior, a latero-lateral radiograph of the knee, and a Rosenberg view.
RESULTS: Patients were followed-up at a mean of 39 months. Clinical evaluation showed no statistical difference (n.s.) between the two groups. Radiological results showed an 86% reproducibility in achieving a mechanical axis of 182degree-186degree in group B compared to a 23% in group A (p = 0.0392); furthermore, in group B, we achieved a modification of posterior tibial slope between -2degree and +2degree in 100% of patients, while in group A, this goal was achieved only in 24% of cases (p = 0.0021).
CONCLUSION: High tibial osteotomy with navigator is more accurate and reproducible in the correction of the deformity compared to standard technique.
LEVEL OF EVIDENCE: Therapeutic study, Level II.
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Long-term effect of removal of knee joint loading on cartilage quality evaluated by delayed gadolinium-enhanced magnetic resonance imaging of cartilage
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OAK 3 - Non-arthroplasty tx of OAK
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Objective: Ankle fracture patients were used as a model to study the long-term effect of the removal of joint loading on knee cartilage quality in human subjects. Design: The knees of 10 patients with ipsilateral ankle fractures were investigated using delayed gadolinium-enhanced magnetic resonance imaging of cartilage (dGEMRIC) at the time of ankle injury. After 6 weeks' prescribed unloading of the affected leg, but no restrictions regarding knee movement, the cast was removed from the ankle and the patient underwent a second dGEMRIC examination. Physiotherapy was then initiated. A third dGEMRIC examination was performed 4 months after remobilization, and a final examination 1 year after the injury. Results: Baseline T1Gd values for the 10 patients were within a narrow range. No significant change in mean T1Gd was observed after 6 weeks' prescribed unloading, but the T1Gd range had increased significantly. Four months after remobilization, the mean T1Gd was significantly lower than in the previous examinations, and the range remained significantly broader than at baseline. At the 1-year follow-up, the mean T1Gd was almost identical to the value after remobilization, and the T1Gd range still showed a significant increase compared to the baseline investigation. Conclusions: Removal of knee cartilage loading for 6 weeks resulted in a measurable effect on the cartilage matrix, as evidenced by a broader T1Gd range. A decrease in mean T1Gd was observed 4 months after remobilization. These differences persisted a year after injury compared to baseline. © 2014 Osteoarthritis Research Society International.
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Vision and falls
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Upper Eyelid and Brow Surgery
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Falls occur in about one third of older people living independently in the community every year. This can lead to significant physical, psychological and financial costs to the individual and the community. While the risk factors for falls in older people are multifactorial, poor vision is considered to be an important contributing factor. The aim of this review is to evaluate current research linking impaired visual function with falls and to review current intervention strategies for the prevention of falls in older individuals. The evidence from the current literature indicates that impairment of visual functions, such as visual acuity, contrast sensitivity, visual fields and depth perception, is associated with an increased risk of falls. Recent studies have also demonstrated that falls can be reduced following cataract surgery as a visual intervention. Optometrists need to be aware of these associations and through appropriate treatment, referral and/or education, they can play a major role in optimising visual function in older people, as part of a multidisciplinary approach to falls prevention.
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Cohort for the study of falls (CEC-2 study): Incidence of falls in the Spanish elderly population
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Management of Hip Fractures in the Elderly
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Introduction.- The objective of this study was to estimate the incidence of falls and fractures among elderly persons in the Spanish population. Method.- This prospective cohort study included 770 subjects older than 64 years and not institutionalised, living in Spain. The sample was gathered using a multistage probability sampling procedure, stratified by sex, size of the residence location, geographic area and age (the later stratum was not proportional but with an oversized group of older-than-79 subjects, to facilitate estimations in this group). In the first sampling stage, towns of different sizes were selected in the pre-established geographic areas; afterwards, different districts were selected within towns; lastly, homes and participants were selected within districts. A baseline evaluation of participants was carried out by in-person interviews, where affiliation and sociodemographic data were collected, as well as information on several risk factors related with falls (data not shown). Telephone follow-up was carried out every three months, where participants were asked about the occurrence of falls and fractures and the fall direction. Total follow-up time was one year. The statistical analysis included the 628 patients, who completed the follow-up. The incidence of falls, repeated falls (> 1) and fractures was calculated for older-than-64 subjects by adjusting the age disproportion generated in the sampling procedure. These incidences were also calculated for older-than- 79 subjects. Results.- Within the older-than-64 group, 23.8% of the subjects had at least one fall (CI 95% 20.6-27.4%) while the percentage of repeated fallers in this group was 8.0% (CI 95% 6.0-10.1%). Within the older-than-79 group, 32.5% had at least one fall (CI 95% 28.1- 37.0%), while the repeated fallers were 11.6% (CI 95% 8.6-14.1%). Women fell more often than men: RR = 1.66 (IC 95% 1.22-2.26%); Chi(2) test: P = 0.001. Subjects most frequently fell forward (44.5%), followed by lateral fall (23.8%). Overall, 9.4% (CI95% 5.1-13.7%) of the fallers had a fracture (3.3% had a hip fracture - CI95% 6.-0.7%) Conclusions.- The incidence of falls, hip fracture and other fractures in the Spanish elderly population is high, with the highest rates affecting women. Regarding direction of the falls, subjects most frequently fall forward
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Emerging ideas: prevention of posttraumatic arthritis through interleukin-1 and tumor necrosis factor-alpha inhibition
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AMP (Acute Meniscal Pathology)
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BACKGROUND: Despite surgical and mechanical stabilization of an acutely injured joint through ligament reconstruction, meniscus repair, or labral repair, the risk of posttraumatic arthritis remains high. Joint injury triggers three phases of pathogenic events: the early (acute) phase involves joint swelling, hemarthrosis, expression of inflammatory cytokines (especially interleukin-1 [IL-1] and tumor necrosis factor-alpha [TNF-alpha]), and biomarkers of cartilage catabolism; an intermediate phase is characterized by reduction of joint inflammation, ongoing joint catabolism, but no evidence yet for typical features of radiographic osteoarthritis (OA); and a late phase characterized by radiographic OA.
HYPOTHESES: We hypothesize that the early phase of acute knee injury represents a window of opportunity for providing biologic treatment to promote healing and to slow or prevent a subsequent cascade of destructive joint processes leading to OA.
PROPOSED PROGRAM: We propose a phase II, randomized, placebo-controlled, double-blinded, clinical trial to treat acute knee injuries with intraarticular injection of an IL-1 inhibitor. Patient-centered outcomes will include pain reduction and improvement of knee function. MR imaging and measurement of biochemical markers will be monitored during the subsequent 2 years to determine if the structural response to injury can be reversed.
SIGNIFICANCE: If this model is validated, modulation of the molecular pathways responsible for articular cartilage breakdown will augment current reconstructive procedures in the treatment of acute joint injuries and prevent the development of injury-related arthritis.
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Transareolar-perinipple (areolar omega) zigzag incision for augmentation mammaplasty
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Reduction Mammoplasty for Female Breast Hypertrophy
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BACKGROUND: Optimal augmentation mammaplasty results not only from proper implant size and breast shape, but also from the minimization of postoperative scarring, especially in patients prone to hypertrophic scars. In this context, the authors present a transareolar-perinipple (areolar omega) zigzag approach. METHODS: Between March of 2003 and June of 2012, a total of 613 patients underwent augmentation mammaplasty using a transareolar-perinipple incision. Among them, 45 patients received a classic (straight line) transareolar-perinipple incision, whereas 568 patients received a modified zigzag transareolar-perinipple incision. RESULTS: Patients' ages ranged from 21 to 60 years. Areola size varied from 2.3 to 4.5 cm in diameter. Follow-up duration ranged from 1 to 10 years, with an average of 2 years 7 months. Postoperative complications included capsular contracture, which occurred in 16 patients (2.6 percent). Nine patients (1.5 percent) had Baker class II and seven patients (1.1 percent) had Baker class III capsular contracture. Mild inferior displacement of the implant occurred in four patients (0.6 percent). The prevalence of areolar distortion was 3.4 percent. Nipple hypesthesia was found in approximately 70 percent of the patients, which returned to normal after 2 to 3 months. Based on third-party observers, 74.7 percent of patients who received zigzag transareolar-perinipple incision had excellent to good scarring results. CONCLUSIONS: The transareolar-perinipple (areolar omega) zigzag incision resulted in satisfactory postoperative scarring and surgical results in Asian patients. This method increases the opening of the areolar incision and can be performed in patients with small (<3.5 cm) areolas. This approach can be an alternative in patients who are prone to hypertrophic scarring. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.
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Recovery of contractile properties of the knee-extensor muscles after arthroscopic partial meniscectomy
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AMP (Acute Meniscal Pathology)
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Context: Contractile characteristics of the knee extensors after arthroscopic meniscectomy are poorly understood. Objective: To measure the recovery of knee-extensormuscle contractility after arthroscopic partial meniscectomy. Design: Single-group repeated measures. Setting: Kinesiology and biomechanics laboratory. Subjects: Fourteen patients with arthroscopic partial medial meniscectomies. Main Outcome Measures: Maximal isometric voluntary contraction (MVC) force, rate of force development (MRFDES), and half-relaxation time (HRTES) of evoked tetanic contraction preoperatively and during 6 months postoperatively. Results: Two weeks postoperatively, a reduction in MVC force of 27.1% and in MRFDES of 17.8% and a prolongation of HRTES of 34.0% in the injured leg were found. A significant MVC-force deficit (17.5%) was observed 3 months postoperatively. Conclusions: The recovery of kneeextensor-muscle voluntary strength is more delayed than are evoked tetanic-contractile characteristics after partial meniscectomy. The rehabilitation protocol seems to be insufficient to attain effective recovery of knee-extensor-muscle voluntary strength.
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Heel bone ultrasound predicts non-spine fracture in Japanese men and women
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Management of Hip Fractures in the Elderly
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A number of prospective studies in the USA and Europe have demonstrated that quantitative ultrasound (QUS) measurements predict fracture risk. To our knowledge, there has been no such study in a Japanese population, and very few studies have measured the prognostic value of QUS measurements among men, even in the USA and Europe. We performed a three-center prospective study to investigate the relationship between baseline heel QUS measurements and non-spine fracture risk. There were 4,028 subjects (1,004 men and 3,024 women), 67.5+/-8.9 years [mean +/- standard deviation (SD)] of age), who underwent heel QUS (Achilles device) at three centers between 1993 and 2000. In 2002, the subjects were mailed a standardized questionnaire that asked about their history of fracture. The mean follow-up period was approximately 5 years. The Achilles measured speed of sound (SOS) and broadband ultrasound attenuation (BUA). We used Cox regression analysis to determine the hazard ratio (HR), using weighted coefficients. SOS, BUA, and stiffness index (SI) predicted self-reported hip, wrist, and total non-spine fractures. After we had adjusted for age, gender, and weight, the HRs of total non-spine fracture were 1.54 [95% confidence interval (CI) 1.39-1.69], 1.53 (1.37-1.70), and 1.80 (1.62-1.98) for 1 SD decrease in SOS, BUA, and SI, respectively. In men, SOS and SI also predicted total non-spine fractures with HRs similar to those in women. The HR of prediction for hip fracture by SOS and SI was better in the short term than in the long term, and the prediction for hip, wrist, and non-spine fracture remained significant between 5 to 10 years of follow-up. Measurements obtained from heel QUS predicted non-spine fracture in Japanese men and women, and the HRs of Japanese of both genders was similar to the risk ratio (RR) of Caucasian men and women. QUS parameters can predict hip, wrist, and non-spine fracture up to 10 years
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Periarticular infiltration of 0.25% bupivacaine on top of femoral nerve block and intrathecal morphine improves quality of pain control after total knee arthroplasty: a randomized double-blind placebo controlled clinical trial
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AAHKS (9/10) Regional Nerve Blocks
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OBJECTIVE: Find out if the addition of periarticular local anesthetic infiltration enhances the quality of postoperative pain control in patients with knee arthroplasty (TKA) in spinal anesthesia and intrathecal morphine plus single shot femoral nerve block (FNB). MATERIAL AND METHOD. Ninety-nine patients scheduled for TKA under spinal anesthesia were enrolled after written informed consent, and randomized into two groups with either periarticular injection of 20 ml 0.25% bupivacaine (B-gr n = 50) or isotonic saline solution (S-gr n = 49). All patients had intrathecal morphine 0.2 mg and single shot FNB with 20 ml bupivacaine 0.25% and were adjusted postoperative analgesic requirement via patient controlled analgesia with morphine. Effect of postoperative pain control and requirement of additional analgesics were recorded.
RESULTS: Randomization created comparable groups. Periarticular infiltration of bupivacaine in addition to femoral nerve block and intrathecal morphine was efficient and superior to saline regarding pain control, morphine consumption, and patient's satisfaction. More patients in B-gr did not require any supplement morphine in the first 24 hours (26% compared to 12.2%, p < or = 0.01). In patients who required morphine, B-gr had longer pain free period (25 hours compared to 14.8 hours, p < 0.001) and needed lower dose of morphine (5.16 mg compared to 8. 67mg, p = 0.005). No significant side effects were recorded.
CONCLUSION: Adding periarticular infiltration to femoral block and intrathecal morphine significantly enhances the quality of postoperative pain therapy in TKA patients. However combining three methods for analgesic therapy may be too much effort. Modifying infiltration techniques including continuous application needs further research.
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Tumescent anaesthesia
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Panniculectomy & Abdominoplasty CPG
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Tumescent anaesthesia describes the practice of injecting a very dilute solution of local anaesthetic combined with epinephrine and sodium bicarbonate into tissue until it becomes firm and tense (tumescent). It was initially described in the field of liposuction but now surgical applications for the technique are widely varied ranging across vascular surgery, breast surgery, plastic surgery and ENT procedures. It is widely used in both hospital- and office-based environments and may form the sole method of anaesthesia for surgery. Advantages include a reduction in blood loss through both epinephrine-induced vasoconstriction as well as hydrostatic compression from the tumescent effect. Sodium bicarbonate reduces pain associated with the injection of an acidic local anaesthetic solution. Due to the unique pharmacokinetic profile of this technique lidocaine doses of 35 mg/kg bodyweight have been shown to be safe for liposuction procedures. Tumescent lidocaine is absorbed very slowly from subcutaneous tissues producing lower, and more delayed, peak blood levels compared to other routes, as well as extended postoperative analgesia. Slow systemic absorption allows the rapid hepatic plasma clearance of lidocaine to maintain safe local anaesthetic blood levels. This slow absorption from subcutaneous tissue has been likened to a depot injection. Careful attention must be given to appropriate local anaesthetic dosage alterations in cases of co-administration with agents affecting hepatic drug clearance or conditions reducing liver blood supply. Adherence to these pharmacological principles has produced an exemplary safety record for this technique to date.
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Evaluating the efficiency of specimen pooling for PCR-based detection of COVID-19
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Coronavirus Disease 2019 (COVID-19)
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In the age of a pandemic, such as the ongoing one caused by SARS-CoV-2, the world faces a limited supply of tests, personal protective equipment, and factories and supply chains are struggling to meet the growing demands. This study aimed to evaluate the efficacy of specimen pooling for testing of SARS-CoV-2 virus, to determine whether costs and resource savings could be achieved without impacting the sensitivity of the testing. Ten previously tested nasopharyngeal and throat swab specimens by real-time PCR, were pooled for testing, containing either one or two known positive specimens of varying viral concentrations. Specimen pooling did not affect the sensitivity of detecting SARS-CoV-2 when the PCR cycle threshold (Ct) of original specimen was lower than 35. In specimens with low viral load (Ct>35), 2 out of 15 pools (13.3%) were false negative. Pooling specimens to test for COVID-19 infection in low prevalence (â?¤1%) areas or in low risk populations can dramatically decrease the resource burden on laboratory operations by up to 80%. This paves the way for large-scale population screening, allowing for assured policy decisions by governmental bodies to ease lockdown restrictions in areas with a low incidence of infection, or with lower risk populations. This article is protected by copyright. All rights reserved.
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Influence of leg length discrepancy on clinical results after total hip arthroplasty - a prospective clinical trial
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PJI DX Updated Search
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The effect of leg length differences on early clinical outcome after total hip arthroplasty remains uncertain. We performed a prospective study on 94 patients who were evaluated preoperatively and one year after surgery for clinical leg length differences, which were then compared with radiological measurements. The effect of leg length differences on walking ability, limp, pain and patient satisfaction was studied. The mean clinical leg length difference after operation was 0.05 cm (-1.5 to 1.5, SD 0.5). Clinical and radiological measurements correlated poorly (Ãâ°=0.36 pre- and Ãâ°=0.186 postoperatively). Patients with a shorter operated leg on clinical assessment were more prone to limping (p<0.05), and patients with a longer leg had more pain compared to patients with equal leg lengths (p<0.05). Walking ability, Harris Hip Score and patient satisfaction were only marginally affected by leg length differences. Virtually equal leg length was achieved for most patients but small differences had a negative influence in relation to limping and pain. Patients should be counselled pre-operatively about possible leg length differences and associated symptoms. é 2011 Wichtig Editore
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Long-term outcomes after pediatric peripheral revascularization secondary to trauma at an urban level I center
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DoD SSI (Surgical Site Infections)
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OBJECTIVE: The purpose of this investigation was to determine our limb-related contemporary pediatric revascularization perioperative and follow-up outcomes after major blunt and penetrating trauma.
METHODS: A retrospective review was performed of a prospectively maintained pediatric trauma database spanning January 2010 to December 2017 to capture all level I trauma activations that resulted in a peripheral arterial revascularization procedure. All preoperative, intraoperative, and postoperative continuous variables are reported as a mean +/- standard deviation; categorical variables are reported as a percentage of the population of interest.
RESULTS: During the study period, 1399 level I trauma activations occurred at a large-volume, urban children's hospital. The vascular surgery service was consulted in 2.6% (n = 36) of these cases for suspected vascular injury based on imaging or physical examination. Our study population included only patients who received an arterial revascularization, which was performed in 23 of the 36 consultations (1.6% of total traumas; median age, 11 years). These injuries were localized to the upper extremity in 60.9% (n = 14), lower extremity in 30.4% (n = 7), and neck in 8.7% (n = 2). The mean Injury Severity Score in the revascularized cohort was 14.0 (+/-7.6). Bone fractures were associated with 39.1% of the vascular injuries (90% of blunt injuries). Restoration of in-line flow was achieved by an endovascular solution in one patient and open surgery in the remainder, consisting of arterial bypass in 59.1% and direct repair in 40.9%. Within 30 days of the operation, we observed no deaths, no infections of the arterial reconstruction, and no major amputations. One patient required perioperative reintervention by the vascular team secondary to the development of a superficial seroma without evidence of graft involvement. Mean follow-up in our cohort was 43.3 (+/-35.4) months. During this phase, no additional deaths, amputations, chronic wounds, or limb length discrepancies were observed. All vascular repairs were patent, and all but one patient reported normal function of the affected limb at the latest clinic visit.
CONCLUSIONS: Traumatic peripheral vascular injury is rare in the pediatric population but is often observed secondary to a penetrating force or after long bone fracture. However, contemporary perioperative and long-term outcomes after surgical revascularization are excellent as demonstrated in this institutional case series.
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Complications of supracondylar osteotomies for cubitus varus
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Pediatric Supracondylar Humerus Fracture 2020 Review
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BACKGROUND: Humeral osteotomies for cubitus varus have a notoriously high complication rate. Pitfalls of this difficult procedure are highlighted. METHODS: A 50-year experience of 68 consecutive surgeries was reviewed. Factors such as surgical approach and fixation technique were compared for complication incidence and type. RESULTS: Seventeen patients (25%) had 23 (34%) clinically remarkable complications. Nine postoperative nerve palsies occurred in 8 patients. Loss of reduction requiring revision or manipulation was seen in 3 patients. The following complications were noted in 2 patients each: nonunion, loss of flexion, lateral prominence, and unsatisfactory scar. Growth arrest, osteomyelitis, and under-correction requiring revision each occurred once. A lateral, triceps-sparing approach was associated with an overall prevalence of complications of 24% (5 of 21) equivalent to the posterior, triceps splitting approach of 24% (10 of 42). An olecranon osteotomy was used in 2 patients both with complications. No nerve injuries occurred in patients who underwent a lateral approach, whereas nerve palsies occurred in 14% (6 of 42) of the patients where a posterior approach was used. An olecranon osteotomy was used in 2 patients with nerve injury occurring in both. A medial approach in 2 patients and a combined medial-lateral approach in 1 patient were used with no complications. Plate and screw fixation was implemented in 29 cases with complications occurring in 6 of them; pin fixation, in 30 cases, 7 of which had complications. There was a higher incidence of under-correction requiring additional surgery with plate fixation (1 of 29) compared with pin fixation which had no under correction but had loss of fixation in 2 of 30. The average correction obtained was similar in the group with complications (32 degrees) versus those without (27 degrees). CONCLUSIONS: Supracondylar humeral osteotomy is a technically demanding procedure fraught with complications. Plate fixation and pin fixation techniques resulted in similar complication rates, but the surgical approach used appeared to make a difference. The posterior, triceps splitting, approach resulted in a high incidence of nerve palsies versus none with the lateral, triceps-sparing approach. LEVEL OF EVIDENCE: This is a retrospective case series, Level IV.
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Impact of surface topography and coating on osteogenesis and bacterial attachment on titanium implants
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Dental Implant Infection
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Titanium (Ti) plays a predominant role as the material of choice in orthopaedic and dental implants. Despite the majority of Ti implants having long-term success, premature failure due to unsuccessful osseointegration leading to aseptic loosening is still too common. Recently, surface topography modification and biological/non-biological coatings have been integrated into orthopaedic/dental implants in order to mimic the surrounding biological environment as well as reduce the inflammation/infection that may occur. In this review, we summarize the impact of various Ti coatings on cell behaviour both in vivo and in vitro. First, we focus on the Ti surface properties and their effects on osteogenesis and then on bacterial adhesion and viability. We conclude from the current literature that surface modification of Ti implants can be generated that offer both osteoinductive and antimicrobial properties.
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Ideal screw positions for multiple screw fixation in femoral neck fractures - Study of proximal femur morphology in a Japanese population
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Hip Fx in the Elderly 2019
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BACKGROUND: Despite the fact that multiple screw fixation is a common option of surgical treatment for femoral neck fractures, there is a paucity of precise morphological study of the femoral neck. To identify appropriate positions and spacing of hip screws for multiple-screw femoral neck fracture fixation, proximal femur morphology in Japanese patients was studied.
METHOD: One hundred hips in fifty knee arthroplasty candidates were studied. Following full limb CT, defined slices were created and anatomical variables measured.
RESULT: The average neck-shaft angle was 126.5degree and the distance from the subcapital line to the subchondral bone on a line parallel to the femoral neck axis (FNA) was approximately 25 mm at the superior and inferior; borders of the femoral neck. The FNA was shown to run anterior to the femoral axis (FA). The cross section of the femoral neck forms a reverse right triangle. The height and width of the neck medullary canal were equal (approximately 25 mm), with the posterior wall closer to the femoral axis than the anterior wall.
CONCLUSION: Based on these data, the anterior screw positioned just above the calcar femorale, 16 mm proximal and 27degree anterior to the FA, and the posterior screw positioned 12 mm proximal and 5 mm posterior to the FA is recommended. For screws inserted with a fixed angle side-plate, <=130degree is recommended.
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SIE, SIES, GITMO evidence-based guidelines on novel agents (thalidomide, bortezomib, and lenalidomide) in the treatment of multiple myeloma
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MSTS 2018 - Femur Mets and MM
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In this project, we produced drug-specific recommendations targeting the use of new agents for multiple myeloma (MM). We used the GRADE (Grades of Recommendation, Assessment, Development, and Evaluation) system which separates the judgments on quality of evidence from the judgment about strength of recommendations. We recommended thalidomide and bortezomib in MM patients candidates to autologous stem cell transplantation (ASCT) (weak positive). We did not recommend novel agents as maintenance therapy after ASCT (weak negative). In patients not candidate to ASCT, thalidomide or bortezomib (strong positive) associated with melphalan and prednisone were recommended. In these patients, no specific course of action could be recommended as for maintenance therapy. In patients who are refractory or relapsing after first-line therapy, we recommended bortezomib and pegylated liposomal doxorubicin, or lenalidomide and dexamethasone combinations (weak positive). © Springer-Verlag 2012.
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Age Predicts Disruption of the Articular Surface of the Femoral Condyles in Knee OCD: Can We Reduce Usage of Arthroscopy and MRI?
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Osteochondritis Dissecans 2020 Review
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BACKGROUND: The purpose of this study was to determine if patient age could accurately identify disrupted articular cartilage overlying an osteochondritis dissecans (OCD) lesion of the femoral condyle in adolescents. This could have important implications for imaging and treatment decisions. METHODS: All patients from 2001 to 2014 who were arthroscopically treated for a femoral condyle OCD were included in this Institutional Review Board-approved study. Exclusion criteria were trochlear and patellar OCD lesions, idiopathic arthritis, and traumatic osteochondral injuries. Arthroscopy was performed to visualize and probe the articular surface. Arthroscopic and magnetic resonance imaging (MRI) findings were recorded as "intact" or "disrupted" cartilage. Extra-articular drilling was performed when the articular cartilage was intact. RESULTS: There were 119 patients (81 male, 68%) with 139 OCD lesions in 136 knees. The mean age at time of surgery was 13.0 years (range, 7.2 to 19.3 y). At arthroscopy, 115 knees had intact cartilage and 24 had disrupted cartilage. There was a significant difference in age between patients with intact versus disrupted cartilage at arthroscopy (12.5 vs. 15.3 y; P<0.0001). Eighty-eight OCD lesions had MRIs preoperatively, showing 69 as intact and 19 (24%) disrupted. MRI reading for cartilage status had 94% sensitivity and 97% specificity. Multivariable regression analysis revealed that age (P<0.01) and MRI status (P<0.0001) were strong predictors of cartilage status. Sixteen years was the critical age in which both sensitivity was maximized and false positive probability was minimized. Over the age of 17 years, 7 of 7 (100%) had disrupted cartilage. Age alone was 100% sensitive for children below the age of 10, and 96% sensitive below the age of 13. CONCLUSIONS: Age was a good predictor of cartilage status in both younger (<13 y) and older (â?¥17 y) patients in this study. For patients in the mid-range group (13 through 16 y), age alone is not an adequate predictor of cartilage status, but adding MRI increased accuracy. SIGNIFICANCE: Age can be used to stratify patients and thereby influence diagnostic and treatment strategies. LEVEL OF EVIDENCE: Level IV.
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Safety and Clinical Effectiveness of Percutaneous Vertebroplasty in the Elderly (=80 years)
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MSTS 2022 - Metastatic Disease of the Humerus
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Purpose: To evaluate the safety and clinical effectiveness of percutaneous vertebroplasty (PVP) in patients aged 80 and over. Methods: One hundred and seventy-three patients (127 women, 46 men; mean age = 84.2y) underwent 201 PVP procedures (391 vertebrae) in our institution from June 2008 to March 2012. One hundred and twenty-six patients (73 %) had osteoporotic vertebral compression fractures (VCF), 36 (20.5 %) were treated for tumour lesions, and the remaining 11 (6.5 %) for lesions from another cause. Comorbidities and American Society of Anesthesiologists (ASA) scores were assessed before treatment. Periprocedural and delayed complications were systematically recorded. A qualitative scale was used to evaluate pain relief at 1-month follow-up, ranging from significant pain worsening to marked improvement or disappearance. New fracture occurrence was assessed on follow-up imaging. Results: Forty-five percent of patients had pretreatment ASA class scores =3. No major complication occurred. Pain was unchanged in 16.9 % of cases, mildly improved in 31.5 %, and disappeared in 47.8 %. We identified 27 (11 %) symptomatic new VCFs in patients with osteoporosis on follow-up imaging. The mean delay in diagnosis of new fractures was 5 ± 8.7 months. Conclusions: Even in the elderly, PVP remains a safe and effective technique for pain relief, independently of the underlying disease. Key Points: • Post-PVP pain improvement was observed in 79.3 % of elderly patients. • PVP remains a safe technique in elderly patients. • No decompensation of comorbidity was observed in our series.
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The effect of triclosan on developing gingivitis
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Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures
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The aim of the study was to examine whether triclosan has an effect on developing gingival inflammation. 10 volunteers, with clinically healthy gingivae were enrolled. The study was performed as a 2-week, double-blind, cross-over, experimental gingivitis trial. Between each plaque accumulation period, there was a wash-out phase of 4 weeks. A baseline examination was performed which included assessment of plaque and gingivitis. The volunteers were asked to refrain from mechanical oral hygiene measures for 2 weeks. During this period, they rinsed 2x daily with one of the randomly assigned mouthrinse preparations. Solution A (period A): 0.06% triclosan+ 2%tween 80. Solution B (period B): 0.06% triclosan+ 0.25% sodium lauryl sulphate. Re-examinations were performed on days 4, 7, 11 and 14. The mean plaque score increased during period A to 2.2 (day 4), 2.8 (day 7), 3.1 (day 11) and 3.1 (day 14). The corresponding scores for period B were significantly lower; 1.2 (day 4), 1.8 (day 7), 2.0 (day 11) and 2.2 (day 14). The mean gingivitis scores at baseline were 0.17 (periods A and B). The mean gingivitis scores increased to 0.45 (day 4), 0.69 (day 7), 0.83 (day 11) and 0.96 (day 14) when the subjects rinsed with solution A and 0.42 (day 4), 0.64 (day 7), 0.78 (day 11) and 0.92 (day 14) in period B. There were no statistically significant differences between periods A and B with respect to gingivitis. Thus, although significantly more plaque formed during period A than period B, no differences could be found between the gingivitis scores in the 2 periods
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Effect of various rinsing protocols after use of amine fluoride/stannous fluoride toothpaste on the bacterial composition of dental plaque
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Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures
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This clinical study evaluated the effect of different oral hygiene protocols on the bacterial composition of dental plaque. After a 2-week period of using fluoride-free toothpaste, 30 participants followed three 1-week experimental protocols, each followed by 2-week fluoride-free washout periods in a randomized crossover examiner-blind controlled trial. The 1-week experimental protocols comprised the use of AmF/SnF(2) toothpaste twice daily, after which participants either (1) rinsed with tap water, (2) did not rinse but only spat out the toothpaste, or (3) rinsed with an AmF/SnF(2) mouthwash. In the fluoride-free washout periods, the participants brushed their teeth with fluoride-free toothpaste without further instructions. Six hours after the last brushing (+/- rinsing) of each period, buccal plaque samples in the upper molar region were taken. The microbiota composition of the plaque samples was analyzed by checkerboard DNA:DNA hybridization. A statistically significant reduction was found in the total amount of DNA of the 39 major plaque species measured, and in the proportions of some acid-producing bacterial strains after the period having used the AmF/SnF(2) toothpaste + AmF/SnF(2) mouthrinsing. The results indicate that using the AmF/SnF(2) toothpaste and rinse combination could result in plaque of lower cariogenicity
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0 |
The Difficult Primary Total Knee Arthroplasty
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OAK 3 - Non-arthroplasty tx of OAK
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Primary total knee arthroplasty (TKA) for the treatment of knee arthritis has substantially increased over the past decade. Because of its success, the indications for primary TKA have expanded to include younger patients who are more active, elderly patients who have multiple comorbidities, and patients who have more complex issues, such as posttraumatic arthritis and severe deformity. TKA also has been used to salvage failed unicondylar arthroplasty and osteotomies about the knee. Exposure may be challenging and outcomes may not be as successful in patients with soft-tissue contractures, such as a stiff knee, who undergo TKA. Bone graft or augments may be required to correct deformity and attain proper knee alignment in patients who have a substantial varus or valgus deformity. TKA is somewhat challenging in patients who have deformity, bone loss, contracture, or multiple comorbidities, or have had prior surgery; therefore, it is necessary for surgeons to be aware of some general principles that may help minimize complications and improve outcomes.
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Preoperative Mild Pericardial Effusion Is Associated With Perioperative Complications In Elderly Patients Following Hip Fracture Surgery
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Hip Fx in the Elderly 2019
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Background: The prevalence and prognostic value of mild pericardial effusion (MPE) has not been examined in patients undergoing non-cardiac surgery. Our study aimed to assess the frequency and prognostic value of MPE in elderly patients undergoing surgery for hip fracture. Methods: This is a single center, and retrospective study including elderly patients who underwent hip fracture surgery. The medical records of all patients, aged >=65 years with femoral neck, intertrochanteric or subtrochanteric hip fracture undergoing surgery (intramedullary hip screw, sliding compression hip screw, hemiarthroplasty, or total hip arthroplasty) from June 2014 to June 2019 were analyzed. Patients with of multiple trauma and accidents were excluded. The MPE was defined as the presence of <10 mm pericardial effusion. The primary outcomes of the study were perioperative adverse medical events and length of stay in hospital. Results: A total of 462 patients (mean age 75.2 +/- 11.7 years, and 53.5% female) were enrolled. MPE was detected in 72 patients (15.6%), and 62 patients (13.4%) experienced perioperative adverse medical events. Patients with MPE were older, had higher prevalence of diabetes, coronary artery disease, and heart failure, and had longer length of stay compared to patients without MPE. Univariate analysis showed a significant association between age, diabetes, coronary artery disease, American Society of Anesthesiologists status, MPE, and perioperative adverse events. After adjustment for age, demographics, and medical history, the presence of MPE remained as significant variable associated with perioperative complications (OR: 2.543, 95% CI: 1.173-3.469, p = 0.003). Conclusion: Our study is the first to demonstrate that the presence of MPE is associated with perioperative adverse events in elderly patients undergoing hip fracture surgery.
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Novel renal markers for the assessment of renal integrity in patients undergoing knee arthroplasty - a pilot study
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AAHKS (8) Anesthetic Infiltration
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BACKGROUND: The feasibility of novel kidney injury biomarkers in consecutive patients having total knee arthroplasty with local infiltration analgesia was evaluated.
METHODS: We enrolled 30 patients scheduled for elective unilateral total knee arthroplasty. Paired plasma and urine samples were taken before surgery and at 4 h, 24 h and 48 h after surgery to measure creatinine, cystatin C, neutrophil gelatinase associated lipocalin, kidney injury molecule-1, interleukin-18 and liver-type fatty acid-binding protein.
RESULTS: At baseline, 13 subjects had normal kidney function, 15 had mild and two had moderate kidney failure evaluated by calculated glomerular filtration rate. None of the subjects had all measured novel renal markers below proposed cut-off concentrations. Altogether 28/30 subjects had one (n = 3), two (n = 7) or three (n = 18) plasma neutrophil gelatinase associated lipocalin values above normal. In seven of these 28 subjects plasma creatinine, calculated glomerular filtration rate and plasma cystatin C were within the reference values. Five subjects had a low urine output, < 0.5 mL/h, indicating transient acute kidney injury, four of these had high plasma neutrophil gelatinase associated lipocalin and one high plasma cystatin C.
CONCLUSIONS: In the present study plasma neutrophil gelatinase associated lipocalin was elevated in most subjects with total knee arthroplasty and local infiltration analgesia as a marker of possible renal proximal tubular injury. Five subjects had transient low urine output, but none developed renal deterioration requiring treatment.
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Inhibiting STAT3 in a murine model of human breast cancer-induced bone pain delays the onset of nociception
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MSTS 2018 - Femur Mets and MM
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Aggressive breast cancer subtypes utilize system x<sub>c</sub><sup>-</sup>, a membrane antiporter, to import cystine for glutathione synthesis and maintenance of redox homeostasis, in turn releasing glutamate as a metabolic pro-nociceptive by-product. Metastatic breast cancers establish themselves at distal sites including bone, where changes in extracellular glutamate levels contribute to cancer-induced bone pain. We previously established that stearically blocking system x<sub>c</sub><sup>-</sup> activity with sulfasalazine delays the onset of nociceptive behaviours and that xCT, the functional antiporter subunit, is positively regulated by signal transducer and activator of transcription 3 (STAT3). In the current investigation, a murine xenograft cancer-induced bone pain model was applied to examine whether pharmacological inhibition of phosphorylated STAT3 (pSTAT3) induces changes in nociception. A high glutamate-releasing, xCT/pSTAT3 over-expressing human breast cancer cell line was selected for injection into the distal epiphysis of the right femur of female nude mice. A 14-day regimen of intraperitoneal injections with either vehicle or the novel STAT3 inhibitor DR-1-55 commenced three weeks after initial intrafemoral bone injection. Nociceptive behaviours were temporally monitored by automated von Frey, dynamic weight bearing and open-field testing for the duration of the study, beginning at the baseline. Prior to sacrifice and at ethical end point, tumour-induced osteolytic lesions were radiographically assessed. Treatment with DR-1-55 significantly delayed the onset and severity of spontaneous and induced nociceptive behaviours, also decreasing human SLC7A11 ( xCT) mRNA levels in tumour-bearing limbs without altering osteolysis. In addition, two pro-inflammatory cytokines released by this cell line, interleukin 6 and interleukin 1beta, were also down-regulated at the mRNA level in response to DR-1-55 treatment in vivo, with lower human interleukin 6 levels detected in the host circulation. This study demonstrates that targeting pSTAT3 may be a viable therapeutic means to manage cancer-induced bone pain, alone or in combination with stearic system x<sub>c</sub><sup>-</sup> blockers.
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Gestational Gigantomastia: A Case Report
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Reduction Mammoplasty for Female Breast Hypertrophy
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Gestational gigantomastia is a rare disorder characterized by rapidly progressive hypertrophy of the breast tissue during pregnancy. Its prevalence is approximately 1:100,000, and although the etiology of this condition remains unclear, it may be related to hormonal change. This study reports the case of a 39-year-old pregnant woman at 22 weeks of gestation with massive enlargement of bilateral breasts (gigantomastia) and presents the sonographic findings of this rare condition which shows different parenchymal patterns from those of normal breasts and is uncommonly seen.
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Single-cell RNA sequencing reveals the cell types heterogenicity of human discoid lateral meniscus cells
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AMP (Acute Meniscal Pathology)
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Discoid lateral meniscus (DLM) is more prone to injury than a normally shaped meniscus. No study has compared the gene expression and cell heterogeneity between discoid and normal menisci. We aimed to identify specific cell clusters and their marker genes in discoid meniscus, thereby providing a theoretical basis for the treatment and etiology of DLM. ScRNA-seq was used in DLM and osteoarthritis lateral meniscus (OAM) cells to identify cell subsets and their gene signatures. Pseudo-time analysis and immunohistochemical staining were used to investigate the temporal and spatial distribution of DLM-specific clusters. ScRNA-seq identified nine clusters originating from DLM and OAM, composed of seven empirically defined populations and two novel populations specific to DLM, namely, the prehypertrophic chondrocyte 2 (PreHTC-2) and regulatory chondrocyte (RegC-2) populations. Single-cell trajectory showed that RegC-2 and PreHTC-2 were mainly distributed in a specific cell fate, with the PreHTC-2 marker gene HAPLN1 highly expressed at the end of this fate. Immunohistochemical staining showed that HAPLN1 + cells were mainly distributed in the white zone of DLM. Matrix metalloproteinase (MMP) variants were expressed in DLM and OAM, with MMP2 highly expressed in OAM-dominant cell clusters, while MMP3 was highly expressed in DLM-dominant cell clusters. We concluded that two novel cell clusters including PreHTC-2 were identified using single-cell sequencing, which were mainly distributed in the white areas of DLM. Differentiated MMP expression in the trajectory may be a possible mechanism of DLM formation.
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Carotid intima-media thickness in patients with carpal tunnel syndrome
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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OBJECTIVES: We measured the carotid intima-media thickness, a surrogate marker of early atherosclerosis, in patients with carpal tunnel syndrome compared to a control group to evaluate the risk of atherosclerotic disease. METHODS: Between January 2011 and December 2011, female patients presenting to the outpatient neurology clinic for pain and paresthesia in the hands were screened for study enrollment. Patients 30 years or older were eligible for the study if they did not have a history of stroke or cardiovascular disease. RESULTS: During the study period, 111 patients (58 in the carpal tunnel syndrome group and 53 in the control group) were enrolled, with a mean age of 56 years (range, 32-79 years). There were no significant differences in baseline characteristics except maximum carotid intima-media thickness and body mass index. The maximum intima-media thickness was greater in the carpal tunnel syndrome group (mean +/- SD, 1.05 +/- 0.17 mm) than the control group (0.85 +/- 0.22 mm; P < .0001). The body mass index was greater among the controls (P = .012). Simple linear regression analysis revealed that age (P < .0001), carpal tunnel syndrome (P < .0001), hypertension (P = .022), and systolic blood pressure (P = .034) were statistically significantly associated with increased intima-media thickness. Multiple linear regression analysis revealed that hypertension (P = .033), systolic blood pressure (P = .022), age (P < .0001), and carpal tunnel syndrome (P < .0001) were significantly associated with increased intima-media thickness, with carpal tunnel syndrome being the most influential factor (beta = 0.489). CONCLUSIONS: The maximum carotid intima-media thickness was significantly increased in patients with carpal tunnel syndrome compared to controls. Chronic inflammation beyond the traditional cardiovascular risk factors might be related to increased carotid intima-media thickness in patients with carpal tunnel syndrome
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Monoflanged Custom-Made Acetabular Components Promote Biomechanical Restoration of Severe Acetabular Bone Defects by Metallic Defect Reconstruction
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Hip Fx in the Elderly 2019
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Background: Custom-made acetabular components (CMAC) are one established method to address severe acetabular bone defects. Monoflanged CMAC may represent an advantageous alternative to establish triflanged CMAC as they promote better primary stability through metallic defect reconstruction and thus anatomic restoration of the center of rotation (COR). Methods: Fifty-eight consecutive (21 triflanged and 37 monoflanged) CMAC were evaluated for overall survival, reasons for revision, radiological restoration of COR, and clinical outcome parameters. Results: There were no significant differences between both design types regarding overall survival, revision rates, Harris Hip Score, or visual analog scale (pain) score at latest follow-up (mean, 56.3 ± 28.7 months). Triflanged CMAC showed a significant lateralization (P � .001) and cranialization (P = .003) of the COR compared to the contralateral side. Monoflanged CMAC restored the anatomic COR. Reasons for revision surgery and explantation were periprosthetic joint infection (n = 12) and aseptic loosening (n = 2) without significant differences between both groups. Conclusion: Monoflanged CMAC demonstrate similar clinical outcome parameters and survival rates as triflanged CMAC but superior biomechanical features and represent therefore a solid alternative treatment option and implant design.
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Postoperative analgesia for elective total knee arthroplasty under subarachnoid anesthesia with opioids: Comparison between epidural, femoral block and adductor canal block techniques (with and without perineural adjuvants). Aprospective, randomized, clinical trial
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AAHKS (9/10) Regional Nerve Blocks
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BACKGROUND: Optimal control of acute postoperative pain and prevention of chronic persistent pain in total knee arthroplasty (TKA) remain a challenge. The main hypothesis was that nerve blocks improve postoperative analgesia especially if perineural adjuvants are added. METHODS: Immediate postoperative pain (24 hours) was evaluated every hour in 639 patients using a verbal rating 11-point scale for patient self-reporting of pain (VRS-11). All patients received subarachnoid anesthesia and were randomly allocated in 8 groups: control group, epidural (EA) and single shots femoral (FNB) or adductor canal blocks (ACB), both with and without adjuvants: dexamethasone (+Dexa) or dexmedetomidine (+Dexm). Patients received intravenous analgesia (metamizole magnesium, dexketoprofen) and rescue analgesia when needed, intravenous (paracetamol and morphine) and/or regional (epidural boluses, femoral and sciatic nerve blocks). Demographics, orthopedic knee scores and adverse effects were also recorded. RESULTS: A45.2% of patients had no immediate postoperative pain (P=0.0001). Rescue analgesia was needed in 48.8% of patients (P=0.0001): control group 72.8% of patients, EA51.9%, FNB 40.0%, FNB+Dexa 33.3%, BNF+Dexm 41.3%, ACB 51.9%, ACB+Dexa 38.3% and ACB+Dexm 61.5% respectively. There were also differences in the total postoperative time without pain (P=0.0001), with mild (P=0.0001) or moderate pain (P=0.001) but not with severe pain (P=0.119). CONCLUSIONS: Peripheral nerve blocks with perineural dexamethasone improve postoperative analgesia for TKA. The addition of dexamethasone to adductor canal block open new possibilities to improve analgesia for TKA, and should be investigated as an alternative to femoral nerve block.
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Botulinum Toxin Injections for Leg Contouring in East Asians
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Panniculectomy & Abdominoplasty CPG
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BACKGROUND: A common aesthetic concern among East Asian women is enlarged calves. Although surgical resection has been a traditional treatment option, botulinum toxin injections into the gastrocnemius muscle are an emerging, noninvasive alternative. OBJECTIVE: To perform a literature review on botulinum toxin injections for leg contouring. MATERIALS AND METHODS: A literature review was conducted using PubMed, Web of Science, Embase, and Cochrane's CENTRAL database to identify articles relating to combinations of the terms botulinum toxin, gastrocnemius, calves, and leg contouring. RESULTS: Based on the limited publications to date, the authors prepared a review on how to treat an enlarged calf with botulinum toxin including injection techniques, anticipated efficacy, outcome monitoring, and potential side effects. CONCLUSION: Botulinum toxin injections for calf reduction are an emerging, noninvasive treatment option. Studies to date suggest that it is an efficacious method with few immediate side effects. Future areas for investigation include defining the criteria for calf hypertrophy, minimum effective dosage of botulinum toxin, and the potential long-term effects of injections.
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Periocular basal cell carcinoma: 5-year outcome following Slow Mohs surgery with formalin-fixed paraffin-embedded sections and delayed closure
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Reconstruction After Skin Cancer
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AIM: The aim of the study was to determine the 5-year outcome of periocular basal cell carcinoma (BCC) managed by Mohs surgery using formalin-fixed, paraffin-embedded sections (Slow Mohs). METHODS: This was a prospective, non-comparative, interventional case series of all patients with periocular BCC treated by Slow Mohs in Newcastle upon Tyne, UK, between 1985 and 1999. Data collected included demographic information, indication for Slow Mohs, tumour site, histology, recurrence rate after 5 years and cosmetic outcome. RESULTS: Of 287 BCCs in 278 patients, 5-year follow-up data were available for 173 (60.2%). Recurrence following Slow Mohs occurred in one patient: 0.34% of total and 0.58% of those with 5-year follow-up. The main indication for Slow Mohs was most frequently due to the tumour site. Cosmetic outcome was deemed excellent in 56%, good in 18%, adequate in 8%, unknown in 14% and revision advised in only 4%. CONCLUSION: The low 5-year recurrence rate (0.58%) reported in this prospective series confirms the importance of margin-controlled removal of recurrent, poorly defined or critically sited BCCs, and illustrates that Slow Mohs is equivalent to standard Mohs. While delayed closure does not appear to compromise cosmetic outcome, this technique offers a histologically superior and cheaper alternative to frozen-section Mohs surgery.
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Tissue engineering for anterior cruciate ligament reconstruction: a review of current strategies
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BMAC (Bone Marrow Aspirate Concentrate)
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The anterior cruciate ligament (ACL) is one the most commonly injured ligaments of the knee. Chronic ACL insufficiency can result in episodic instability, chondral and meniscal injury, and early osteoarthritis. The intra-articular environment of the ligament precludes normal healing and surgical replacement of the injured ligament is often mandated to restore stability. Current surgical strategies include the use of local autograft or allograft tissues for ligament reconstruction. These procedures have yielded superior long-term clinical results yet have the potential for serious associated morbidities. Existing limitations have prompted ongoing research designed to engineer a replacement ligament that will parallel the native ACL in both its biologic properties and mechanical durability. Ligament engineering necessitates the use of appropriate source cells and a growth matrix to support cell proliferation and collagen synthesis. The identification of appropriate growth modulators including both biochemical factors and mechanical stimuli are requisites for successful tissue growth. The characterization of the elements essential for successful graft development represents a significant challenge for investigators. This review examines the current literature regarding the potential and limitations of ligament engineering and describes the development of a novel 3-dimensional scaffold and bioreactor system at our institution. [References: 94]
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Steroid sulfatase, arylsulfatases A and B, galactose-6-sulfatase, and iduronate sulfatase in mammary cells and effects of sulfated and non-sulfated estrogens on sulfatase activity
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Reduction Mammoplasty for Female Breast Hypertrophy
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Sulfatase enzymes have important roles in metabolism of steroid hormones and of glycosaminoglycans (GAGs). The activity of five sulfatase enzymes, including steroid sulfatase (STS; arylsulfatase C), arylsulfatase A (ASA; cerebroside sulfatase), arylsulfatase B (ASB; N-acetylgalactosamine-4-sulfatase), galactose-6-sulfatase (GALNS), and iduronate-2-sulfatase (IDS), was compared in six different mammary cell lines, including the malignant mammary cell lines MCF7, T47D, and HCC1937, the MCF10A cell line which is associated with fibrocystic disease, and in primary epithelial and myoepithelial cell lines established from reduction mammoplasty. The effects of estrogen hormones, including estrone, estradiol, estrone 3-sulfate, and estradiol sulfate on activity of these sulfatases were determined. The malignant cell lines MCF7 and T47D had markedly less activity of STS, ASB, ASA, and GAL6S, but not IDS. The primary myoepithelial cells had highest activity of STS and ASB, and the normal epithelial cells had highest activity of GALNS and ASA. Greater declines in sulfatase activity occurred in response to estrone and estradiol than sulfated estrogens. The study findings demonstrated marked variation in sulfatase activity and in effects of exogenous estrogens on sulfatase activity among the different mammary cell types.
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Experience of valgus osteotomy for neglected and failed osteosynthesis in fractures neck of femur
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DoD SSI (Surgical Site Infections)
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PURPOSE: There is vast literature supporting valgus osteotomy in fracture neck of femur. However, little or no distinction has ever been made to evaluate the success of the procedure in these two different scenarios-non-unions due to failed osteosynthesis and neglected fractures neck of femur. The aim of our study was to compare the results of valgus osteotomy in neglected neck femur fractures and non-union fractures of neck of femur.
METHODS: This is a single tertiary centre-based retrospective study. The records of all patients aged less than 45 years who underwent valgus osteotomy for neck of femur fractures from 2012 to 2017 were evaluated. Patients with fracture neck of femur of over one month's duration, where no previous surgical intervention was undertaken were placed in neglected fracture group. Patients with failed primary osteosynthesis surgery, either cannulated cancellous screw or dynamic hip screw, were placed in fixation failure group. There were 23 patients in neglected group and 17 patients in fixation failure group. Demographical details, fracture patterns, and preoperative radiograph, surgery time, blood loss, post-operative complications, union time, and non-unions were studied in both groups.
RESULTS: Osteotomy site united in mean time of 11 weeks in fixation failure group and 11.3 weeks in neglected group (p = .434). Time to radiological union of fracture was 16 weeks (12-23 weeks) for neglected fracture group compared to 25 weeks (20-32 weeks) for fixation failure group which was statistically significant (p = .02). Seven out of 17 fractures did not unite in fixation failure group compared to one non-union out of 23 patients in neglected group. (p = .004) There were two loss of fixation with implant failure in fixation failure group compared to none in neglected group (p = .174). Neither of the groups had any surgical site infection.
CONCLUSION: Valgus osteotomy results in excellent union rates for neglected fractures of neck of femur. However, the union rates of valgus osteotomy are lower in neck femur fractures with failed implants compared to neglected fractures and the procedure should be cautiously used in such circumstances.
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Hospitalized patients' views on in-ward psychological counseling
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DoD PRF (Psychosocial RF)
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This qualitative study explores the feelings and beliefs of patients hospitalized in an orthopedic rehabilitation ward for receiving psychological help in that setting. Semi-structured interviews with 10 hospitalized patients were audiotaped, transcribed verbatim, and analyzed using interpretative phenomenological analysis (IPA). Themes of an approach-avoidance conflict towards receiving psychological help were identified, some of them unique to the hospital setting. Approach tendencies were associated with high psychological distress, awareness of free accessibility, and beliefs in body-mind relationship. Avoidance tendencies were associated with fears of psychotherapy, misconceptions, and perceived threats to one's independence and self-esteem. The implications of these findings for the provision of psychological counseling in hospital settings are discussed.
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Is ACL reconstruction only for athletes? A study of the incidence of meniscal and cartilage injuries in an ACL-deficient athlete and non-athlete population: an Indian experience
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AMP (Acute Meniscal Pathology)
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While anterior cruciate ligament (ACL) reconstruction is readily offered to athletes, non-athletes are often treated conservatively. We carried out a retrospective, cross-sectional analysis study to compare the incidence of meniscal and cartilage injuries in an athlete and non-athlete population in relation to time of presentation since injury. The results were used to assess the need and relevance of ACL reconstruction in the non-athlete population. The study included 1375 patients who underwent ACL reconstruction between 1998 and 2004. These patients were initially broadly divided into two categories: athletes (575) and non-athletes (800). Each category was then sub-divided into four subgroups based on time elapsed between the injury and presentation at our clinic (Group A, 3 months; Group B, 3-12 months; Group C, 1-3 years; Group D, more than 3 years). Arthroscopic findings were documented for medial and lateral meniscus and cartilage injuries, and comparisons were made between the incidence of associated injuries in the corresponding groups. There was a statistically significant increase in the incidence of meniscal injuries and cartilage injuries after 1 year in both the groups. There was no difference in the incidence of meniscal and cartilage injuries in athletes and non-athletes among the corresponding groups. (chi-square test, p = 0.05). These results demonstrate that both athletes and non-athletes are equally susceptible for long-term meniscal and cartilage injuries if ACL reconstruction is not carried out early.
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Functional assessment of tissue-engineered meniscal cartilage by magnetic resonance imaging and spectroscopy
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AMP (Acute Meniscal Pathology)
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A perfusion bioreactor system was used to grow bioartificial meniscal cartilage tissue in vitro. Magnetic resonance imaging and magnetic resonance spectroscopy methods were used to characterize the flow and perfusion profiles and the growth, distribution, and bioenergetics of the fibrochondrocytes in the resulting constructs. These measurements were correlated with each other and with subsequent histologic analysis. The study has demonstrated that these noninvasive magnetic resonance methods will be useful for designing bioreactor operation strategies and cell scaffolds that lead to the production of tissue-engineered meniscal cartilage constructs with properties resembling those of the native tissue.
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Lower eyelid reverse ptosis repair
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Upper Eyelid and Brow Surgery
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PURPOSE: To report the results of the surgical repair of lower eyelid reverse ptosis. METHODS: Retrospective case series. Eight patients ranging in age from 31 to 77 years underwent surgical repair of lower eyelid reverse ptosis. The pupillary axis of the affected eye(s) in each patient was obscured in downgaze, interfering with reading. The lower eyelid reverse ptosis resulted from involutional changes in 3 patients, previous orbital decompression in 3 patients, multiple prior retinal and extraocular muscle operations in 1 patient, and previous orbital floor fracture and repair in 1 patient. Transcutaneous advancement of the lower eyelid retractors was performed in 12 eyelids of the 8 patients. RESULTS: The mean preoperative vertical eyelid fissure was 6.2 mm (median, 6 mm; range, 3-9 mm), increasing after surgery to a mean of 7.7 mm (median, 8 mm; range, 5-11 mm). The mean preoperative distance between the central light reflex and the lower eyelid margin was 1.7 mm (median, 1.25 mm; range, 1-4 mm); this distance increased to a mean of 3.3 mm (median, 3.25 mm; range, 2.5-4.5 mm) after surgery. Symptoms improved in all patients, and there were no perioperative complications. Follow-up intervals ranged from 2 months to 24 months (mean, 9 months; median, 13 months). CONCLUSIONS: Analogous to upper eyelid ptosis repair by advancement of the levator aponeurosis, lower eyelid reverse ptosis may be corrected effectively and safely by advancing the lower eyelid retractors.
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Detection of extraosseous metastases from osteosarcoma with (99m)Tc polyphosphate bone scanning
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MSTS 2018 - Femur Mets and MM
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Two cases of osteosarcoma of the femur are presented. In both patients, bone scans confirmed the presence of pulmonary metastases. (99m)Tc polyphosphate (TcPP) localizes in the extraskeletal pulmonary metastases, including some not demonstrated radiographically. Thus the TcPP scan is a valuable adjunct in the staging and therapeutic planning of patients with primary malignant bone tumors.
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Failure of the gamma nail in a highly unstable proximal femur fracture: report of four cases encountered in The Netherlands
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Management of Hip Fractures in the Elderly
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Static forces of body weight and dynamic forces induced by walking are a challenge toward lasting fixation devices in the case of unstable peritrochanteric fractures. Experiences with the newly developed gamma nail internal fixation technique are promising. The fixation is stable, complication rates are low, and fractures of the gamma nail itself have not been reported before. From the Dutch experience, the authors describe the four known cases of implant failure. In cases in which the process of bony healing is disturbed, the dynamic stresses during ambulation become large enough to cause metal fatigue fractures. In these cases adjuvant and appropriate measures should be undertaken
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Effects of epinephrine in local anesthetic mixtures on hemodynamics and view quality during knee arthroscopy
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Surgical Management of Osteoarthritis of the Knee CPG
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We compared three different methods of anesthesia for outpatient knee arthroscopy in terms of perioperative surgical conditions, pain, and hemodynamics. In a prospective and double-blind study ( n=130) the patients were randomized into three groups. A 50-ml mixture composed of 20 ml 0.5% bupivacaine hydrochloride, 10 ml 2% lidocaine hydrochloride, and 20 ml 0.9% sodium chloride was prepared for local anesthesia. The knee joint was injected with 40 ml of the mixture. The portal sites were then injected with 10 ml of the mixture in group I. Using the same technique 250 micro g epinephrine was added to the same mixture in group II. In group III the knee joint was injected with 40 ml of the mixture, and only 50 micro g epinephrine was then added to 10 ml of the mixture left before the portal site injections. A tourniquet was not used. There were some statistically significant changes in hemodynamic data. Also the data on visual analogue scale scores, time of arthroscopy, and amount of liquid used for intra-articular flushing in group II and III were significantly lower than those in group I. According to our experience, bleeding in arthroscopy comes mostly from portal incision to intra-articular field, except when performing extensive synovial shaving, ligament reconstruction, and lateral retinacular release. Therefore, when hemostasis is obtained at portals, the arthroscopic view becomes clearer. We think that adding epinephrine to only portal site injections is sufficient to obtain a clear view and, furthermore, when carrying out arthroscopy in this manner, no significant changes are encountered in heart rate, mean arterial pressure, pain during arthroscopy, or time of arthroscopy
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Examination of concomitant glenohumeral pathologies in patients treated arthroscopically for calcific tendinitis of the shoulder and implications for routine diagnostic joint exploration
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Glenohumeral Joint OA
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BACKGROUND: Glenohumeral exploration is routinely performed during arthroscopic removal of rotator cuff calcifications in patients with calcific tendinitis of the shoulder (CTS). However, evidence on the prevalence of intraarticular co-pathologies is lacking and the benefit of glenohumeral exploration remains elusive. The aim of the present study was to assess and quantify intraoperative pathologies during arthroscopic removal of rotator cuff calcifications in order to determine whether standardized diagnostic glenohumeral exploration appears justified in CTS patients.
METHODS: One hundred forty five patients undergoing arthroscopic removal of calcific depots (CD) that failed conservative treatment were included in a retrospective cohort study. Radiographic parameters including number/localization of calcifications and acromial types, intraoperative arthroscopic findings such as configuration of glenohumeral ligaments, articular cartilage injuries, and characteristics of calcifications and sonographic parameters (characteristics/localization of calcification) were recorded.
RESULTS: One hundred forty five patients were analyzed. All CDs were removed by elimination with a blunt hook probe via "squeeze-and-stir-technique" assessed postoperatively via conventional X-rays. Neither subacromial decompression nor refixation of the rotator cuff were performed in any patient. Prevalence of glenohumeral co-pathologies, such as partial tears of the proximal biceps tendon (2.1%), superior labral tears from anterior to posterior (SLAP) lesions (1.4%), and/or partial rotator cuff tears (0.7%) was low. Most frequently, glenohumeral articular cartilage was either entirely intact (ICRS grade 0 (humeral head/glenoid): 46%/48%) or showed very mild degenerative changes (ICRS grade 1: 30%/26%). Two patients (1.3%) required intraarticular surgical treatment due to a SLAP lesion type III (n = 1) and an intraarticular rupture of CD (n = 1).
CONCLUSIONS: Routine diagnostic glenohumeral exploration does not appear beneficial in arthroscopic treatment of CTS due to the low prevalence of intraarticular pathologies which most frequently do not require surgical treatment. Exploration of the glenohumeral joint in arthroscopic removal of CD should only be performed in case of founded suspicion of relevant concomitant intraarticular pathologies.
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0 |
Connections between the tendons of the musculus flexor digitorum profundus involving the synovial sheaths in the carpal tunnel
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
|
In the carpal tunnel anatomical interconnections between the tendons of the musculus flexor digitorum profundus are systematically present. These interconnections limit the mutual tendon displacements, which decreases finger independence and may be problematic in a musician's hand. The present study investigates a possible role of the synovial sheaths in the formation of these intertendinous connections in the carpal tunnel. To this end a morphological model is provided which correlates the often distinctly fibrous structure of the deep flexor tendons in the carpal tunnel and the frequent exchange of tendon fibres between the tendons to the different fingers, with the tendency of the synovial membranes to strongly adhere to the tendons. This model is validated by gross dissection results, and by cross sections of the flexor tendons in the carpal tunnel. In agreement with the model, the anatomic data show that the synovial membranes tend to invade and become trapped in tendons made up from individualised tendon strands, and also strongly adhere to the substantial amounts of tendon fibres which may be exchanged between the flexor tendons proximal to the lumbrical origins. These fibres and the synovial membranes may form a strong fabric able to withstand substantial stretching forces of interconnected oppositely pulled flexor tendons
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1 |
Anchor-line abdominoplasty: a comprehensive approach to abdominal wall reconstruction and body contouring
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Panniculectomy & Abdominoplasty CPG
|
BACKGROUND: Classic abdominoplasty leads to disappointing aesthetic results in patients with preexisting supraumbilical scars. Various techniques involving vertical and horizontal incisions have been described. The authors point out the validity of the "anchor-line" approach. METHODS: In a retrospective study, the authors reviewed the charts of 42 patients who underwent an anchor-line abdominoplasty between March of 1997 and March of 2003 at the Campus Bio-Medico University in Rome. The vascular anatomy of the abdominal wall was carefully reviewed, and they reported Huger's classification into three zones (zones I, II, and III). The third zone, which corresponds to the lateral areas of the abdomen, provides the vascular supply to the undermined abdominal wall flaps. Whenever this lateral vascularization is spared, there is no risk of skin necrosis. The anchor-line abdominoplasty implies the en bloc resection of a lower horizontal ellipsis plus an upper vertical triangle of abdominal skin and subcutaneous fat. The vertical triangle entails the supraumbilical scars. Plication of the rectus muscle sheath is always carried out. RESULTS: Follow-up ranged from 1 to 5 years. The following complications were seen: seroma (n = 3), anemia (n = 2), infection (n = 1), and minor skin necrosis (n = 1). CONCLUSION: The anchor-line technique, because of its easy execution, is a valid procedure in candidates for an abdominoplasty with supraumbilical median or paramedian scars.
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0 |
Bone metastases from differentiated thyroid carcinoma
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MSTS 2018 - Femur Mets and MM
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The presence of distant metastases from differentiated thyroid carcinoma decreases the 10-year survival of patients by 50%. Bone metastases represent a frequent complication especially of follicular thyroid cancer and severely reduce the quality of life causing pain, fractures, and spinal cord compression. Diagnosis is established by correlating clinical suspicion with imaging. Imaging is essential to detect, localize, and assess the extension of the lesions and should be used in conjunction with clinical evidence. Bone metastases are typically associated with elevated markers of bone turnover, but these markers have not been evaluated in differentiated thyroid cancer. Skeletal and whole-body magnetic resonance imaging and fusion 2-deoxy-2-[18F]fluoro-D-glucose whole-body positron emission tomography/computed tomography (PET/CT) are the best anatomic and functional imaging techniques available in specialized centers. For well-differentiated lesions, iodine-PET scan combined (124)I-PET/CT is the newest imaging development and (131)I is the first line of treatment. Bisphosphonates reduce the complications rate and pain, alone or in combination with radioiodine, radionuclides, or external beam radiotherapy and should be employed. Surgery and novel minimally invasive consolidation techniques demand an appropriate patient selection for best results on a multimodal approach. Basic research on interactions between tumor cells and bone microenvironment are identifying potential novel targets for future more effective therapeutic interventions for less differentiated tumors. [References: 128]
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1 |
Competitive swimmers with hypermobility have strength and fatigue deficits in shoulder medial rotation
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Trial Systematic Review Project
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Generalised Joint Hypermobility including shoulder hypermobility (GJHS) in swimmers is considered an intrinsic risk factor for shoulder injuries. The aim was to investigate the association of GJHS with shoulder strength, fatigue development and muscle activity during swimming-related shoulder rotations. Totally, 38 competitive swimmers (aged 13–17 years) participated, 19 were competitive swimmers with GJHS and 19 were age, sex and club matched swimmers without GJHS. Concentric isokinetic force in medial and lateral rotations were measured at 60°/s (5 repetitions) and 180°/s (10 repetitions). Electromyographic activity was measured from upper trapezius, lower trapezius, serratus anterior, infraspinatus and pectoralis major muscles. Swimmers with GJHS produced significantly lower peak torque (0.53 vs. 0.60 Nm/kg; p =.047) and maximum work (0.62 vs. 0.71 J/kg; p =.031) than controls during medial rotation (60°/s). Swimmers with GJHS showed significantly larger isokinetic fatigue at 180°/s (0.321 J/repetition; p =.010), and tendencies to lower levels of muscle activity in infraspinatus (20%, p =.066) and pectoralis major (34%, p =.092) at 60°/s during medial rotation. Young competitive swimmers with GJHS, despite no formal diagnosis, displayed strength and fatigue deficits in medial rotation, potentially inherent with greater risk of shoulder injury. Whether GJHS swimmers benefit from medial rotation strengthening is an important topic for future studies.
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0 |
Enzymatic and immunohistochemical evaluation of tyrosine phosphorylation in breast cancer specimens
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Reduction Mammoplasty for Female Breast Hypertrophy
|
Using a synthetic peptide substrate, tyrosine protein kinase (TPK) activity was measured in 21 tumors from patients with histologically confirmed breast cancer and in five normal breast tissues from patients undergoing reduction mammoplasty. In 20 of 21 cancer specimens, tumor was available to assess phosphotyrosine (PT) immunohistochemically. Breast cancer specimens possessed significantly more TPK activity than normal breast tissues (Cancer = 43.9 +/- 3.1 pm/mg protein/min, [Mean +/- S.E.M.]; Normal = 3.4 +/- 0.9, p < 0.001). TPK activity was higher in the clinically more aggressive infiltrating ductal cancers compared to the less aggressive intraductal cancers (Infiltrating = 55.9 +/- 5.8; Intraductal = 17.2 +/- 3.4, p < 0.01). TPK activity in tumors with both infiltrating and intraductal histology was intermediate (34.0 +/- 7.2). Significant correlation existed between membrane TPK enzymatic activity and PT expression by immunohistochemistry. There was no relationship between estrogen or progesterone receptor status and TPK activity or PT; however, TPK activity from node negative breast cancer tissue was significantly less than from node positive specimens (p < 0.01). We conclude that breast cancer specimens possess elevated amounts of TPK which correlate with PT expression, and that increased tyrosine phosphorylation appears to correlate with the biologic aggressiveness of the malignant tumor.
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0 |
What Is the Normal Ulnar Bow in Adult Patients?
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Distal Radius Fractures
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BACKGROUND: Rotation of the forearm is a result of the complex interaction among the radius, ulna, and interosseous membrane. Although the radius is recognized as curved, the ulna is generally thought of as a "straight bone." To better describe normal anatomy, which may lead to more successful anatomic fixation of forearm fractures, we aimed to apply a method of measuring the normal ulnar bow and determine the mean ulnar bow in adults., QUESTIONS/PURPOSES: (1) To what degree is the ulna bowed in the coronal and sagittal planes in normal adult forearms? (2) To what degree is the radius bowed in the coronal plane in normal adult forearms?, METHODS: Radiographs of the forearms of adults taken during a 1-year period were initially obtained retrospectively. These radiographs were performed for various reasons, including forearm pain and routine radiographic follow-up. Radiographs were excluded if evidence of a fracture or post-fracture fixation was found, if a patient had missing AP or lateral images, or if a suboptimal technique was used. The coronal and sagittal bow of the ulna was measured with a method adapted from previous studies that assessed radial bow using AP and lateral radiographs, respectively. Similar measurements were made in the coronal plane for the radius. All measurements were performed independently by the four authors. There was excellent interobserver reliability for ulnar bow in the coronal and sagittal planes (interclass correlation coefficient = 0.96 and 0.97, respectively) and for radial bow in the coronal plane (interclass correlation coefficient = 0.90)., RESULTS: The mean maximal coronal ulnar bow was 7 +/- 2 mm and was located at 75% of the ulnar length, measured proximally to distally. The location of coronal bow was consistently distal to the radial bow location. The mean maximal sagittal ulnar bow was 6 +/- 3 mm and was located at 39% of the ulnar length. The mean maximal coronal bow of the radius was 14 +/- 2.0 mm and was 59% of the total length of the radius from proximal to distal., CONCLUSIONS: The ulna is not a "straight bone," as is commonly thought, but rather has a bow in both the coronal and sagittal planes., CLINICAL RELEVANCE: Knowledge of the standard ulnar bow may be pivotal to prevent malunion of the ulna during surgery. Future research using these data in preoperative planning may lead to changes in plate contouring and clinical outcomes in forearm fracture management.
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0 |
Non-skeletal determinants of fractures: the potential importance of the mechanics of falls. Study of Osteoporotic Fractures Research Group
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Management of Hip Fractures in the Elderly
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Bones break because the forces applied to them exceed their strength. For most non-spine fractures, this force results from a fall. Falls generate at least 10 times the energy necessary to fracture the proximal femur, but only 5%-10% of falls in older white women cause fractures and only 1% cause hip fractures. The mechanics of the fall plays a very important role in whether a fracture will occur and which bone will fracture. This review postulates that orientation of the fall and location of the impact determine the type of fracture, and whether a fracture occurs depends on the energy of the fall (distance to impact and weight of the moving parts) and how much of that energy is absorbed by protective responses, the impact surface and soft tissues over the bone. Recent case-control studies support the view that the mechanics of a fall are the most important determinant of whether it will result in a hip fracture
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0 |
Stepping strategy used to recover balance during an induced fall is associated with impaired function and strength in people with knee osteoarthritis
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OAK 3 - Non-arthroplasty tx of OAK
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AIM: We investigated differences in function, strength and pain in those with knee osteoarthritis (OA) who responded with a single step compared to multiple steps during balance recovery during an induced forward fall.
METHOD: The stepping response of 24 participants with knee OA (50% female, age 68.6 +/- 6.2 years) as they recovered balance from an induced forward fall was recorded. Participants were grouped based on their stepping response as single-stepper and multi-stepper. Comparison was made between the groups for functional and strength tests and self-reported pain, function, quality of life, fear of falls and physical activity.
RESULTS: Fourteen of the participants (58%) responded with a multiple step response. Multiple steppers demonstrated greater time for the up and go (P = 0.01), the stair climb tests (P = 0.05), as well as reduced distance during the 2 min walk test (P = 0.001) and reduced isokinetic knee extension strength (P = 0.02).
CONCLUSION: Those who demonstrated multiple step response had impaired function, reduced strength and were less physically active. Given the high prevalence of falls in people with knee OA, further studies are required to better understand the ability of people with knee OA to respond and avoid falls.
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0 |
Distally Based Sural Adipofascial Turnover Flap for Coverage of Complicated Wound in the Foot and Ankle Region
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DoD SSI (Surgical Site Infections)
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BACKGROUNDS: Distally based perforator propeller flap from the lower leg region is a versatile local reconstructive technique for the foot and ankle defects. However, flap venous congestion remains a tough nut to crack. We hypothesize that raising an adipofascial flap with turnover mode of transposition can improve venous drainage and enhance flap safety.
METHODS: Based on the 2 rows of septocutaneous perforators in the posterior distal third of the lower leg, distally based adipofascial flap was raised from medial sural region nourished by 1 perforator bundle from the posterior tibial artery or from the lateral sural region from the peroneal artery. The superficial dissection was performed in subdermal plane and deep in to the subfascial space. The flap was nourished by perforator-plus-adipofascial pedicle and turned over 180 degrees upside down to reach the distal wounds. One week later, a split-skin graft was used to cover the exposed fascial flap. Postoperatively, flap survival, complications, and patient functional recovery were evaluated.
RESULTS: Distally based sural turnover adipofascial flaps were used in 12 cases with complicated wounds of the distal third lower leg, foot, and ankle region. All wounds were caused by trauma and experienced fracture implants fixation and 5 with osteomyelitis. The comorbidities include diabetes in 9 cases and smoking in 7. There were 8 medial ural flaps and 4 lateral sural flaps. The adipofiscial flaps measured from 6.0 cm x 5.0 cm to 17.0 cm x 6.0 cm (mean, 61.3 cm). Postoperatively, all flaps survived uneventfully without any complication such as flap ischemia and/or necrosis. Two minor donor site complications were encountered, one was postoperative hematoma, and another was hyperproliferative scar. After a mean of 14.6 months of follow-up, the adipofascial flap plus skin graft showed a durable esthetic coverage, with normal shoe wearing and walking.
CONCLUSIONS: Distally based sural adipofascial turnover flap is a simple and reliable wound coverage technique. It avoids venous congestion as usually seen in distally based fasciocutaneous flaps.
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0 |
Prevalence of Osteoporosis During Long-Term Androgen Deprivation Therapy in Patients with Prostate Cancer
|
MSTS 2018 - Femur Mets and MM
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Objectives: To know the prevalence of osteoporosis in patients with prostate cancer according to the duration of androgen deprivation therapy (ADT). Methods: Dual energy x-ray absorptiometry was used to assess the bone mineral density (BMD) at the lumbar spine, femoral neck, Ward's triangle, trochanter, and total hip in 390 patients free of bone metastases. Osteoporosis was diagnosed if a T-score of less than 2.5 was detected at any measurement site. A subset of 124 patients were hormone naive at BMD testing, and 112 had undergone ADT for 2 years, 61 for 4 years, 37 for 6 years, 35 for 8 years, and 21 for 10 years or longer. Results: The osteoporosis rate was 35.4% in hormone-naive patients, 42.9% after 2 years of ADT, 49.2% after 4 years, 59.5% after 6 years, 65.7% after 8 years, and 80.6% after 10 or more years. Conversely, the rate of normal BMD decreased from 19.4% in hormone-naive patients to 17.8% after 2 years of ADT, 16.4% after 4 years, 10.8% after 6 years, 5.7% after 8 years, and 0% after 10 or more years of ADT. Conclusions: The prevalence of osteoporosis seemed high in hormone-naive patients with prostate cancer, and it increased to more than 80% after 10 years of ADT. Because of the increased risk of bone fractures in those patients, clinicians should be aware of the impact of ADT on BMD to prevent bone mass loss. © 2007 Elsevier Inc. All rights reserved.
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0 |
(Mis)understanding in patient-health care provider communication about total knee replacement
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Surgical Management of Osteoarthritis of the Knee CPG
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Objective. To examine whether communication factors affect health care provider and patient agreement on the need for, risks of, and benefits of joint replacement, and also whether degree of agreement predicts patient satisfaction and intent to follow treatment recommendations. Methods. Health care providers (n = 27) and patients (n = 74) with severe osteoarthritis (OA) were recruited from clinics in Houston, Texas. Patients completed a baseline survey prior to the consultation. After the visit, patients and providers completed measures of the severity of the patient's OA, the expected benefits of total knee replacement (TKR), and concern about surgical complications. Patients also completed satisfaction and intent to adhere measures. Provider communication and patient participation were measured by patient self-report and by observers' codings of audiorecordings of the consultations. Results. Provider-patient agreement was modest to poor regarding severity of the patient's OA and the expected benefits and risks of TKR. Providers and patients were more aligned on the patient's OA severity when providers used more partnership building but spent less time simply giving information. Differences between providers' and patients' concerns about surgery were greater when patients were less participatory, African American, or expressed lower trust in their doctors. Patient satisfaction and intent to adhere were predicted by provider-patient agreement on the benefits of TKR. Conclusion. Patients and providers often differ in their beliefs about the need for, risks of, and benefits of TKR, and these differences can affect patient satisfaction and commitment to treatment. Facilitating active patient participation might contribute to greater physician-patient agreement on the patient's concerns about OA and surgical interventions. (copyright) 2009, American College of Rheumatology
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1 |
An iliopsoas plane block does not cause motor blockadeââ?¬â?쳌A blinded randomized volunteer trial
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AAHKS (9/10) Regional Nerve Blocks
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Background: A femoral nerve block relieves pain after total hip arthroplasty, but its use is controversial due to motor paralysis accompanied by an increased risk of fall. Assumedly, the iliopsoas plane block (IPB) targets the hip articular branches of the femoral nerve without motor blockade. However, this has only been indicated in a cadaver study. Therefore, we designed this volunteer study. Methods: Twenty healthy volunteers were randomly allocated to blinded paired active vs. sham IPB (5Ã? mL lidocaine 18Ã? mg/mL with epinephrine vs saline). The primary outcome was reduction of maximal force of knee extension after IPB compared to baseline. Secondary outcomes included reduction of maximal force of hip adduction, and the pattern of injectate spread assessed with magnetic resonance imaging. Results: Mean (confidence interval) change of maximal force of knee extension from baseline to after IPB was âË?â??9.7Ã? N (âË?â??22, 3.0) (PÃ? =.12) (nÃ? =Ã? 14). The injectate was consistently observed in an anatomically wellâ?defined closed fascial compartment between the intraâ? and extraâ?pelvic components of the iliopsoas muscle anterior to the hip joint. Conclusion: We observed no significant reduction of maximal force of knee extension after an IPB. The injectate was contained in a fascial compartment previously shown to contain all sensory branches from the femoral nerve to the hip joint. The clinical consequence of selective anesthesia of all sensory femoral nerve branches from the hip could be a reduced risk of fall compared to a traditional femoral nerve block. Registration of Trial: The trial was prospectively registered in EudraCT (Reference: 2018â?000089â?12, https://www.clinicaltrialsregister.eu/ctrâ?search/search?query=2018â?000089â?12).
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0 |
Magnetic resonance imaging of musculoskeletal injuries
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AMP (Acute Meniscal Pathology)
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Magnetic resonance (MR) imaging has been applied toward the assessment of a wide spectrum of injuries to the musculoskeletal system. This use of MR imaging has been enthusiastically accepted by orthopedic surgeons, and the assessment of musculoskeletal trauma has emerged as one of the most commonly utilized applications of this diagnostic method. This article encompasses the major applications of MR imaging in the assessment of injuries to bone and soft tissue. Emphasis is placed on the most commonly encountered conditions, namely, those that are accidental, exercise-, and sports-related. Technical considerations as they pertain to the design and interpretation of trauma-related musculoskeletal MR imaging are addressed.
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0 |
Knee osteoarthritis: hyaluronic acid, platelet-rich plasma or both in association?
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PRP (Platelet-Rich Plasma)
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INTRODUCTION: Bidirectional interactions between cells and fluidic surroundings regulate cellular functions and maintain tissue or organ architecture. Accordingly, the synovial fluid is the primary source of environmental signals and determines to a great extent the molecular interactions within the joint capsule, both in homeostasis and pathology.
AREAS COVERED: We provided an update on hyaluronic acid (HA) and platelet-rich plasma (PRP) concepts necessary to build the rationale for creating a combined treatment. The information is based on a PubMed search using the terms 'platelet-rich plasma', 'hyaluronic acid', 'knee pathology', 'knee osteoarthritis' (OA).
EXPERT OPINION: In OA, a deleterious fluidic microenvironment is established, with presence of HA fragments, catabolic enzymes and inflammatory molecules. The central concept underlying intra-articular injection is to modify deleterious fluidic microenvironments. PRP administration has shown pain remission and function improvement, but less than half of the patients showed clinically significant improvement. PRP exceeds HA, the comparator used in PRP clinical trials, albeit both HA and PRP alleviate symptoms in mild-to-moderate OA patients. Combining PRP and HA may benefit from their dissimilar biological mechanisms and help in controlling delivery and presentation of signaling molecules. Three armed randomized studies, using both HA and PRP as comparators, will provide information about the impact of this approach.
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0 |
The epidemiology of humeral shaft fractures
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The Treatment of Pediatric Supracondylar Humerus Fractures AUC
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We have analysed 249 consecutive fractures of the humeral shaft treated over a three-year period. The fractures were defined by their AO morphology, position, the age and gender of the patient and the mechanism of injury. Open fractures were classified using the Gustilo system and soft-tissue injury, and closed fractures using the Tscherne system. The fractures were classified as AO type A in 63.3%, type B in 26.2% and type C in 10.4%. Most (60%) occurred in the middle third of the diaphysis with 30% in the proximal and 10% in the distal third. The severity of the fracture and soft-tissue injury was greater with increasing injury severity. Less than 10% of the fractures were open. There was a bimodal age distribution with a peak in the third decade as a result of moderate to severe injury in men and a larger peak in the seventh decade after a simple fall in women
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0 |
Motivators for and barriers to physical activity in people with knee osteoarthritis: A qualitative study
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OAK 3 - Non-arthroplasty tx of OAK
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Objectives: We aimed to explore the motivators for and barriers to regular physical activity in people with knee osteoarthritis. Methods: We performed a cross-sectional, monocentric qualitative study based on 20 semi-structured individual interviews and two focus groups. People with knee osteoarthritis according to American College of Rheumatology criteria were recruited from spa therapy resorts (Royat, France). Data were collected by interviews, which were then transcribed and coded. The analysis was performed according to the researcher triangulation method. Results: Among the 27 participants (17 women), the mean age was 67 years (SD 7.8) and mean body mass index 29.2 kg/m2 (SD 8.2). The motivators for physical activity were physical (well-being, decreased pain, self-perception), personal (lifestyle, psychological well-being), societal (relationships, othersâ?? views), and environmental (living). The motivators differed by gender, with the concept of performance predominant for men and othersâ?? views for women. The barriers were psychological (fear of pain, lack of motivation) and physical (knee pain, asthenia) and were also potentially related to life events (depression, hospitalization). Conclusions: The study population had an overall positive idea of the value of physical activity for knee osteoarthritis. The participants expressed beliefs and knowledge generally in line with current recommendations. Compliance with these recommendations remains moderate. An educational support for progressive adapted physical activity and identification of barriers and motivators could help improve adherence.
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0 |
Ganglion Cyst of Knee from Hoffa's Fat Pad Protruding Anterolaterally Through Retinacular Rent: A Case Report
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PJI DX Updated Search
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INTRODUCTION: Intra-articular ganglion cysts of the knee joint are rare occurrences. They are usually encountered as incidental findings in magnetic resonance imaging (MRI), or in arthroscopy. They may originate from both the cruciate ligaments and the menisci, from the popliteus tendon and alar folds, infrapatellar fat pad of Hoffa, and subchondral bone cysts. Those arising from the Hoffa's fat pad, usually present as palpable mass at anterior aspect of the knee joint. We report a case of intraarticular ganglion cyst of knee arising from the infrapatellar fat pad and protruding anterolaterally through retinacular rent into the subcutaneous plane. CASE REPORT: A 19-year-old young man, presented with a painless gradually increasing swelling at the anterior aspect of left knee of 9 months duration. MRI scan revealed a multilobulated, cyst with septations within the anterior aspect of the knee joint, just inferolateral to the patella, with deep extension into the infrapatellar fat pad, and superficial extension into the subcutaneous space across the retinaculum. After diagnostic arthroscopy, we performed an open excision of the cystic mass and confirmed the retinacular rent pre-operatively. CONCLUSION: Arthroscopic resection and debridement is the gold standard treatment in ganglion cyst of the knee. However, a subcutaneous extension may lead to incomplete arthroscopic resection: Leaving behind the residual tissue which may cause recurrence. Therefore, proper pre-operative evaluation of MR images of these cases is very important
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0 |
Effect of prosthesis selection on flexion-extension function after total knee arthroplasty
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Surgical Management of Osteoarthritis of the Knee CPG
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Background: With the development of new materials and the improvement of prosthesis design, total knee arthroplasty(TKA), a commonly used surgery, has exhibited satisfying effect on the treatment of rheumatoid arthritis and osteoarthrosis. However, many problems still remain a headache to operation performers. Objective: To discuss how to select the prosthesis for total knee replacement and to summarize the key factors that affect the curative effect. Design: A controlled study of the effect before and after the operation. Setting: Department of Orthopedics, First Hospital of Xi'an Jiaotong University. Participants: Thirty-six patients (24 males and 12 females) who received TKA in the Department of Orthopaedics, First Hospital of Xi'an Jiaotong University during February 2000 to September 2003 were included in this study. Methods: A retrospective study was carried out. Thirty-six patients (48 knees) underwent total knee replacement, and the knee joint function was evaluated with American John N Install scoring system. The post-operation effect was evaluated by comparing the scores of each diseased knee before and after the operation. Main outcome measures: The function of knees and the score of every knee before and after operation were evaluated. Results: The mean score before operation was 39, but it was 85 after follow-up visit. Totally 95% of them were up to the standard. The pain was reduced after the operation. The flexion-extension function and mobility of the knee joints improved obviously. Conclusion: TKA with posterior stabilized prosthesis and resection of posterior cruciate ligament(PCL) improved the function of the diseased knees after the operation. And the operation was simple and without complications. The key factors that affect the curative effect include the mechanical balance of the soft tissues during the operation, perioperative anticoagulant treatment for the prevention of deep vein thrombosis(DVT) and postoperative rehabilitation training. Peripheral tissue of knee joints should be released adequately; otherwise, it may cause unstable joint or limitation of joint activity
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0 |
Wind swept elbow: injury pattern and reconstruction
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Distal Radius Fractures
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Sweeping injuries of the elbow characterized by traumatic loss of medial or lateral epicondyles, collateral ligaments, and surrounding soft tissue result in loss of joint stability. Reconstruction of medial or lateral collateral ligaments is challenging due to loss of the cortical bone and the resultant difficulty in identifying the isometric attachment point. We describe a unique injury pattern and a surgical technique to restore joint stability using a bone tendon (Achilles) allograft. The technique was applied to 4 consecutive patients with a mean age of 35 (22-57) years and a mean follow-up of 20 months. Three patients with the lateral sweep injury had losses of the lateral epicondyle, lateral collateral ligament along with radial nerve palsy in 2. One patient with the medial sweep injury lost the medial epicondyle, medial collateral ligament, and had ulnar nerve palsy. All patients had an unstable ulnohumeral joint and underwent bone-tendon allograft (Achilles) reconstruction. The elbow joint was covered with a rotational radial forearm flap in 1 patient: myofasciocutaneous-free gracilis flap in 1 and rotational fasciomyocutaneous latissimus dorsi flap in 2 patients. One patient had an open reduction and internal fixation of distal third humerus shaft fracture, intercalary nerve grafting to the ulnar nerve, and repair of the brachial artery. At the final follow-up, average elbow motion was 115 degrees. Radiographic bone-to-bone healing was achieved in all patients. According to the American Shoulder and Elbow Surgeon's Assessment; average patient rated pain, function, and satisfaction scores were 3.4, 2.3, and 5, respectively. The average Disabilities of the Arm, Shoulder and Hand questionnaire score was 25. The use of bone-tendon allograft to reconstruct collateral ligaments of the elbow restored the elbow stability with a satisfactory functional outcome (evidence: level 4).
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0 |
Better late than never? Experience with intravenous pamidronate treatment in patients with low bone mass or fractures following cardiac or liver transplantation
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Management of Hip Fractures in the Elderly
|
Organ transplantation is associated with a high turnover of bone metabolism, and an increased loss of bone mass and incidence of osteoporotic fractures. Established therapies for osteoporosis after organ transplantation are still lacking, however. We report on an intravenous bisphosphonate therapy initiated in transplant patients because of a high rate of bone loss or incident osteoporotic fractures. Twenty-one patients after liver transplantation and 13 patients after heart transplantation received 30 mg pamidronate intravenously every 3 months, combined with 1000 mg calcium and 1000 IU vitamin D per day. The median time interval between transplantation and start of pamidronate treatment was 1.9 years in cardiac patients and 2.3 years in liver patients. Lumbar spine bone mineral density (LS BMD) and femoral neck BMD (FN BMD) were measured before and every 6 months after pamidronate therapy was initiated. Spinal radiographs were performed annually. Biochemical markers of bone metabolism were determined every 3 months, immediately before pamidronate administration. From a previous observational study, 58 patients treated only with calcium and vitamin D were matched for age, sex, pretransplantation LS BMD and time interval between transplantation and the first pamidronate treatment. In the pamidronate-treated patients, the mean increase in LS BMD adjusted for baseline values amounted to 0.080 +/- 0.038 g/cm(2) (8.6 +/- 4.0 %) after 1 year and 0.091 +/- 0.058 g/cm(2) (10.4 +/- 6.1%) after 2 years compared with 0.001 +/- 0.037 g/cm(2) (0.26 +/- 4.0%) after 1 year and 0.015 +/- 0.057 g/cm(2) (1.8 +/- 6.0%) after 2 years in the historical control group (absolute LS BMD changes pamidronate group vs historical group p < 0.0001 after 1 and 2 years). The changes of FN BMD were 0.024 +/- 0.043 g/cm(2) (3.2 +/- 6.1%) after 1 year and 0.046 +/- 0.052 g/cm(2) (7.0 +/- 6.1%) after 2 years in the pamidronate group compared with -0.012 +/- 0.043 g/cm(2) (-1.6 +/- 6.1%) after 1 year and -0.013 +/- 0.052 g/cm(2) (-1.1 +/- 6.1%) after 2 years in the historical control group (absolute FN BMD changes pamidronate group vs historical group p = 0.003 after 1 year and p = 0.001 after 2 years). From a total of 287 application cycles of pamidronate treatment, no severe side effects were observed and non-severe side effects were seen in only 39 cycles (13.6%). We conclude that cyclic intravenous pamidronate treatment is beneficial to patients with low bone mass or osteoporotic fractures following transplant, even when not immediately initiated
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1 |
Subchondral stem cell therapy versus contralateral total knee arthroplasty for osteoarthritis following secondary osteonecrosis of the knee
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BMAC (Bone Marrow Aspirate Concentrate)
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PURPOSE: Total knee arthroplasty (TKA) implanted in patients with secondary osteonecrosis (ON) related to corticosteroids have relatively poor outcome (20% revision rate) at a mean follow-up of only eight years. With the hypothesis that subchondral bone marrow injection might improve knees in these patients, we evaluated 30 patients who had bilateral knee osteoarthritis with severe joint space narrowing and received TKA in one knee and subchondral bone marrow concentrate injection in the contralateral knee.
MATERIAL AND METHODS: A prospective randomized controlled clinical trial was carried out in 60 knees of 30 patients (mean age 28 years, 18-41) who presented bilateral osteoarthritis secondary to knee ON related to corticosteroids in relation with different severe medical conditions. During the same anesthesia, one knee received TKA; for the other knee, a bone marrow graft containing an average of 6500 MSCs/mL (counted as CFU-F, range 3420 to 9830) was delivered to the subchondral bone of the femur and tibia. The length of anesthesia related to each procedure (bone marrow aspiration and subchondral injection of concentrated bone marrow versus total knee arthroplasty) was measured. Peri-operative outcomes, morbidity, complications, and safety of the two procedures were compared. Subsequent admissions for revision surgery were identified. At the most recent follow-up (average of 12 years, range 8 to 16 years), clinical outcomes of the patient (Knee Society score) were obtained along with radiological imaging outcomes (MRIs for knees with subchondral bone marrow injection).
RESULTS: Anesthesia related to the TKA side was longer than for the cell therapy group. Medical and surgical complications were more frequent after TKA. A higher number of thrombophlebitis was observed on the side with TKA (15%) versus none on the side with cell therapy (0%). At the most recent follow-up (average of 12 years, range 8 to 16 years), six (out of 30) TKA knees needed subsequent surgery versus only one with cell therapy. The Knee Score had improved and remained similar in the TKA and cell therapy groups (respectively 80.3 points +/- 11 versus 78.3 +/- 23); 21 patients preferred the knee with cell therapy and 9 preferred the knee with TKA. Knees with cell therapy had improvement on cartilage and bone marrow lesions observed at the site of bone marrow subchondral injection.
CONCLUSIONS: Subchondral autologous bone marrow concentrate was an effective procedure for treating young patients with knee osteoarthritis following secondary ON of the knee related to corticosteroids with a lower complication rate and a quicker recovery as compared with TKA.
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0 |
Hand rejuvenescence by fat filling
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Panniculectomy & Abdominoplasty CPG
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The advantages of fat filling for hand rejuvenescence are discussed. Seventy-two patients treated by this method are presented, including their follow-up, complication rate, and details of combined operations. Preference is given to local anesthesia when no other major surgeries are associated with the method. A highly satisfactory rate was obtained (98.62%) with a low complication rate (4.15%).
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1 |
The effects of resistance exercise in patients with knee osteoarthritis: a systematic review and meta-analysis
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OAK 3 - Non-arthroplasty tx of OAK
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OBJECTIVE: To analyze the effectiveness of resistance exercise in the treatment of knee osteoarthritis on pain, stiffness, and physical function.
DESIGN: Systematic review and meta-analysis of randomized controlled trials.
DATA SOURCES: PubMed, Embase, Cochrane Central Register of Controlled Trials, the Web of Science, and Chinese Biomedical Literature Database were searched from the date of inception to August 2015.
METHODS: Trials comparing effects of resistance exercise intervention with either non-intervention or psycho-educational intervention were selected by two reviewers independently. The risk of bias was assessed and studies with similar outcomes were pooled using a fixed or random effects model.
RESULTS: Data from 17 randomized clinical trials including 1705 patients were integrated. The main source of methodological bias in the selected studies was lack of double blinding. The meta-analysis results suggested that resistance exercise training relieved pain (standard mean difference [SMD]: -0.43; 95% confidence interval [CI]: -0.57 to -0.29; P < 0.001), alleviated stiffness (SMD: -0.31; 95%: CI -0.56 to -0.05; P = 0.02), and improved physical function (SMD -0.53; 95% CI: -0.70 to -0.37; P < 0.001).
CONCLUSION: Resistance exercise is beneficial in terms of reducing pain, alleviating stiffness, and improving physical function in patients with knee osteoarthritis.
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Comparison of an etiologic-based exercise and conventional strengthening exercises on knee loading in individuals with Knee osteoarthritis
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OAK 3 - Non-arthroplasty tx of OAK
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INTERVENTION: Intervention 1: intervention group: Patients will be treated for 4 weeks and 3 sessions per week by electrical stimulation, educational leaflet, continues ultrasoundtherapy, hot pack and strengthening training include flexion and extension exercise of knee joint. Intervention 2: intervention group: Patients will be treated for 4 weeks and 3 sessions per week by electrical stimulation, educational leaflet, continues ultrasoundtherapy, hot pack and etiologicâ?based exercise includes medial thrust gait and maintaining goddess and warrior postures. intervention group: Patients will be treated for 4 weeks and 3 sessions per week by electrical stimulation, educational leaflet, continues ultrasoundtherapy, hot pack and etiologicâ?based exercise includes medial thrust gait and maintaining goddess and warrior postures. intervention group: Patients will be treated for 4 weeks and 3 sessions per week by electrical stimulation, educational leaflet, continues ultrasoundtherapy, hot pack and strengthening training include flexion and extension exercise of knee joint. Treatment â? Other CONDITION: Knee osteoarthritis. ; Primary gonarthrosis, bilateral Primary gonarthrosis, bilateral PRIMARY OUTCOME: Knee joint loading. Timepoint: pre and post treatment and 1 month after treatment. Method of measurement: assesment of knee aduction moment by 3D motion analysis and force plate. SECONDARY OUTCOME: Functional activity. Timepoint: pre and post intervention and one month after intervention. Method of measurement: using of 2 minute walking test. Pain. Timepoint: study pre and post intervention and one month after intervention. Method of measurement: using of visual analogue scale and the short WOMAC scale. INCLUSION CRITERIA: INCLUSION CRITERIA: having mild to moderate chronic osteoarthritis of unilaterally or bilaterally tibiofemoral joint according to the method of Kellgren and Lawrance; 45â?76 years old; a history of symptoms more than a month; being able to walk without assistant devices; having the recent anterior and lateral xâ?ray image of knee. Exclusion criteria: Reporting other diseases such as: diabetes, diseases of musculoskeletal, neuromuscular and uncontrolled diseases of cardiovascular, respiratory and hypertension; the use of injections or other invasive treatments (such as surgery) in the lower extremities during the last three months; having an artificial hip or knee joints; taking painkiller; history of trauma to knee joint during last week; performing regular professional exercise; extreme physical weakness.
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1 |
Higher early mortality with simultaneous rather than staged bilateral TKAs: results from the Swedish Knee Arthroplasty Register
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Surgical Management of Osteoarthritis of the Knee CPG
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Patients with knee osteoarthritis (OA) often present with symptoms that warrant bilateral TKAs. There are potential benefits to operating on both knees on the same day, but the safety of simultaneous bilateral TKAs has been questioned. To evaluate whether there were any differences in 30-day mortality between patients having simultaneous bilateral TKAs and those having staged bilateral TKAs, we analyzed data from the Swedish Knee Arthroplasty Register and the Swedish Cause of Death Register. We included 48,931 patients with OA having 60,062 primary TKAs during 1985 to 2004; 1139 had surgery on both knees on the same day (simultaneous bilateral) and 3432 had surgery on both knees on two different occasions with less than 1 year between operations (staged bilateral). The 30-day mortality after simultaneous bilateral TKAs was 7.53 (confidence interval, 2.62-21.69) times higher than after the second of staged TKA and 3.77 (confidence interval, 2.04-6.98) times higher than after a primary unilateral TKA. Assuming the total risk for a staged procedure is twice that of a unilateral procedure, the risk of mortality within 30 days is 1.94 (confidence interval, 1.05-3.59) times higher with simultaneous than staged TKA. It is safer to operate on one knee at a time. Level of Evidence: Level II, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence
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0 |
Infective endocarditis caused by Streptococcus mutans
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Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures
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Members of the viridans group of streptococci are the commonest causes of bacterial endocarditis. However, Streptococcus mutans, a member of this group associated with dental caries which might be expected to be commonly associated with endocarditis, has only rarely been reported. This is possibly because of difficulties in isolation and identification. Differing blood culture media may affect the chances of isolation of these organisms, and, though brain-heart infusion, thiol, tryptic soy, and glucose-brain infusion broths have all proved satisfactory, subcultures may require increased CO2 concentrations for growth. Plemorphism in the resultant colonies and in the individual organisms may give rise to a hazardous misinterpretation of this appearance as contamination. Strep. mutans and the similarly penicillin sensitive Strep. bovis may be differentiated from the penicillin resistant enterococci by their lincomycin sensitivity and intolerance of 6-3 per cent sodium chloride. Precise differentiation of streptococci in bacterial endocarditis is of value both epidemiologically and in the management of the disease
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0 |
Oral hormone therapy with 17beta-estradiol and 17beta-estradiol in combination with norethindrone acetate in the prevention of bone loss in early postmenopausal women: dose-dependent effects
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Management of Hip Fractures in the Elderly
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OBJECTIVE: A 2-year multicenter, double-blind, randomized, placebo-controlled study examined the efficacy and safety of different doses of 17beta-estradiol (E(2)) alone and continuous-combined oral formulations of E(2) and norethindrone acetate (NETA) versus placebo in the prevention of bone loss in newly menopausal women.DESIGN: Patients were randomized to one of seven groups: placebo, E(2) 0.25 mg, E2 0.5 mg, E(2) 1 mg, E(2) 1 mg/NETA 0.25 mg, E(2) 1 mg/NETA 0.5 mg, or E(2) 2 mg/NETA 1 mg. Treatment was a once-daily tablet taken for 26 months. The primary efficacy endpoint was the change in bone mineral density (BMD) at the lumbar spine, measured by dual-energy x-ray absorptiometry, at screening and at 13, 19, and 26 months. BMD changes at the femoral neck and trochanter were also assessed. Biochemical markers of bone metabolism were measured at baseline, and at 3, 6, 13, 19, and 26 months. Histological diagnoses of endometrial samples were tabulated for each treatment group.RESULTS: A total of 327 women were randomized and 189 women completed the 2-year trial. BMD at the lumbar spine decreased 2.3% in the placebo group. The lowest dose of unopposed E(2) prevented bone loss at the spine and hip. Significant increases in spine BMD compared with placebo occurred in all groups of treatment with E(2) and were more pronounced in the combination groups. Compared with placebo, women receiving active treatment experienced greater reductions in bone resorption markers. The effects were evident by 6 months and generally remained stable thereafter. Adverse events, primarily associated with the endometrium, were the most common reasons for discontinuation.CONCLUSIONS: There is a dose-dependent effect of E(2) on BMD. The addition of NETA seems to enhance the response in BMD observed with E(2). Low doses of E(2) (1 mg and lower) can be considered for the prevention of osteoporosis, while titrating the hormone dose to individual patient's needs
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Cost-effectiveness analysis of hyalgan versus synvisc in the treatment of osteoarthritis
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Surgical Management of Osteoarthritis of the Knee CPG
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BACKGROUND: Osteoarthritis (OA) is the most common and costly form of arthritis. Treatment goals for OA are to reduce pain, maintain and/or improve joint mobility, and limit functional impairment. Nonsteroidal anti-inflammatory drugs (NSAIDs) are the most common pharmacological treatment for OA. Hyalgan (sodium hyaluronate) and Synvisc (hylan G-F20) are viscosupplements aimed to restore viscosity and elasticity of the synovial fluid. These agents are often used after NSAID treatment has failed and also to postpone the time a patient would undergo total knee replacement (TKR) surgery. For the standard course of therapy, Hyalgan costs less than Synvisc, which has fewer injections. OBJECTIVE: To evaluate the cost-effectiveness of Hyalgan compared to Synvisc in delaying the time to TKR surgery in patients with knee pain due to OA. METHODS: Using a societal perspective, a 5-year Markov model evaluated the treatment of knee pain due to OA and the progression to TKR surgery using Hyalgan versus Synvisc in a cohort of 1,000 hypothetical patients. A literature search was conducted to derive estimates of probabilities and health utility scores. Costs were derived from the Federal Supply Schedule and Center for Medicaid and Medicare Services. Using a cycle length of 6 months, treatments were compared based on discounted total costs and discounted quality-adjusted life years (QALYs) at 3% per cycle. Parameters were then varied in a 1-way sensitivity analyses. RESULTS: The average cost per QALY for the treatments were $2,940 and $2,390 for Hyalgan and Synvisc, respectively; thus, Synvisc has a lower cost with greater QALYs gained compared to Hyalgan. Sensitivity analyses revealed that the model was most sensitive to variations in efficacy rates and number of injections per course of therapy. A 25% decrease in Hyalgan's efficacy rate and number of injections resulted in a decrease in incremental cost-effectiveness ratio of about 600% and 100%, respectively. CONCLUSIONS: When comparing the base case standard course of therapy, Synvisc cost less per QALY gained compared to Hyalgan. However, if the number of Hyalgan injections is fewer, it may be more cost-effective than Synvisc. This study is limited by the amount of current evidence provided by literature
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0 |
Overview of the intra aortic balloon pump
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DOD - Acute Comp Syndrome CPG
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An intra aortic balloon pump is a device that primarily increases coronary artery blood flow and decreases myocardial oxygen demand by inflating and deflating during the cardiac cycle. Its main use is in the failing or ischaemic myocardium, but there are increasingly more indications with improving technology. An increasing number of patients are being admitted to critical care units with balloon pumps and it is therefore essential for critical care staff to be familiar with these devices. This article provides an overview.
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0 |
Cartilage repair and joint preservation: medical and surgical treatment options
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Surgical Management of Osteoarthritis of the Knee CPG
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BACKGROUND: Articular cartilage defects are most often caused by trauma and osteoarthritis and less commonly by metabolic disorders of the subchondral bone, such as osteonecrosis and osteochondritis dissecans. Such defects do not heal spontaneously in adults and can lead to secondary osteoarthritis. Medications are indicated for symptomatic relief. Slow-acting drugs in osteoarthritis (SADOA), such as glucosamine and chondroitin, are thought to prevent cartilage degeneration. Reconstructive surgical treatment strategies aim to form a repair tissue or to unload compartments of the joint with articular cartilage damage. METHODS: In this article, we selectively review the pertinent literature, focusing on original publications of the past 5 years and older standard texts. Particular attention is paid to guidelines and clinical studies with a high level of evidence, along with review articles, clinical trials, and book chapters. RESULTS: There have been only a few randomized trials of medical versus surgical treatments. Pharmacological therapies are now available that are intended to treat the cartilage defect per se, rather than the associated symptoms, yet none of them has yet been shown to slow or reverse the progression of cartilage destruction. Surgical debridement of cartilage does not prevent the progression of osteoarthritis and is thus not recommended as the sole treatment. Marrow-stimulating procedures and osteochondral grafts are indicated for small focal articular cartilage defects, while autologous chondrocyte implantationis mainly indicated for larger cartilage defects. These surgical reconstructive techniques play a lesser role in the treatment of osteoarthritis. Osteotomy near the knee joint is indicated for axial realignment when unilateral osteoarthritis of the knee causes axis deviation. CONCLUSION: Surgical reconstructive techniques can improve joint function and thereby postpone the need for replacement of the articular surface with an artificial joint
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1 |
Skeletal complications in patients with bone metastases from renal cell carcinoma and therapeutic benefits of zoledronic acid
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MSTS 2018 - Femur Mets and MM
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Bone metastases in patients with renal cell carcinoma are associated with a high risk of skeletal complications. Therefore, a subset analysis of a larger clinical trial was performed to determine the efficacy of zoledronic acid in renal cell carcinoma patients. Patients with bone metastases from solid tumors other than breast or prostate cancer (n=773) were randomized to receive zoledronic acid or placebo via 15-minute infusion every 3 weeks for 9 months. Patients were monitored for skeletal-related events, which were defined as pathological fracture, spinal cord compression, radiotherapy, or surgery to bone. Among the subset of 74 patients with renal cell carcinoma, 46 patients were treated with 4 mg of zoledronic acid or placebo. Significantly fewer patients treated with 4 mg zoledronic acid had a skeletal-related event (37% versus 74% for placebo, P=0.015), and zoledronic acid significantly prolonged the time to first skeletal-related event (median not reached at 9 months versus 72 days for placebo; P=0.006). Zoledronic acid significantly reduced the annual incidence of skeletal-related events by approximately 21% (mean 2.68 versus 3.38 events per year for placebo, P=0.014) and significantly reduced the risk of developing a skeletal-related event by 61% compared with placebo (risk ratio=0.394, P=0.008) by multiple event analysis. Median time to progression of bone lesions was also significantly extended with zoledronic acid treatment (P=0.014). Zoledronic acid is the first bisphosphonate to significantly reduce skeletal morbidity and significantly prolong time to bone lesion progression in patients with bone metastases from renal cell carcinoma. [References: 25]
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Effectiveness of calcium hydroxide-based intracanal medicaments against Enterococcus faecalis
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Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures
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AIM: To evaluate the antimicrobial efficacy of calcium hydroxide-based intracanal medicaments against Enterococcus faecalis. METHODOLOGY: One hundred and six single-rooted human teeth were inoculated with E. faecalis (ATCC 29212) and incubated in an microaerophilic environment for 21 days. Teeth were divided according to the medicaments and period: G1 - Calen (7 days); G2 - Calen (14 days); G3 - Calen/camphorated paramonochlorophenol (CMCP) (7 days); G4 - Calen/CMCP (14 days); G5 - Calen/0.4% chlorhexidine (CHX) (7 days); G6 - Calen/0.4% CHX (14 days); G7 - Calen/1% CHX (7 days); G8 - Calen/1% CHX (14 days); G9 - chemo-mechanical preparation with no medication and
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Successful management of osteosynthesis infection caused by Enterococcus faecium after severe leg trauma
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Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures
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Background: Infection of alloplastic material is usually caused by staphylococci. Enterococci rarely have been implicated in infections after osteosynthesis. Enterococcus faecium is resistant to most antibiotics with glycopeptides being considered the treatment of choice. Methods: We describe the case of a 41-year-old with multiple open fractures of the right femur, tibia, food and toes. Results: Initial treatment included stabilizing the fractures using external fixation and debridement of wounds with the application of a vacuum assisted device. On the third day post trauma, the fracture was stabilized by osteosynthesis with LISS lateral and of the median condyle. Repeatedly, soft tissue necroses were debrided and the VAC-system changed and after four weeks the skin was covered with a
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0 |
Arthrodesis for septic arthritis of the ankle: risk factors and complications
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DoD LSA (Limb Salvage vs Amputation)
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Introduction: Septic ankle joint arthrodesis is a good therapeutic option in cases of infection after trauma or orthopedic surgical procedures. Many different procedures have been described, but external fixation seems to be standard. Aim of this study is to identify risk factors for complications in septic ankle joint arthrodesis with the external AO frame fixator. Materials and methods: Patients who received septic ankle joint arthrodesis between January 2008 and December 2012 were included in this study. Patients were evaluated clinically and with radiographs or CT scans. Results: Follow-up of 74 of 79 patients with an external AO frame fixator could be evaluated; follow-up was 411 days (105â??991). The mean age at surgery was 57.7 years (19â??87). At this time, complications occurred in 41 patients (52 %) with wound healing problems (17 patients, 22 %) and non-union (12 patients, 15 %), and some needed surgical revision. In our collective, men had a significant higher non-union rate (p = 0.031), age or BMI showed no difference. Patients with diabetes and alcohol consumption showed a higher risk for complications (p = 0.049 and p = 0.031, respectively). 62 % of primary arthrodesis showed union, whereas in the case of revision, arthrodesis only 39 % showed union. Conclusions: Septic ankle joint arthrodesis with the external AO frame fixator is a probable tool to achieve union. This study showed that there is a high complication rate and some risk factors for complications could be identified. A blinded and prospective study is needed to compare intramedullary nailing and external fixation to evaluate the possible advantage of intramedullary devices in septic ankle arthrodesis.
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Effect of nutritional intervention on length of stay, postoperative complications, functional status and mortality in hip fracture patients: A multi-centre randomised controlled trial (RCT)
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Management of Hip Fractures in the Elderly
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Rationale: Hip fractures have a high burden on health care resources and as a consequence high health care costs. Our aim was to assess whether nutritional intervention in elderly hip fracture patients reduces length of stay, postoperative complications, and one-year mortality rate, and improves functional status and quality of life. Methods: Design: multi-centre RCT. Patients in the intervention group received nutritional intervention comprising intensive dietetic counselling (10 face-to-face contacts and/or telephone calls) and oral nutritional supplements (ONS) for 3 months. Patients in the control group received usual dietetic care. Primary outcome measure was total length of stay in hospital and rehabilitation clinic. Secondary outcome measures were functional, mental and cognitive status, quality of life and complications over 6 months post-surgery and one-year mortality. Data were analysed according to intention-to-treat, by Cox proportional hazards analysis or linear/logistic regression analysis as appropriate. Results: Of 152 patients enrolled, 73 were randomised to the intervention group and 79 to the control group. Median total length of stay was 36 (4 185) days in intervention group vs. 38 (3 183) days in control group (p = 0.85). In hospital and in rehabilitation clinic separately length of stay was also comparable in both groups. No significant effect of nutritional intervention on secondary outcomes at 3 and 6 months postoperatively was detected. Conclusion: Intensive nutritional intervention comprising intensive dietetic counselling and ONS for 3 months after hip fracture did not influence length of stay, postoperative complication rate, functional, mental, and cognitive status, quality of life, or one-year mortality
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1 |
The influence of vacuum-assisted closure on inflammatory tissue reactions in the postoperative course of ankle fractures
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DoD SSI (Surgical Site Infections)
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Vacuum-assisted closure (vacuum sealing) is a surgical procedure for the local treatment of severe soft-tissue damage. However, systemic consequences to the host are unknown. The aim of this study was to disclose the effects of vacuum sealing on the host's immune response and to demonstrate the early time course of endotoxin, interleukin-6 (IL-6), C-reactive protein (CRP), haptoglobin, transferrin, orosomucoid, 6-keto-prostaglandin (6KPG), a1-antitrypsin and complement C3 and C4. A total of 35 patients with closed ankle fractures were randomized into two groups and operated on within 6 h after injury. After osteosynthesis, one group was treated by vacuum sealing (VS) and the other by immediate skin closure (IS). Blood was collected immediately after admission and regularly up to 96 h after surgery. Morbidity was checked during the first year after injury. Preoperative endotoxin plasma level was increased compared with that of voluntary individuals (0.06 ± 0.02 EU/ml versus 0.021 ± 0.001 EU/ml) and peaked in patients with immediate skin suture 0.5 h after the surgical procedure at 0.11 ± 0.03 EU/ml. However, in patients with vacuum sealing, this peak was absent (0.07 ± 0.02 EU/ml). Endotoxaemia decreased to almost normal values after 24 h. Plasma IL-6 peaked 12 h postoperatively, decreasing thereafter with no difference between the groups. The plasma level of 6KPG decreased immediately after the surgical procedure in vacuum-sealed patients (before operation, 415 pg/ml; 12 h later, 251 pg/ml), but increased first in patients with immediate skin suture. CRP peaked 48 h after injury (VS, 48 ± 6 mg/l; IS, 38 ± 7 mg/l) with no difference between the groups. Transferrin decreased postoperatively (pre-op: VS, 2.49 ± 0.14 g/l; IS, 2.85 ± 0.19 g/l, 24 h: VS, 2.16 ± 0.08 g/l and IS 2.33 ± 0.11 g/l), whereas haptoglobin (pre-op: VS, 2 ± 0.21 g/l; IS, 1.7 ± 0.18 g/l; 96 h: VS, 3.4 ± 0.25 g/l, IS, 3.2 ± 0.24 g/l) and orosomucoid (pre-op: VS, 0.85 ± 0.05 g/l, IS, 0.83 ± 0.07 g/l; 96 h: VS, 0.85 ± 0.05 g/l, IS 1.14 ± 0.08 g/l) increased until day 4 with no significant difference between VS and IS. There was no relevant intergroup difference for complement C3, C4, a1-antitrypsin and morbidity (VS/IS: wound infection, 1/1; metal loosening, 1/1; prolonged healing, 1/0; prolonged pain, 3/2; and motor disturbance, 1/1). Surgery for ankle fractures is associated with temporary endotoxaemia and substantial changes in acute-phase proteins. Vacuum-assisted closure has only limited and no negative systemic immune consequences after surgery for malleolar fractures, is safe and can be used to manage severe soft-tissue damage. However, if feasible, primary skin closure is preferable.
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Preoperative Smoking and Narcotic, Benzodiazepine, and Tramadol Use are Risk Factors for Narcotic Use After Hip and Knee Arthroplasty
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OAK 3 - Non-arthroplasty tx of OAK
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BACKGROUND: The use of narcotics has been found to be a modifiable risk factor for success of arthroplasty. We sought to determine the risk factors leading to increased narcotic use after total hip arthroplasty and total knee arthroplasty.
METHODS: A retrospective chart review was performed on new patients presenting to an orthopedic reconstructive-service clinic. New patients aged 18 years or older with osteoarthritis of the hip or knee who presented over a 1-year period and underwent total knee arthroplasty or total hip arthroplasty were included. The Arkansas prescription monitoring program was then used to determine recent narcotic and benzodiazepine prescriptions filled within 3 months of surgery, and this was converted into morphine milligram equivalents (MME).
RESULTS: One hundred seventy-nine patients met the inclusion criteria. When compared with patients who did not take any preoperative opioids, narcotic- and tramadol-only users filled an average of 86% and 38% more MME, respectively. Benzodiazepine users required an average of 81% more MME postoperative than nonusers, and smokers required an average of 90% more MME postoperative than nonsmokers. Subjects with body mass index >40 kg/m<sup>2</sup> had 82% higher average postoperative MME than subjects with body mass index <25 kg/m<sup>2</sup>. Age and sex had no significant correlation with postoperative narcotic use.
CONCLUSION: This study suggests that a patient's preoperative narcotic, tramadol, benzodiazepine, and tobacco use are correlated to the amount of postoperative narcotic prescriptions filled in the 3 months following surgery. Predisposition to substance abuse may be a characteristic which leads to increased postoperative narcotic use.
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0 |
Comparative, validity and responsiveness of the HOOS-PS and KOOS-PS to the
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Surgical Management of Osteoarthritis of the Knee CPG
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Objective: To evaluate the internal consistency of the Hip disability and Osteoarthritis Outcome Score-Physical Function Short-form (HOOS-PS) and the Knee injury and Osteoarthritis Outcome Score-Physical Function Short-form (KOOS-PS) in total hip replacement (THR) and total knee (TKR) replacement. Construct validity and responsiveness were compared to the Western Ontario McMaster Universities' Osteoarthritis Index (WOMAC) Likert 3.0 physical function (PF) subscale and the PF excluding the items in the short measures (PF-exclusions). Methods: Participants completed the full HOOS or KOOS, measures of fatigue, anxiety, depression and the Chronic Pain Grade (CPG) pre-surgery and the HOOS or KOOS 6 months post-surgery. Internal consistency for the HOOS-PS and KOOS-PS was calculated using Cronbach's alpha. For construct validity, it was hypothesized that correlations between the HOOS-PS or KOOS-PS and PF and PF-exclusions with fatigue, CPG, anxiety and depression and HOOS/KOOS pain scales would differ by magnitudes of <0.1. Standardized response means (SRMs) were calculated for the
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0 |
Choice of peripheral venoarterial extra-corporeal membrane oxygenation cannulation site in patients above 15 kilograms
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DOD - Acute Comp Syndrome CPG
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Background Extracorporeal membrane oxygenation (ECMO) is a life-saving measure for pediatric patients with cardiopulmonary failure. The option of cannulating neck vessels versus those of the groin exists for patients over 15 kg; however, each carries the risk for complications. We present a single-center experience comparing the risks and benefits of these alternate peripheral ECMO cannulation sites. Methods All pediatric patients supported by venoarterial (VA) ECMO via peripheral cannulation from January 2006 to May 2013 were retrospectively reviewed, excluding those weighing less than 15 kg. We compared complications of neck versus groin cannulation sites, including neurologic dysfunction, limb ischemia, and in-hospital mortality. Univariate analysis and multivariable logistic regression were performed to identify factors for complications including mortality. Results Thirty-six patients (median age 10.8 years, interquartile range: 6.0-15.8) were cannulated for VA ECMO. Forty-four percent were cannulated via neck vessels and 47% were cannulated via groin. Nine percent were cannulated at both sites. Overall survival was 72% at decannulation and 67% at hospital discharge. No statistically significant survival difference between groin and neck cannulation subgroups was found. Rate of neurologic injury was higher in neck (25%) versus groin (12%) cannulation, but this was not statistically significant (p = 0.52). Extremity ischemia occurred in five patients having groin cannulation (29%, p = 0.04). Conclusions Neck cannulation is a valuable alternative to groin vessels in patients above 15 kg. Risk of limb ischemia with groin cannulation is significant, and must be considered when choosing the cannulation site for ECMO support.
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Outcomes of total and unicompartmental knee arthroplasty for secondary and spontaneous osteonecrosis of the knee
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Surgical Management of Osteoarthritis of the Knee CPG
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BACKGROUND: The reported outcomes of patients who underwent total or unicompartmental knee arthroplasty for secondary and spontaneous osteonecrosis of the knee are often from studies that lack the number of subjects necessary to generate meaningful conclusions. We systematically reviewed the available literature in order to define the outcomes of patients after total knee arthroplasty for secondary osteonecrosis and after total or unicompartmental knee arthroplasty for spontaneous osteonecrosis of the knee. METHODS: A literature review yielded twenty cohorts with demographic patient information and outcome scores (global knee scores, radiographic outcomes, and revision rates) for patients who had knee arthroplasty as treatment for either secondary or spontaneous osteonecrosis of the knee. The mean preoperative and postoperative global knee scores, the mean revision rate, and the categorization of the mean "poor" and mean "good" outcomes for the knees with each underlying disease were tabulated and reported. The demographic data and the reported mean global knee scores were weighted by the number of knees in each study. RESULTS: Total knee arthroplasty was performed in 150 knees with secondary osteonecrosis and 148 knees with spontaneous osteonecrosis, and unicompartmental knee arthroplasty was performed in sixty-four knees with spontaneous osteonecrosis. Total knee arthroplasty for spontaneous osteonecrosis of the knee was associated with the best outcomes (higher "good" and postoperative global knee scores and lower revision [3%] and "poor" outcome [6%] rates compared with the other two groups). The outcomes after total knee arthroplasty in knees with secondary osteonecrosis as well as in knees with spontaneous osteonecrosis were better in the cohorts operated on during or after 1985 than in those operated on before 1985. Similarly, the outcomes after unicompartmental knee arthroplasty in knees with spontaneous osteonecrosis of the knee were also better in the cohorts operated on during or after 1985 than in those operated on before 1985. CONCLUSIONS: Total knee arthroplasty performed as treatment for either secondary osteonecrosis or spontaneous osteonecrosis and unicompartmental knee arthroplasty performed as treatment for spontaneous osteonecrosis were associated with improved outcomes in cohorts with more recent operative dates. The evidence suggests that the use of contemporary cemented implants in total knee arthroplasty and the selective use of stems and augments in patients who have development of secondary osteonecrosis after total knee arthroplasty are producing outcomes that are comparable to those seen after total knee arthroplasty for osteoarthritis. Although the outcomes of patients who have total knee arthroplasty for the treatment of spontaneous osteonecrosis of the knee have historically been favorable, such outcomes have also shown particular improvement in the studies from more recent operative periods. Although poor outcomes were seen after unicompartmental knee arthroplasty in earlier studies of patients with spontaneous osteonecrosis of the knee, it is possible that those results were secondary to inappropriate patient selection, as the authors of the most recent and, to our knowledge, the only study to follow established operative indications regarding the use of unicompartmental knee arthroplasty reported excellent results. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions to Authors on jbjs.org for a complete description of levels of evidence
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Prior Anterior Cruciate Ligament Reconstruction Effects on Future Total Knee Arthroplasty
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OAK 3 - Non-arthroplasty tx of OAK
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Background: The impact of prior anterior cruciate ligament (ACL) reconstruction on total knee arthroplasty (TKA) has rarely been studied. The objective of this study was to compare intraoperative characteristics in patients who underwent TKA with pre-existing hardware from prior ACL reconstruction with a matched cohort control group. Methods: A retrospective study of patients who had undergone primary TKA with pre-existing hardware from prior ACL reconstruction was performed from June 2012 through June 2017. These patients were 2-to-1 matched to the ACL group based on similar patient demographic and provider variables. Outcomes investigated included operative time, estimated blood loss (EBL), and postoperative complications. Results: One hundred one patients met the inclusion/exclusion criteria. The mean age was 54 ± 9 years, and the mean body mass index was 32.6 ± 6.5 kg/m2. The ACL group was divided into 4 subgroups: group 1, no pre-existing hardware removed (22 TKAs); group 2, pre-existing hardware removed from the femur only (8 TKAs); group 3, pre-existing hardware removed from the tibia only (45 TKAs); and group 4, pre-existing hardware removed from both the femur and tibia (26 TKAs). There was no statistical difference in EBL and postoperative complication between the ACL group and controls. Statistical differences were detected between 2 subgroups regarding mean operative time variables: ACL group 3 (74 ± 23 minutes; control: 64 ± 21 minutes, P =.020) and group 4 (79 ± 24 minutes; control: 65 ± 19 minutes, P =.010). Conclusion: Hardware retained, especially on the tibia, from prior ACL reconstruction has a major impact on TKA surgical procedure operative time but not on EBL and/or complications.
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Outcomes of knee arthroscopy under local anaesthesia
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AMP (Acute Meniscal Pathology)
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Objective To evaluate the outcome of knee arthroscopy performed under local anaesthesia. Methods In a retrospective study between 1999 and 2004, the medical charts, theatre reports and radiological images of 225 patients were reviewed. Function was assessed from SF-36, WOMAC, Tegner and Lysholm scores. Patients were interviewed by telephone or by the Internet. Results Of the 115 patients who completed the study, 88 (77%) were men and 27 (23%) were women, with a mean age of 48 (±11.5) years. The mean follow-up was 18 months (range, 3-60). The left knee was operated on in 62 (54%) cases and the right knee in 53 (46%) cases. Both patient and surgeon satisfaction was >90%, especially in the case of normal healthy patients and patients with mild systemic disease, minimal synovitis, a good response to local anaesthesia, minimal ipsilateral hip osteoarthritis and no recent partial collateral ligament injury. Conclusion Arthroscopy under local anaesthesia is an effective, safe method for treating knee disease. Our results are comparable to those in the current literature. © 2013 Taibah University. Production and hosting by Elsevier Ltd. All rights reserved.
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Acute effects of salmon calcitonin in multiple myeloma: a valuable method for serial evaluation of osteoclastic lesions and disease activity--a prospective study of 125 patients
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MSTS 2018 - Femur Mets and MM
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Hypocalcemia induced by salmon calcitonin (SCT) was evaluated in 125 patients with multiple myeloma (MM) and compared with 20 normal individuals (NCs) and 20 individuals with monoclonal gammopathy of undetermined significance (MGUS). It is now well documented that the maximum hypocalcemia (M delta CA) induced in man by SCT is related to the prevailing rate of osteoclastic resorption. In patients with MGUS, the level of M delta CA was normal. Conversely, the M delta CA was significantly abnormal in patients with MM (P less than .0001 for differences between NC/MGUS patients) and was correlated with (1) initial calcium levels (P less than .001), (2) the extent of lytic bone lesions (LBLs) (P less than .01), and (3) the myeloma cell mass (P less than .001) plus disease activity. The M delta CA was found to be of predictive value for new LBLs with or without hypercalcemia and to have dramatic influence on the survival of patients with MM. We conclude that the SCT-induced hypocalcemia test is of significant importance in the evaluation of the instantaneous rate of bone resorption and in the prognosis of patients with MM.
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Respiratory physiotherapy in patients with COVID-19 infection in acute setting: a Position Paper of the Italian Association of Respiratory Physiotherapists (ARIR)
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Coronavirus Disease 2019 (COVID-19)
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Respiratory physiotherapy in patients with COVID-19 infection in acute setting: a Position Paper of the Italian Association of Respiratory Physiotherapists (ARIR) On February 2020, Italy, especially the northern regions, was hit by an epidemic of the new SARS-Cov-2 coronavirus that spread from China between December 2019 and January 2020. The entire healthcare system had to respond promptly in a very short time to an exponential growth of the number of subjects affected by COVID-19 (Coronavirus disease 2019) with the need of semi-intensive and intensive care units.
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Evaluation of the anterior cruciate ligament integrity and degenerative arthritic patterns in patients undergoing total knee arthroplasty
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Surgical Management of Osteoarthritis of the Knee CPG
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We prospectively reviewed 107 consecutive primary total knee arthroplasties performed over a 1-year period. Intraoperatively, the integrity of the anterior cruciate ligament (ACL), the characteristics of the intercondylar notch, and the patterns of cartilage wear were evaluated. The ACL was found to be deficient in 41 knees (39%) at the time of surgery. The ACL-deficient knee had significantly narrower intercondylar notch widths compared with knees with an intact ACL (average, 9.75 vs 16 mm, P < .01). Furthermore, patients with ACL deficiency were found to have a higher percentage of Outerbridge grade IV changes at the lateral femoral condyle, lateral tibial plateau, and patellar surfaces when compared to the ACL-intact group. An intact ACL appeared to be protective against severe patellar degeneration. In conclusion, intercondylar notch narrowing from the arthritic process can lead to attrition and rupture of the ACL. An ACL deficiency appears to be associated increased wear of the lateral femorotibial and patellofemoral joints
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An empirical Bayes method for studying variation in knee replacement rates
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Surgical Management of Osteoarthritis of the Knee CPG
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Knee replacement is the most commonly used surgical treatment for knee arthritis. It has been reported that knee replacement rates vary across both regions and counties. This paper used data from Medicare patients to develop explanations for the variation. One problem with our data is that we do not have patient level information for Medicare patients who did not have a knee replacement during the study period. Therefore, even though our data have a natural hierarchical structure (region, county, patient), we cannot use a typical hierarchical model for the analysis due to missing patient level information. In this paper, we used a two-stage approach to analyse our data. In the first stage, we used an extra Poisson regression to model within-region variation of knee replacement rates while adjusting for the type of patient demographic information we had, and in the second stage, we used an empirical Bayes method to model between-region variation of knee replacement rates
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1 |
Evaluation of the effectiveness and cost-effectiveness of lightweight fibreglass heel casts in the management of ulcers of the heel in diabetes: A randomised controlled trial
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Hip Fx in the Elderly 2019
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Background: Ulcers of the foot in people with diabetes mellitus are slow to heal and result in considerable cost and patient suffering. The prognosis is worst for ulcers of the heel. Objective: To assess both the clinical effectiveness and the cost-effectiveness of lightweight fibreglass casts in the management of heel ulcers. Design: A pragmatic, multicentre, parallel, observer-blinded randomised controlled trial. A central randomisation centre used a computer-generated random number sequence to allocate participants to groups. Setting: Thirty-five specialist diabetic foot secondary care centres in the UK. Those recruited were aged â?¥ 18 years and had diabetes mellitus complicated by ulcers of the heel of grades 2â??4 on the National Pressure Ulcer Advisory Panel and European Pressure Ulcer Advisory Panel scale. Participants: In total, 509 participants [68% male, 15% with type 1 diabetes mellitus, mean age 67.5 years (standard deviation 12.4 years)] were randomised 1 : 1 to the intervention (n = 256) or the control (n = 253) arm. The primary outcome data were available for 425 participants (212 from the intervention arm and 213 from the control arm) and exceeded the total required; attrition was 16.5%. The median ulcer area at baseline was 275 mm2 [interquartile range (IQR) 104â??683 mm2] in the intervention group and 206 mm2 (IQR 77â??649 mm2) in the control group. There were no differences between the two groups at baseline in any parameter, neither in relation to the participant nor in relation to their ulcer. Interventions: The intervention group received usual care supplemented by the addition of an individually moulded, lightweight, fibreglass heel cast. The control group received usual care alone. The intervention phase continued either until the participantâ??s ulcer had healed (maintained for 28 days) or for 24 weeks, whichever occurred first. During this intervention phase, the participants were reviewed every 2 weeks, and the fibreglass casts were replaced when they were no longer usable. Main outcome measures: The primary outcome measure was ulcer healing (confirmed by a blinded observer and maintained for 4 weeks) within 24 weeks. Other outcome measures included the time taken for the ulcer to heal, the percentage reduction in the cross-sectional area, the reduction in local pain, amputation, survival and health economic analysis. The study was powered to define a difference in healing of 15% (55% intervention vs. 40% control). Results: Forty-four per cent (n = 94) of the intervention group healed within 24 weeks, compared with 37% (n = 80) of the control participants (odds ratio 1.42, 95% confidence interval 0.95 to 2.14; p = 0.088), using an intention-to-treat analysis. No differences were observed between the two groups for any secondary outcome. Limitations: Although the component items of care were standardised, because this was a pragmatic trial, usual care was not uniform. There was some evidence of a small excess of adverse events in the intervention group; however, non-blinded observers documented these events. There was no excess of adverse device effects. Conclusions: There may be a small increase in healing with the use of a heel cast, but the estimate was not sufficiently precise to provide strong evidence of an effect. There was no evidence of any subgroup in which the intervention appeared to be particularly effective. A health economic analysis suggested that it is unlikely that the intervention represents good value for money. The provision of a lightweight heel cast may be of benefit to some individuals, but we have found no evidence to justify the routine adoption of this in clinical practice.
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1 |
Complex limb reconstruction with simultaneous muscle transfer and circular external fixation
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DoD LSA (Limb Salvage vs Amputation)
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Introduction: Successful treatment of the mangled lower extremity can be very difficult. Management of large soft-tissue and bony defects is complex and are often treated with amputation. In carefully selected patients, limb salvage with combined muscle transfer and circular external fixation can be a safe and effective treatment. The purpose of this article is to present the surgical technique and case series. Technique: After careful patient selection, initial limb stabilization with a circular external fixator and serial debridement is carried out until a sterile wound is achieved. Often the patient is left with a large soft-tissue and bone defect. A free-tissue transfer is performed by the microvascular surgeons and the circular frame construct is completed. Bone transport through corticotomy and distraction osteogenesis is then performed to bridge the bony defect. Bone grafting at the docking site is frequently necessary after bone transport is complete. Results: A total of 127 patients were treated with free-tissue transfer and circular external fixation for limb salvage over a 22-year period. Three failures resulted in amputation. Two patients undergoing amputation failed treatment due to psychosocial issues and 1 because of medical comorbidity. There were 2 flap losses in the acute period and 1 flap with partial necrosis. Conclusions: Single-stage limb reconstruction with simultaneous muscle transfer and circular external fixation is a safe and effective method for limb salvage. It requires careful patient selection, thoughtful planning, and meticulous surgical technique.
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Upper extremity deep venous thrombosis after port insertion: What are the risk factors?
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MSTS 2022 - Metastatic Disease of the Humerus
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BACKGROUND: Totally implantable venous access devices (ports) are widely used, especially for cancer chemotherapy. Although their use has been associated with upper extremity deep venous thrombosis, the risk factors of upper extremity deep venous thrombosis in patients with a port are not studied adequately.
METHODS: The Healthcare Cost and Utilization Project's Florida State Ambulatory Surgery and Services Database was queried between 2007 and 2011 for patients who underwent outpatient port insertion, identified by Current Procedural Terminology code. Patients were followed in the State Ambulatory Surgery and Services Database, State Inpatient Database, and State Emergency Department Database for upper extremity deep venous thrombosis occurrence. The cohort was divided into a test cohort and a validation cohort based on the year of port placement. A multivariable logistic regression model was developed to identify risk factors for upper extremity deep venous thrombosis in patients with a port. The model then was tested on the validation cohort.
RESULTS: Of the 51,049 patients in the derivation cohort, 926 (1.81%) developed an upper extremity deep venous thrombosis. On multivariate analysis, independently significant predictors of upper extremity deep venous thrombosis included age <65 years (odds ratio = 1.22), Elixhauser score of 1 to 2 compared with zero (odds ratio = 1.17), end-stage renal disease (versus no kidney disease; odds ratio = 2.63), history of any deep venous thrombosis (odds ratio = 1.77), all-cause 30-day revisit (odds ratio = 2.36), African American race (versus white; odds ratio = 1.86), and other nonwhite races (odds ratio = 1.35). Additionally, compared with genitourinary malignancies, patients with gastrointestinal (odds ratio = 1.55), metastatic (odds ratio = 1.76), and lung cancers (odds ratio = 1.68) had greater risks of developing an upper extremity deep venous thrombosis.
CONCLUSION: This study identified major risk factors of upper extremity deep venous thrombosis. Further studies are needed to evaluate the appropriateness of thromboprophylaxis in patients at greater risk of upper extremity deep venous thrombosis.
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Ideal length of thread forms for screws used in screw fixation of nondisplaced femoral neck fractures
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Hip Fx in the Elderly 2019
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BACKGROUND: It is common practice when placing cannulated screws within the femoral head when treating femoral neck fractures to avoid the thread-forms from crossing the fracture line. Despite the widespread use of cannulated screws in internal fixation of femoral neck fractures, there is no study to our knowledge that describes the ideal length of thread-forms.
PURPOSE: The purpose of this study is to determine the thread length that will maximize purchase within the femoral head while minimizing risk of crossing the fracture line. Additional analysis was conducted to identify factors associated with the maximal possible length of treads in minimally and non-displaced femoral neck fractures.
METHODS: We performed a retrospective study of all patients treated for a minimally or non-displaced femoral neck fracture from April 1, 2004 through December 31, 2017. Only patients who had received a pre-operative CT or MRI scan were included. Fixation was then templated using radiographs and the distance from the subchondral bone to the fracture line was then measured.
RESULTS: The study included 127 patients. The average estimated length of lag screw threads was 33.2 +/- 6.67 mm, with lower quartile of 29.1 mm and higher quartile of 37.2 mm. The median was 32.0 mm and most frequently encountered estimate was 29 mm. Estimated lag screw size did not differ significantly based on age or BMI, but both height (p < 0.001) and race (0.04) were positively correlated with estimated lag screw size and males had longer measurements compared to females, 37.2 +/- 7.0 mm vs 31.4 +/- 5.7 mm (p < 0.001), respectively.
CONCLUSION: In conclusion, we propose an additional lag screw thread form with length 26.0 mm to capture 90% of femoral neck fractures.
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0 |
Current status of total joint replacement in the upper extremity
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Surgical Management of Osteoarthritis of the Knee CPG
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The principles ot total joint arthroplasty recently have been expanded to the upper extremity, following the dramatic success with total hip and total knee replacement procedures. New problems have been encountered with the rebalancing of the soft tissues and the technical nature of joint mechanics in the upper extremities. Work on shoulder joint replacement is in the very early stages and of unknown success. Several prostheses are being used and tested. For elbow and wrist replacement, early and predictable success has been accomplished, enabling relief of pain and satisfactory motion. Total joint replacement in the fingers and thumb has provided excellent relief of pain but has been hindered by difficulties in rebalancing the soft tissues in patients with rheumatoid arthritis. It appears that total reconstruction of arthritic upper-extremity joints will be commonplace in the not-too-distant future. Clinical trials are being expanded, with increasing success
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Effect of a comprehensive rehabilitation nursing program on patients undergoing elbow arthrolysis
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Pediatric Supracondylar Humerus Fracture 2020 Review
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Objective: To investigate the effect of a comprehensive rehabilitation nursing program on patients undergoing elbow arthrolysis. Methods: Patients who received unilateral elbow arthrolysis in the Department of Orthopedics in Shanghai Sixth Peopleâ??s Hospital East Affiliated to Shanghai University of Medicine and Health Sciences from December 2016 to February 2017 were selected for the study and were randomized into two groups: experimental group and the control group. Patients in both groups received routine nursing care, while patients in the experimental group also received comprehensive rehabilitation nursing, which was a program after elbow arthrolysis including postoperative pain management, standardized management of postoperative drainage, application of cryotherapy, prevention of heterotopic ossification, and personalized functional training. The visual analogue scale (VAS) was used to assess patientsâ?? pain levels, and the elbow joint range of motion (ROM) was measured for evaluating the amount of movement around the joint. In addition, the Mayo elbow performance index (MEPI) was employed to assess patientsâ?? elbow joint function. A satisfaction survey was also conducted. Results: A total of 60 patients were included in the study and were assigned to either the experimental group or the control group (30 cases in each group). As compared with the control group, patients in the experimental group achieved better results in elbow joint ROM with greater improvement. Flexion, extension, pronation, supination and rotation angles in the experimental group were (131±8)°, (7±8)°, (69±17)°, (82±18)° and (151±33)° respectively, which were all better than those in the control group ((120±14)°, (16±16)°, (48±32)°, (63±31)° and (111±58)°, P=0.001, 0.009, 0.002, 0.006 and 0.002). The experimental group also had higher MEPI score (experimental group: 95±7, control group: 86±9, P=0.000), higher percentage of excellent result evaluated by MEPI (experimental group: 70%, control group: 43.3%, P=0.034), and lower VAS score between 2nd and 5th day after operation (P<0.001, 0.001, 0.001, and 0.001) as compared with those in control group. Additionally, the patient satisfaction in the experimental group was also greater (P=0.026). Conclusion: A comprehensive rehabilitation nursing program can help relieve pain, improve elbow joint ROM and promote recovery of the elbow joint function in patients who undergo elbow arthrolysis.
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0 |
Study of the therapy of multiple myeloma monoclonal antibody
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MSTS 2018 - Femur Mets and MM
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This paper aims to discuss the initial clinical effect of treating bone defect of long bone osteomyelitis with Masquelet technology. A retrospective analysis was made among the recruited 25 patients with long bone osteomyelitis patients from April, 2013 to February 2014 from Henan Provincial People's Hospital. Clinical effect of treating long bone osteomyelitis with Masquelet technology and the possible effects of vancomycin in different doses on knitting were also evaluated in follow-up visit lasting for 6~18 months, and 22 cases' bone was healed on imaging at the last follow up. According to Samantha X ray score criteria, Samantha score of regular dose group and high dose group in 4 months after operation was 4.16 and 3.09, respectively. There were 12 cases in regular-dose antibiotic group, among which, 1 case had delayed wound healing, and 3 cases reoccurred; there were 10 cases in high-dose antibiotic group, among which, no cases reoccurred after operation. Masquelet technology is a reliable and easy osteomyelitis treatment. Notably, it shows significant advantages for long bone reconstruction induced by infection and trauma. Bone cement with high dose of vancomycin has better effect on controlling osteomyelitis than bone cement with regular dose of vancomycin.
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1 |
MRI of the knee joint with a 3-D gradient echo sequence. Equivalent to diagnostic arthroscopy?
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Anterior Cruciate Ligament Injuries CPG
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Three-dimensional (3-D) gradient echo sequences offer the advantage of volume imaging within a few minutes scanning time and creating thin contiguous slices. An optimized sequence (FISP 3D 40) was evaluated for its potential to detect lesions of the menisci, cruciate ligaments, and articular cartilage in 80 patients compared to arthroscopy as the standard. Magnetic resonance imaging showed a sensitivity of 97.9%, a specificity of 97.3%, and an accuracy of 97.5% for meniscal lesions, and a sensitivity of 100%, a specificity of 97.1%, and an accuracy of 97.5% for lesions of the cruciate ligaments. Based upon morphological criteria normal cartilage was identified in 91.5%, but fibrillation of different depths (grades 1-3) was poorly recognized. All full-thickness defects (grade 4) were recognized. Measurement of mean signal intensity (95% confidence intervals) was more useful to discriminate normal from abnormal cartilage (grades 1-3). This method promises the capability to detect early stages of oestoarthritis in future. The present results show MRI of the knee joint with a 3-D fast imaging technique to be a noninvasive alternative to diagnostic arthroscopy
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Improving hip fracture care: Striving for excellence
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Hip Fx in the Elderly 2019
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Hip fracture is a common and potentially devastating injury that occurs mainly in older people. The incidence is predicted to rise by 30% in the next 10 years alone. Many of those who recover suffer a loss of mobility and independence. There is growing emphasis to improve the care of patients sustaining hip fracture, especially in those with concurrent cognitive impairment. This review focuses on current best practice as well as several key areas of management, including analgesia, anaemia and nutrition. In doing so, we hope to identify interventions that may form the basis of a future Enhanced Recovery Pathway dedicated to hip fracture care. © 2013 Cambridge University Press.
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Total hip arthroplasty using direct anterior approach and dual mobility cup: safe and efficient strategy against post-operative dislocation
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Developmental Dysplasia of the Hip 2020 Review
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AIM: We hypothesize that a dual mobility cup can be safely used via the direct anterior approach, without increasing the risk of complications or incorrect positioning. MATERIALS AND METHODS: This retrospective study compared 201 primary total hip arthroplasties using a dual mobility cup performed via direct anterior approach without a traction table, to 101 arthroplasties performed via posterolateral approach. Implant positioning, function scores, and early complications were recorded. RESULTS: Implant positioning was appropriate in both groups, with a higher cup anteversion in direct anterior approach. The complications rates were similar in both groups, with no dislocation or infection. CONCLUSION: The direct anterior approach without traction table associated with a dual mobility cup does not increase the risk of complications or non-optimal positioning of implants. This strategy is interesting for patients with high risk of post-operative dislocation.
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