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Meniscectomy
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AMP (Acute Meniscal Pathology)
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Meniscal injury is a common cause of knee pain and major cause of functional impairment of the knee at young athletic population. Although the menisci were thought to be a vestigial tissue and treated with disrespect as an unnecessary appendage for many years; today it is known that the menisci provide mechanical support, localized pressure distribution, and lubrication to the knee joint. Therefore, a shift toward meniscal preservation has led to the development of new surgical techniques in recent decades as removal of the meniscus constitutes a risk factor for osteoarthritis. Therefore, total meniscectomy has been replaced by arthroscopic partial meniscectomy rather than total meniscectomy. Treatment choice of a meniscal pathologies also depend on patient's age, health, lifestyle, sporting activity level, and request to undergo major surgery and also the location and type of meniscal tear. In this article, we provide a general perspective on evolution of surgical management especially better understanding on meniscectomy procedures in various types of meniscal tears. Copyright © 2010 by Lippincott Williams & Wilkins.
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Outcome of Unicondylar Knee Arthroplasty vs Total Knee Arthroplasty for Early Medial Compartment Arthritis: A Randomized Study
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OAK 3 - Non-arthroplasty tx of OAK
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Background With increasing number of patients with early osteoarthritis of knee opting for total knee arthroplasty (TKA), there has been increase in patients dissatisfied with surgical outcomes. It is being presumed that offering unicondylar knee arthroplasty (UKA) to them would improve outcomes. Methods Primary objective of our study was to look for any difference in patient-reported outcome and function at 2-year follow-up in patients undergoing UKA as compared to TKA. Our study was a randomized study with parallel assignment conducted at a high-volume specialized arthroplasty center. Eighty patients with bilateral isolated medial compartment knee arthritis were randomized into simultaneous 2-team bilateral TKA (n = 40) and UKA (n = 40) group. We finally analyzed 36 patients in each group. Main outcome measure was improvement in Knee Outcome Survey-Activities of Daily Living Scale (KOS-ADLS) and High Activity Arthroplasty Score (HAAS) obtained at 2-year follow-up. Results Improvement in KOS-ADLS and HAAS at 2 years was similar (P = .2143 and .2010) in both groups. Performance as assessed with Delaware index was also similar. Length of hospital stay was less in UKA group (6.6 days as against 5.4 days). Complications and readmission rates were more in TKA group (nil in UKA group; 08 in TKA group). Conclusion At 2-year follow-up, UKA provides similar improvement in patient-reported outcomes, function, and performance as compared to TKA when performed in patients with early arthritis. However, UKA patients have shorter hospital stay and fewer complications.
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Valdecoxib: a review of its use in the management of osteoarthritis, rheumatoid arthritis, dysmenorrhoea and acute pain
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Surgical Management of Osteoarthritis of the Knee CPG
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Valdecoxib is an orally administered, highly selective cyclo-oxygenase (COX)-2 inhibitor with anti-inflammatory and analgesic properties. In well designed trials, valdecoxib demonstrated efficacy versus placebo in patients with osteoarthritis (OA), rheumatoid arthritis (RA), primary dysmenorrhoea and postoperative pain. Initial results in patients with migraine headache were promising. The efficacy of valdecoxib appears dose dependent up to 40 mg/day. Valdecoxib 10 mg/day was as effective as naproxen and rofecoxib in improving signs and symptoms of OA. The American College of Rheumatology 20% response rate was similar in recipients of valdecoxib, naproxen and diclofenac in patients with RA. In patients with dysmenorrhoea, valdecoxib 20 or 40 mg up to twice daily provided as effective pain relief as naproxen sodium 550 mg twice daily. In acute post-surgical pain, single-dose valdecoxib 40 mg had a rapid onset of action, provided similar analgesia to oxycodone 10 mg plus paracetamol (acetaminophen) 1000 mg and provided a longer time to rescue medication than rofecoxib or oxycodone/paracetamol after oral surgery. Pre-emptive administration of valdecoxib 10-80 mg was particularly effective in dental pain. Valdecoxib had opioid-sparing effects after hip or knee arthroplasty and reduced pain after laparoscopic cholecystectomy. Valdecoxib is generally well tolerated. The incidence of gastroduodenal ulcers was generally lower than with nonselective NSAIDs (i.e. NSAIDs not specifically developed as selective COX-2 inhibitors). With concomitant aspirin, the ulcer rate in valdecoxib recipients increased significantly, but was still lower than that in recipients of aspirin plus nonselective NSAIDs. In conclusion, valdecoxib, a COX-2-selective inhibitor, is as efficacious in pain relief as nonselective NSAIDs, with better gastrointestinal tolerability. It was as effective in RA, OA and primary dysmenorrhoea (the approved indications) as nonselective NSAIDs and as effective as rofecoxib in RA flare. In acute post-surgical pain, valdecoxib provided similar pain relief to oxycodone/paracetamol, had a long duration of action, a rapid onset of analgesia and was opioid-sparing. Valdecoxib provides a valuable alternative in the treatment of chronic arthritis pain and acute pain
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Effectiveness of preventive and corrective surgical intervention on hip disorders in severe cerebral palsy: a systematic review
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SR for PM on OA of All Extremities
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Abstract Purpose: This review presents an overview of the effectiveness of preventive and corrective surgical interventions to treat hip displacement in patients with severe cerebral palsy (CP). Method: A systematic literature search was applied to identify studies concerning surgical procedures in hip(sub)luxations in severe CP (GMFCS IV and V). A qualitative analysis and a best evidence synthesis were performed for soft tissue surgery and osteotomies. Results: The literature search identified 15 studies, all of which were observational. Five studies involved soft tissue surgery and 10 involved osteotomies. Only one study involving soft tissue surgery was of sufficient quality. Nine of the 10 studies involving osteotomies were of sufficient quality, including a total of 189 patients. The mean MP (migration percentage) at follow-up ranged from 6 to 29%. No relationship could be established between the effect of the surgical procedure and the patients' age or the duration of follow-up. The percentage of patients reporting pain decreased from 81% preoperatively to 5% at follow-up. Twenty-five percent had complications such as osteoarthritis, ulcers or fractures. Conclusions: There is insufficient evidence for the effectiveness of soft tissue surgery to stabilize the hip, due to insufficient quality of the retrospective observational studies. This review shows indicative findings (provided by consistent, statistically significant findings on outcome and/or process measures in at least two Observational Studies with sufficient quality) for an effect of bony surgery in stabilizing the hip. Timing of the procedure remains an issue. Multicenter trials could shed further light on this complicated subject. Implications for Rehabilitation There is insufficient evidence for soft tissue surgery in children with severe cerebral palsy (GMFCS 4 and 5) aimed to prevent luxation of the hip. Varus derotational osteotomy (VDRO) can be a beneficial procedure in children with severe CP and a painful hipluxation. Clinicians have insufficient evidence and thus tools to decide whether and when to perform surgery in luxation of the hip in severe CP
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Short scar mastopexy with flap transposition
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Reduction Mammoplasty for Female Breast Hypertrophy
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A personalized technique using a vertical scar mastopexy is described. The breast tissue is utilized as a transposition flap behind the nipple- areolar complex to increase its projection. The inferior pole of the breast can be developed either as a superiorly pedicled or inferiorly pedicled flap for that purpose and the indication for each version is described. The technique has been successfully utilized in 80 patients with pleasing results. Illustrative cases are presented.
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Lesions of the scapholunate ligaments in acute wrist trauma--arthroscopic diagnosis and minimally invasive treatment
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Distal Radius Fractures
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The final result of the treatment of distal intra-articular radius fractures depends both on the accuracy of the fracture reduction and on the presence of additional carpal injuries. In particular, lesions of the intrinsic ligaments usually lead to severe degenerative damage of the wrist joint if they are missed primarily. With the introduction of wrist arthroscopy, these tears can be evaluated and treated earlier. Since 1993 arthroscopically assisted treatment has been performed in 23 patients with distal intra-articular fractures of the radius (mainly C-fractures according to the AO classification system or group VII and VIII fractures according to Frykman). Scapholunate (SL) tears were found in 11 patients (47.8%), 7 of whom showed marked instability intraoperatively and were stabilised at the time of surgery.
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Arthroscopic meniscal suture with the "double-loop technique"
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AMP (Acute Meniscal Pathology)
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A new personal technique of arthroscopic meniscal suture in which the knots are all inside the knees, fixed only in the meniscus is presented. Using a new tool, a flexible double-loop allows the suture in the posterior horn of the meniscus to pass the suture from the anterior portal to the posterior portal without the necessity of large posterior incision to protect the vascular-nervous plexus. This paper presents the indication and the technique, as well as a variety of possible knots and their advantages.
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Median nerve suture in the distal part of the forearm. MRI evaluation
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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The aim of the study was to assess MR images of median nerve suture in the distal part of the forearm on fresh cadavers and injured patients. The median nerve was dissected in the distal one-third of the forearm in four fresh cadaveric specimens, divided and repaired in three of them in two cases with 3/0 nylon (one with well-apposed edges and the other with a lateral gap) and, in the third specimen, with 9/0 nylon with well apposed edges. The course of the median nerve was then studied on MR imaging in different planes and the quality of the nerve repair was evaluated. A good correlation was found between the MR images and the type of nerve suture. These findings were applied in management of two clinical cases in whom reexploration and revision of the median nerve repair was carried out
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Healthcare utilization and costs of knee or hip replacements versus pain-relief injections
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AAHKS (2) Corticosteroids
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BACKGROUND: Given the dramatic increase in total knee and hip replacement procedures among the US population aged 45 years and older, there is a need to compare the downstream healthcare utilization and costs between patients who undergo joint replacement and those who receive intraarticular injections as a low-cost alternative. OBJECTIVE: To compare changes in osteoarthritis (OA)-related healthcare utilization and costs for Medicare members with OA who underwent knee or hip replacement versus those receiving steroid or viscosupplementation injections. METHODS: Medicare members aged â?¥45 years diagnosed with OA were identified for this retrospective longitudinal study. Data were compared for patients who underwent primary knee or hip replacement surgery between July 1, 2007, and June 30, 2012, and those receiving injection of pain-relief medication during the same period. The date of joint replacement surgery was considered the index date. For the comparison cohort, the index date was 180 days postinjection of the first intraarticular injection. Medical and pharmacy claims were examined longitudinally in 90-day increments, from 180 days preindex until 360 days postindex. Difference-in-difference analyses were conducted to compare the change in OArelated healthcare costs, postindex versus preindex, between the study cohorts. Time-to-event analyses were used to measure rates of readmissions and venous thromboembolism (VTE). RESULTS: The mean age was 70.7 years for patients with knee replacement, 71.7 years for those with hip replacement, and 71.1 years for those receiving pain-relief injection (P <.0001). The RxRisk-V comorbidity index scores were 4.7, 4.4, and 4.8, respectively (P <.0001). Difference-in-difference analyses indicated that decreases in OA-related costs were greater for the joint replacement cohorts (coefficient for knee replacement*time: â??0.603; hip replacement*time: â??0.438; P <.001 for both) than for the comparison cohort. The VTE rates were 5.6% (knee) and 5.1% (hip) postsurgery versus 1.4% (knee) and 1.3% (hip) presurgery. CONCLUSION: The overall difference-in-difference results showed a greater decrease in healthcare utilization and costs for the members with joint replacement than for those receiving injection.
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Locking versus non-locking plates in fixation of extra-articular distal humerus fracture: a randomized controlled study
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Pediatric Supracondylar Humerus Fracture 2020 Review
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INTRODUCTION: Studies have shown that the use of nonlocking (reconstruction) plates in fixing distal humerus fractures may not yield stable fixation which therefore requires long immobilization and suboptimal functional results. There are reports showing that locking plates are biomechanically superior to nonlocking plates. The aim of this study was to compare elbow functional outcomes between locking and nonlocking plates in fixation of distal humerus fractures. METHODS: A single-centre, randomized control study was conducted at an academic level 1 trauma centre. A total of 60 patients with type 13-A fracture (AO/OTA classification) were randomized into two equal groups, locking plates group, and nonlocking plates group. The primary outcome measure was the Mayo elbow performance score (MEPS) at one year. Secondary outcomes measures were elbow flexion/extension arc, union, operative time, and complications (e.g., infection, heterotrophic ossification). RESULTS: The Mayo Elbow Performance Score (MEPS) at one year was 88 ± 10.1 in locking plates group and 75.8 ± 12.8 in nonlocking plates group. The difference was found to be statically significant (P value = 0.01). Elbow flexion/extension arc of motion at one year was 116° ± 15° in locking plates group and 113° ± 28° in nonlocking plates. The difference was not found to be statistically significant (P value = 0.17). CONCLUSION: Both implants yield similar results, with locking plates showing slightly better clinical scores.
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Identification of bacteria in endodontic infections by sequence analysis of 16S rDNA clone libraries
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Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures
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A significant proportion of oral bacteria are unable to undergo cultivation by existing techniques. In this regard, the microbiota from root canals still requires complementary characterization. The present study aimed at the identification of bacteria by sequence analysis of 16S rDNA clone libraries from seven endodontically infected teeth. Samples were collected from the root canals, subjected to the PCR with universal 16S rDNA primers, cloned and partially sequenced. Clones were clustered into groups of closely related sequences (phylotypes) and identification to the species level was performed by comparative analysis with the GenBank, EMBL and DDBJ databases, according to a 98% minimum identity. All samples were positive for bacteria and the number of phylotypes detected per subject varied from two to 14. The majority of taxa (65.2%) belonged to the phylum Firmicutes of the Gram-positive bacteria, followed by Proteobacteria (10.9%), Spirochaetes (4.3%), Bacteroidetes (6.5%), Actinobacteria (2.2%) and Deferribacteres (2.2%). A total of 46 distinct taxonomic units was identified. Four clones with low similarity to sequences previously deposited in the databases were sequenced to nearly full extent and were classified taxonomically as novel representatives of the order Clostridiales, including a putative novel species of Mogibacterium. The identification of novel phylotypes associated with endodontic infections suggests that the endodontium may still harbour a relevant proportion of uncharacterized taxa
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The health-related quality of life and cost implications of falls in elderly women
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Management of Hip Fractures in the Elderly
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Summary: Fractures and falls are serious cause of morbidity and cost to society. Our results suggest that the main burden to morbidity, measured as impact on health-related quality of life, is due to fear of falling rather than falls or their sequelae, such as fractures. Introduction: Fractures and falls are serious cause of morbidity and cost to society. We investigated the impact on health-related quality of life (HRQoL) associated with falls, fractures and fear of falling and falls and fractures cost. Methods: Three datasets providing longitudinal data on fear of falling, HRQoL and a common set of baseline risk factors for fracture (smoking status, weight and age) were analysed. Multilevel random effects models were used to estimate the long-term impact on HRQoL associated with falls, fractures and fear of falling. Healthcare resource use primary data were collected to estimate falls and fractures cost. Results: Older, low weight and smoking women reported lower HRQoL. The impact on HRQoL of a fracture was at least twice as large as that associated with falls. The largest negative effect on HRQoL was associated with self-reported fear of falling. The cost of falls was (pounds)1088. Similarly, the cost of falls leading to a fracture was (pounds)15,133, (pounds)2,753, (pounds)1,863, (pounds)1,331 and (pounds)3,498 for hip, wrist, arm, vertebral and other fractures, respectively. Discussion: The main burden to morbidity is due to fear of falling. Interventions aimed at reducing fear of falling may produce larger gains in HRQoL. (copyright) 2008 International Osteoporosis Foundation and National Osteoporosis Foundation
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Translational potential of ginsenoside Rb1 in managing progression of osteoarthritis
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AMP (Acute Meniscal Pathology)
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BACKGROUND: Osteoarthritis (OA) is the most common degenerative joint disorder. Inflammatory cytokine plays an important role in OA progression. Previous studies have demonstrated that ginsenoside Rb1 would prevent inflammation and apoptosis in chondrocytes. However, we have not found any animal study reporting that Rb1 attenuates the severity of OA.
OBJECTIVE: In this study, we used a rat anterior cruciate ligament transaction plus medial meniscus resection (ACLT + MMx) model of OA and a cell model, to investigate whether administration of ginsenoside Rb1 may attenuate the progression of arthritis.
METHODS: In this in vivo study, 16-week-old male Sprague-Dawley rats were divided into three groups: Group 1 (sham control group), Group 2 (Rb1-treated group), and Group 3 (OA group). In Groups 2 and 3, OA was induced in the right knee joint with ACLT + MMx in rats. Then Group 2 received continuous infusion of ginsenoside Rb1 via osmotic mini-pumps implanted subcutaneously. At 4 weeks after treatment, the rats were sacrificed. Interleukin-1beta (IL-1beta) level was evaluated by enzyme-linked immunosorbent assay (ELISA); cartilage damage was assessed via histology (Safranin-O/fast green stain) and immunohistochemistry [matrix metalloproteinase-13 (MMP13) and type X collagen (Col X)]. For cell study, C5.18 (rat chondrocyte cell line) was used in this research. The effect of Rb1 on IL-1beta-induced MMP13 or Col X expression level in C5.18 cells was investigated.
RESULTS: In this in vivo study, characteristics of OA were present in the OA group, in contrast to less severe damage generally observed in the Rb1 treatment group: first, IL-1beta level was significantly decreased, and second, cartilage degeneration was attenuated, as indicated by lower histologic damage scores and lower percentages of MMP13 or Col X-positive chondrocytes. In the cell study, the results showed that Rb1 treatment would relieve the MMP13 or Col X expression in C5.18 cells induced by IL-1beta.
CONCLUSION: In the present study, we demonstrated that Rb1 can attenuate the progression or severity of arthritis by reducing inflammation.
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Postoperative analgesic and adverse effects of two low doses of intrathecal neostigmine and its influence on spinal bupivacaine anaesthesia after knee arthroscopy
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Surgical Management of Osteoarthritis of the Knee CPG
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Background: Neostigmine is a spinal analgesic that could be a useful adjunct. This study was conducted to evaluate the postoperative analgesic efficacy and the safety of two low doses of intrathecal (IT) neostigmine in patients undergoing knee arthroscopy under spinal bupivacaine anaesthesia. Methods: By using a double-blinded study design, 80 patients undergoing knee arthroscopy during spinal anaesthesia were divided into four groups: bupivacaine group (Group B) received 15 mg hyperbaric bupivacaine; bupivacaine + fentanyl group (Group BF) received 15 mg hyperbaric bupivacaine mixed with 25 (mu)g fentanyl; bupivacaine + neostigmine group 1 (Group BN1) received 15 mg hyperbaric bupivacaine mixed with 25 (mu)g neostigmine; bupivacaine + neostigmine group 2 (Group BN2) received 15 mg hyperbaric bupivacaine mixed with 35 (mu)g neostigmine. The postoperative visual analog scale (VAS) and the incidence of adverse effects were recorded for 24 h after administration of study drugs. Results: VAS scores were significantly lower in group BN2 compared with group B, group BF and group BN1 at 2, 4, 6, 12, and 24 h after operation (P < 0.05). The time to the first patients' demand for morphine administration after surgery was significantly prolonged in group BN2 compared with group B or group BN1 (P < 0.05). There was no significant difference between four groups in incidence of nausea and vomiting. Conclusion: Our study showed that IT neostigmine (35 (mu)g) enhanced bupivacaine spinal anaesthesia (15 mg) and produced prolonged postoperative analgesia for about 24 h without producing significant more adverse effects such as nausea and vomiting. Crown Copyright (copyright) 2008
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Tibial torsion: cause or consequence of osteoarthritis?
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OAK 3 - Non-arthroplasty tx of OAK
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OBJECTIVE: The purpose of this study was to evaluate the relationship between torsional variations of the lower extremity and the development of medial osteoarthritis in the knee.
METHODS: Computed tomography measurements of the femoral and tibial torsion were evaluated in 21 lower extremities of 19 patients with primary bilateral gonarthrosis and compared with 14 lower extremities of eight normal individuals.
RESULTS: There was no statistically significant difference between lower extremities with and without gonarthrosis in terms of tibial torsion (26.20degree +/- 9.78degree and 25.32degree +/- 11.50degree,respectively), femoral torsion (15.89degree +/- 8.63degree and 13.91degree +/- 7.26degree, respectively) and tibiofemoral index (10.30degree +/- 13.06degree and 11.39degree +/- 12.84degree,respectively) (p>0.05).
CONCLUSION: We conclude that medial compartment osteoarthritis in the early arthritic period is not always associated with torsional deformities of the lower limb.
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Does intermeniscal ligament tenodesis affect meniscal allograft extrusion? Retrospective comparative study at a minimum follow-up of 2 years
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AMP (Acute Meniscal Pathology)
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INTRODUCTION: Meniscal allograft transplantation (MAT) is indicated for the treatment of post-meniscectomy syndrome in young patients who do not have severe cartilage loss. While its clinical effectiveness is well established in the short- and mid-term, it does not appear to stop the progression of osteoarthritis. Meniscal extrusion often occurs early on and is irreversible. The aim of this study was to evaluate results of arthroscopic MAT combined with reconstruction of the intermeniscal ligament (IML).
HYPOTHESIS: Concurrent reconstruction of the IML decreases the incidence of early allograft extrusion when compared to conventional soft-tissue techniques.
MATERIALS AND METHODS: This was a retrospective single-centre comparative study of 55 patients operated between 2011 and 2018. The 34 patients who met the inclusion criteria were divided into two subgroups: the IML group (MAT with IML repair, n=14) and the non-IML group (MAT without IML repair, n=20). Clinical outcomes consisted of the KOOS at the last follow-up visit and the surgical revision rate. MRI was performed at a minimum of 12 months (mean 34+/-25 months) to determine absolute and relative meniscal extrusion, sagittal anterior and posterior extrusion, and cartilage coverage in the frontal and sagittal planes.
RESULTS: The KOOS score was not significantly different between the two groups. There were no reoperations in the IML group, but there were four in the non-IML group (13%) (p=0.13). Meniscal extrusion of the allograft occurred in 43% of patients (6/14) in the IML group versus 85% (17/20) in the non-IML group (p<0.03). Absolute meniscal extrusion was 2.9mm ([2.2-3.6] SD=1.2) in the ILM group versus 5.4 mm ([4.1-6.7] SD=2.9) (p=0.004) in the non-ILM group.
DISCUSSION: Adding ILM tenodesis or reconstruction can significantly limit early extrusion of the meniscal allograft. Clinical outcomes at a mean of 34 months are not different when compared to standard procedure. These patients should be re-evaluated in the long term to determine whether the incidence of osteoarthritis is lower with ILM tenodesis.
LEVEL OF EVIDENCE: III; case-control study.
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Intrapartum antibiotic prophylaxis increases the incidence of gram-negative neonatal sepsis
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Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures
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OBJECTIVE: To investigate the influence of the increased use of intrapartum chemoprophylaxis on the incidence of vertically transmitted neonatal sepsis. METHODS: Multiple institutional databases were queried for the number of cases in which intrapartum antibiotics were used, the obstetric risk factors that were present, and the number of resultant cases of neonatal sepsis that occurred for deliveries from 1992 through 1997. Intrapartum antibiotic use was compared between the first and fourth quarter of 1997. Comparisons were made between the years 1992-1996 and 1997 for the incidence of the various pathogens causing neonatal sepsis; group B streptococcus (GBS), gram-negative sepsis, and others. RESULTS: We found a significant increase in intrapartum chemoprophylaxis between the first and fourth quarters of 1997 corresponding to the increased physician awareness of published guidelines. As expected, the incidence of neonatal GBS sepsis was drastically reduced (from 1.7/1000 live births to 0 in 3730 births, P = 0.02). Unfortunately, there was a concomitant increase in the incidence of gram-negative sepsis (0.29/1000 vs. 1.3/1000, P = .02). The overall incidence of neonatal sepsis remained unchanged (2.7/1000 vs. 2.1/1000, P = .69). CONCLUSIONS: Published guidelines have encouraged physicians to increase the use of intrapartum chemoprophylaxis to reduce vertical transmission of GBS. This study confirms the efficacy of this approach. Unfortunately, this reduction comes at the cost of increasing the incidence of ampicillin-resistant gram-negative neonatal sepsis with a resultant increased mortality. These data provide compelling evidence that the policy of providing ampicillin chemoprophylaxis in selected patients needs to be reconsidered
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Early impairment of foveal magno- and parvocellular pathways in juxta chiasmal tumours
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Upper Eyelid and Brow Surgery
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Foveal pathway visual function was assessed in 11 patients having tumours extending into the suprasellar region but without evidence of visual impairment as assessed by visual acuity and Bjerrum screen campimetry. Psychophysical and routine visual evoked potential (VEP) measurements were obtained from the eye ipsilateral to the maximal suprasellar extension. The sensitivity of luminance and chromatic pathways was assessed psychophysically by measuring increment thresholds for white and red flashes of light presented on a white adapting field. Temporal sensitivity was assessed psychophysically by measuring threshold modulation sensitivity for sinusoidally modulating stimuli (de Lange attenuation characteristic). The patient group showed approximately equal significant psychophysical losses in chromatic, luminance and temporal sensitivities relative to normal controls. Midline VEP P100 latencies of the patient group did not significantly differ from those of the normal control group. It is concluded that tumours extending into the suprasellar region can cause foveal pathway dysfunction affecting both magno- and parvocellular pathways, even in the presence of normal visual acuity and fields suggesting a more widespread and insidious abnormality of the visual pathways in this condition than previously thought.
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Epidemiology of hallucinogen use in the U.S. results from the National epidemiologic survey on alcohol and related conditions III
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DoD PRF (Psychosocial RF)
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BACKGROUND: Population-based data regarding the epidemiology of hallucinogen use and co-occurring psychiatric disorders is largely absent from the literature. We aim to present findings on the prevalence, sociodemographic correlates, psychiatric comorbidity, treatment utilization, social support and associated disability of hallucinogen use using nationally representative data.
METHOD: We analyzed data from the National Epidemiologic Study on Alcohol and Related Conditions-III (2011-2012, N=36,309). We conducted multivariate logistic regression analyses in unadjusted and adjusted models in order to explore the odds of psychiatric disorders and associated disability among hallucinogen users.
RESULTS: Prevalence of twelve-month and lifetime hallucinogen use was 0.62% and 9.32%, respectively. Hallucinogen use was found to be significantly associated with mood disorders, anxiety disorders, eating disorders, personality disorders and substance use disorders. Following adjustment, significant associations were retained with several substance use disorders (adjusted odds ratio (AOR) for heroin use disorder=4.89 (95% CI, 1.90-12.58), personality disorders (AOR=2.10 (95% CI, 1.81-2.44)), Post-Traumatic Stress Disorder (AOR=1.86, 95% CI 1.00-3.45) and past suicide attempts (AOR=1.49, 95% CI 1.21-1.85).
CONCLUSIONS: Lifetime hallucinogen use in the US is prevalent and highly comorbid with other substance use and psychiatric disorders. Hallucinogen Use Disorder is relatively uncommon, with a low risk of development following exposure to hallucinogens. There are significant associations between hallucinogen use and substance use disorders, personality disorders, PTSD and past suicide attempts. The evolving therapeutic utility of this class of substances requires further assessment of short- and long-term risks of use, before large scale clinical application is pursued.
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Utilization and costs of formal and informal care, home adaptations, and physiotherapy among older patients with hip fracture
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Hip Fx in the Elderly 2019
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Aims: This feasibility study investigates the utilization and cost of health resources related to formal and informal care, home adaptations, and physiotherapy among patients aged 60 years and above after hip fracture from a multicentre cohort study (World Hip Trauma evaluation (WHiTe)) in the UK. Methods: A questionnaire containing health resource use was completed at baseline and four months post-injury by patients or their carer.completion rate and mean cost of each health resource item were assessed and sensitivity analysis was performed to derive a conservative estimate of the informal care cost. All costs are presented in 2017/18 pound sterling. Results: A total of 4, 183 patients from the WHiTe cohort completed the baseline questionnaire between May 2017 and April 2018, of whom 3, 524 (84.2%) completed the four-month health resource section. estimated mean costs of formal and informal care, home adaptations, and physiotherapy during the four months following injury were £2, 843 (sD 5, 467), £6, 613 (sD 15, 146), £706 (sD 1, 706) and £9 (sD 33), respectively. Mean cost of informal care decreased to £660 (sD £ 1,040) in the sensitivity analysis when informal care was capped at 17.2 hours per day. Conclusion: Informal care is a significant source of costs after hip fracture and should therefore be included in future economical analyses of this patient group. our results show that there is considerable variation in the interpretation of time-use of informal care among patients and further work is needed to improve how data regarding informal care are collected in order to obtain a more accurate cost estimate.
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Contemporary Results of Surgical Management of Peripheral Mycotic Aneurysms
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DoD LSA (Limb Salvage vs Amputation)
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BACKGROUND: Mycotic aneurysms of the extremities occur infrequently but can cause severe life and limb complications. Traditional treatment typically includes debridement and revascularization, though in select patients ligation may be well tolerated. We reviewed our experience with these aneurysms treated with these 2 modalities. METHODS: A retrospective review of patients treated for peripheral mycotic aneurysms at one institution from January 2005 to December 2015 was performed under an institutional review board-approved protocol. Demographics, perioperative details, and long-term outcomes were collected, and standard statistical methods were used to compare treatments. RESULTS: We identified 28 patients with 29 peripheral mycotic aneurysms. Most patients (19: 67.9%) were male with an average age of 60.1 +/- 17 years. Among cases with a known cause, direct injury to artery was the most common precursor to mycotic aneurysm formation; iatrogenic causes were the most common (15: 51.7%) followed by intravenous drug use (5: 17.2%). Distal bacterial translocation was the other cause of mycotic aneurysm formation due to osteomyelitis (2:10.5%) and bacterial endocarditis (1:3.5%). The causes of the remainder of cases (6:20.7%) were unknown. Symptoms included fever (46.4%), drainage (42.9%), rupture (35.7%), erythema (21.4%), and limb ischemia (17.9%). Staphylococcus aureus was the most common bacteria isolated (38.5%, from 7 positive blood cultures and 3 positive wound cultures) with 30% of these being methicillin-resistant Staphylococcusaureus), followed by Streptococcus species (11.5%), and other Staphylococcus (7.7%). Eight (30.7%) patients had negative cultures. The most common location of arterial aneurysm was the common femoral artery (17:58.6%), with 17.2% (5) occurring in the popliteal artery, 13.8% (4) in the brachial artery, 10.3% (3) in the radial or ulnar artery, and 3.5% (1) in the external iliac artery. Eighteen patients underwent revascularization, whereas 11 had resection/ligation without revascularization (4 femoral, 2 popliteal, 3 radial/ulnar, 1 brachial, and 1 external iliac). There was no significant difference in limb-threatening ischemia between these 2 groups (P = 0.14). Of those who were not revascularized, 1 developed significant initial ischemia but died before amputation, and the other underwent revascularization within 1 year after tolerating the initial ligation. Upper extremity aneurysms were more likely to be reintervention-free than those in the lower extremities (P = 0.01). CONCLUSIONS: In this series, resection or ligation of peripheral mycotic aneurysms without revascularization was well tolerated. With close follow-up of these patients, resection or ligation may obviate the more extensive initial revascularization procedures in these infected fields.
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0 |
Goal Management Training Combined With External Cuing as a Means to Improve Emotional Regulation, Psychological Functioning, and Quality of Life in Patients With Acquired Brain Injury: A Randomized Controlled Trial
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DoD PRF (Psychosocial RF)
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OBJECTIVE: To investigate whether goal management training (GMT) expanded to include external cuing and an emotional regulation module is associated with improved emotional regulation, psychological functioning, and quality of life (QOL) after chronic acquired brain injury (ABI).
DESIGN: Randomized controlled trial with blinded outcome assessment at baseline, posttraining, and 6-month follow-up.
SETTING: Outpatient.
PARTICIPANTS: Persons with ABI and executive dysfunction (N=70; 64% traumatic brain injury; 52% men; mean age +/- SD, 43+/-13y; mean time since injury +/- SD, 8.1+/-9.4y).
INTERVENTION: Eight sessions of GMT in groups, including a new module addressing emotional regulation, and external cuing. A psychoeducative control condition (Brain Health Workshop) was matched on amount of training, therapist contact, and homework.
MAIN OUTCOME MEASURES: Emotional regulation was assessed with the Brain Injury Rehabilitation Trust Regulation of Emotions Questionnaire, the Emotional Control subscale and the Emotion Regulation factor (Behavior Rating Inventory of Executive Function-Adult Version), and the Positive and Negative Affect subscales from the Dysexecutive Questionnaire. Secondary outcome measures included psychological distress (Hopkins Symptom Checklist-25) and QOL (Quality of Life After Brain Injury Scale).
RESULTS: Findings indicated beneficial effects of GMT on emotional regulation skills in everyday life and in QOL 6 months posttreatment. No intervention effects on measures of psychological distress were registered.
CONCLUSIONS: GMT is a promising intervention for improving emotional regulation after ABI, even in the chronic phase. More research using objective measures of emotional regulation is needed to investigate the efficacy of this type of training.
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0 |
Timed instrumental activities of daily living tasks: relationship to visual function in older adults
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Upper Eyelid and Brow Surgery
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PURPOSE: To identify instrumental activities of daily living (IADL) tasks whose completion time is related to visual function in older adults. METHODS: Visual function (acuity, contrast sensitivity, and useful field of view) and the time to complete 17 visual tasks of everyday life were measured in a sample of 342 older adults (mean age 71 years, range 56 to 86) recruited from eye clinics. The timed IADL (TIADL) tasks included a variety of visual activities such as reading ingredients on cans of food and instructions on medicine bottles, finding a phone number in a directory, locating items on a crowded shelf and in a drawer, and using a screwdriver. RESULTS: Multiple regression analysis indicated that poorer scores for acuity, contrast sensitivity, and useful field of view were independently associated with longer times to complete visual TIADL tasks, even after adjusting for age, educational level, depression, and general health. Cognitive status also had a significant, independent association with timed task performance. CONCLUSIONS: Older adults' timed performance in everyday tasks is related to various aspects of visual function independent of the influences of other functional and health problems and advanced age. This suggests that TIADL tasks may eventually be useful as performance outcomes in intervention evaluations targeted at reversing vision impairment or minimizing its impact. To understand the relationship between vision impairment and TIADL task performance in older adults, cognitive impairment needs to be taken into account because it has a relatively strong and independent relationship with visual TIADL task performance.
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0 |
Principles of surgical treatment of congenital, developmental and acquired female breast asymmetries
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Reduction Mammoplasty for Female Breast Hypertrophy
|
BACKGROUND/AIM: There is a natural asymmetry in normal female brests. When the difference in the shape, size or position of the breast and nipple-areola complex is visible, surgical correction is the only treatment option and presents one of the greatest challenges for a plastic surgeon. Based on the Nahai classification presented in details, the aim of the study was to present the possibilities of plastic surgery to correct primary (congenital), secondary (developmental) and tertiary (acquired) brest asymmetries.
METHODS: We conducted a retrospective analysis of female breast asymmetry surgeries performed in the Clinic for Plastic Surgery and Burns, Military Medical Academy (MMA), Belgrade over the last seven years (January 2002 - January 2009).
RESULTS: During the above mentioned period, 82 female patients, 18 - 65 years of age, underwent surgery for breast asymmetry. The most frequent asymmetries were developmental, "pubertal" (n = 43); acquired asymmetries as a consequence of tumor surgery were found in the other 22 patients, while 7 patients were diagnosed with primary asymmetries such as congenital chest-wall asymmetry (Sy. Poland), accessory and tuberous breasts. All patients underwent preoperative ultrasound examination, while hormone status was determined in those with developmental, "pubertal" asymmetries. The selection of surgical procedure for correction of breast asymmetry depended upon clinical examination findings and patient's wish relating to the shape and size of the breasts. The most of breast asymmetries were corrected by a combination of surgical procedures including primary and secondary reconstruction, reduction, suspension or augmentation mammoplasty. Having combined different surgical procedures, we managed to achive satisfactory results. The hypertrophic scar formation after reduction mamoplasty was seen in some cases, however, they caused no significant patient's discomfort.
CONCLUSION: Application of plastic, reconstructive and aesthetic surgical principles can considerably contribute to achieving excellent results in corrective surgery for breast asymmetries. In addition to most suitable breast asymmetry surgical procedures choice, motivation of a patient is also very important for achieving satisfactory results.
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0 |
Human histologic evaluation of a bone graft combined with GTR in the treatment of osseous dehiscence defects: a case report
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Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures
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There are many possible goals and outcomes of periodontal surgical therapy, but the ultimate goal is regeneration. Since the definition of periodontal regeneration is histologic, it is difficult to document. The purpose of this study was to evaluate a technique that combined a bone graft and guided tissue regeneration (GTR) to see if regeneration occurred. Four teeth with dehiscence-type osseous defects that were scheduled for extraction were treated with bone grafts and GTR. During the surgical procedure, a notch was placed into the root at the apical extent of the calculus. The teeth were extracted with conservative block sections 7 months after the treatment. They were processed, sectioned, stained, and evaluated histologically. The results revealed that regeneration did not occur in any of the teeth treated. In 2 of the teeth new connective tissue attachment was formed. In these 2 teeth cementum could be seen in the notch with connective tissue fibers inserting into the cementum. In one of the teeth the junctional epithelium extended apical to the notch, while in 3 cases the epithelium stopped at or coronal to the notch. In this case report, no regeneration could be documented, but new attachment could be seen in 2 of the 4 teeth treated
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0 |
Trauma in elderly people: What proportion of fractures are a consequence of bone fragility?
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Management of Hip Fractures in the Elderly
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Epidemiologists have tended to equate osteoporotic fractures with those which occur after only moderate trauma, or which affect elderly people. We set out to critically examine this epidemiological approach, because even among elderly people some fractures will be a result of severe trauma and these cannot be assumed to reflect bone fragility. In a population based study of all Cardiff residents aged over 60 we identified everyone who presented with a fracture during 1996. We considered the events that led to each fracture, to establish which fractures were a result of 'severe' trauma: trauma greater than a fall from a standing height. We identified 1335 people who between them sustained a total of 1372 fractures. 168 (12%) of the fractures resulted from severe trauma, but in people aged over 80 only 6% of all fractures, 4% of hip fractures, and 3% of wrist fractures followed severe trauma. In older subjects severe trauma makes only a very small contribution to the causation of fracture, so that the age-sex distribution of fractures following moderate trauma closely resembles that of fractures overall. For epidemiological purposes it does appear justifiable to equate the consequences of bone fragility with the occurrence of osteoporosis associated fractures in elderly people
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1 |
A Systematic Review of Adverse Events and Complications After Isolated Posterior Medial Meniscus Root Repairs
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AMP (Acute Meniscal Pathology)
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BACKGROUND: Medial meniscus posterior root (MMPR) tears are recognized as a substantial cause of disability and morbidity. However, meniscus root repair, regardless of technique, is not without potential complications.
PURPOSE: To evaluate the reported incidence of complications and adverse events after isolated MMPR repair.
STUDY DESIGN: Systematic review; Level of evidence, 4.
METHODS: A systematic review was conducted according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines using Embase, PubMed, and Scopus databases with the following search terms combined with Boolean operators: "meniscus,""root," and "repair." Inclusion criteria consisted of level 1 to 4 human clinical studies in English or English-language translation reporting complications and adverse events after isolated posterior medial meniscus root repairs. The overall incidence of specific complications was estimated from the pooled sample of the included studies.
RESULTS: Eleven studies with a total pooled sample of 442 patients were identified. The mean patient age was 58.1 years, while the mean final follow-up time was 37.2 months (range, 12-84.8 months). The overall incidence of complications was 9.7% (n = 43/442), with the most commonly reported complication being progressive degenerative changes within the knee (10.4%; n = 25/240; n = 5 studies). A total of 1.25% (n = 3/240) of patients who experienced degenerative changes required conversion to total knee arthroplasty. Repair failures were reported in 3.1% (n = 10/327; n = 8 studies) of patients.
CONCLUSION: Repairing MMPR tears is critical in preventing accelerated progression of knee osteoarthritis in patients without significant knee osteoarthritis preoperatively. While this repair is still recommended and necessary in appropriate patients, this review found that the incidence of complications after isolated posterior medial meniscus root repair was 9.7%, primarily involving the presence of progressive degeneration, while repair failure was reported in 3% of patients.
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0 |
Comparison of patients in three different rehabilitation settings after knee or hip arthroplasty: A natural observational, prospective study
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OAK 3 - Non-arthroplasty tx of OAK
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Background: Patients after primary hip or knee replacement surgery can benefit from postoperative treatment in terms of improvement of independence in ambulation, transfers, range of motion and muscle strength. After discharge from hospital, patients are referred to different treatment destination and modalities: intensive inpatient rehabilitation (IR), cure (medically prescribed stay at a convalescence center), or ambulatory treatment (AT) at home. The purpose of this study was to 1) measure functional health (primary outcome) and function relevant factors in patients with hip or knee arthroplasty and to compare them in relation to three postoperative management strategies: AT, Cure and IR and 2) compare the post-operative changes in patient's health status (between preoperative and the 6 month follow-up) for three rehabilitation settings. Methods: Natural observational, prospective two-center study with follow-up. Sociodemographic data and functional mobility tests, Timed Up and Go (TUG) and Iowa Level of Assistance Scale (ILOAS) of 201 patients were analysed before arthroplasty and at the end of acute hospital stay (mean duration of stay: 9.7 days +/- 3.9). Changes in health state were measured with the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) before and 6 months after arthroplasty. Results: Compared to patients referred for IR and Cure, patients referred for AT were significantly younger and less comorbid. Patients admitted to IR had the highest functional disability before arthroplasty. Before rehabilitation, mean TUG was 40.0 s in the IR group, 33.9 s in the Cure group, and 27.5 s in the AT group, and corresponding mean ILOAS was 16.0, 13.0 and 12.2 (50.0â??=â??worst). At the 6 months follow-up, the corresponding effect sizes of the WOMAC global score were 1.32, 1.87, and 1.51 (>0 means improvement). Conclusions: Age, comorbidity and functional disability are associated with referral for intensive inpatient rehabilitation after hip or knee arthroplasty and partly affect health changes after rehabilitation.
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0 |
Does cognitive/physical screening in an outpatient setting predict institutionalization after hip fracture?
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Hip Fx in the Elderly 2019
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BACKGROUND: Institutionalization after hip fracture is a socio-economical burden. We examined the predictive value of Instrumental Activities of Daily Living (IADL) and Mini Mental State Examination (MMSE) for institutionalization after hip fracture to identify patients at risk for institutionalization.
METHODS: Fragility hip fracture patients >=65 years of age (n = 584) were comprehensively examined at a geriatric outpatient clinic 4 to 6 months after surgery and followed 1 year postoperatively. A telephone interview with a structured inquiry was performed at 1, 4, and 12 months after hip fracture.
RESULTS: Age-adjusted univariate logistic regression analysis revealed that IADL and MMSE scores measured at the outpatient clinic were significantly associated with living arrangements 1 year after hip fracture. Multivariate logistic regression analysis established that institutionalization 1 year after hip fracture was significantly predicted by institutionalization at 4 months (odds ratio [OR] 16.26, 95 % confidence interval [CI] 7.37-35.86), IADL <5 (OR 12.96, 95 % CI 1.62-103.9), and MMSE <20 (OR 4.19, 95 % CI 1.82-9.66). A cut-off value of 5 was established for IADL with 100 % (95 % CI 96 %-100 %) sensitivity and 38 % (95 % CI 33 %-43 %) specificity and for MMSE, a cut-off value of 20 had 83 % (95 % CI 74 %-91 %) sensitivity and 65 % (95 % CI 60 %-70 %) specificity for institutionalization. During the time period from 4 to 12 months, 66 (11 %) patients changed living arrangements, and 36 (55 %) of these patients required more supportive accommodations.
CONCLUSION: IADL and MMSE scores obtained 4 to 6 months after hospital discharge may be applicable for predicting institutionalization among fragility hip fracture patients >=65 years of age at 1 year after hip fracture. An IADL score of >=5 predicted the ability to remain in the community. Changes in living arrangements also often occur after 4 months.
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0 |
Dehydroepiandrosterone (DHEA) replacement reduces growth hormone (GH) dose requirement in female hypopituitary patients on GH replacement
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AAHKS (2) Corticosteroids
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OBJECTIVE: GH dose requirement is lower in ACTH replete compared with ACTH deficient hypopituitary patients suggesting that adrenal androgens may augment IGF-I generation for a given GH dose. This study aimed to determine the effect of dehydroepiandrosterone (DHEA) administration on GH dose requirements in hypopituitary adults.
DESIGN: A double blind placebo controlled trial was conducted adding 50 mg DHEA to the standard replacement of hypopituitary patients, including GH, over an initial 6 months, followed by an open phase study of 6 months DHEA replacement and a final 2 month washout phase after DHEA withdrawal. The dose of GH was adjusted to achieve a constant serum IGF-I.
PATIENTS: Thirty female and 21 male hypopituitary patients were enrolled. Data from 26 women and 18 men were analysed after patient withdrawal.
MEASUREMENTS: The primary outcome objective was the GH dose required to achieve a stable serum IGF-I. Secondary outcome measures were lipoprotein profiles, insulin, insulin sensitivity, IGFBP-3, waist/hip ratio and indices of bone remodelling.
RESULTS: DHEA replacement in female patients lead to a 14.6 +/- 20% reduction in the dose of GH for a constant serum IGF-I (P < 0.05, 95% CI: 1.8, 32.7). This was maintained for 12 months and there was a significant fall in serum IGF-I two months after withdrawal of DHEA. There was no change in the male group.
CONCLUSIONS: DHEA replacement may reduce GH dose requirements in female hypopituitary patients.
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0 |
Prognostic factors in localized soft-tissue sarcomas
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MSTS 2022 - Metastatic Disease of the Humerus
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The prognostic factors associated with local failure and overall survival and the effect of radiotherapy were determined in 77 patients with localized (extremity and nonextremity) operable soft-tissue sarcoma. There were 52 male and 25 female patients; median age was 50 years (range: 15-83). Histologic grade of the tumors was as follows: low-intermediate grade in 32 cases and high grade in 29 cases. The primary tumors were treated by marginal resection (20 patients), wide resection (52 patients), and radical resection (5 patients). Adjuvant radiotherapy was applied to 50 (65%) patients. The 5-year local recurrence-free survival rate was 70.6%. Treatment with adjuvant radiotherapy and development of metastases were the significant prognostic factors associated with local recurrence. Radiotherapy was more effective in patients with tumors 10 cm or larger, marginally resected, extremity located, and high grades. The overall survival rate was 64.4% at 5 years. Significant adverse prognostic factors were high grade tumors, presence of local recurrence, and development of metastases in univariate analyses. Development of metastases and old age were the only adverse prognostic factors by multivariate analysis. The best 5-year survival rate was obtained in female patients younger than 50 years (90%). The present study demonstrated the importance of adjuvant radiotherapy and development of metastases as prognostic factors for local control. Again, development of metastases and age were the most important prognostic factors in operable soft-tissue sarcomas.
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1 |
Survivorship Between 2 Different Ceramic-on-Ceramic Total Hip Arthroplasty With or Without a Metal-Backed Titanium Sleeve Bearing: A 5- to 14-Year Follow-Up Study
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Hip Fx in the Elderly 2019
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BACKGROUND: The aim of the study was to compare the clinical and radiographic results of consecutive ceramic-on-ceramic bearings with and without a metal-backed titanium sleeve in patients undergoing total hip arthroplasty.
METHODS: Eighty-five patients (64 women and 21 men; average age 55.2 years) were included in the A group without sleeve while 147 patients (116 women and 31 men; average age 54.2 years) were included in the B group with sleeve. Clinical and radiologic measurements at follow-up (range, 5-14 years; average, 8.1 years) were analyzed.
RESULTS: The mean latest postoperative Harris Hip Score was 89.1 for patients from both groups. One joint (1.2%) in the A group displayed ceramic liner fracture, while no incidences of liner fracture occurred in the B group. Audible squeaking was observed in 1 joint (1.2%) in the A group and 1 (0.7%) in the B group. The mean annual liner rate of wear was 0.0049 and 0.0046 mm/y for the A group and B group, respectively. Three joints in the A group (3.5%) required revision total hip arthroplasty because of individual episodes of aseptic cup loosening, ceramic liner fracture, and infection. One joint in the B group (0.7%) required revision because of progressive osteolysis of the proximal femur. Ten-year Kaplan-Meier survivorship, based on an end point of component loosening and bearing failure, was 97.6% for the A group and 99.3% for the B group.
CONCLUSION: There were no clinical, radiographic, or survivorship differences between groups.
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0 |
Classification of knee osteoarthritis according to spatiotemporal gait analysis
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Surgical Management of Osteoarthritis of the Knee CPG
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Methods: Gait analysis of 2,900 patients from AposTherapy dataset (AposTherapy, Herzeliya, Israel) suffering from knee OA were included in the study. Men and women were analyzed separately. The analysis included three stages - clustering, classification and clinical validation. Clustering of gait analysis data by the kmeans method created four groups. Two thirds of the patients were used to create a simplified classification tree algorithm. The model's accuracy was checked by using the remaining one third of the patients. Clinical validation of the classification method was done by SF-36 and WOMAC questionnaires. Results: The clustering algorithm divided the data to four groups according to gait analysis severity. The classification tree algorithm used stride length and cadence as predicting variables for classification. The correct classification accuracywas 89.5%, and 90.8% forwomenand men, respectively. Clinical scores of the WOMAC and SF-36 questionnaires correlated well according to severity group. For example, in women, the rate of total knee replacement within a year after the gait analysis was 1.4%, 2.8%, 4.1% and 8.2% for knee OA grades 1-4, respectively. Conclusions: Spatio-temporal gait analysis can be used to classify patients with knee OA according to disease severity. The most differentiating variables for classification are stride length and cadence. Furthermore, gait analysis based on disease grading correlated with clinical data of pain, function and quality of life
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0 |
Bacterial endocarditis: risk factors in Cork dental hospital patients
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Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures
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An examination was carried out of the records of 2500 patients who attended the University Dental School and Hospital, Cork, Republic of Ireland during the period 1981-1986. 3.6% of these patients were found to have factors which put them at risk of developing bacterial endocarditis. Mention is made of the level of risk factors elsewhere in Ireland and in the U.S.A. The morbidity rate, mortality, dental aetiology, and prophylaxis of bacterial endocarditis are covered briefly
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0 |
The local effects of metal corrosion in total hip arthroplasty
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PJI DX Updated Search
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Corrosion has long been recognized to occur in total hip arthroplasty, but the local effects of this process have only recently become better understood. This article provides an overview of corrosion at modular junctions, and discusses the various etiologic factors for corrosion and the biologic response to metal debris released from this junction. Algorithms are provided for diagnosis and treatment, in accordance with the best available data. é 2014 Elsevier Inc
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0 |
Outcome of revision for mechanical stem failure using the cemented Charnley's stem
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Management of Hip Fractures in the Elderly
|
Three hundred ninety-nine cemented stem revision total hip arthroplasties performed in cases with mechanical stem failure without infection and having a minimum follow-up period of 3 years were prospectively studied. Two hundred eighty-three were revised for aseptic stem loosening and 116 were revised for fractured stem. Bone-grafting was not performed in any of the cases. The average follow-up period was 7 years 5 months. At the last follow-up evaluation, 70.4% of the patients were pain free and 20.6% had only mild or occasional discomfort. On radiographic evaluation, 31 stems (7.8%) were loose. Thirty-five hips (8.8%) required a rerevision, of which only 20 (5.0%) were for recurrence of mechanical stem failure. Clinical survivorship of the revised stem was 93.9% at 10 years, whereas radiographic survivorship was 91.5% at 10 years. On radiographic analysis, the mechanical failure rate at the last follow-up evaluation was greater after revision for fractured stem than after revision for aseptic stem loosening. Prerevision femoral cortical bone stock did not appear to adversely affect the outcome of the procedure. The clinical and radiologic results achieved with cemented stem revision arthroplasty for mechanical stem failure are excellent
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0 |
Clinical and experimental evaluation of the thromboprophylactic effect of hydroxychloroquine sulfate after total hip replacement
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AAHKS (8) Anesthetic Infiltration
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The rate of postoperative deep vein thrombosis was studied by the 125I-fibrinogen method in 35 patients after total hip replacement. 12 out of 18 patients treated prophylactically with hydroxychloroquine sulfate developed deep vein thrombosis compared with 11 out of 17 patients in the control group. Platelet aggregability was inhibited in vitro by high concentrations of hydroxychloroquine sulfate, but these concentrations were not obtained in vivo and platelet aggregation was not inhibited in patients treated with hydroxychloroquine sulfate (Plaqvenil®).
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1 |
Orthodromic sensory conduction along the ring finger in normal subjects and in patients with a carpal tunnel syndrome
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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The purpose of the present study was to examine the value of measuring sensory conduction along the median and ulnar nerves of the fourth finger in the diagnosis of a carpal tunnel syndrome (CTS). In 23 controls, sensory conductions along median and ulnar nerves were identical. In 28 of 38 patients with CTS, stimulation of the ring finger revealed a reduced conduction velocity along sensory median nerve fibres in contrast to normal conduction along ulnar sensory nerve fibres. In 5 patients, a sensory action potential was absent over the median nerve and in another 5 sensory conduction was normal along both nerves. We conclude that testing of sensory conduction along the ring finger is useful in about 74% of patients with CTS, while in the remaining 26% other fingers must be examined to establish the diagnosis
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1 |
An effective antibiotic cover for the prevention of endocarditis following dental and other post-operative bacteraemias
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Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures
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Pre- and post-extraction blood cultures were taken from 242 patients. The post-extraction ones were taken from 100 unpremedicated patients, from 42 with an erythromycin estolate cover, and from 100 patients after protection with pyrrolidino methyl tetracycline. The 100 post-extraction blood cultures from unpremedicated patients gave 64 positive results which yielded 155 strains, 88 of which were not aerobes. One hundred and fifteen representative strains were tested for sensitivity to 22 antibiotics. Of the 42 patients who received the erythromycin orally, 16 yielded positive blood cultures of mixtures of aerobes and anaerobes and of the 100 given one intravenous injection of the tetracycline three only developed a bacteraemia of a single type of aerobe. The serum concentrations obtained with the tetracycline given intravenously were 15 to 20 times higher than the serum levels obtained with the erythromycin given orally. There is a strong indication for using this kind of efficient antibiotic cover for dental extractions and other operative procedures known to be followed by a bacteraemia
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0 |
High body mass index is associated with increased diurnal strains in the articular cartilage of the knee
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OAK 3 - Non-arthroplasty tx of OAK
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OBJECTIVE: Obesity is an important risk factor for osteoarthritis (OA) and is associated with changes in both the biomechanical and inflammatory environments within the joint. However, the relationship between obesity and cartilage deformation is not fully understood. The goal of this study was to determine the effects of body mass index (BMI) on the magnitude of diurnal cartilage strain in the knee.
METHODS: Three-dimensional maps of knee cartilage thickness were developed from 3T magnetic resonance images of the knees of asymptomatic age- and sex-matched subjects with normal BMI (18.5-24.9 kg/m2) or high BMI (25-31 kg/m2). Site-specific magnitudes of diurnal cartilage strain were determined using aligned images recorded at 8:00 AM and 4:00 PM on the same day.
RESULTS: Subjects with high BMI had significantly thicker cartilage on both the patella and femoral groove, as compared to subjects with normal BMI. Diurnal cartilage strains were dependent on location in the knee joint, as well as BMI. Subjects with high BMI, compared to those with normal BMI, exhibited significantly higher compressive strains in the tibial cartilage. Cartilage thickness on both femoral condyles decreased significantly from the AM to the PM time point; however, there was no significant effect of BMI on diurnal cartilage strain in the femur.
CONCLUSION: Increased BMI is associated with increased diurnal strains in articular cartilage of both the medial and lateral compartments of the knee. The increased cartilage strains observed in individuals with high BMI may, in part, explain the elevated risk of OA associated with obesity or may reflect alterations in the cartilage mechanical properties in subjects with high BMI.
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0 |
Do demographic and perioperative parameters really affect the final outcomes of pediatric femur shaft fractures managed by elastic nails? A prospective study
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DoD SSI (Surgical Site Infections)
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Objective: Pediatric femoral shaft fractures are more commonly treated with intramedullary titanium elastic nail system (TENS). Adhering to the principles, most studies had supported excellent results with this instrumentation and attributed the variation in age, weight, immobilization protocols, technical factors like fracture pattern, reduction and complications as reasons to poor outcomes in their individual studies. Hence, we wanted to identify the potential demographic and perioperative parameters that could affect the final outcomes in this cohort. Methods: A prospective (level III) study done in a single center between November 2013 and January 2017 on isolated closed femoral shaft fractures in patients of age between 6 and 15 years managed with TENS. The demographic and perioperative parameters were recorded. The patients were followed up regularly with plain radiographs. The final outcomes were computed at end of one year and recorded as poor, satisfactory and excellent as defined by Flynn criteria. Results: Among the thirty patients included, mean age was 8.2 years. 80% of the patients weighing over 40 kg had satisfactory to poor outcomes. (p = 0.005). 45% of patients with proximal and distal level fractures that were long oblique spiral or comminuted types had satisfactory outcomes; however it was not statistically significant. The mean delay to surgical fixation was 5.87 days, surgical time was between 45 and 150 min and open reduction was required in about 17 cases (57%). Patients with immobilization beyond 6 weeks had satisfactory outcomes (p = 0.001). We had 5 patients with minor complications (4 bursitis and 3 superficial infections) and one major complication (chronic osteomyelitis and deep venous thrombosis) leading to satisfactory and poor outcomes respectively. Significant osseous union was noted between 6 and 11 months with 97% of patients attaining union within 9 months. Conclusions: Intramedullary TENS is an excellent modality to treat femoral shaft fractures in patients of school going age. However, factors like weight of the patient >40 kg, immobilization beyond 6 weeks, minor and major complications in the perioperative period could pose risks for poor to satisfactory outcomes and should be anticipated and explained accordingly.
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0 |
Subtrochanteric fracture after Garden screw fixation: a review of predisposing factors and management in nine cases
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Management of Hip Fractures in the Elderly
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Nine cases of subtrochanteric fracture are reviewed following 300 fixations of subcapital fractures with Garden screws. In six cases technical operative errors were considered to contribute to the fracture. It is stressed that adequate reduction and suitably placed crossed Garden screws are demanding requirements and that every attempt should be made to avoid making extra holes with guidewires. In two technically satisfactory cases the low position of the lower Garden screw-hole in the femur probably predisposed to the subtrochanteric fracture. A computerized two-dimensional finite analysis confirmed smaller magnitudes of stress at a more proximally positioned lower Garden screw, and in patients at risk, particularly those with a valgus femoral neck or valgus reduction, it is suggested that if this method of internal fixation is to be used, the screws should be crossed less obliquely, with the lower screw more proximally positioned in the femur
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0 |
The effect of FTO variation on increased osteoarthritis risk is mediated through body mass index: A mendelian randomisation study
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SR for PM on OA of All Extremities
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Objective: Variation in the fat mass and obesity-associated (FTO) gene influences susceptibility to obesity. A variant in the FTO gene has been implicated in genetic risk to osteoarthritis (OA). We examined the role of the FTO polymorphism rs8044769 in risk of knee and hip OA in cases and controls incorporating body mass index (BMI) information. Methods: 5409 knee OA patients, 4355 hip OA patients and up to 5362 healthy controls from 7 independent cohorts from the UK and Australia were genotyped for rs8044769. The association of the FTO variant with OA was investigated in case/control analyses with and without BMI adjustment and in analyses matched for BMI category. A mendelian randomisation approach was employed using the FTO variant as the instrumental variable to evaluate the role of overweight on OA. Results: In the meta-analysis of all overweight (BMI(greater-than or equal to)25) samples versus normal-weight controls irrespective of OA status the association of rs8044769 with overweight is highly significant (OR[CIs] for allele G=1.14 [01.08 to 1.19], p=7.5null10(-7)). A significant association with knee OA is present in the analysis without BMI adjustment (OR[CIs]=1.08[1.02 to 1.14], p=0.009) but the signal fully attenuates after BMI adjustment (OR[CIs]=0.99[0.93 to 1.05], p=0.666). We observe no evidence for association in the BMI-matched meta-analyses. Using mendelian randomisation approaches we confirm the causal role of overweight on OA. Conclusions: Our data highlight the contribution of genetic risk to overweight in defining risk to OA but the association is exclusively mediated by the effect on BMI. This is consistent with what is known of the biology of the FTO gene and supports the causative role of high BMI in OA. (copyright) 2013 BMJ Publishing Group Ltd & European League Against Rheumatism
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1 |
Concomitant posterior anchoring further reduces posterior meniscal extrusion during pullout repair of medial meniscus posterior root tears: a retrospective study
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AMP (Acute Meniscal Pathology)
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PURPOSE: Transtibial pullout repair improves the clinical outcomes of medial meniscus (MM) posterior root tears (PRTs); however, reducing MM extrusion remains challenging. Thus, the purpose of this study was to examine the role of additional posterior anchoring (PA) during pullout repair in reducing the severity of MM extrusion compared to pullout repair alone.
METHODS: Patients who underwent pullout repair with two-cinch stitches (TCS) only or TCS combined with PA (TCS-PA)-deployment of an additional suture anchor in the posteromedial corner of MM-were included retrospectively. MM medial and posterior extrusion (MMME and MMPE), MM extrusion and remaining volume (MMEV and MMRV), and corresponding ratios were evaluated pre-operatively and three months post-operatively using a three-dimensional meniscal model at 10degree and 90degree of knee flexion and compared within and between groups.
RESULTS: A total of 15 and 16 patients treated with TCS and TCS-PA, respectively, were enrolled. At 90degree knee flexion, both techniques significantly reduced MMPE (TCS: 4.2 +/- 0.7 mm to 3.5 +/- 0.6 mm, p < 0.05; TCS-PA: 3.7 +/- 0.8 mm to 2.8 +/- 0.7 mm, p < 0.05) at three months post-operatively. TCS-PA reduced MMPE more significantly than TCS alone (p < 0.05). Only TCS-PA significantly improved the MMEV and MMRV ratios (39.6 +/- 8.9% to 28.1 +/- 6.0%, p < 0.05 and 60.4 +/- 8.9% to 71.9 +/- 6.0%, p < 0.05, respectively). Significance was not found in all other comparisons.
CONCLUSIONS: Both techniques improved MMPE at knee flexion at the three month follow-up, with TCS-PA providing significantly superior results. Our findings support the evidence that the application of PA may be an effective surgical option for alleviating persistent MMPE.
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0 |
Implantation of autogenous meniscal fragments wrapped with a fascia sheath enhances fibrocartilage regeneration in vivo in a large harvest site defect
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AMP (Acute Meniscal Pathology)
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BACKGROUND: Concerning meniscal tissue regeneration, many investigators have studied the development of a tissue-engineered meniscus. However, the utility still remains unknown. HYPOTHESIS: Implantation of autogenous meniscal fragments wrapped with a fascia sheath into the donor site meniscal defect may significantly enhance fibrocartilage regeneration in vivo in the defect. STUDY DESIGN: Controlled laboratory study. METHODS: Seventy-five mature rabbits were used in this study. In each animal, an anterior one-third of the right medial meniscus was resected. Then, the animals were divided into the following 3 groups of 25 rabbits each: In group 1, no treatment was applied to the meniscal defect. In group 2, the defect was covered with a fascia sheath. In group 3, after the resected meniscus was fragmented into small pieces, the fragments were grafted into the defect. Then, the defect with the meniscal fragments was covered with a fascia sheath. In each group, 5 rabbits were used for histological evaluation at 3, 6, and 12 weeks after surgery, and 5 rabbits were used for biomechanical evaluation at 6 and 12 weeks after surgery. RESULTS: Histologically, large round cells in group 3 were scattered in the core portion of the meniscus-shaped tissue, and the matrix around these cells was positively stained by safranin O and toluisin blue at 12 weeks. The histological score of group 3 was significantly higher than that of group 1 and group 2. Biomechanically, the maximal load and stiffness of group 3 were significantly greater than those of groups 1 and 2. CONCLUSION: This study clearly demonstrated that implantation of autogenous meniscal fragments wrapped with a fascia sheath into the donor site meniscal defect significantly enhanced fibrocartilage regeneration in vivo in the defect at 12 weeks after implantation in the rabbit. CLINICAL RELEVANCE: This study proposed a novel strategy to treat a large defect after a meniscectomy.
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0 |
Pathophysiology of surgical site infection in total hip arthroplasty
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Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures
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This article is a case report of a 69-year-old man who underwent a right total hip replacement procedure and developed a surgical site infection. Areas of concern in prevention and treatment of hip arthroplasty infection are presented, focusing on the pathophysiologic process involved. A review of the patient risk factors and the pathophysiologic action potentiating risk for infection include host immunity, nutritional status, diabetes, age, use of steroids or immunosuppressive drugs, rheumatoid arthritis, and urinary tract or other infections. The case report identifies the patient's age, multiple instrumentation of the bladder resulting in bacteriuria and the reinfusion of 400 cc of autologous shed blood via cell saver, a controversial risk subject, as the primary risk factors for surgical site infection in this patient. Readmission to the hospital on day 16 after the operation was completed on identification of 2 pathogenic organisms, methicillin-resistant Staphylococcus aureus and Acinetobacter calcoaceticus bio anitratus. The infection was successfully treated with oral ciprofloxacin and intravenous administration of tobramycin, preventing progression from superficial to deep infection and preserving the prosthesis
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0 |
Efficacy and safety of 3D-conformal half body irradiation in patients with multiple bone metastases
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MSTS 2018 - Femur Mets and MM
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Half-body irradiation (HBI) represented a standard treatment for multiple painful bone metastases (BMs). However, its use has progressively reduced due to the associated toxicity rates. The aim of this paper was to evaluate HBI delivered by conformal radiotherapy (RT) technique in a large patients population with widespread BMs. HBI was delivered in 3Â Gy fractions, bid, â?¥ 6Â h apart, on 2 consecutive days (total dose: 12Â Gy) using 3-dimensional conformal RT (3D-CRT) box technique. The target included pelvic bones, lumbar-sacral vertebrae and upper third of femurs. Acute and late toxicity was scored based on RTOG and EORTCâ??RTOG scales, respectively. Pain was evaluated using the Pain-Drug scores and the Visual Analog Scale (VAS). One hundred and eighty patients were eligible for inclusion in this retrospective analysis. Grade 3 and 4 acute toxicity rates were 1.1% and 0.0%, respectively. Mean VAS before and after HBI was 5.3 versus 2.7, respectively (p: 0.0001). Based on VAS, 37.5% of patients showed complete pain relief (VAS: 0) while 38.1% had partial response (â?¥ 2-point VAS reduction). Overall, Pain and Drug Score reduction was observed in 76.3% and 50.4% of patients, respectively. 1-, 2-, and 3-year pain progression free survival was 77.0%, 63.4%, and 52.7%, respectively. Thirty patients (16.7%) underwent RT retreatment on the same site with median 15.9Â months interval (range 2â??126Â months). HBI delivered with 3D-CRT technique is safe and effective. It provides long lasting pain control in patients with multiple BMs with negligible rates of relevant toxicity.
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1 |
Rates and odds ratios for complications in closed and open tibial fractures treated with unreamed, small diameter tibial nails: A multicenter analysis of 467 cases
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DOD - Acute Comp Syndrome CPG
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Objective: A multicenter trial analyzed complications and odds for complications in open and closed tibial fractures stabilized by small diameter nails. Design: Retrospective. Setting: Four Level I trauma centers. Patients: Four hundred sixty-seven tibial fractures were included in the study. There were fifty-two proximal fractures, 219 midshaft fractures, and 196 distal fractures. Breakdown into different AO/OTA groups showed 135 Type A fractures, 216 Type B fractures, and 116 Type C fractures. Two hundred sixty-five were closed fractures and 202 were open fractures. Outcome Measurements: Clinical and radiographic analysis. Methods: 467 patients' tibial fractures were stabilized with small diameter tibial nails using an unreamed technique. Indications for the use of small diameter tibial nails using an unreamed technique included all types of open or closed diaphyseal fractures. The operating surgeons decided whether or not to ream based on personal experience, fracture type, and soft-tissue damage. Surgeons of Center 1 preferred to treat AO Type A and B fractures with unreamed nails, and surgeons of Centers 2, 3, and 4 preferred to treat AO Type B and C fractures with unreamed nails. Closed and open fractures were treated in approximately the same ratio. Results: Analysis showed five (1.1 percent) deep infections (with a 5.4 percent rate of deep infections in Gustilo Grade III open fractures), forty-three delayed unions (9.2 percent), and twelve (2.6 percent) nonunions. Compartment syndromes occurred in sixty-two cases (13.3 percent), screw fatigue in forty-seven cases (10 percent), and fatigue failure of the tibial nail in three cases (0.6 percent). Conclusions: Fracture distraction of more than three millimeters should not be tolerated when stabilizing tibial fractures with unreamed, small-diameter nails as this increases the odds of having a delayed union by twelve times (p < 0.001) and a nonunion by four times (p = 0.057). There was a significant increase of complications in the group of Grade III open fractures (p < 0.001), AO/OTA Type C fractures (p = 0.002), and to a lesser extent in distal fractures. However, the rate of severe complications resulting in major morbidity was low.
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0 |
Modified mini-Hardinge access for hip prosthesis implantation in the supine position
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DoD SSI (Surgical Site Infections)
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OBJECTIVE: Total hip arthroplasty with a minimal-incision technique that can be performed in the widely used supine position. The accustomed and good overview of this position allows safe positioning of the implant and combines this with the advantage of a soft tissue preserving technique. All standard instruments and implants can be further applied. INDICATIONS: Primary and secondary coxarthrosis, femoral head necrosis. CONTRAINDICATIONS: Revision surgery, severe anatomic deformity, implantation of hip resurfacing arthroplasty. SURGICAL TECHNIQUE: Supine position. The skin incision runs from the innominate tubercle proximally and falls slightly in the dorsal direction (20-30°). Incision of the iliotibial tract and exposure of the vastogluteal muscle sling. Starting from the greater trochanter, the sinewy onset of the minimal and medium gluteal muscle is split with an arched-shaped incision, which also falls proximally in the dorsal direction. Exposition of the joint capsule, longitudinal incision and resection of the ventrolateral parts. Dislocation of the hip by a combined adduction and external rotation movement. Osteotomy of the femoral neck and resection of the femoral head are performed in a figure-of-four position without adduction. To prepare the acetabulum and to insert the cup, the leg is placed in neutral position with a slight flexion of 20° in the hip. Preparation of the femur and implantation of the stem is again performed in a figure-of-four position in adduction. Reduction of the hip and stepwise wound closure. POSTOPERATIVE MANAGEMENT: Mobilization on postoperative day 1. Starting with half weight bearing and after completed wound healing rapid increase to full weight bearing. Intensive physiotherapy and rehabilitation. Thrombosis prophylaxis according to guidelines. RESULTS: The mini-incision approach has successfully been used in our clinic for years. Between September 2004 and November 2005, the less-invasive technique was evaluated in a randomized controlled trial with 51 patients (52 hips). Compared to the standard approach a significantly shorter incision length (8.9 vs. 14.0 cm) and a slightly lower blood loss (502 vs. 660 ml) were observed for the modified mini-Hardinge. Moreover, the mini-incision group showed slightly better functional results in the early course. A higher rate of implant malpositioning or a higher peri- and postoperative complication rate was not observed.
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0 |
Complications in Eyelid Surgery
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Upper Eyelid and Brow Surgery
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Eyelid surgery consists of challenging reconstructive and cosmetic procedures. Because of the complex anatomy and corresponding vital functions of the upper and lower eyelids, the avoidance of eyelid complications is of vital importance. Complications after eyelid surgery include basic complications (infection, granuloma) and vision-threatening complications. Preoperative history, physical examination, surgical planning, and meticulous surgical technique must be undertaken to prevent complications after eyelid surgery. In addition, patient knowledge, expectations, and motivations must be determined before surgery is performed.
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0 |
Etiology and prevention of age-related hip fractures
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Management of Hip Fractures in the Elderly
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Falls and fall-related injuries are among the most serious and common medical problems experienced by the elderly. Hip fracture, one of the most severe consequences of falling in the elderly, occurs in only about 1% of falls. Despite this, hip fracture accounts for a large share of the disability, death, and medical costs associated with falls. As measured by their frequency, influence on quality of life, and economic cost, hip fractures are a public health problem of crisis proportions. Without successful international initiatives aimed at reducing the incidence of falls and hip fractures, the implications for allocations of health resources in this and the next century are staggering. Identifying those at risk for harmful falls requires an understanding of what kinds of falls result in injury and fracture. In elderly persons who fall, in most of whom hip bone mineral density is already several standard deviations below peak values, fall severity (as reflected in falling to the side and impacting the hip) and body habitus are important risk factors for hip fracture and touch on a domain of risk entirely missed by knowledge of bone mineral density. These findings clearly suggest that factors related to both loading and bone fragility play important roles in the etiology of hip fracture. We provide a strategy, based on engineering approaches to fracture risk prediction, for determining the relative etiologic importance of loading and bone fragility and to summarize some of what is known about both sets of factors. We define a factor of risk, phi, as the ratio of the loads applied to the hip divided by the loads necessary to cause fracture and summarize available data on the numerator and the denominator of phi. We then provide an overview of the complex interplay between the risks associated with the initiation, descent, and impact phases of a fall, thereby suggesting an organized approach for evaluating intervention efforts being used to prevent hip fractures. The findings emphasize the continuing need for combined intervention strategies that focus on fall prevention, reductions in fall severity, and maintaining or increasing femoral bone mass and strength, either through targeted exercise programs, optimal nutrition (Ca, Vitamin D), and/or in the use of osteodynamic agents. By developing and refining the factor of risk, a property that captures both the contributions of bone density and the confounding influences of body habitus and fall severity, we believe these intervention strategies can be targeted more appropriately
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0 |
Bicruciate retaining
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OAK 3 - Non-arthroplasty tx of OAK
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Total knee replacement (TKR) is a procedure used to treat knee arthropathy. Patients' dissatisfaction is still relevant (literature reports dissatisfaction rates as high as 40%). The anterior cruciate ligament is usually removed while performing a total knee arthroplasty, thus changing knee biomechanics. As patients' mean age to surgery is decreasing, bicruciate retaining models, which preserve normal biomechanics, may be useful in increasing patients' outcomes. Limited data concerning bicruciate retaining arthroplasty is available; although clinical results are encouraging, there are concerns regarding surgical exposure, anterior cruciate integrity evaluation, and implant fixation.
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0 |
The case for evidence in wound care: investigating advanced treatment modalities in healing chronic diabetic lower extremity wounds
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DoD LSA (Limb Salvage vs Amputation)
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BACKGROUND: Major complications of diabetes mellitus include lower leg and foot ulcers, which can result in amputation. Further study is needed to determine optimal treatments for these challenging wounds. Growth factor therapy and hyperbaric oxygen (HBO) treatments are 2 advanced therapeutic modalities that hold promise. PURPOSE: This descriptive, retrospective review investigated healing rates of patients with diabetes mellitus and lower- extremity ulcers managed by growth factor therapy and HBO as compared to standard wound care. DESIGN: Retrospective review of medical records. SUBJECTS AND SETTING: We reviewed medical records of 89 patients with diabetes and lower-extremity wounds treated at a major outpatient wound care program in the southwestern United States. METHODS: Patients were categorized according to 4 treatment modalities: (1) standard wound care, (2) growth factor therapy, (3) standard wound care plus HBO, and (4) growth factor therapy plus HBO. Wounds were measured at the start of the analysis and then weekly for a total of 8 weeks. The change in wound volume from the first to the eighth week was recorded. RESULTS: All patient groups demonstrated healing with the patients who received growth factor therapy alone and those who received growth factor therapy and the HBO treatments demonstrating the greatest decrease in wound volume over the 8 weeks. A 2-by-2 factorial analysis of covariance demonstrated that patients who received HBO as part of their wound care regimen demonstrated significantly greater healing than patients who received only standard wound care or growth factor therapy (P < .0001). Although the combination of hyperbaric and growth factor therapy did not show significant synergistic effects for wound healing in this study, it should be noted that the mean size of the wounds in this group was 2.8 times larger than the mean size of the wounds in the other groups. CONCLUSION: Patients managed in a state-of-the-art wound care center experienced progress toward wound healing, regardless of the treatment modality selected. Those who received HBO as part of their wound care regimen healed faster than those who received standard treatment or growth factor therapy.
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0 |
Treatment results with debridement and retention of infected hip prostheses
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Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures
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A retrospective systematic review of the management of a periprosthetic joint infection (PJI) cohort of 78 cases was conducted at a single-centre, middle-sized Norwegian hospital from 1997 to 2007. We analysed 40 cases that were managed by surgical debridement with hip prosthesis retention followed by long-lasting pathogen-directed antibiotic therapy. A follow-up time of 58 to 510 weeks free from PJI relapse occurred in 27 of 40 PJI cases (67.5%). The need for a more advanced secondary orthopaedic procedure was recognized in 13 cases. The pathogen responsible for PJI was recovered in only 80% of cases, hence 20% were managed as culture-negative PJI. In cases without prior hip infection or hip surgery, success rate reached 96.3%. Multiple risk factors were found in most cases undergoing PJI relapse. Debridement with hip prosthesis retention should be restricted to only current management guidelines
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0 |
Carpal tunnel syndrome in a patient with a Cimino-Brescia fistula
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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A case of a carpal tunnel syndrome in a patient with chronic renal insufficiency undergoing hemodialysis by means of a Cimino-Brescia arteriovenous fistula is reported. Surgical decompression of the median nerve at the wrist was followed by the immediate and complete relief of the patient's symptoms. Ischemia related to a vascular 'steal' phenomenon or increased venous pressure have been proposed as primary alterations which can cause a damage of the median nerve at the wrist. In our case, we found symptoms relating to both of these pathogenetic hypotheses
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1 |
Histological findings in breast tissue specimens from reduction mammoplasties
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Reduction Mammoplasty for Female Breast Hypertrophy
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Tissue specimens from 55 consecutive reduction mammoplasty operations were studied histologically for changes considered to be associated to an increased risk in the development of invasive breast cancer. A thorough sampling of all removed tissues was performed and nearly all solid parts were processed for histological evaluation. We found that in 47 specimens, most of which belonged to women younger than 40 years of age (39), both breasts presented either no-proliferative changes or mild hyperplastic lesions of the usual type and thus the women had no increased risk for breast cancer development. In 7 breast specimens, all of them from women older than 30 years, the changes observed ranged from florid hyperplasia to atypical ductal or lobular hyperplasia, which are lesions considered to be associated to a relatively increased risk of invasive carcinoma. Finally we present a case of infiltrative ductal carcinoma with extensive lesions of atypical hyperplasia and combined ductal and lobular carcinoma in situ in both breasts, which developed 3 years after reduction mammoplasty in which changes of atypical hyperplasia were found. We suggest that reduction mammoplasty specimens should be handled with particular care and according to the women's age.
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1 |
Preoperative cardiac evaluation of patients with acute hip fracture
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Management of Hip Fractures in the Elderly
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The goals of the present study were to assess if there is an association between preoperative cardiac evaluation and surgery timing in patients with a hip fracture, to evaluate the relationship between surgery timing and postoperative morbidity and mortality, and to determine if the proper patients are being selected for noninvasive cardiac testing based on the practice guidelines published by the American College of Cardiology/American Heart Association Task Force. Surgery delay secondary to cardiac clearance may be a risk factor for increased postoperative complications that is independent of a patient's general medical condition. Surgical treatment of acute hip fractures may be delayed by many factors besides preoperative cardiac clearance, but it is the job of the orthopedic surgeon, who best understands the importance of timely surgery for a hip fracture, to minimize delays. Careful screening of patients who have sustained a hip fracture can improve overall outcomes by minimizing the number of patients whose surgical treatment is unnecessarily delayed for cardiac clearance
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0 |
Case report: Capnocytophaga canimorsus a novel pathogen for joint arthroplasty
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Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures
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We report the case of a 59-year-old man with Waldenstrom's macroglobulinemia and active alcohol use who presented with bilateral knee pain 5 years after a bilateral staged TKA. Cultures of synovial fluid and periprosthetic tissue specimens from both knees yielded, after prolonged anaerobic incubation, a catalase- and oxidase-positive gram-negative bacillus, which was identified as Capnocytophaga canimorsus by 16S ribosomal RNA PCR analysis. C canimorsus, an organism that is commonly found in dog and cat saliva, is a rare cause of various infections in immunocompromised and healthy individuals. However, a review of the medical literature indicates C canimorsus has not been reported previously to cause infection after joint arthroplasty. The patient was immunocompromised by cytotoxic chemotherapy, corticosteroids, and alcohol use. The patient was managed successfully with bilateral two-stage exchange and 6 weeks of intravenous ertapenem therapy. Because of its fastidious and slow-growing characteristics, C canimorsus may be an unrecognized cause of culture-negative joint arthroplasty infections, especially in cases when dog and cat exposure is evident in the clinical history. (copyright) 2008 The Association of Bone and Joint Surgeons
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0 |
Stability of total hip arthroplasty in patients 75 years or older
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Management of Hip Fractures in the Elderly
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Increasing patient age (> 75 years) is a known risk factor for dislocation of total hip arthroplasty. This is a study of total hip arthroplasties by one surgeon in patients 75 years or older to determine the prevalence of dislocation and a review of the surgical options for prevention and treatment of instability in this population. Of 140 primary total hip arthroplasties done in patients 75 years or older who were followed up for at least 1 year, the preoperative diagnosis was osteoarthritis in 82% and the mean followup time was 4 years. The acetabular component was cementless: modular in 121 arthroplasties and cemented in 19 arthroplasties. There were five dislocations (3.5%), but only two were recurrent and the patients were treated successfully by modular component exchange. Bipolar arthroplasty has a lower rate of dislocation, but there are problems with residual pain and high rates of reoperation, wear, and osteolysis. Constrained components may be indicated in older patients with dementia, abductor insufficiency, or failure of modular exchange. Large femoral heads, to increase the range of motion before dislocation occurs, may be used with highly cross-linked acetabular liners. Modular cementless acetabular components are preferable in patients who are 75 years or older. A 28-mm or 32-mm femoral head is recommended, but larger femoral heads should be considered in patients with fractures and for the treatment of recurrent dislocation
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0 |
Acromioclavicular joint arthrosis in persons with spinal cord injury and able-bodied persons
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Glenohumeral Joint OA
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OBJECTIVE: To compare the prevalence, severity and risk of acromioclavicular (AC) joint arthrosis in persons presenting with shoulder pain between a spinal cord injury (SCI) and able-bodied population. In the SCI population, prevalence and severity of AC joint arthrosis were examined with respect to age, gender and lesion characteristics.
METHODS: Retrospective analysis of medical records and magnetic resonance images (MRI) collected in an outpatient orthopaedics clinic.
RESULTS: Sixty-eight persons with SCI and 105 able-bodied persons were included in the study. The overall MRI prevalence of AC joint arthrosis was 98% and 92%, respectively. In both groups AC joint arthrosis was frequently accompanied by MRI diagnosis of rotator cuff tears and biceps tendon ruptures. Sensitivity of clinical testing was found to be low in SCI (0.31) and in able-bodied persons (0.24). The odds of increasingly severe arthrosis were nearly four times higher in persons with SCI as compared with able-bodied persons (P<0.0001), about 72% lower in females as compared with males (P=0.0001), and 10% higher per additional year of age (P<0.0001). Arthrosis severity in the SCI-group was weakly associated with time since injury, not with neurological classification of SCI or level of injury (paraplegia vs tetraplegia).
CONCLUSION: SCI patients presenting with shoulder pain showed similar prevalence, yet more advanced, AC joint arthrosis than able-bodied patients. As early diagnosis of arthrosis is a prerequisite for the initiation of successful conservative interventions of shoulder deterioration, we recommend routine assessment of shoulder status including diagnostic imaging during check-ups.
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1 |
Functional and radiographic outcomes of Gartland type II supracondylar humerus fractures managed by closed reduction under nitrous oxide as conscious sedation
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Pediatric Supracondylar Humerus Fracture 2020 Review
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The management of Gartland type II supracondylar fractures remains controversial. This study aimed to evaluate the clinical, functional, and radiographic outcomes of Gartland type II supracondylar fractures treated by immediate closed reduction and casting in the emergency department using equimolar nitrous oxide as conscious sedation. All patients were treated non-operatively using equimolar nitrous oxide as conscious sedation during closed reduction and cast immobilization. Three out of 34 patients (three elbows; 8.8%) were lost during follow-up. The mean follow-up time was 26.4 months (range: 6-48). The mean Quick DASH score at cast removal was 22.4 (range: 19-40) and 2.3 (range: 0-9) at the last follow-up visit in patients without secondary displacement (n = 26; 76.5%). The mean Quick-DASH score of patients (n = 5; 16.1%) requiring closed reduction and percutaneous pinning under general anesthesia because of secondary displacement was 21.4 (range: 19-25) at cast removal and 0.9 (range: 0-2.3) at the last follow-up visit. No significant differences between the two groups were found at any time (P = 0.38 and P = 0.48, respectively). The two groups also showed a comparable radiographic outcome and similar Flynn's criteria. The mean Numeric Pain Intensity was three (range: 0-6). No complications related to the administration of equimolar nitrous oxide were recorded. The use of equimolar nitrous oxide as conscious sedation for closed reduction and casting appears to be a safe, inexpensive, and appropriate conservative method of treatment for displaced Gartland type II supracondylar fractures in children. A regular follow-up is mandatory to detect early secondary displacement, as 16.1% of fractures required additional closed reduction and percutaneous pinning under general anesthesia. Level IV, retrospective study.
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0 |
Sublinear elliptic problems with a Hardy potential
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Glenohumeral Joint OA
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Purpose: Arthralgia occurs in up to 50% of breast cancer survivors treated with aromatase inhibitors (AIs) and is the most common reason for poor AI adherence. We conducted, in 121 breast cancer survivors receiving an AI and reporting arthralgia, a yearlong randomized trial of the impact of exercise versus usual care on arthralgia severity. Patients and Methods: Eligibility criteria included receiving an AI for at least 6 months, reporting � 3 of 10 for worst joint pain on the Brief Pain Inventory (BPI), and reporting < 90 minutes per week of aerobic exercise and no strength training. Participants were randomly assigned to exercise (150 minutes per week of aerobic exercise and supervised strength training twice per week) or usual care. The BPI, Western Ontario and McMaster Universities Osteoarthritis (WOMAC) index, and Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire were completed at baseline and at 3, 6, 9, and 12 months. Intervention effects were evaluated using mixed-model repeated measures analysis, with change at 12 months as the primary end point. Results: Over 12 months, women randomly assigned to exercise (n = 61) attended 70% (± standard deviation [SD], 28%) of resistance training sessions and increased their exercise by 159 (± SD, 136) minutes per week. Worst joint pain scores decreased by 1.6 points (29%) at 12 months among women randomly assigned to exercise versus a 0.2-point increase (3%) among those receiving usual care (n = 60; P < .001). Pain severity and interference, as well as DASH and WOMAC pain scores, also decreased significantly at 12 months in women randomly assigned to exercise, compared with increases for those receiving usual care (all P < .001). Conclusion: Exercise led to improvement in AI-induced arthralgia in previously inactive breast cancer survivors.
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0 |
Malalignment after minimally invasive plate osteosynthesis in distal femoral fractures
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Pediatric Diaphyseal Femur Fractures 2020 Review
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INTRODUCTION: Although minimally invasive plate osteosynthesis (MIPO) is a preferred operative treatment for fractures of the distal femur, malalignment is a significant concern because of indirect reduction of the fracture. The purpose of this study, therefore, was to evaluate radiologic alignment after MIPO for distal femoral fractures. PATIENTS AND METHODS: Of the 138 patients with fracture of the distal femur who underwent MIPO, we enrolled 51 patients in whom bilateral rotational alignment could be assessed by postoperative computed tomography (CT). The patients included 32 men and 19 women, with a mean age of 54.3 years. Thirteen patients had femoral shaft fractures (according to the AO/OTA classification: 32-A, n=2; 32-B, n=6; 32-C, n=5), whereas 38 patients had distal femoral fractures (33-A, n=7; 33-C, n=31). Coronal and sagittal alignments were assessed using simple radiography, whereas rotational alignment was assessed using CT. According to the difference between the affected and unaffected sides, we divided the patients into satisfactory and unsatisfactory groups (reference point of 8°, using Handolin's classification). Thereafter, we determined which factors can lead to malalignment, including fracture location (distal femoral shaft fracture or metaphyseal fracture), fracture pattern (simple fracture, n=15; complex fractures, n=36 patients), coronal and sagittal alignments, and combined ipsilateral long bone fractures. RESULTS: Coronal and sagittal alignment were satisfactory in 96.2% (average, 2.8°) and 98% (average, 2.2°), respectively, whereas the rotational alignment was satisfactory in 56.9% of patients. Leg length discrepancy was satisfactory in 92.3% of the patients (average, 10.9mm). Concerning rotational malalignment, an unsatisfactory result was obtained in 48.6% of subjects with complex fractures and 26.7% of subjects with simple fractures (p=0.114). No significant correlation was noted between the angular deformity in the coronal and sagittal planes and the degree of rotational alignment (p=0.607 and 0.774, respectively). CONCLUSIONS: Regardless of the fracture pattern, rotational malalignment may occur at an extremely high rate after MIPO for fractures of the distal femur.
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0 |
Osteochondral allografts: applications in treating articular cartilage defects in the knee
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Surgical Management of Osteoarthritis of the Knee CPG
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Chondral injury in the knee is a unique challenge to the orthopaedic surgeon. Given the high probability of progression to knee arthrosis, the treatment of symptomatic cartilage defects of the knee has become an important surgical intervention in young, active patients. The demand for an alternative to prosthetic resurfacing has driven the trend towards biologic resurfacing and joint preservation. Osteochondral allografts are composed of hyaline cartilage attached to subchondral bone and are suited for large osteochondral lesions. This allograft tissue must be harvested, processed, and stored appropriately to reduce the risks of graft failure and potential complications. With appropriate indications and surgical techniques, osteochondral allografts have been shown to have good long-term graft survival and patient outcomes
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0 |
Renal cell carcinoma detection and systemic therapy with tumour-affine gallium-67 and with yttrium-90 citrate solutions
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MSTS 2018 - Femur Mets and MM
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BACKGROUND: There have been no major advances in the systemic detection of renal cell carcinoma (RCC) and its unpredictable metastases. Surgery, thus, remains the mainstay of the curative treatment for the localized disease. The propose of the present study has been to systemically detect and treat advanced RCC respectively with Ga-67 and Y-90 radiopharmaceuticals containing tumour-affine species.
PATIENTS AND METHODS: Thirty-three RCC patients were imaged with Tc-99m-MDP and then with Ga-67 citrate solution in order to detect RCC and its metastases. Yttrium-90 citrate solution, containing the radionuclide species chromatographically and electrophoretically identical to those in RCC-affine Ga-67 solution, was administered i.v. for systemic therapy of advanced RCC. Total-body distribution of Y-90 was studied with a gamma-camera equipped with an ultra-high-sensitivity collimator. The efficacy of the therapy was studied by the clinical condition of the patient and by the total-body scintigraphic imaging with Tc-99m-MDP and with Ga-67 citrate solution.
RESULTS: Ga-67 detects RCC bone metastases better than Tc-99m-MDP. Systemic therapy of RCC metastasized to bones, lung and brain was obtained with RCC-affine Y-90 citrate solution.
CONCLUSIONS: Third group metal radionuclides, Ga-67 and Y-90, detect and treat advanced RCC.
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0 |
Efficacy, safety, tolerability and pharmacokinetics of a novel human immune globulin subcutaneous, 20%: a Phase 2/3 study in Europe in patients with primary immunodeficiencies
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DoD SSI (Surgical Site Infections)
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A highly concentrated (20%) immunoglobulin (Ig)G preparation for subcutaneous administration (IGSC 20%), would offer a new option for antibody replacement therapy in patients with primary immunodeficiency diseases (PIDD). The efficacy, safety, tolerability and pharmacokinetics of IGSC 20% were evaluated in a prospective trial in Europe in 49 patients with PIDD aged 2–67 years. Over a median of 358 days, patients received 2349 IGSC 20% infusions at monthly doses equivalent to those administered for previous intravenous or subcutaneous IgG treatment. The rate of validated acute bacterial infections (VASBIs) was significantly lower than 1 per year (0·022/patient-year, P < 0·0001); the rate of all infections was 4·38/patient-year. Median trough IgG concentrations were = 8 g/l. There was no serious adverse event (AE) deemed related to IGSC 20% treatment; related non-serious AEs occurred at a rate of 0·101 event/infusion. The incidence of local related AEs was 0·069 event/infusion (0·036 event/infusion, when excluding a 13-year-old patient who reported 79 of 162 total related local AEs). The incidence of related systemic AEs was 0·032 event/infusion. Most related AEs were mild, none were severe. For 64·6% of patients and in 94·8% of IGSC 20% infusions, no local related AE occurred. The median infusion duration was 0·95 (range = 0·3-4·1) h using mainly one to two administration sites [median = 2 sites (range = 1–5)]. Almost all infusions (99·8%) were administered without interruption/stopping or rate reduction. These results demonstrate that IGSC 20% provides an effective and well-tolerated therapy for patients previously on intravenous or subcutaneous treatment, without the need for dose adjustment.
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0 |
Extracorporeally frozen tumour-bearing bone combined with free vascularised fibula for the intercalary reconstruction of femoral defect after resection of bony sarcoma
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PJI DX Updated Search
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BACKGROUND: With the improved survival for patients with bone sarcomas, there is a trend to reconstruct intercalary femur defects using biologic techniques. This study examined whether the results of a frozen femur autograft with vascularised fibula are comparable to other reconstructive options in terms of the functional outcomes and the complications. MATERIALS AND METHODS: Between 2008 and 2012, eight patients with bony sarcoma of the femur were subjected to reconstruction with a recycled frozen autograft combined with a vascularised fibula flap inside. The oncologic and functional results were analysed retrospectively. RESULTS: The mean follow-up was 48.7 months (37-71). The oncologic results were continuously disease free in five patients; there was no evidence of disease in one, one patient was alive with disease and another died of the disease. The average length of defect was 13.6 cm (9-21). Bone union was achieved in all cases. The mean time to bone union was 7.9 months (5-19) and to full weight bearing was 7.8 months (6-11). There was no infection or construct fracture in this series. Two complications were observed. One tumour recurrence in soft tissue was treated with reresection. One tibia fracture was successfully managed with cast immobilisation. The average Musculoskeletal Tumor Society functional score was 95% (27-30). The construct was intact in all patients. CONCLUSIONS: Vascularised fibular flap combined with frozen autografts is a dependable and durable option for the reconstruction of large bony defects after femoral sarcoma resection. It had the merits of reliable bone union and low complications, which compare well with other biological reconstructions. Evidence Rating Scale for Therapeutic Studies Level IV, therapeutic study
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0 |
Spine-Hip T-Score Difference Predicts Major Osteoporotic Fracture Risk Independent of FRAX((registered trademark)): A Population-Based Report From
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Management of Hip Fractures in the Elderly
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The WHO fracture risk assessment tool (FRAX((registered trademark))) estimates an individual's 10-yr major osteoporotic and hip fracture probabilities. When bone mineral density (BMD) is included in the FRAX calculation, only the femoral neck measurement can be used. Recently, a procedure was reported for adjusting major osteoporotic fracture probability from FRAX with femoral neck BMD based on the difference (offset) between the lumbar spine and the femoral neck T-score values. The objective of the current analysis was to independently evaluate this algorithm in a population-based cohort of 4575 women and 1813 men aged 50yr and older from the Canadian Multicentre Osteoporosis Study. For women and men combined, there was a 15% (95% confidence interval 7-24%) increase in major osteoporotic fracture risk for each offset T-score after adjusting for FRAX probability calculated with femoral neck BMD. The effect was stronger in women than men, but a significant sex interaction was not detected. Among the full cohort, 5.5% had their risk category reclassified after using the offset adjustment. Sex- and age-dependent offsets (equivalent to an offset based on Z-scores) showed improved risk classification among individuals designated to be at moderate risk with the conventional FRAX probability measurement. In summary, the T-score difference between the lumbar spine and femoral neck is an independent risk factor for major osteoporotic fractures that is independent of the FRAX probability calculated with femoral neck BMD. (copyright) 2011 The International Society for Clinical Densitometry
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1 |
Effectiveness and safety of continuous ultrasound-guided femoral nerve block versus epidural analgesia after total knee arthroplasty
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AAHKS (9/10) Regional Nerve Blocks
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OBJECTIVES: Total knee arthroplasty is associated with severe postoperative pain. The aim of this study was to compare continuous ultrasound-guided femoral nerve block with continuous epidural analgesia, both with low concentrations of local anaesthetic after total knee arthroplasty.
MATERIAL AND METHODS: A prospective, randomised, unblinded study of 60 patients undergoing total knee replacement, randomised into two groups. A total of 30 patients received continuous epidural block, while the other 30 received continuous ultrasound-guided femoral nerve block, as well as using 0.125% levobupivacaine infusion in both groups. Differences in pain control, undesirable effects, and complications between the two techniques were assessed, as well as the need for opioid rescue and the level of satisfaction with the treatment received during the first 48hours after surgery.
RESULTS: No differences were found in demographic and surgical variables. The quality of analgesia was similar in both groups, although in the first six hours after surgery, patients in the epidural group had less pain both at rest and with movement (P=.007 and P=.011). This difference was not observed at 24hours (P=.084 and P=.942). Pain control at rest in the femoral block group was better at 48hours after surgery than in the epidural group (P=.009). The mean consumption of morphine and level of satisfaction were similar. Epidural analgesia showed the highest rate of side effects (P=.003).
CONCLUSIONS: Continuous ultrasound-guided femoral nerve block provides analgesia and morphine consumption similar to epidural analgesia, with the same level of satisfaction, but with a lower rate of side effects after total knee arthroplasty.
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1 |
Open versus Endoscopic Carpal Tunnel Release: A Meta-analysis of Randomized Controlled Trials
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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BACKGROUND: Carpal tunnel syndrome is a common compressive neuropathy of the median nerve. The efficacy and safety of endoscopic versus open carpal tunnel release remain controversial. QUESTIONS/PURPOSES: The purpose of this study was to determine whether endoscopic compared with open carpal tunnel release provides better symptom relief, validated outcome scores, short- and long-term strength, and/or digital sensibility; entails a differential risk of complications such as nerve injury, scar tenderness, pillar pain, and reoperation; allows an earlier return to work; and takes less operative time. METHODS: The English-language literature was searched using MEDLINE, the Cumulative Index to Nursing and Allied Health Literature, and the Cochrane Central Register of Controlled Trials. Randomized controlled trials that compared endoscopic and open carpal tunnel release were included in the meta-analysis. Methodologic quality was assessed with the Consolidated Standards Of Reporting Trials (CONSORT) checklist, and a sensitivity analysis was performed. Symptom relief, Boston Carpal Tunnel Questionnaire (BCTQ) scores, strength, digital sensibility, complications, reoperation, interval to return to work, and operative time were analyzed. Twenty-one randomized controlled trials containing 1859 hands were included. RESULTS: Endoscopically treated patients showed similar symptom relief and BCTQ scores; better early recovery of grip strength (mean difference [MD], 3.03 kg [0.08-5.98]; p = 0.04) and pinch strength (MD, 0.77 kg [0.33-1.22]; p < 0.001) but no advantage after 6 months; lower risk of scar tenderness (risk ratio [RR], 0.53 [0.35-0.82]; p = 0.005); higher risk of nerve injury (RR, 2.84 [1.08-7.46]; p = 0.03), most of which were transient neurapraxias. Similar risk of pillar pain and reoperation; an earlier return to work (MD, -8.73 days [-12.82 to -4.65]; p < 0.001); and reduced operative time (MD, -4.81 minutes [-9.23 to -0.39]; p = 0.03). CONCLUSIONS: High-level evidence from randomized controlled trials indicates that endoscopic release allows earlier return to work and improved strength during the early postoperative period. Results at 6 months or later are similar according to current data except that patients undergoing endoscopic release are at greater risk of nerve injury and lower risk of scar tenderness compared with open release. While endoscopic release may appeal to patients who require an early return to work and activities, surgeons should be cognizant of its elevated incidence of transient nerve injury amid its similar overall efficacy to open carpal tunnel release. Additional research is required to define the learning curve of endoscopic release and clarify the influence of surgeon volume on its safety
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0 |
Shortwave ultraviolet radiation in operating rooms
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Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures
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We have evaluated the effect of shortwave ultraviolet radiation on bacterial levels in an operating theatre, both in experimental conditions and during 20 hip operations. When compared with the use of sham blue light, there was a significant reduction in the number of bacteria. The reduced level was comparable with that suggested for ultraclean air ventilation systems
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Percutaneous Pins Versus Volar Plates for Unstable Distal Radius Fractures: A Biomechanic Study Using a Cadaver Model
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Distal Radius Fractures
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Purpose: A biomechanic study using a cadaver model of a dorsally unstable distal radius fracture was used to compare the stability of percutaneous pinning and volar fixed-angle plating. Among the many surgical options for treating distal radius fractures are percutaneous pinning and internal plate fixation. Although percutaneous pin fixation requires less soft-tissue trauma and has low complication rates, plate fixation allows for early active movement with good clinical results. The biomechanic stability of these 2 methods was studied by using a cadaver model of a dorsally unstable intra-articular distal radius fracture. Methods: This study was performed on 7 fresh-frozen cadaver arms, in each of which an unstable intra-articular fracture with dorsal comminution was created. The fracture was first fixed with 0.062-mm K-wires inserted in standard crossed fashion and was tested in a pneumatic loading device that indirectly loaded the wrists through the 5 motor tendons 3 times at each level of force in flexion and extension. Testing was then repeated after removal of the pins and fixation with a fixed-angle DVR distal volar radius plate system (Hand Innovations, Inc., Miami, FL). Testing was performed in flexion up to 68 N and in extension up to 100 N, and the distance across the fracture site was measured. Results: Volar plating was significantly more stable than pinning, with an average movement across the fracture site of 2.51 mm for pin fixation and 1.07 mm for plate fixation. The pins also showed a substantial degree of slipping after repeated stressing, but the plates remained stable. Conclusions: These results show the superior biomechanic stability of internal fixation using plates for dorsally comminuted intra-articular distal radius fractures in this cadaver model. Further clinical correlations are needed. © 2007 American Society for Surgery of the Hand.
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0 |
Radiofrequency lumbar sympatholysis. The evolution of a technique for managing sympathetically maintained pain
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Surgical Management of Osteoarthritis of the Knee CPG
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BACKGROUND AND OBJECTIVES: To develop lumbar radiofrequency sympatholysis for the relief of pain in patients with neuropathic pain who had previously responded to sympathectomy or sympathetic blocks. METHODS: The technique described by Sluijter was modified to attempt to obtain long lasting pain relief in each patient. No one technique was universally applicable. The variations in technique are illustrated by the case reports. The basic technique that evolved is as follows: a 20-gauge 15-cm insulated needle with a 5-mm active tip was inserted in the direction of an x-ray beam (C arm). The initial target was slightly cephalad to the middle of the L3 vertebra. Contrast medium was injected to confirm the location of the needle. The temperature of the tip of the needle was controlled at 80 degrees C for 90 seconds. RESULTS: Thirty-eight procedures were performed on 20 patients. Reproduction of the pain for which the sympatholysis was undertaken, induced dysesthesia, spread of dye, rapidity of temperature rise in the legs, and increase in pulse volume of the toes were useful guides to proper placement of the needle. Five patients continue to be pain free 5 months to 3 years after the last radiofrequency sympatholysis. Fifteen had temporary relief or no relief at all. The procedure was temporarily complicated by an excessively hot, swollen foot, and postsympathectomy neuralgia in a few cases. CONCLUSIONS: A single technique of radiofrequency sympatholysis does not appear to be applicable to all patients with reflex sympathetic dystrophy or sympathetically maintained pain. Despite early successful sympathetic block with radiofrequency, as confirmed by a warm foot, long lasting pain relief was difficult to obtain. The author concludes that individualized patient management is necessary when considering radiofrequency sympatholysis in the treatment of patients with sympathetically maintained pain
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Selective inhibition of matrix metalloproteinase-2 in the multiple myeloma-bone microenvironment
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MSTS 2018 - Femur Mets and MM
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Multiple myeloma is a plasma cell malignancy that homes aberrantly to bone causing extensive skeletal destruction. Despite the development of novel therapeutic agents that have significantly improved overall survival, multiple myeloma remains an incurable disease. Matrix metalloproteinase-2 (MMP-2) is associated with cancer and is significantly overexpressed in the bone marrow of myeloma patients. These data provide rationale for selectively inhibiting MMP-2 activity as a multiple myeloma treatment strategy. Given that MMP-2 is systemically expressed, we used novel "bone-seeking" bisphosphonate based MMP-2 specific inhibitors (BMMPIs) to target the skeletal tissue thereby circumventing potential off-target effects of MMP-2 inhibition outside the bone marrow-tumor microenvironment. Using in vivo models of multiple myeloma (5TGM1, U266), we examined the impact of MMP-2 inhibition on disease progression using BMMPIs. Our data demonstrate that BMMPIs can decrease multiple myeloma burden and protect against cancer-induced osteolysis. Additionally, we have shown that MMP-2 can be specifically inhibited in the multiple myeloma-bone microenvironment, underscoring the feasibility of developing targeted and tissue selective MMP inhibitors. Given the well-tolerated nature of bisphosphonates in humans, we anticipate that BMMPIs could be rapidly translated to the clinical setting for the treatment of multiple myeloma.
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1 |
Treatment of pediatric femoral shaft fractures by stainless steel and titanium elastic nail system: A randomized comparative trial
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Pediatric Diaphyseal Femur Fractures 2020 Review
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PURPOSE: Literature suggests that the lower modulus of elasticity of titanium makes it ideal for use in children compared with stainless steel. Better fracture stability was observed in association with titanium nails on torsional and axial compression testing. However, stainless steel nails are stiffer than titanium counterparts, which may provide a rigid construct when fixing paediatric femoral shaft fractures. Complications have been observed more frequently by various researchers when titanium nails are used for fracture fixation in patients with increasing age or weight. The concept of this study was to compare the functional outcome after internal fixation with titanium elastic nail system and stainless steel elastic nail system in paediatric femoral shaft fractures. METHODS: The study was conducted on 34 patients admitted in the department of orthopaedics, LLRM Medical College & SVBP Hospital, Meerut, India from January 2013 to August 2014. We included patients aged 5-12 years with fracture of the femoral shaft, excluding compound fractures, pathological fractures and other lower limb fractures. Patients were treated by titanium (n=17) or stainless steel (n=17) elastic nail system and followed up for one year. The clinical parameters like range of motion at hip and knee joints, time to full weight bearing on the operated limb and radiological parameters like time to union were compared between two groups. A special note was made of intra- and post-operative complications. Functional outcomes were analysed according to Flynn criteria. RESULTS: Based on the Flynn criteria, 59% of patients had excellent results, 41% had satisfactory results, and no one showed poor results. There was no clinically significant difference between the two groups with respect to time to union and full weight bearing. But the incidence of puncture of the opposite cortex while inserting the nail and trying to advance it through the diaphysis during operation is greatly different. Only one such case was observed in titanium group but five in stainless steel group. CONCLUSION: Majority of paediatric femoral shaft fractures are now treated operatively by elastic stable intramedullary nails. Operative intervention results in a shorter hospital stay and has economic and social benefits over conservative treatment. The cost of stainless steel nail is one third the cost of titanium nail. However, the clinico-radiological results are not significantly different between titanium and stainless steel nails at one year follow-up as observed by our study.
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Hemorrhagic-acquired factor XIII deficiency associated with tocilizumab for treatment of rheumatoid arthritis
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PJI DX Updated Search
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Factor XIII (FXIII) is the final enzyme in the coagulation cascade. Acquired
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0 |
Targeting p38 MAPK for the treatment of inflammatory arthritis
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MSTS 2018 - Femur Mets and MM
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Inflammatory bone destruction is a relatively frequent and incapacitating complication of rheumatoid arthritis and other chronic inflammatory joint diseases, and is a product of acceleratesd osteoclast recruitment and activation in bone under the aegis of cytokines produced in the inflammatory milieu. Over the past decade there have been major advances in our understanding of the mechanisms of this family of diseases. It is now clear that p38 mitogen-activated protein kinase plays an essential role in the production of proinflammatory cytokines and cytokine-induced osteoclastogenesis, thus providing a potential tool for preventing pathologic bone loss. This review outlines our current understanding of the mechanisms mediating inflammatory arthritis and highlights potential therapeutic strategies targeting p3B mitogen-activated protein kinase. © 2008 Future Medicine Ltd.
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Assessment of effects of ultrasound therapy on reduction of pain in gonarthrosis
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OAK 3 - Non-arthroplasty tx of OAK
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AIM: To examine the effects of sonotherapy on the activities of daily living or as well as the reduction of pain in gonarthrosis.
METHODS: A retrospective- prospective clinical study included 63 patients, 47 to 86 years old with a verified diagnosis of gonarthrosis. Subjects were divided into two groups. The first group included 26 patients treated with kinesitherapy in combination with electrotherapy; the second group included 37 patients treated with kinesitherapy combined with sonotherapy. The age, sex, activities of daily living by Barthel Index and the intensity of pain by visual pain scale (VAS) was analyzed at admission and discharge of the patients.
RESULTS: Both groups were matched for age, sex, and Barthel index values at admission and discharge. There was no statically significant difference between the groups according to demogrfphic characteristics. Visual pain scale at admission was almost identical in both groups; VAS at discharge waa lower in the group treated with kinesiotherapy and sonotherapy. Visual pain scale at discharge was lower in both groups than at admission, but without statisticay difference (p more than 0.05).
CONCLUSION: Sonotherapy and electrotherapy improved the activities of patien's' lives. Both types of therapy, in combination with kinesitherapy, led to a decrease of pain in patients with gonarthrosis.
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1 |
Knee extensor strength gains mediate symptom improvement in knee osteoarthritis: secondary analysis of a randomised controlled trial
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OAK 3 - Non-arthroplasty tx of OAK
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OBJECTIVE: To determine if an increase in knee extensor strength mediates the effect of a 12-week knee extensor strength training program on pain and physical function improvement in people with knee osteoarthritis (OA).
DESIGN: Secondary analysis from a randomised controlled trial comparing the effects of a 12-week knee extensor strengthening exercise program to a control group with no intervention.
METHODS: Data from participants with complete data (n = 97) enrolled in a previous clinical trial were analysed. Baseline and 12-week follow-up assessments included peak isometric knee extensor strength, pain and physical function. Peak knee extensor strength (Nm/kg) was assessed on an isokinetic dynamometer and subscales of the Western Ontario and McMaster Universities (WOMAC) Osteoarthritis Index were used to assess pain and physical function. Twelve-week change in pain and physical function were regressed separately, on 12-week change in knee extensor strength and group allocation. Covariates included baseline pain or physical function as appropriate, and baseline knee extensor strength, age, sex and knee alignment (stratification variable).
RESULTS: Improved knee extensor strength mediated the effect of the strengthening program on both pain relief (mediated effect size = 0.69, 95% confidence intervals (CI) 0.05-1.33, P = 0.03), and improved physical function (mediated effect size = 1.86, 95% CI 0.08-3.64, P = 0.04), at 12 weeks.
CONCLUSIONS: Increased knee extensor strength partially mediates the effect of a knee extensor strength training program on pain and physical function improvement in people with knee OA.
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Do facet joint capsular ligaments contain estrogen receptors? Application to pathogenesis of degenerative spondylolisthesis
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Glenohumeral Joint OA
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Studies showing that degenerative spondylolisthesis is 4 to 5 times more common in females than in males have suggested that hormonal influences account for this gender difference. Estrogen has been shown to play a role in other instabilities, such as those of the anterior cruciate ligament and the shoulder capsular ligaments, and estrogen receptors have been identified in these tissues. We wanted to assess facet joint capsular ligaments for the presence of such receptors. Accordingly, we collected facet joint capsular ligaments from 14 consecutive patients undergoing lumbar spinal fusion. Tissue sample analysis was performed by immunohistology using prediluted estrogen monoclonal antibody (Vantana) and automated immunostaining on a Vantana instrument. None of the specimens analyzed contained estrogen receptors. We conclude that, though degenerative spondylolisthesis may have hormonal influences, estrogen seems not to play a direct role in its development.
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Chronic joint pain in the lower body is associated with gait differences independent from radiographic osteoarthritis
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OAK 3 - Non-arthroplasty tx of OAK
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Gait is an important indicator of health. Chronic lower body pain may impair gait and lead to morbidity and mortality. We investigated the associations between lower body pain and gait in community-dwelling individuals, independent from osteoarthritis (OA). This population based cohort study included 2304 Rotterdam Study participants who underwent electronic walkway gait assessment. Thirty different variables resulting from gait assessment were summarized into seven gait domains using principle components analysis: i.e. Rhythm, Variability, Phases, Pace, Tandem, Turning, and Base of Support. Chronic lower body pain was assessed using pain drawings. OA was defined as a Kellgren & Lawrence score of 2 or higher on radiographs of the hip and/or knee. Linear regression analysis was used to study associations.
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Reading performance and central field loss
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Upper Eyelid and Brow Surgery
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Age-related macular degeneration is a major cause of blindness in Europe and the U.S. and a leading cause of significant loss of visual acuity in elderly patients. Reading is a key visual task in everyday living involving a synthesis of a number of different motor, sensory and cognitive functions. When the centre of a reader's visual field is obscured, reading speed declines and oculomotor pattern differs, compared to normal reading. Improvement in the generation of visual stimuli using computer-generated images and projection/display systems as well as advances in eye movement recording techniques, including infrared pupil tracking and magnetic search coils, have contributed greatly to our understanding of these sensorimotor abnormalities. The developed reading strategies have been thoroughly investigated in individuals with central field loss either induced artificially or related to eye pathology.The following review aims at presenting the contemporary literature regarding the sensory and oculomotor deficits in reading ability, resulting from central field loss and should contribute to a greater understanding of the functional visual deficit caused by this visual impairment.
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Role of psychosocial stress in recovery from common whiplash
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DoD PRF (Psychosocial RF)
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It is widely accepted that psychosocial factors are related to illness behaviour and there is some evidence that they may influence the rate of recovery from post-traumatic disorders. The abilities of psychosocial stress, somatic symptoms, and subjectively assessed cognitive impairment to predict delayed recovery from common whiplash were investigated in a follow-up study. 78 consecutive patients referred 7.2 (SD 4.5) days after they had sustained common whiplash in car accidents were assessed for psychosocial stress, negative affectivity, personality traits, somatic complaints, and cognitive impairment by semistructured interview and by several standardised tests. On examination 6 months later 57 patients were fully recovered adn 21 had persisting symptoms. The groups' scores for the independent variables assessed at the baseline examination were compared. Stepwise regression analysis showed that psychosocial factors, negative affectivity, and personality traits were not significant in predicting the outcome. However, initial neck pain intensity, injury-related cognitive impairment, and age were significant factors predicting illness behaviour. This study, which was based on a random sample and which considered many other possible predictive factors as well as psychosocial status, does not support previous findings that psychosocial factors predict illness behaviour in post-trauma patients.
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0 |
Fresh and frozen articular cartilage allografts
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Diagnosis and Treatment of Osteochondritis Dissecans AUC
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Fresh and frozen cartilage allografts both function well to relieve joint pain due to cartilage injury. Fresh cartilage allografts appear to remain alive for many months and are most applicable to small injuries such as osteochondritis dissecans, traumatic defects, and osteonecrosis. Frozen cartilage allografts have been used mostly for treatment of bone tumors which most often involve the subchondral and the metaphyseal areas of the long bones, particularly around the knee and hip. Frozen cartilage allografts appear to survive well and maintain joint space for several years. Deterioration of either type of graft does not appear to result in joint pain, making these grafts useful for long periods of time
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Clinical outcomes of suture delay in forehead flap
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Reconstruction After Skin Cancer
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The delay phenomenon is a surgical procedure performed to raise a wider skin flap and to improve the survival of skin flaps. Surgery, chemicals, sutures, and lasers can be used for the delay procedure. In this study, delayed forehead flaps created by suturing were used for coverage of nasal skin defects in eleven patients. In 7 patients, the cross-paramedian forehead flap was used to increase the extent of flap lengthening. In the first session, suture delay was performed on both sides of the forehead flap margin. In the second session, the flap was elevated and sutured to its new position, 7 to 10 days after the initial surgery. All flaps were completely viable, and patient satisfaction was optimal in all cases. The positive effect of surgical delay on flap survival has been shown in experimental and clinical studies. However, experimentally, suture delay or chemical delay procedures have been shown to be beneficial in flap survival only. Suture delay seems to be an inexpensive, effective, easily performed, atraumatic, and safe technique, especially among patients with systemic diseases such as diabetes or cardiovascular diseases, smoking patients who may lose the flap, or patients who need very wide and long flaps.
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Hip Resurfacing Using Highly Cross-linked Polyethylene: Prospective Study Results at 8.5 Years
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Hip Fx in the Elderly 2019
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BACKGROUND: Hip resurfacing is an option to consider when treating younger, more active patients. Advantages over total hip arthroplasty include a more normal gait and a lower incidence of thigh pain.
METHODS: In this prospective study, 190 hip resurfacing procedures (164 participants) were performed using a cobalt-chromium femoral component and a cementless acetabular cup with a 3.8-mm highly cross-linked polyethylene acetabular liner.
RESULTS: The mean follow-up was 8.5 (range, 7-10) years. Two participants were lost to follow-up and 2 died. One participant underwent successful revision surgery for acetabular loosening. Four participants underwent successful revision to a total hip arthroplasty because of femoral neck fracture (2), femoral loosening, or infection. The Kaplan-Meier survivorship was 97%. Acetabular bone conservation was assessed using computed tomography by measuring the medial acetabular wall. The mean thickness was 9 mm. Femoral bone was well preserved with a mean head:neck ratio of 1.37. There were 4 (2%) osteolytic defects up to 0.9 cm(3) on computed tomography and no instances of impending polyethylene wear-through. Seven polyethylene retrievals had a measured wear rate of 0.05 mm/y.
CONCLUSION: Hip resurfacing using a highly cross-linked polyethylene acetabular component is a reliable procedure. Both femoral and acetabular bones are reasonably preserved compared with prior resurfacing methods. The low incidence of osteolysis and the low rate of wear found on retrievals suggest that many years of use in highly active patients is possible.
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0 |
Scarred muscle excision for the treatment of established ischemic contracture of the lower extremity
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DOD - Acute Comp Syndrome CPG
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Nine patients with rigid equinocavovarus contractures of the foot and ankle after ischemic episodes of the leg were treated from 1986 to 1989. The ischemic contractures occurred after tibial and fibular fractures in six cases, and after a trimalleolar ankle fracture, an electrical burn, and cardiac bypass surgery in one case each. Previous tendon and nerve releases had failed. The scarred portion of the various involved muscles of the deep posterior compartment were widely excised along with the respective tendons. A variety of additional foot procedures were generally necessary to obtain a plantigrade foot. Night splinting to maintain a plantigrade foot was prescribed for all patients.
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0 |
Antibiotic bone cement for the treatment of Pseudomonas aeruginosa in joint arthroplasty: comparison of tobramycin and gentamicin-loaded cements
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Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures
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One hundred clinical isolates of Pseudomonas aeruginosa were collected from 22 medical centers throughout Europe and were challenged with two aminoglycoside-loaded bone cements, employing a modified in vitro Kirby-Bauer susceptibility model. The results of this study show that Simplex P with tobramycin exhibits antibacterial activity against 98% of the strains tested, compared to 93% for Palacos with gentamicin. Additionally, for strains that were susceptible to the antibiotic bone cement formulations, the average zone of inhibition produced around the tobramycin-loaded cement disks was approximately 25% greater than that seen around the gentamicin-loaded cement disks. This difference was statistically significant (p << 0.01). Tobramycin-loaded bone cement is therefore the preferred formulation when addressing Pseudomonas aeruginosa in septic joint arthroplasty
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0 |
Social support contributes to outcomes following distal radius fractures
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Distal Radius Fractures
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Background. Distal radius fractures are the most common fracture of the upper extremity and cause variable disability. This study examined the role of social support in patient-reported pain and disability at one year following distal radius fracture. Methods. The Medical Outcomes Study Social Support Survey was administered to a prospective cohort of 291 subjects with distal radius fractures at their baseline visit. Pearson correlations and stepwise linear regression models (F -to-remove 0.10) were used to identify whether social support contributes to wrist fracture outcomes. The primary outcome of pain and disability at one year was measured using the Patient Rated Wrist Evaluation. Results. Most injuries were low energy (67.5%) and were treated nonoperatively (71.9%). Pearson correlation analysis revealed that higher reported social support correlated with improved Patient Rated Wrist Evaluation scores at 1 year, r (n = 181) = - 0.22, P < 0.05. Of the subscales within the Social Support Survey, emotional/informational support explained a significant proportion of the variance in 1-year Patient Rated Wrist Evaluation scores, R2 = 4.7 %, F (1, 181) = 9.98, P < 0.05. Conclusion. Lower emotional/informational social support at the time of distal radius fracture contributes a small but significant percentage to patient-reported pain and disability outcomes. © 2013 Caitlin J. Symonette et al.
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Large-volume liposuction and extensive abdominoplasty: a feasible alternative for improving body shape
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Reduction Mammoplasty for Female Breast Hypertrophy
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Forty-two female patients underwent liposuction of large volumes and extensive abdominoplasty during an 18-month period, with an average follow-up period of 9 months. Fifty-two percent of the patients underwent a third surgical procedure, which was basically aesthetic. The average age was 40 years; weight varied between 51 kg and 113 kg, with only 11 percent of the patients at their ideal weight. The tumescent technique was used for performing liposuction, which was done on the loins, trochanters, lumbar, upper scapular, and upper lateral abdominal regions, avoiding liposuction of the abdominal flap in all cases except for one. The abdominoplasty was extensive with detachment to the xiphoid process without detaching liposuctioned areas. Volumes of 1600 ml to 11,200 ml were obtained through liposuction, with an average of 4230 cc, and minimal blood loss. Fatty dermal tissue was removed through abdominoplasty and it varied between 400 g and 5000 g with an average of 1300 g. Only the two heaviest patients required an autologous blood unit, because they underwent breast reduction at the same time. All the other patients were managed exclusively with intravenous crystalloids solutions. No major complications arose, and only five patients had minor complications. Based on these results, we consider it to be feasible to combine the liposuctioning of large volumes with abdominoplasty to improve body shape, even with the addition of a third surgical procedure. Nevertheless, it is essential to use the tumescent technique for liposuction to reduce bleeding to a minimum and to allow us to perform other procedures.
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Can an injured discoid lateral meniscus be returned to the correct anatomic position and size of the native lateral meniscus after surgery?
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AMP (Acute Meniscal Pathology)
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BACKGROUND: No previous studies have compared the position and size of the remaining discoid lateral meniscus (DLM) with that of a normal lateral meniscus. This study aimed to evaluate the postoperative position and size of DLM compared with that of normal controls using magnetic resonance imaging (MRI).
METHODS: This retrospective study involved 52 symptomatic complete type DLMs (discoid group) who underwent arthroscopic surgery and 50 normal controls (control group). Pre- and postoperative MRI evaluations, height, width, and relative percentage of extrusion (RPE) were assessed. Sagittal position parameters, including distances from articular cartilage center to anterior meniscus (CAMD) and from anterior articular cartilage margin to anterior horn (ACMD), were also assessed. Logistic regression analysis was performed to find factors with extrusion of remaining DLM.
RESULTS: The height of the discoid group was significantly lower than that of the control group (P = 0.000). RPE in the discoid group was significantly larger than in the control group (P = 0.005). Only CAMD and ACMD in the discoid group were different (positioned more anteriorly) from the control group (P = 0.000). Preoperative meniscal shift (odds ratio (OR): 12.448; P = 0.003) and operative technique, especially partial meniscectomy with repair (OR: 19.125; P = 0.000), were the major factors associated with extrusion.
CONCLUSION: The width of remaining DLM was comparable to that of normal controls, but the position was found to be more anterior and lateral than that of normal controls. Preoperative meniscal shift and combined meniscus repair were the major factors for smaller width and greater extrusion; thus, surgeons should address and counsel these factors before surgery.
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Hereditary multiple exostoses of the hip
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Osteochondritis Dissecans 2020 Review
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PURPOSE: To assess the radiographic features of 36 hips with hereditary multiple exostoses (HME). METHODS: Hip parameters of 12 males and 6 females (36 hips) aged 2 to 28 years with HME were assessed using anteroposterior radiographs. The recorded features included the sites of osteochondromas, the femoral head/neck ratio, the Reimer's migration percentage, Sharp's acetabular angle, the centre edge angle, the femoral neck-shaft angle, and degenerative changes. RESULTS: 15 of the 18 patients were asymptomatic; 3 complained of pain (2 underwent excision or bone biopsy); no lesion was malignant. Osteochondromas were most commonly located in the femur followed by the ilium; only one was intra-articular. 32 hips had coxa valga; 26 had an abnormal Reimer's migration percentage; 17 had an abnormal Sharp's acetabular angle; 12 had an abnormal centre edge angle; 32 had an abnormal femoral neck-shaft angle; and 6 had degenerative changes. Acetabular and femoral dysplasia as well as subluxation are common in patients with HME. CONCLUSION: Borderline subluxated hips and those with marked coxa valga and/or acetabular dysplasia should be closely monitored to determine the need for surgery in the future. Subluxated hips should be operated on early, particularly in children and symptomatic adults.
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Surgery of Cosmetic sequelae after breast-conserving therapy
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Reduction Mammoplasty for Female Breast Hypertrophy
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Although a considerable number of patients have an unfair cosmetic result after breast-conserving therapy, which correlates with poor psychosocial functioning, surprisingly, really only very few patients undergo surgical correction. The purpose of this article was to report our experience in the surgical treatment of such patients and analyze a special subgroup which required bilateral reduction mammaplasty because of associated symptomatic macromastia and their desire to reduce their breast size. From July 2000 to November 2008, some 23 patients consulted for unsatisfactory cosmetic outcome after breast-conserving therapy, fourteen of them accepting the surgical treatment proposed and these were operated upon. We used the following techniques: reduction mammaplasty of the contralateral breast for symmetrization (9), bilateral reduction mammaplasty (4), one mammaplasty and augmentation of contra-lateral breast and one myocutaneous dorsi flap for surgical correction of ipsilateral breast. One patient had serious complications, having partial necrosis of the areola, fat and breast skin necrosis, and needed reoperation for surgical removal of necrotic tissue. Some factors such as obesity and heavy smoking habits could explain this. We were able to evaluate cosmetic outcome in ten patients; late cosmetic outcome was good in seven patients, fair in two and poor in one. Despite the fact that most patients treated by breastconserving therapy are satisfied with the fact that they have retained their breasts and minimized an unfair cosmetic outcome, cosmetic evaluation should be introduced as a matter of routine. © 2010 Wiley Periodicals.
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Octamethylcyclotetrasiloxane (D4)
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Reduction Mammoplasty for Female Breast Hypertrophy
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Octamethylcyclotetrasiloxane (D4; CAS No. 556-67-2) is used as a monomer in the manufacture of polymeric materials, which are widely used in various industrial and/or medical applications, such as breast implants. D4 has a relatively low order of toxicity following acute administration via the oral, dermal, and inhalation routes of exposure and is not considered to be a dermal or eye irritant or to be a dermal sensitizer. There is no appreciable dermal absorption of D4 based on results from in vivo and in vitro studies. D4 has not been shown to be genotoxic/mutagenic when tested in a number of short-term in vitro and in vivo assays. Overall, studies have demonstrated adverse effects on specific female reproductive endpoints at higher exposure concentrations; however, no D4 exposure-specific effects were noted with respect to developmental endpoints. Inhalation exposure of rats to 700 ppm D4 for up to 24 months produced effects in the liver, kidney, and uterus (weight changes, hepatocellular hypertrophy, endometrial hyperplasia, and nephropathy). Changes in the nasal epithelium (eosinophilic globules) were also noted at 150 and 700 ppm. Despite 24 months of exposure, only mild to minimal inflammatory responses were found at 150 ppm, and overall, the basic integrity of the respiratory tract was unchanged at this dose. At 700 ppm, there was an increased incidence of endometrial adenomas in female rats. Based on the adverse changes in the respiratory tract, kidney, and female reproductive tract in the chronic inhalation study, 150 ppm was determined to be the no-observed-adverse-effect level (NOAEL) and was selected as the point of departure for the derivation of the workplace environmental exposure level (WEEL(R)) value. The inhalation NOAEL was adjusted to account for interindividual variability and residual uncertainty regarding upper respiratory tract changes still occurring at 150 ppm. An 8-h time-weighted average WEEL value of 10 ppm is expected to provide a significant margin of safety against any potential adverse health effects in workers exposed to airborne D4.
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Interventions for increasing ankle range of motion in patients with neuromuscular disease
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Management of Hip Fractures in the Elderly
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BACKGROUND: Reduced ankle dorsiflexion range of motion, or ankle equinus, is a common and disabling problem for patients with neuromuscular disease. Clinicians devote considerable time and resources implementing interventions to correct this problem although few of these interventions have been subject to rigorous empirical investigation. OBJECTIVES: To assess the effect of interventions to reduce or resolve ankle equinus in people with neuromuscular disease. SEARCH STRATEGY: We searched the Cochrane Neuromuscular Disease Group Trials Specialized Register (August 2009), Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 3, 2009), MEDLINE (1966 to August 2009), EMBASE (1980 to August 2009), CINAHL 1982 to August 2009), AMED (1985 to August 2009) and The Physiotherapy Evidence Database (PEDro) (1929 to August 2009). We searched the reference lists of identified articles and also contacted known experts in the field to identify additional or unpublished data. SELECTION CRITERIA: Randomised controlled trials evaluating interventions for increasing ankle dorsiflexion range of motion in neuromuscular disease. Outcomes included ankle dorsiflexion range of motion, functional improvement, foot alignment, foot and ankle muscle strength, health-related quality of life, satisfaction with the intervention and adverse events. DATA COLLECTION AND ANALYSIS: Two authors independently selected papers, assessed trial quality and extracted data. MAIN RESULTS: Four studies involving 149 participants met inclusion criteria for this review. Two studies assessed the effect of night splinting in a total of 26 children and adults with Charcot-Marie-Tooth disease type 1A. There were no statistically or clinically significant differences between wearing a night splint and not wearing a night splint. One study assessed the efficacy of prednisone treatment in 103 boys with Duchenne muscular dystrophy. While a daily dose of prednisone at 0.75 mg/kg/day resulted in significant improvements in some strength and function parameters compared with placebo, there was no significant difference in ankle range of motion between groups. Increasing the prednisone dose to 1.5 mg/kg/day had no significant effect on ankle range of motion. One study evaluated early surgery in 20 young boys with Duchenne muscular dystrophy. Surgery resulted in increased ankle dorsiflexion range at 12 months but functional outcomes favoured the control group. By 24 months, many boys in the surgical group experienced a relapse of achilles tendon contractures. AUTHORS' CONCLUSIONS: There is no evidence of significant benefit from any intervention for increasing ankle range of motion in Charcot-Marie-Tooth disease type 1A or Duchenne muscular dystrophy. Further research is required. INTERVENTIONS FOR INCREASING ANKLE FLEXIBILITY IN PEOPLE WITH NEUROMUSCULAR DISEASE: Loss of ankle flexibility is a common problem for people with neuromuscular disease. It can cause foot deformity, pain and problems walking. The purpose of this review was to assess the evidence regarding the effectiveness of interventions for improving ankle flexibility in people with neuromuscular disease. Four studies were included in the review involving a total of 149 participants. Two studies showed that wearing a night splint was no more effective than not wearing a night splint for increasing ankle flexibility in 26 people who had Charcot-Marie-Tooth disease type 1A. One study showed corticosteroids (prednisone) did not significantly improve ankle flexibility in 103 boys with Duchenne muscular dystrophy and the other study showed that while orthopaedic surgery initially increased ankle flexibility in 20 young boys with Duchenne muscular dystrophy this was not sustained in the long term. This review shows that, currently, there is limited evidence supporting any intervention for improving ankle flexibility in patients with Charcot-Marie-Tooth disease type 1A and Duchenne muscular dystrophy. More research is needed
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Incidence of acute care adverse events and long-term health-related quality of life in patients with TSCI
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DoD PRF (Psychosocial RF)
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Background context: Adverse events (AEs) with significant resultant morbidity are common during the acute hospital care of patients with traumatic spinal cord injury (TSCI). The Rick Hansen SCI Registry (RHSCIR) collects Canada-wide data on patients with TSCI, such as sociodemographic, injury, diagnosis, intervention, and health outcome details. These data contribute to an evidence base for informing best practice and improving SCI care. As the RHSCIR captures data on patients from prehospital to community phases of care, it is an invaluable resource for providing information on health outcomes resulting from TSCI, including outcomes related to AEs. Purpose: To determine the incidence and types of AEs occurring in patients with TSCI during acute care and the impact on length of stay (LOS) and health-related quality of life (HRQOL). Study design/setting: Prospective cohort study at an academic quaternary referral center. Patient sample: Patients with TSCI discharged from our institution between 2008 and 2010 were identified using the RHSCIR. The RHSCIR includes patients admitted to one of the participating centers across Canada, who have been clinically diagnosed with an acute TSCI or classified as AIS A, B, C, D, or cauda equina. Outcome measures: Acute-phase LOS and HRQOL were assessed for impact resulting from the number and type of AEs experienced. Health-related quality of life was determined using the short-form 36 (SF-36) physical and mental component summary scores and functional independence measure. Methods: Data related to patients' injury, diagnoses, hospital admission, and SF-36 scores were obtained from the local RHSCIR. Data on intra-, pre-, and postoperative AEs were collected prospectively using the Spine Adverse Events Severity System data collection system, documenting all AEs experienced by each patient. Multivariate analyses were performed to determine whether patient and injury characteristics were associated with the number and type of AEs experienced and whether these were associated with LOS and HRQOL determined on follow-up. Results: One hundred seventy-one patients with TSCI were included, 81.3% were men and mean age at injury was 47.2±20.3 years. Adverse events occurred in 77.2% of patients, 14.6% experienced an intraoperative and 73.7% experienced a pre/postoperative event. The most frequent pre/postoperative AEs were urinary tract infections (UTIs) (32.2%), pneumonias (32.8%), neuropathic pain (15.2%), decubitus ulcers (14.6%), and delirium (18.7%). Length of stay was significantly affected by decubitus ulcers, delirium, pneumonias, and UTIs (p<.01), increasing 1.7 (UTIs) to 2.2 (decubitus ulcers) times compared with patients without the specific AEs. Health-related quality of life was not affected by acute care AEs but rather those identified at 1-year follow-up. Conclusions: This prospective study found that more than 77% of patients with TSCI sustain an AE during acute hospital care, significantly higher than previously reported. We demonstrate the utility of a dedicated AE collection system and the effect of these events on health status.
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Intrathecal Diamorphine Versus Femoral Nerve Block in Primary Total Knee Arthroplasty
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OAK 3 - Non-arthroplasty tx of OAK
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In 2008, the Prospect Working Group, a multidisciplinary expert panel, published their consensus guidelines on the relative merits of different anaesthetic and analgesic techniques for TKA based on a review of the available published literature up to 2005. These guidelines supported the use of general anaesthesia combined with a femoral nerve block for surgery and postoperative analgesia, or alternatively spinal anaesthesia with local anaesthetic combined with spinal morphine. The preference for femoral nerve block in favour of intrathecal opiates was as a consequence of the greater potential for side effects with the latter technique. The authors conceded that there were a lack of wellâ?conducted studies on this subject, graded their recommendations as level D (expert opinion), and concluded further research was needed. Consequently there has been debate around the conclusions drawn and clinicians have not universally accepted the recommendations. Most researchers to date have focused on shortâ?term outcomes such as static pain scores and/or opiate consumption. It is also important however to investigate dynamic pain scores, patient reported outcomes, the attainment of rehabilitation goals, length of stay and longer term functional outcomes. In addition, the use of the total pain relief score (TOTPAR) as described by Cooper and Beaver, assesses the cumulative response to treatment. This is a well validated area under the timeâ?analgesic effect curve (AUC) derivation for pain relief which is commonly used by metaâ?analyses of analgesic interventions. The aim of this study is to investigate all these endpoints in patients receiving a singleâ?shot femoral nerve block (FNB) for TKA as compared to intrathecal diamorphine (ID), a more commonly used spinal opiate in United Kingdom anaesthetic practice.
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Knee arthroscopy with the use of local anesthesia--an increased risk for repeat arthroscopy? A prospective, randomized study with a six-month follow-up
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Surgical Management of Osteoarthritis of the Knee CPG
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Although there have been many reports of good results when local anesthesia is used with knee arthroscopy, it is not used as a standard anesthetic. Concerns about local anesthesia include the fear of prolonged surgery, which could result in inadequate anesthesia, thus causing the patient unnecessary discomfort. The purpose of this study was to evaluate the risk of repeat arthroscopy and the patient satisfaction rate up to 6 months after knee arthroscopy under local anesthesia. In this prospective, randomized study, 400 patients scheduled for elective knee arthroscopy were allocated to one of three groups: local anesthesia (200 patients), spinal anesthesia (100 patients), or general anesthesia (100 patients). All enrolled patients were asked to complete a questionnaire 6 months after surgery and all of their medical records were reviewed. No repeat arthroscopies occurred in the spinal and general anesthesia groups and only three occurred in the local anesthesia group, a nonsignificant difference. In only one of these three cases was the clinical course altered by the repeat arthroscopy. There was no difference in the satisfaction rate between the three anesthesia groups. We conclude that the choice of anesthesia does not influence the frequency of repeat arthroscopy, satisfaction with the procedure, or recovery at 6 months after knee arthroscopy
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In vivo models of multiple myeloma (MM)
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MSTS 2018 - Femur Mets and MM
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The development of the plasma cell tumor (PCT) model was the first widely accepted in vivo model of multiple myeloma (MM). Potter and colleagues used this chemically induced PCT model to study the pathophysiology of malignant plasma cells and also used it to screen anti-MM agents. Two decades later the C57BL/KaLwRij mouse strain was found to spontaneously develop MM. Testing of pamidronate using this endogenously arising MM model revealed significant reductions in MM-associated bone disease, which was subsequently confirmed in human trials in MM patients. Transgenic models have also been developed in which the MM is localized in the bone marrow causing lytic bone lesions. Experiments in a transgenic model showed that a new oral proteasome inhibitor was effective at reducing MM burden. A clinical trial later confirmed this observation and validated the model. The xenograft model has been used to grow human MM in immunocompromised mice. The xenograft models of MM have been very useful in optimizing drug schedules and doses, which have helped in the treatments given to MM patients. However, in vivo models have been criticized for having a low clinical predictive power of new chemical entities (NCEs). Despite this, the knowledge gained from in vivo models of MM has without a doubt benefited MM patients.
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Low haemoglobin at admission is associated with mortality after hip fractures in elderly patients
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Hip Fx in the Elderly 2019
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AIMS: Low haemoglobin (Hb) at admission has been identified as a risk factor for mortality for elderly patients with hip fractures in some studies. However, this remains controversial. This study aims to analyze the association between Hb level at admission and mortality in elderly patients with hip fracture undergoing surgery.
PATIENTS AND METHODS: All consecutive patients (prospective database) admitted with hip fracture operated in a tertiary hospital between 2012 and 2016 were analyzed. We collected patient characteristics, time to surgery, duration and type of surgery, comorbidities, Hb at admission, nadir of Hb after surgery, the use and amount of red blood cells (RBCs) transfusion products, postoperative complications, and death. The main outcome measures were mortality at 30 days, 90 days, 180 days, and one year after surgery.
RESULTS: We included 829 patients; the mean age was 81 years (sd 11). Mortality at 30 days, 90 days, 180 days, and one year was 5.7%, 12.3%, 18.1%, and 23.5%, respectively. The highest mortality was observed in patients aged over 80 years (162/557, 29%) and in male patients (85/267, 32%). Survival at 90 days, 180 days, and one year after surgery was significantly lower in patients with a Hb level below 120 g/l at admission. In multivariate analysis, Hb level below 120 g/l at admission was found to be an independent factor associated with mortality (adjusted hazard ratio (aHR) 1.68 (95% confidence interval (CI) 1.22 to 2.31); p = 0.001), along with age (aHR 1.06 (95% CI 1.04 to 1.06); p < 0.001), male sex (aHR 2.19 (95% CI 1.61 to 2.96); p < 0.001), and need for RBC transfusions (aHR 1.10 (95% CI 1.02 to 1.19); p = 0.01).
CONCLUSION: Our results suggest that low Hb at admission along with age and RBC transfusions is significantly associated with short- and long-term mortality after hip fracture surgery, independently of comorbidity confounders. Further studies should be performed to understand how preoperative Hb could be taken into account in perioperative management. Cite this article: Bone Joint J 2019;101-B:1122-1128.
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