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A nationwide survey on the prevalence and risk factors of late life depression in South Korea
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DoD PRF (Psychosocial RF)
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OBJECTIVE: This study aimed to estimate prevalence rates and risk factors of LLD among a large nationwide sample of Korean elders in South Korea.
METHOD: Of 8199 randomly sampled Koreans aged 65 years or more, 6018 participated (response rate=73.4%). Using the Korean version of the short form Geriatric Depression Scale (SGDS-K), we classified individual scoring 8 or 9 as having possible depression and those scoring >= 10 as having probable depression.
RESULTS: The age-, gender-, education-, and urbanicity-standardized prevalences were 10.1% (95% CI=9.3-10.8) for possible depression, 17.8% (95% CI=16.8-8.7) for probable depression, and 27.8% (95% CI=26.7-29.0) for overall depression. Poverty, living alone, low education, illiteracy, smoking, history of head trauma, and low Mini Mental Status Examination score were associated with greater risk of depression, while mild alcohol use and moderate to heavy exercise were associated with lower risk of depression. However gender difference in the risk of depression was not found.
CONCLUSION: LLD is decidedly common in South Korea. It was associated with various sociodemographic and clinical factors, some of which are amendable through policy actions. This study was limited by use of the SGDS-K rather than a standardized clinical interview.
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Spectroscopic measurement of cartilage thickness in arthroscopy: ex vivo validation in human knee condyles
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Surgical Management of Osteoarthritis of the Knee CPG
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PURPOSE: To evaluate the accuracy of articular cartilage thickness measurement when implementing a new technology based on spectroscopic measurement into an arthroscopic camera. METHODS: Cartilage thickness was studied by ex vivo arthroscopy at a number of sites (N = 113) in human knee joint osteoarthritic femoral condyles and tibial plateaus, removed from 7 patients undergoing total knee replacement. The arthroscopic image spectral data at each site were used to estimate cartilage thickness. Arthroscopically derived thickness values were compared with reference cartilage thickness as measured by 3 different methods: needle penetration, spiral computed tomography scanning, and geometric measurement after sample slicing. RESULTS: The lowest mean error (0.28 to 0.30 mm) in the regression between arthroscopic and reference cartilage thickness was seen for reference cartilage thickness less than 1.5 mm. Corresponding values for cartilage thickness less than 2.0 and 2.5 mm were 0.32 to 0.40 mm and 0.37 to 0.47 mm, respectively. Cartilage thickness images--created by pixel-by-pixel regression model calculations applied to the arthroscopic images--were derived to demonstrate the clinical use of a camera implementation. CONCLUSIONS: On the basis of this investigation on osteoarthritic material, when one is implementing the spectroscopic method for estimating cartilage thickness into an arthroscopic camera, errors in the range of 0.28 to 0.30 mm are expected. This implementation does not, however, influence the fact that the spectral method performs less well in the cartilage thickness region from 1.5 to 2.5 mm and cannot assess cartilage thicker than 2.5 mm. CLINICAL RELEVANCE: Imaging cartilage thickness directly in the arthroscopic camera video stream could serve as an interesting image tool for in vivo cartilage quality assessment, in connection with cartilage diagnosis, repair, and follow-up
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The effect of exercise training programs on bone mass: a meta-analysis of published controlled trials in pre- and postmenopausal women
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HipFx Supplemental Cost Analysis
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With the aging of the population, the medical and social costs of skeletal fragility leading to fractures will cause an immense burden on society unless effective prophylactic and therapeutic regimens can be developed. Exercise is suggested as a possible regimen against involutional bone loss. The purpose of the present meta-analysis is to address a quantitative review of the randomized controlled trials (RCTs) and nonrandomized controlled trials (CTs) on the effects of exercise training programs on bone mass, measured as bone mineral density (BMD) or bone mineral content (BMC), of the lumbar spine (LS) and the femoral neck (FN) in pre- and postmenopausal women. The literature from 1966 through December 1996 was searched for published RCTs and CTs. Study treatment effect is defined as the difference between percentage change in bone mass per year in the training group and the control group. Overall treatment effects (OTs) with the 95% confidence intervals of these study treatment effects were calculated using inverse-variance weighting. Of the 62 articles identified, 25 met the inclusion criteria and were maintained for further analyses. The weighted OTs for the RCTs showed very consistently that the exercise training programs prevented or reversed almost 1% of bone loss per year in both LS and FN for both pre- and postmenopausal women. The two OTs that could be calculated for strength training programs did not reach significance. The OTs for the CTs were almost twice as high as those for the RCTs, which gives an indication of the confounding introduced by the nonrandom allocation of the subjects to groups
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Operative and nonoperative therapy of intraabdominal infections
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DOD - Acute Comp Syndrome CPG
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The basic principles for treating intraabdominal infections are fourfold: (1) to obliterate the infectious source; (2) to purge bacteria and toxins; (3) to maintain organ system function and (4) to tame the inflammatory process. Operative and nonoperative treatment options are available. Operative therapy includes different strategies: (1) the standard operation; (2) advanced procedures to decompress the abdominal compartment syndrome and (3) percutaneous drainage of abscesses. Nonoperative management includes: (1) antibiotic therapy; (2) hemodynamic and pulmonary support; (3) nutrition and metabolic support; (4) detoxification support (including support of renal and hepatic function) and (5) inflammation modulating therapy. Standard operative management addresses the first two principles and has been shown to reduce mortality by more than 50%. A recent extensive series of studies reports mortality rates around 20%. Patients with an abdominal compartment syndrome (intraabdominal pressure over 25 torr) and patients with advanced disease and compounding risk factors best documented by high APACHE-II scores are candidates for more advanced operations. The mortality rate following abdominostomy (leaving the abdomen open) in 869 patients participating in 37 studies was 42%, when the abdomen was simply left open for decompression (open abdominostomy). When a mesh was used to cover the abdominal wound (mesh abdominostomy) 39% of 439 patients enrolled in 12 studies died. Patients who underwent staged abdominal repair (STAR abdominostomy) faired better. Of 385 patients in 11 studies 28% died. Data from antibiotic studies as well as from immunomodulating therapy are nonconclusive at this point with respect to reducing mortality in intraabdominal infection.
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The Efficacy and Safety of Invossa K Injection in Patients Diagnosed With Knee Osteoarthritis
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OAK 3 - Non-arthroplasty tx of OAK
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The purpose of this study is to evaluate the efficacy and safety of intraarticular Invossa K Injection patients diagnosed with Kellgren & Lawrence grade 2 knee osteoarthritis.
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1 |
Clinical profile, electrodiagnosis and outcome in patients with carpal tunnel syndrome: a Singapore perspective
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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INTRODUCTION: Carpal tunnel syndrome (CTS ) is the most common entrapment neuropathy seen in our neurodiagnostic laboratory referrals. We describe the clinical profile, and outcome in patients with electrophysiological diagnosis of CTS seen in our centre over a six month period. METHODS: A retrospective study was carried out and included 134 consecutive patients with CTS referred to the Neurodiagnostic Laboratory, National Neuroscience Institute, from October 2003 to March 2004, for the confirmatory testing. Severity grade was assigned following American Association of Electrodiagnostic Medicine criteria of CTS. RESULTS: The majority of patients were female (81.3 percent) with mean age of presentation being 53.6 years. Chinese women constitute the majority racial group. Paraesthesia (70.1 percent) and numbness (19.4 percent) were the presenting sensory symptoms. In the nerve conduction study, 108 patients had bilateral CTS with 35 having unilateral symptoms. Dominant hand involvement was present in 92.3 percent. Overall, 40.3 percent had mild, 46.3 percent had moderate and 13.4 percent had severe CTS, with median duration of symptoms of two, four and 12 months, respectively. Follow-up data were available for 115 patients. 27 patients with surgical treatment showed resolution or improvement in 53.3 percent with moderate CTS, and 83.3 percent with severe CTS, at three-month follow-up. 14 patients turned up for six-month follow-up and 92.9 percent showed improvement in symptoms. 88 patients were managed conservatively; symptoms were unchanged or worsened in 80.6 percent with mild CTS, 65.9 percent with moderate CTS, and 62.5 percent with severe CTS at three-month follow-up. Of the 54 patients who turned up for six-month follow-up, the clinical symptom remain unchanged or worsened in 68.5 percent. CONCLUSION: The severity of CTS is associated with longer duration of symptoms. Sensory symptoms and dominant hand involvement is more common. There is a high default rate in the clinical follow-up. Early surgical intervention results in either resolution or improvement in symptoms, whereas conservative management does not affect the natural history with symptoms that persisted or worsened with time
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Gaze movements and spatial working memory in collision avoidance: a traffic intersection task
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Upper Eyelid and Brow Surgery
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Street crossing under traffic is an everyday activity including collision detection as well as avoidance of objects in the path of motion. Such tasks demand extraction and representation of spatio-temporal information about relevant obstacles in an optimized format. Relevant task information is extracted visually by the use of gaze movements and represented in spatial working memory. In a virtual reality traffic intersection task, subjects are confronted with a two-lane intersection where cars are appearing with different frequencies, corresponding to high and low traffic densities. Under free observation and exploration of the scenery (using unrestricted eye and head movements) the overall task for the subjects was to predict the potential-of-collision (POC) of the cars or to adjust an adequate driving speed in order to cross the intersection without collision (i.e., to find the free space for crossing). In a series of experiments, gaze movement parameters, task performance, and the representation of car positions within working memory at distinct time points were assessed in normal subjects as well as in neurological patients suffering from homonymous hemianopia. In the following, we review the findings of these experiments together with other studies and provide a new perspective of the role of gaze behavior and spatial memory in collision detection and avoidance, focusing on the following questions: (1) which sensory variables can be identified supporting adequate collision detection? (2) How do gaze movements and working memory contribute to collision avoidance when multiple moving objects are present and (3) how do they correlate with task performance? (4) How do patients with homonymous visual field defects (HVFDs) use gaze movements and working memory to compensate for visual field loss? In conclusion, we extend the theory of collision detection and avoidance in the case of multiple moving objects and provide a new perspective on the combined operation of external (bottom-up) and internal (top-down) cues in a traffic intersection task.
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Stance time variability during stair stepping before and after total knee arthroplasty: A pilot study
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OAK 3 - Non-arthroplasty tx of OAK
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The main objectives of this pilot study were to: (1) investigate stance time variability (STV) during stair stepping in older adults with osteoarthritis (OA) before and after total knee arthroplasty (TKA), and compare to an age- and sex-matched group of healthy controls with native knees and (2) evaluate the relationship between quadriceps strength and STV during stair stepping before and after TKA. A prospective, observational, pilot study was carried out on 13 individuals (15% male, mean age 62.71. ±. 6.84. years) before and after TKA using an instrumented stairway, patient-reported outcomes, timed stair stepping test, and quadriceps strength measures. At 6-months post-operatively, STV during stair descent was significantly greater in the TKA-GROUP compared to the CONTROL-GROUP, but was not significantly different at 12-months compared to controls. There were no significant differences in STV for stair ascent between the pre- and post-operative visits, or compared to controls. There was a trend toward significance for the relationship between quadriceps strength and STV during stair ascent (. P=. 0.059) and descent (. P=. 0.073). Variability during stair stepping may provide an important, short-term rehabilitation target for individuals following TKA and may represent another parameter to predict declines in functional mobility.
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Radiographs and low field MRI (0.2T) as predictors of efficacy in a weight loss trial in obese women with knee osteoarthritis
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OAK 3 - Non-arthroplasty tx of OAK
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BACKGROUND: To study the predictive value of baseline radiographs and lowâ?field (0.2T) MRI scans for the symptomatic outcome of clinically significant weight loss in obese patients with knee osteoarthritis. METHODS: In this study we hypothesize that imaging variables assessed with radiographs and MRI scans preâ?treatment can predict the symptomatic changes following a recommended clinically significant weight reduction Patients were recruited from the Department of Rheumatology, Frederiksberg Hospital, Denmark. Eligibility criteria were: age >18 years; primary osteoarthritis according to ACR; BMI > 28 kg/m2; motivation for weight loss. Subjects were randomly assigned to either intervention by lowâ?energy diet (LED) for 8 weeks followed by another 24 weeks of dietary instruction or controlâ?group. MRI scans and radiographs were scored for structural changes and these parameters were examined as independent predictors of changes in osteoarthritis symptoms after 32 weeks. The outcome assessor and statistician were blinded to group allocation. RESULTS: No significant correlations were found between imaging variables and changes in Western Ontario and McMaster Universities Index of Osteoarthritis (Spearman's test, r < 0.33 and P > 0.07).Only the LED group achieved a weight loss, with a mean difference of 16.3 kg (95%CI: 13.4â?19.2;P < 0.0001) compared to the control group. The total WOMAC index showed a significant difference favouring LED, with a group mean difference of â? 321.3 mm (95%CI: â?577.5 to â?65.1 mm; P = 0.01). No significant adverse events were reported. CONCLUSION: Stage of joint destruction, assessed on either radiographs or lowâ?field MRI (0.2T), does not preclude a symptoms relief following a clinically relevant weight loss in elderly obese female patients with knee osteoarthritis.
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Cancer cachexia syndrome in head and neck cancer patients: Part I. Diagnosis, impact on quality of life and survival, and treatment
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MSTS 2022 - Metastatic Disease of the Humerus
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Background. Cancer cachexia is a debilitating, wasting condition that affects many cancer patients, including those with head and neck cancer. The overall incidence of cancer cachexia is quite high for some types of cancer, and cachexia will be the main cause of death for more than 20% of all cancer patients. This syndrome uniquely challenges patients with head and neck cancer. This article outlines the diagnosis of cancer cachexia, reviews its impact on patient quality of life (QOL) and survival, and updates the reader on potential therapies that may suppress it. Methods. A comprehensive literature search was performed using PubMed of the National Library of Medicine, which includes more than 15 million citations back to the 1950s. The Cochrane Library and Google search engine were used as well. Results. This syndrome differs significantly from starvation, and thus accurate and timely diagnosis is essential. Nutritional therapy alone is insufficient. Current management strategies include corticosteroids and megesterol acetate, in conjunction with nutritional therapy. Future strategies may include nutraceuticals, omega-3 fatty acids, inflammatory antagonists, and other targeted treatments. Conclusions. Because cancer cachexia differs significantly from starvation, nutritional supplementation must be used in conjunction with other anti-cachexia agents to reverse the chronic systemic inflammatory state and the effects of circulating tumor-derived factors seen in cachexia. Careful identification of patients at risk and those suffering from this syndrome will lead to better outcomes and treatments. Ultimately, more research is needed to better treat this devastating condition. © 2007 Wiley Periodicals, Inc.
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Electrical impedance tomography of human brain activity with a two-dimensional ring of scalp electrodes
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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Previously, electrical impedance tomography (EIT) has been used to image impedance decreases in the exposed cortex of rabbits during brain activity. These are due to increased blood volume at the site of the stimulated cortex; as blood has a lower impedance than brain, the impedance decreases. During human brain activity similar blood flow changes have been detected using positron emission tomography (PET) and functional magnetic resonance imaging (fMRI). If blood volume also changes then the impedance of human cortex will change during brain activity; this could theoretically be imaged with EIT. EIT data were recorded from a ring of 16 scalp electrodes in 34 recordings in 19 adult volunteers before, during and after stimulation with (1) a visual stimulus produced by an 8 Hz oscillating checkerboard pattern or (2) sensory stimulation of the median nerve at the wrist by a 3 Hz electrical square wave stimulus. Reproducible impedance changes, with a similar timecourse to the stimulus, were seen in all experiments. Significant impedance changes were seen in 21 (plus or minus) 5% (n = 16. mean (plus or minus) SEM) and 19 (plus or minus) 3% (n = 18) of the electrode measurements for visual and somatosensory paradigms respectively. The reconstructed 2D EIT images showed reproducible impedance changes in the approximate region of the stimulated cortex in 7/16 visual and 5/18 somatosensory experiments. This demonstrates that reproducible impedance changes can be measured during human brain activity. The final images contained spatial noise; the reasons for this and strategies to reduce this in future are discussed
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Range of motion during the perioperative period in total knee arthroplasty
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Surgical Management of Osteoarthritis of the Knee CPG
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Introduction: This study focused on the change in the range of motion (ROM) during the perioperative period, i.e., the preoperative and intraoperative ROM, and that on discharge, and compared the difference between posterior cruciate ligament-retaining (PCLR) and -sacrificing (PCLS) prostheses. Materials and methods: In this prospectively randomized study, we compared the changes in the ROM in PCLR (n = 50) and PCLS (n = 50) total knee arthroplasties. Results: The mean flexion in PCLR prostheses was 130.0(degrees) preoperatively, 120.0(degrees) intraoperatively, and 105.0(degrees) at discharge, and 125.0(degrees), 120.0(degrees), and 100.0(degrees), respectively, in PCLS. The designs did not differ statistically in each period (P > 0.05). Both designs showed significant correlations between the preoperative and intraoperative ROM, and between the preoperative and discharge ROM. Only the PCLS showed a significant correlation between the intraoperative and discharge ROM, and a significant difference was observed in correlation of rank coefficient between the two prostheses (P < 0.001). Conclusions: The PCLS design has an advantage in rehabilitation planning because of the predictable changes in the ROM during the perioperative period, although the acquired average ROM at discharge did not differ statistically. (copyright) Springer-Verlag 2007
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Meniscal Repair Using Fibrin Clots Made From Bone Marrow Blood Wrapped in a Polyglycolic Acid Sheet
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AMP (Acute Meniscal Pathology)
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Meniscal repair is one of the most common procedures for meniscal tears; however, a previous systematic review showed meniscal repairs have a greater reoperation rate compared with partial meniscectomies. Therefore, an improvement of existing meniscal repair techniques is warranted. Clinical results of polyglycolic acid (PGA) sheets have been reported for rotator cuff repairs. In recent years, we have performed meniscal repairs using wrapped fibrin clots in PGA sheet. We considered the use of wrapped fibrin clots with a PGA sheet to treat meniscus tears. The purpose of this paper is to introduce a step-by-step guide to our new delivery technique using fibrin clots.
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A prospective study concerning the relationship between metal allergy and post-operative pain following total hip and knee arthroplasty
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PJI DX Updated Search
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PURPOSE: A prospective study was conducted to detect whether a relationship exists between metal allergy and post-operative pain in total hip and knee arthroplasty patients. We postulated that to some extent a relationship does exist between them. MATERIALS AND METHODS: Patients who had undergone total hip and knee arthroplasty surgery because of hip and knee disease were included. The exclusion criteria were patients who were treated with immunosuppressor two weeks pre-operatively, skin conditions around the patch testing site, and other uncontrollable factors. Each patient agreed to patch testing for three days before surgery. Photographic images before patch testing, two and three days after patch testing were obtained to evaluate the final incidence of metal allergy. The patch tests contained 12 metal elements; chromium, cobalt, nickel, molybdenum, titanium, aluminium, vanadium, iron, manganese, tin, zirconium, and copper. Two independent observers evaluated the images. The results were divided into a non-metal allergy group and a metal allergy group. Pre-operative and postoperative VAS score, lymphocyte transforming test, and X-rays were collected to detect the relationship between metal allergy and post-operative pain following total hip and knee arthroplasty. RESULTS: There were 96 patients who underwent pre-operative patch testing. The overall metal allergy rate was 51.1% (49/96) in our study. Nickel, cobalt, manganese, and tin were the most common allergic metal elements in our study. Nine inappropriate cases were excluded, and 87 patients were finally included in our study. There were 36 metal allergy and 26 non-metal allergy patients in the THA group, while 11 metal allergy and 14 non-metal allergy patients were found in the TKA group. We found no relationship existed between metal allergy and post-surgery pain in total hip and knee arthroplasty. CONCLUSION: Pain caused by metal allergy usually presents as persistent and recurrent pain. The white cell count, C-reactive protein, erythrocyte sedimentation rate and postoperative radiographs were not affected. Currently, patch testing and lymphocyte transforming tests are used for metal allergy diagnosis. We deemed that a relationship between post-surgery pain and metal allergy in total hip and knee patients may exist to some extent. Larger samples and longer follow-up time are essential for further study
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Aetiological relationships between factors associated with postnatal traumatic symptoms among Japanese primiparas and multiparas: A longitudinal study
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DoD PRF (Psychosocial RF)
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OBJECTIVE: this study aims to identify the aetiological relationships of psychosocial factors in postnatal traumatic symptoms among Japanese primiparas and multiparas.
DESIGN: a longitudinal, observational survey.
SETTING: participants were recruited at three institutions in Tokyo, Japan between April 2013 and May 2014. Questionnaires were distributed to 464 Japanese women in late pregnancy (> 32 gestational weeks, Time 1), on the third day (Time 2) and one month (Time 3) postpartum.
MEASUREMENTS: The Japanese Wijma Delivery Expectancy/Experience Questionnaire (JW-DEQ) version A was used to measure antenatal fear of childbirth and social support, while the Impact of Event Scale Revised (IES-R) measured traumatic stress symptoms due to childbirth.
FINDINGS: of the 464 recruited, 427 (92%) completed questionnaires at Time 1, 358 (77%) completed at Time 2, and 248 (53%) completed at Time 3. Total 238 (51%) were analysed. A higher educational level has been identified in analysed group (p=0.021) Structural equation modelling was conducted separately for primiparas and multiparas and exhibited a good fit. In both groups antenatal fear of childbirth predicted Time 2 postnatal traumatic symptoms (beta=0.33-0.54, p=0.002-0.007). Antenatal fear of childbirth was associated with a history of mental illness (beta=0.23, p=0.026) and lower annual income (beta =-0.24, p=0.018). Among multiparas, lower satisfaction with a previous delivery was related to antenatal fear of childbirth (beta =-0.28, p < 0.001).
KEY CONCLUSIONS: antenatal fear of childbirth was a significant predictor of traumatic stress symptoms after childbirth among both primiparous and multiparous women. Fear of childbirth was predicted by a history of mental illness and lower annual income for primiparous women, whereas previous birth experiences were central to multiparous women.
IMPLICATION FOR PRACTICE: the association between antenatal fear of childbirth and postnatal traumatic symptoms indicates the necessity of antenatal care. It may be important to take account of the background of primiparous women, such as a history of mental illness and their attitude towards the upcoming birth. For multiparous women, focusing on and helping them to view their previous birth experiences in a more positive light are vital tasks for midwives.
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Arthroscopic Distal Clavicle Glenoid Augmentation: An Ideal Graft Option
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Osteochondritis Dissecans 2020 Review
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Recent work has demonstrated the importance of addressing bone loss in the surgical management of anterior shoulder instability. Multiple options exist for reconstituting the glenoid articular surface to include anatomic vs nonanatomic techniques, and utilizing autograft vs allograft material. An ideal approach would provide an autograft source of osteochondral material that is well matched to the defect, readily available, cost effective, and with minimal comorbidity. The distal clavicle autograft provides such an option. The graft has a cortical and cancellous side for direct fixation, and is amenable to arthroscopic techniques. Recent work has demonstrated the utility of this graft noting that the distal clavicle graft provides an anatomic restoration of the glenoid radius with an articular cartilage cap comparable in thickness to that of the native glenoid. Along with a summary of the pertinent literature, this review article outlines the rationale, indications, and technical notes for this procedure.
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Performing two DIEP flaps in a working day: an achievable and reproducible practice
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Reduction Mammoplasty for Female Breast Hypertrophy
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BACKGROUND: While the deep inferior epigastric artery perforator (DIEP) flap is a reliable technique for autologous breast reconstruction, the meticulous dissection of perforators may require lengthy operative times. In our unit, we have performed 600 free flaps for breast reconstruction over 8 years and have reduced operative times with a combination of preoperative computed tomographic angiography (CTA), various anastomotic techniques and the Cook-Swartz implantable Doppler probe for perfusion monitoring. We sought to assess the feasibility of performing two DIEP flaps within the working hours of a single day.
METHODS: A review of 101 consecutive patients undergoing DIEP flap breast reconstruction in a 12-month period was performed, comparing one DIEP flap per day (n=43) to two DIEP flaps per day (n=58). Complications, outcomes and techniques used were critically analysed. For cases of two DIEP flaps per day, a comparison was made between the use of two separate operating theatres (n=44) and a single consecutive theatre (n=14).
RESULTS: Complications did not increase when two DIEP flaps were performed in a single working day. The use of vascular closure staple (VCS) sutures and ring couplers resulted in statistically significant reductions in anastomotic times. The use of two separate theatres for performing two DIEP flaps resulted in a reduction of 59min in operative time per case (p=0.004).
CONCLUSION: Two DIEP flaps can be safely and routinely performed within the hours of a single working day. By minimising operative times, these techniques can improve productivity and substantially decrease surgeon fatigue.
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1 |
Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures
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Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures
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The Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures evidence-based clinical practice guideline was codeveloped by the American Academy of Orthopaedic Surgeons (AAOS) and the American Dental Association. This guideline replaces the previous AAOS Information Statement, "Antibiotic Prophylaxis in Bacteremia in Patients With Joint Replacement," published in 2009. Based on the best current evidence and a systematic review of published studies, three recommendations have been created to guide clinical practice in the prevention of orthopaedic implant infections in patients undergoing dental procedures. The first recommendation is graded as Limited; this recommendation proposes that the practitioner consider changing the long-standing practice of routinely prescribing prophylactic antibiotic for patients with orthopaedic implants who undergo dental procedures. The second, graded as Inconclusive, addresses the use of oral topical antimicrobials in the prevention of periprosthetic joint infections. The third recommendation, a Consensus statement, addresses the maintenance of good oral hygiene
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Effectiveness of a multifaceted intervention on falls in nursing home residents
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Management of Hip Fractures in the Elderly
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OBJECTIVES: To evaluate the effectiveness of a multifaceted, nonpharmaceutical intervention on incidence of falls and fallers. DESIGN: Prospective, cluster-randomized, controlled 12-month trial. SETTING: Six community nursing homes in Germany. PARTICIPANTS: Long-stay residents (n = 981) aged 60 and older; mean age 85; 79% female. INTERVENTIONS: Staff and resident education on fall prevention, advice on environmental adaptations, progressive balance and resistance training, and hip protectors. MEASUREMENTS: Falls, fallers, and fractures. RESULTS: The incidence density rate of falls per 1,000 resident years (RY) was 2,558 for the control group (CG) and 1,399 for the intervention group (IG) (relative risk (RR) = 0.55, 95% confidence interval (CI) = 0.41-0.73). Two hundred forty-seven (52.3%) fallers were detected in the CG and 188 (36.9%) in the IG (RR = 0.75, 95% CI = 0.57-0.98). The incidence density rate of frequent fallers (>2/year) was 115 (24.4%) for the CG and 66 (13.0%) for the IG (RR = 0.56, 95% CI = 0.35-0.89). The incidence density rate of hip fractures per 1,000 RY was 39 for the CG and 43 for the IG (RR = 1.11, 95% CI = 0.49-2.51). Other fractures were diagnosed with an incidence density rate of 52 per 1,000 RY for CG and 41 per 1,000 RY for IG (RR = 0.78, 95% CI = 0.57-1.07). CONCLUSION: The incidence density rate of falls and fallers differed considerably between the control and intervention groups. The study was underpowered to demonstrate a significant difference of hip or nonhip fractures. Because of a low fracture rate in both groups, the investigation of fracture rates would have required a larger sample size to detect an effect of the intervention
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Serum Urate Levels Predict Joint Space Narrowing in Non-Gout Patients With Medial Knee Osteoarthritis
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OAK 3 - Non-arthroplasty tx of OAK
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Objective: The pathogenesis of osteoarthritis (OA) includes both mechanical and inflammatory features. Studies have implicated synovial fluid uric acid (UA) as a potential OA biomarker, possibly reflecting chondrocyte damage. Whether serum UA levels reflect/contribute to OA is unknown. We investigated whether serum UA levels predict OA progression in a non-gout knee OA population. Methods: Eighty-eight patients with medial knee OA (body mass index [BMI] <33 kg/m2) but without gout were studied. Baseline serum UA levels were measured in previously banked serum samples. At 0 and 24 months, patients underwent standardized weight-bearing fixed-flexion posteroanterior knee radiography to determine joint space width (JSW) and Kellgren/Lawrence grades. Joint space narrowing (JSN) was calculated as the change in JSW from 0 to 24 months. Twenty-seven patients underwent baseline contrast-enhanced 3T knee magnetic resonance imaging for assessment of synovial volume. Results: Serum UA levels correlated with JSN values in both univariate (r = 0.40, P < 0.01) and multivariate (r = 0.28, P = 0.01) analyses. There was a significant difference in mean JSN after dichotomization at a serum UA cut point of 6.8 mg/dl, the solubility point for serum urate, even after adjustment (JSN of 0.90 mm for a serum UA â?¥6.8 mg/dl and 0.31 mm for a serum UA <6.8 mg/dl; P < 0.01). Baseline serum UA levels distinguished progressors (JSN >0.2 mm) and fast progressors (JSN >0.5 mm) from nonprogressors (JSN â?¤0.0 mm) in multivariate analyses (area under the receiver operating characteristic curve 0.63 [P = 0.03] and 0.62 [P = 0.05], respectively). Serum UA levels correlated with the synovial volume (r = 0.44, P < 0.01), a possible marker of JSN, although this correlation did not persist after controlling for age, sex, and BMI (r = 0.13, P = 0.56). Conclusion: In non-gout patients with knee OA, the serum UA level predicted future JSN and may serve as a biomarker for OA progression.
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What is the best treatment option in postmenopausal, hormone responsive breast cancer patients with isolated bone metastases?
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MSTS 2018 - Femur Mets and MM
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BACKGROUND: Bone is the most common metastatic site for breast cancer.
AIM: To determine the effectiveness of addition of chemotherapy to hormonal therapy in postmenopausal hormone receptor-positive breast cancer patients with isolated bone metastases.
MATERIALS AND METHODS: Between June 2001 and January 2007, 101 patients were classified into two groups according to initial treatment modalities; patients who received hormonotherapy only (group I) and chemotherapy followed by hormonotherapy (group II). The effect of treatment choice on clinical course, time to progression, and overall survival were evaluated.
RESULTS: There were 70 patients in group I and 31 patients in group II. Bone metastases in 27 patients (26.7%) were synchronous and the remainder were metachronous. The median follow-up time was 41 months. The two groups showed similar results when patients' tumor characteristics were compared. However, 81% of synchronous cases had upfront chemotherapy following hormonotherapy, whereas this ratio was only 12% in the metachronous group. All patients received systemic antiresorptive bisphosphonates whereas only 24 patients required palliative radiotherapy at some time during the course of their disease. In groups I and II, the median time to progression was 12 and 16 months (P: 0.96) and median overall survival was 41 and 40 months (P: 0.79), respectively. In HER-2-positive patients, a trend of prolongation of overall survival was observed in group II, but it was not statistically significant (P: 0.12).
CONCLUSIONS: Anti-hormonal therapy still seems to be considered as the ideal treatment of choice for postmenapousal breast cancer patients with isolated bone metastases.
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Acute infections after fracture repair: management with hardware in place
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Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures
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Managing infections in fractures treated with open reduction and internal fixation is an ongoing dilemma. Little published data exist to support the current practice of treating these infections with retained hardware, irrigation, debridement, and antibiotic suppression. We evaluated the effectiveness of this approach. We identified potential subjects from a central trauma database and selected them based on chart review and specific inclusion and exclusion criteria. We divided the patients into two groups. Patients achieving successful union with original hardware in place were considered as having successful results and patients who required hardware removal before healing were considered to have failed results. Data, including age, gender, tobacco use, diabetic status, site of fracture, Orthopaedic Trauma Association class, open grade, type of fixation, joint involvement, and organism, were gathered and compared between the groups by analysis of variance. Sixty-nine cases were available for analysis. Forty-seven (68%) were successful and 22 (32%) were unsuccessful. Average time to healing was 130 days. Most of the failures occurred within 120 days from the time of injury. Smoking was a major risk factor with a 3.7 times greater likelihood of procedures being unsuccessful per month than procedures among nonsmokers. Treating infected fractures with hardware in place is less successful than widely believed. LEVEL OF EVIDENCE: Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence
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Patellofemoral cartilage stresses are most sensitive to variations in vastus medialis muscle forces
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OAK 3 - Non-arthroplasty tx of OAK
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The purpose of this study was to evaluate the effects of variations in quadriceps muscle forces on patellofemoral stress. We created subject-specific finite element models for 21 individuals with chronic patellofemoral pain and 16 pain-free control subjects. We extracted three-dimensional geometries from high resolution magnetic resonance images and registered the geometries to magnetic resonance images from an upright weight bearing squat with the knees flexed at 60°. We estimated quadriceps muscle forces corresponding to 60° knee flexion during a stair climb task from motion analysis and electromyography-driven musculoskeletal modelling. We applied the quadriceps muscle forces to our finite element models and evaluated patellofemoral cartilage stress. We quantified cartilage stress using an energy-based effective stress, a scalar quantity representing the local stress intensity in the tissue. We used probabilistic methods to evaluate the effects of variations in quadriceps muscle forces from five trials of the stair climb task for each subject. Patellofemoral effective stress was most sensitive to variations in forces in the two branches of the vastus medialis muscle. Femur cartilage effective stress was most sensitive to variations in vastus medialis forces in 29/37 (78%) subjects, and patella cartilage effective stress was most sensitive to variations in vastus medialis forces in 21/37 (57%) subjects. Femur cartilage effective stress was more sensitive to variations in vastus medialis longus forces in subjects classified as maltrackers compared to normal tracking subjects (p = 0.006). This study provides new evidence of the importance of the vastus medialis muscle in the treatment of patellofemoral pain.
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MR Arthrography of the Knee
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Diagnosis and Treatment of Osteochondritis Dissecans AUC
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The role of magnetic resonance imaging (MRI) in the evaluation of musculoskeletal injuries has been well documented during the last decade. There remain several important clinical situations in which noncontrast MRI has been disappointing. In the knee, magnetic resonance arthrography (MRA) can supplement noncontrast MRI in the evaluation of specific conditions, such as postoperative meniscus and osteochondritis dissecans. MRA significantly increases accuracy in the diagnosis of meniscal retear, as is seen in cases in which there has been a meniscal resection of more than 25% or after meniscal suturing. Also, in the evaluation of osteochondritis dissecans, the addition of intra-articular contrast has proved beneficial. Aside from assessing the integrity of the articular cartilage surface and documenting loose bodies, the contrast allows the clinician to distinguish fibrovascular granulation tissue from fluid partially or completely surrounding the osteochondritic fragment. These topics are discussed in this article
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The national cost of acute care of hip fractures associated with osteoporosis
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Management of Hip Fractures in the Elderly
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During 1976, the median cost of the direct medical care for a fracture of the proximal femur related to osteoporosis in Rochester, Minnesota, was $5,644. Age- and sex-specific incidences for this fracture were determined for a 10-year period in the same population. When these data are applied to the United States population, it can be estimated that osteoporosis leads to over 150,000 hip fractures annually, with a short-term direct cost in excess of one billion dollars
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Sacrum and coccyx radiographs have limited clinical impact in the emergency department
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Hip Fx in the Elderly 2019
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OBJECTIVE: The purpose of this study was to determine the yield and clinical impact of sacrum and coccyx radiographs in the emergency department (ED). MATERIALS AND METHODS: Consecutive sacrum and coccyx radiographs obtained in the EDs of four hospitals over a 6-year period were categorized as positive for acute fracture or dislocation, negative, or other. Five follow-up metrics were analyzed: follow-up advanced imaging in the same ED visit, follow-up advanced imaging within 30 days, new analgesic prescriptions, clinic follow-up, and surgical intervention within 60 days. RESULTS: Sacrum and coccyx radiographs from 687 patients (mean age, 48.1 years; 61.6% women and 38.4% men) obtained at level-1 (n = 335) and level-2 (n = 352) trauma centers showed a positivity rate of 8.4% ± 2.1% (n = 58/687). None of the 58 positive cases had surgical intervention. At the level-1 trauma centers, there was no significant association between sacrum and coccyx radiograph positivity and analgesic prescription or clinical followup (p = 0.12; odds ratio [OR], 2.3; 95% CI, 0.81-6.20). At the level-2 trauma centers, 97.1% (n = 34/35) of patients with positive sacrum and coccyx radiographs received analgesic prescriptions or clinical referrals, whereas negative cases were at 82.9% (OR, 7.0; 95% CI, 0.94-52.50). Of all cases, 5.7% (n = 39) and 4.3% (n = 29) had advanced imaging in the same ED visit and within 30 days, respectively. Sacrum and coccyx radiography results had no significant correlation with advanced imaging in the same ED visit (level-1, p = 0.351; level-2, p = 0.179). There was no significant difference in 30-day advanced imaging at the level-1 trauma centers (p = 0.8), but there was at the level-2 trauma centers (p = 0.0493). CONCLUSION: ED sacrum and coccyx radiographs showed a low positivity rate and had no quantifiable clinical impact. We recommend that sacrum and coccyx radiographs be eliminated from ED practice and patients treated conservatively on the basis of clinical parameters.
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The collagen Ia1 SP1 polymorphism is associated with differences in ultrasound transmission velocity in the calcaneus in postmenopausal women
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Management of Hip Fractures in the Elderly
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Bone mineral density (BMD) and fracture risk are under genetic control. An association of a G to T polymorphism in the Sp1 binding site of the collagen Ia1 (COLIa1) gene with the risk for fractures has been previously reported. This association is only partly explained by differences in BMD. Thus, we analyzed the relationship between the COLIa1 Sp1 polymorphism and ultrasound (US) transmission velocity (speed of sound; SOS) in bone. In a population-based sample of 740 women (aged 55-80 years) we determined COLIa1 genotype and US parameters in the calcaneus. SOS in the "GG" genotype group was 1522 +/- 31 m/sec, in the "GT" group, 1519 +/- 30 m/sec, and in the "TT" group 1508 +/- 30 m/sec (P = 0.01). While the difference between the GG and TT genotype groups corresponds to 0.5 SD or 1%, we observed an allele-dose-effect of 4.3 m/sec decrease in SOS per each copy of the "T" allele (P = 0.01). The differences remained significant after adjustment for BMD measured at the femoral neck. When we analysed 45 incident nonvertebral fractures in this group of women, we found the risk for fracture by COLIA1 Sp1 genotype to be partly explained by SOS differences as well as by BMD differences. Linear regression analysis showed a progressive negative slope of the regression line of SOS over age from "GG" over "GT" to "TT" genotype. These data indicate that the collagen Ia1 Sp1 polymorphism is associated with the modulus of elasticity of bone as determined in vivo by acoustical measurement. The relationship is independent of BMD and increases with age, contributing to an explanation of the increased fracture risk observed for this polymorphism
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Increased arterial stiffness in patients with end-stage osteoarthritis: a case-control study
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PJI DX Updated Search
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BACKGROUND: Both osteoarthritis (OA) and cardiovascular diseases (CVD) are prevalent conditions which often co-exist. Vascular involvement in the pathogenesis of these diseases, as well as increased cardiovascular risk in OA patients give occasion to investigate arterial stiffness in OA. The aim of this study was to establish associations between OA and arterial stiffness. METHODS: The characteristics of arterial stiffness were measured with Sphygmocor and HDI devices in 48 patients (age 63 +/- 7 years (mean +/- SD)) with end-stage OA awaiting knee and hip replacement and in 49 age and gender matched controls (61 +/- 7 years). Independent Student's t-test or the Mann-Whitney U test was used to compare means between the groups. Correlation between variables was determined using Pearson's or Spearman's correlation analysis and stepwise multiple regression analysis. RESULTS: Carotid-femoral pulse wave velocity (car-fem PWV) was increased in the patients with OA compared to the controls (9.6 +/- 2.4 and 8.4 +/- 1.9 m/s, p = 0.015 respectively). High-sensitivity C-reactive protein and white blood cells count were significantly higher in the OA patients compared with the controls (1.80 +/- 1.10 and 1.48 +/- 1.32 mg/l, p = 0.042; 6.5 +/- 1.5 and 5.6 +/- 1.9 10(9)/l, p = 0.001 respectively). In multiple regression analysis age (p < 0.001), mean arterial blood pressure (p = <0.001) and OA status (p = 0.029) were found to be independent predictors of car-fem PWV. CONCLUSIONS: This study showed that patients with OA had increased aortic stiffness compared to non-OA controls. The potential link between arterial stiffening and OA suggests that vascular alterations are involved in OA pathogenesis and could be responsible for increased cardiovascular risk in end-stage OA patients
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Arthroscopic Partial Meniscectomy - Short-Term Clinical Outcome in an Orthopaedic Center in Southwestern Nigeria
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AMP (Acute Meniscal Pathology)
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BACKGROUND: Meniscal tears are one of the common causes of knee pain.
AIM: To evaluate the early clinical results of arthroscopic partial meniscectomy in the treatment of meniscal tears.
STUDY DESIGN: This was a prospective study in which consecutive patients presenting with meniscal injury, who met the inclusion criteria were recruited for the study.
SETTING: National Orthopaedic Hospital, Lagos.
METHODOLOGY: Biodemographic data and clinical findings were obtained. The visual analogue pain score and WOMET score were computed pre-operatively and at least 6-months post-operatively and these values compared using the Wilcoxon's signed rank. The level of significance was set at 0.05.
RESULTS: A total of 19 patients with 19 knees were included. Degenerative longitudinal tears were the commonest findings in 15 (79%), complex tears in 3 (16%) and radial tear in 1 (5%). The medial meniscus was more affected (52%) than lateral meniscus (48%). The red-white zone was involved in 12 (63%) cases and the white-white zone in 5 (37%). The median duration of follow up was 7 months while the median (IQR) WOMET score decreased from 59 (IQR =22) to 26.5(IQR=23), (Z= -3.409, P=001 ) and the visual analogue pain rating scale improved from 5 (IQR=1.5) to 3 (IQR=2.5) (Z= -3.346, P=001 ).
CONCLUSION: Arthroscopic partial meniscectomy offers a good short term clinical outcome for patients with knee pain secondary to meniscal injury.
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Multimodal analgesia with gabapentin, ketamine and dexamethasone in combination with paracetamol and ketorolac after hip arthroplasty: a preliminary study
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AAHKS (5) Gabapentinoids
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BACKGROUND AND OBJECTIVE: It has been hypothesized that combinations of analgesics with different mechanisms of action may reduce or even prevent postoperative pain. We, therefore, investigated the analgesic effect of gabapentin, dexamethasone and low-dose ketamine in combination with paracetamol and ketorolac as compared with paracetamol and ketorolac alone after hip arthroplasty.
METHODS: In this double-blind study, 42 patients were randomly assigned to either a combination group [gabapentin 1200 mg+dexamethasone 8 mg+ketamine (0.15 mg kg(-1))+paracetamol 1 g+ketorolac 15 mg] or a control group (placebo+paracetamol 1 g+ketorolac 15 mg). The medication was given preoperatively except for ketorolac, which was given at the end of surgery. Postoperative pain treatment was paracetamol 1 gx3; ketorolac 15 mgx3; and patient-controlled intravenous morphine. Morphine consumption, pain intensity at rest and during mobilization, nausea and vomiting, sedation, dizziness, hallucination and consumption of ondansetron were recorded 2, 4 and 24 h after operation. A P value of less than 0.05 was considered statistically significant.
RESULTS: Morphine consumption was not significantly different between groups (P=0.085). Overall pain scores were improved in the combination group as compared with the control group both at rest (P=0.042) and during mobilization (P=0.027). In the combination group, individual pain score above 30 mm on a 100 mm visual analogue scale was almost eliminated. The incidence of side effects did not differ between the groups.
CONCLUSION: Preoperative gabapentin, dexamethasone and ketamine combined with paracetamol and ketorolac reduced overall pain scores in patients after hip arthroplasty as compared with paracetamol and ketorolac alone. Morphine consumption was not reduced.
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Patient blood management in Europe
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PJI DX Updated Search
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Summary Preoperative anaemia is common in patients undergoing orthopaedic and other major surgery. Anaemia is associated with increased risks of postoperative mortality and morbidity, infectious complications, prolonged hospitalization, and a greater likelihood of allogeneic red blood cell (RBC) transfusion. Evidence of the clinical and economic disadvantages of RBC transfusion in treating perioperative anaemia has prompted recommendations for its restriction and a growing interest in approaches that rely on patients own (rather than donor) blood. These approaches are collectively termed 'patient blood management' (PBM). PBM involves the use of multidisciplinary, multimodal, individualized strategies to minimize RBC transfusion with the ultimate goal of improving patient outcomes. PBM relies on approaches (pillars) that detect and treat perioperative anaemia and reduce surgical blood loss and perioperative coagulopathy to harness and optimize physiological tolerance of anaemia. After the recent resolution 63.12 of the World Health Assembly, the implementation of PBM is encouraged in all WHO member states. This new standard of care is now established in some centres in the USA and Austria, in Western Australia, and nationally in the Netherlands. However, there is a pressing need for European healthcare providers to integrate PBM strategies into routine care for patients undergoing orthopaedic and other types of surgery in order to reduce the use of unnecessary transfusions and improve the quality of care. After reviewing current PBM practices in Europe, this article offers recommendations supporting its wider implementation, focusing on anaemia management, the first of the three pillars of PBM. é The Author [2012]
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Seasonal variation in the incidence of hip fractures in Emilia-Romagna and Parma
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Management of Hip Fractures in the Elderly
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Though some reports suggest the existence of seasonal changes in hip fracture incidence, with a peak in winter months, other investigations have failed to confirm this finding. In this study we present data on the month-to-month variability of hip fractures in Emilia-Romagna, a region of Northern Italy with a population of approximately four million inhabitants, and in Parma, a province of Emilia-Romagna (population of approximately 400,000). Data on cervical and trochanteric fractures were obtained from two sources: a) records of all operative procedures in the five orthopaedic centres serving the area of the Parma province; and b) a computerised database of all hospital discharges from public and private hospitals of Emilia-Romagna. In both cases, the analysis gave similar results, with no evidence of a consistent seasonal pattern in hip fracture rates
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Critical analysis of results of treatment of 201 tibial shaft fractures
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DoD SSI (Surgical Site Infections)
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Two hundred one tibial shaft fractures, 160 closed and 41 open (Grades I and II), were treated between January 1978 and June 1982. Sixty patients underwent closed intramedullary Arbeitsgemeinschart Osteosynthesisfragen/Association for the Study of Problems of Internal Fixation (AO/ASIF) nailing with reaming and 141 patients were treated with closed reduction and cast immobilization. Intramedullary nailing resulted in one (1.7%) nonunion, two (3.3%) infections, and no malunions. In the cast treatment group there were 14 (9.9%) delayed or nonunions, two (1.4%) infections, and six (4.3%) malunions. Within this group there were 19 early failures from either inadequate reduction or loss of reduction, which led to a change from nonoperative to operative methods of management. The interval between injury and return to work was 22 weeks in the nailed group, compared with 25.8 weeks in the cast immobilization group.
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Gouty involvement of flexor tendons
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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This article presents three patients suffering from complications related to tophi deposited within the hand and wrist synovium and flexor tendons. One patient had no previous history of gout or acute arthritis, with uricemia within normal values upon admission. The pathophysiology and treatment of gout in these special circumstances are discussed
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Hip fracture in the elderly: An interdisciplinary team approach to rehabilitation
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Hip Fx: Early-Weight Bearing Search
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The rising incidence of hip fractures in the elderly in a disturbing trend with serious health and socioeconomic consequences, including morbidity, loss of function, long-term institutionalization, and mortality. When preventive measures fail, the interdisciplinary healthcare team works together to provide operative treatment, reduce the risk of postoperative complications, and guide the patient through the recovery process. A team approach that ensures appropriate treatment, careful discharge planning, and coordinated rehabilitation can reduce the impact of the injury, speed recovery, and restore patient independence
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Progressive nerve territory overgrowth after subtotal resection of lipomatosis of the median nerve in the palm and wrist: A case, a review and a paradigm
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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Background: Lipomatosis of the nerve (LN) is a rare disorder characterized by the massive enlargement of peripheral nerves, frequently accompanied by generalized fibroadipose proliferation and skeletal overgrowth. The treatment of this disorder remains controversial, in part because of the rarity and the variability of presentation. Some authors have advocated total resection of this benign lesion including the functioning nerve, while others recommend symptomatic decompression alone. Methods: We have been routinely following a 10-year-old boy for lipomatosis of the median nerve at the wrist noted shortly after birth. He underwent median nerve resection accompanied by sural nerve grafting at another institute. We review the literature on LN and the efficacy of nerve grafting. Results: Clinically, he made a good recovery, with mild loss of thenar function and relatively preserved sensation. Serial magnetic resonance imaging over 5 years has revealed progression of the LN at both coaptation sites, fibrofatty proliferation within the nerve grafts as well as distal digital nerves, and enlargement of a fibrous scar at the coaptation sites. This has never been reported in the 9 decades of study of this disease. Conclusion: We present the first medium-term follow-up of a patient who underwent nerve sacrifice to attempt to cure the LN alongside a historical review of treatment. We believe that macroscopic gross total resection (i.e., microscopic subtotal resection) is insufficient in stopping the potential progression of this hamartomatous lesion because of the persistent effect of trophic factors. (copyright) 2013 Springer-Verlag Wien
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Morbidity and mortality associated with geriatric ankle fractures
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Hip Fx in the Elderly 2019
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Investigation performed at the Department of Orthopaedic Surgery, Brown University, Providence, Rhode Island Background: The purpose of this study was to examine the incidence of adverse events in elderly patients who required inpatient admission after sustaining an ankle fracture and to consider these data in relation to geriatric hip fracture and other geriatric patient admissions. Methods: A retrospective cohort study of patients admitted with an ankle fracture, a hip fracture, or any other diagnosis was performed with the Medicare Part A database for 2008. The primary outcome measure was the one-year mortality rate, examined with multivariate analysis factoring for both patient age and preexisting comorbidity. Secondary outcome measures analyzed additional morbidity as reflected by length of stay, discharge disposition, readmissions, and medical complications. Results: There were 19,648 patients with ankle fractures, 193,980 patients with hip fractures, and 5,801,831 patients with other admitting diagnoses. Significant differences (p < 0.001) were noted in both age and comorbidity status between the group with ankle fractures and the group with hip fractures. The one-year mortality after admission was 11.9% for patients with ankle fracture, 28.2% for patients with hip fracture, and 21.5% for patients with any other admission. Upon using multivariate analysis to account for both age and comorbidity, the hazard ratio for one-year mortality associated with fracture was 1.088 for patients with hip fracture and 0.557 for patients with ankle fracture. Conclusions: Even after selecting for admitted patients and accounting for both age and comorbidity, geriatric patients with ankle fractures were found to have a lower one-year morbidity compared with geriatric patients who had sustained a hip fracture or alternative admitting diagnoses. Geriatric patients with ankle fractures are likely healthier and more active in ways that are not captured by simply accounting for age and comorbidity. These findings may support more aggressive definitive management of such injuries in this population. Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Thermal changes during healing of distal radius fracturesâ??Preliminary findings
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Distal Radius Fractures
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Introduction The bone healing process is very complex. In simple terms, bone healing comprises three basic steps, the inflammation phase, the repair phase and the remodelling phase. The increase in blood flow around the fracture during the healing process increases the temperature of the surrounding tissue. Infrared thermography is a method of measuring body temperature that can detect temperature changes during bone healing. Studies on the application of thermography in traumatology are scarce, and there are no studies of thermal changes during normal bone healing. The authors have tried to determine the dynamics of thermal changes during bone healing. Material and methods The Flir ThermaCam B2 (FLIR Systems, Inc., Oregon, USA) was used for all measurements. Thermographic recordings were made one, three, five, 11 and 23 weeks after fracture. The contralateral, healthy, forearm was used for comparison. Results A total of 25 patients of mean age 65.9 ± 10.4 years (range 50â??80 years) with fracture of the distal radius were examined in this study. The mean temperature difference between healthy and fractured distal forearm one week after fracture was 1.20 ± 0.48 °C, three weeks after fracture was 1.42 ± 0.54 °C, five weeks after fracture was 1.04 ± 0.53 °C, 11 weeks after fracture was 0.50 ± 0.30 °C, and 23 weeks after fracture was 0.22 ± 0.25 °C. Conclusion Preliminary findings during this research showed significant temperature changes during healing of distal radius fractures. Infrared thermography is a simple and reliable method in clinical practice that could be used as a good follow-up method in traumatology, but further investigations on more patients are needed.
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Generation of tumor-initiating cells by exogenous delivery of OCT4 transcription factor
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Reduction Mammoplasty for Female Breast Hypertrophy
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INTRODUCTION: Tumor-initiating cells (TIC) are being extensively studied for their role in tumor etiology, maintenance and resistance to treatment. The isolation of TICs has been limited by the scarcity of this population in the tissue of origin and because the molecular signatures that characterize these cells are not well understood. Herein, we describe the generation of TIC-like cell lines by ectopic expression of the OCT4 transcription factor (TF) in primary breast cell preparations.
METHODS: OCT4 cDNA was over-expressed in four different primary human mammary epithelial (HMEC) breast cell preparations from reduction mammoplasty donors. OCT4-transduced breast cells (OTBCs) generated colonies (frequency ~0.01%) in self-renewal conditions (feeder cultures in human embryonic stem cell media). Differentiation assays, immunofluorescence, immunohistochemistry, and flow cytometry were performed to investigate the cell of origin of OTBCs. Serial dilutions of OTBCs were injected in nude mice to address their tumorigenic capabilities. Gene expression microarrays were performed in OTBCs, and the role of downstream targets of OCT4 in maintaining self-renewal was investigated by knock-down experiments.
RESULTS: OTBCs overcame senescence, overexpressed telomerase, and down-regulated p16INK4A. In differentiation conditions, OTBCs generated populations of both myoepithelial and luminal cells at low frequency, suggesting that the cell of origin of some OTBCs was a bi-potent stem cell. Injection of OTBCs in nude mice generated poorly differentiated breast carcinomas with colonization capabilities. Gene expression microarrays of OTBC lines revealed a gene signature that was over-represented in the claudin-low molecular subtype of breast cancer. Lastly, siRNA-mediated knockdown of OCT4 or downstream embryonic targets of OCT4, such as NANOG and ZIC1, suppressed the ability of OTBCs to self-renew.
CONCLUSIONS: Transduction of OCT4 in normal breast preparations led to the generation of cell lines possessing tumor-initiating and colonization capabilities. These cells developed high-grade, poorly differentiated breast carcinomas in nude mice. Genome-wide analysis of OTBCs outlined an embryonic TF circuitry that could be operative in TICs, resulting in up-regulation of oncogenes and loss of tumor suppressive functions. These OTBCs represent a patient-specific model system for the discovery of novel oncogenic targets in claudin-low tumors.
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Frequency of radiculopathy in patients with carpal tunnel syndrome and paracervical pain
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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OBJECTIVE: To determine if patients with carpal tunnel syndrome (CTS) and neck or suprascapular pain (paracervical pain) have frequent electrophysiologic evidence of cervical radiculopathy.BACKGROUND: Patients with paracervical pain and paresthesias affecting a median distribution (or the entire hand) are often incorrectly diagnosed with cervical radiculopathy. Nerve conduction studies, in such patients, usually confirm median nerve entrapment. How frequent such patients have electrophysiologic evidence of cervical radiculopathy is unclear.DESIGN/METHODS: We reviewed charts from patients with CTS seen in our EMG laboratory between 2009 and 2011. All patients presented with clinical features of CTS and had at least one median nerve conduction parameter showing slowing across the wrist. Cases were divided into two groups: those with and without paracervical pain. Cervical radiculopathy was defined electrophysiologically as the presence of fibrillations in 2 or more muscles from the same myotome. The Fisher exact test was used to compare the frequency of radiculopathy between the groups and to determine if the rate of radiculopathy varied depending on the degree of median nerve entrapment (5 grades). A p value of <0.05 was considered statistically significant.RESULTS: Of 133 charts reviewed, 108 patients were included; there were 87 (80.56%) females and 21 (19.44%) males. Of 115 limbs meeting selection criteria, 59 (51.30%) had paracervical pain 56 (48.70%) did not. Ten of 59 limbs with paracervical pain (16.95%) and 6 of the 56 without pain (10.71%) had cervical radiculopathy (p=0.42). There was also no difference in the frequency of radiculopathy related to the severity of median nerve entrapment (p=0.57).CONCLUSIONS: In patients with median nerve distribution paresthesias, paracervical pain is not associated with more frequent cervical radiculopathy than those without paracervical pain. Cervical radiculopathy is not more frequent in patients with more severe CTS. Paracervical pain in patients with CTS is likely due to myofascial pain from spondylosis rather than radiculopathy. This may reflect an association of tenosynovitis with CTS rather than nulldouble-crush' injury
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Application of endoscopic techniques in aesthetic plastic surgery
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Panniculectomy & Abdominoplasty CPG
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Although plastic surgeons had been slow to incorporate endoscopic techniques into their surgical armamentarium, there has been considerable interest in this field during the last 2 years. The aim of endoscopic brow lifting has been to achieve elevation of the brow through small scalp incisions without the associated nerve damage of the open approach and to accurately address excision of the muscles responsible for frowning. Endoscopic neck lift is a more recently pioneered technique which, although still in developmental stages, appears to provide good results. The technique involves undermining the skin of the neck extending from the chain to the jawline around the ear. Endoscopic facelifting is still very much in the experimental stages. Endoscopic techniques reduce the need for an incision in front of the ears. Using the endoscope, it has become a simple matter to perform a transaxillary breast augmentation using very small axillary incisions and precise placement of the implants. This results in excellent symmetry postoperatively and easy scar concealment. Abdominoplasty is another example of a procedure usually associated with a long incision and some degree of postoperative pain and immobility. Endoscopic abdominoplasty has been devised to provide not only contouring of abdominal fat through liposuction, but correction of the weakened abdominal muscle through a small incision placed just above the suprapubic hairline.
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Surgery for rotator cuff disease
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SR for PM on OA of All Extremities
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Background: This review is one in a series of Cochrane reviews of interventions for shoulder disorders.Objectives: To determine the effectiveness and safety of surgery for rotator cuff disease.Search methods: We searched the Cochrane Controlled Trials Register, (The Cochrane Library Issue 1, 2006), MEDLINE, EMBASE, CINAHL, Sports Discus, Science Citation Index (Web of Science) in March 2006 unrestricted by date or language.Selection criteria: Only studies described as randomised or quasi-randomised clinical trials (RCTs) studying participants with rotator cuff disease and surgical interventions compared to placebo, no treatment, or any other treatment were included.Data collection and analysis: Two independent review authors assessed methodological quality of each included trial and extracted data.Main results: We included 14 RCTs involving 829 participants. Eleven trials included participants with impingement, two trials included participants with rotator cuff tear and one trial included participants with calcific tendinitis. No study met all methodological quality criteria and minimal pooling could be performed. Three trials compared either open or arthroscopic subacromial decompression with active non operative treatment (exercise programme, physiotherapy regimen of exercise and education, or graded physiotherapy strengthening program). No differences in outcome between these treatment groups were reported in any of these trials. One trial which also included a placebo arm (12 sessions detuned soft laser) reported that the Neer score of participants in both active treatment arms improved significantly more than those who received placebo at six months.Six trials that compared arthroscopic with open subacromial decompression reported no significant differences in outcome between groups at any time point although four trials reported a quicker recovery and/or return to work with arthroscopic decompression. Adverse events, which occurred in three trials and included infection, capsulitis, pain, deltoid atrophy, and reoperation, did not differ between surgical groups.Authors' conclusions: Based upon our review of 14 trials examining heterogeneous interventions and all susceptible to bias, we cannot draw firm conclusions about the effectiveness or safety of surgery for rotator cuff disease. There is "Silver" (www.cochranemsk.org) level evidence from three trials that there are no significant differences in outcome between open or arthroscopic subacromial decompression and active non-operative treatment for impingement. There is also "Silver" level evidence from six trials that there are no significant differences in outcome between arthroscopic and open subacromial decompression although four trials reported earlier recovery with arthroscopic decompression
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Epidemiology of hip fractures in Zanjan, Iran
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HipFx Supplemental Cost Analysis
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Summary: The aim of this study was to estimate the incidence of hip fracture in Zanjan, Iran and to describe its seasonal variation. A total of 244 cases of hip fractures (131 men, 113 women) were recorded during 1 year. The annual age-standardized incidence rates were 206.5 and 214.8 per 100,000 men and women, respectively. Most fractures occurred in winter, in-house and daytime. In-hospital mortality was 2.5%. Incidence rate of hip fracture (HF) was less than in western countries mostly due to lower incidence in women, which is probably because of breast-feeding. Introduction: One of the most important consequences of osteoporosis is HF, which causes high mortality, morbidity, and significant costs. The incidence of HF in the elderly varies in different areas. Various incidence rates of HF have been reported from countries in the Middle East. The aim of this prospective study was to estimate the annual incidence of hip fracture in Zanjan, a province of Iran, and to describe the seasonal variation of HF incidence which has not been evaluated in two previous studies conducted in this country. Materials and methods: All cases of HF aged 50 years or more admitted in three referral hospitals with orthopedics facilities in Zanjan province between 21 March 2006 and 20 March 2007 were subjected in the study. The age- and sex-specific incidence rates of hip fracture per 100,000 person-years were calculated using the population data from the last national census in Iran 2007. Results: A total of 244 cases of hip fractures (131 men, 113 women) were recorded. The annual age-standardized incidence rate was 214.8 per 100,000 women and 206.5 per 100,000 men. The number (%) of fall-induced HF was 88 (67.2%) in men and 102 (90.3%) in women. The female to male ratio for total and fall-related HF was 1.0 and 1.1, respectively. The HF was more predominant in winter (38.5%). In-hospital mortality was 2.5%, and majority of HF were sustained in-house and daytime. Conclusion: We found a relatively low incidence of hip fracture and fall-related hip fracture in Iran than those in western countries, which is mostly due to the lower rate in women. These findings disagree with our expectations considering the bone mineral density and vitamin D status of Iranian population, especially women. Breastfeeding could be one of the probable protective factors. (copyright) International Osteoporosis Foundation and National Osteoporosis Foundation 2008
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Management of nonunion of humeral medial condyle fracture: A case series and review of the literature
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Pediatric Supracondylar Humerus Fracture 2020 Review
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Pediatric humeral medial condyle fracture (HMCF) is a rare condition and is difficult to detect, especially in young children. The management of late presentation of HMCF is challenging and lacks consensus. Herein, we reported four cases of HMCF nonunion received open reduction and internal fixation (ORIF) or supracondyle osteotomy from our institution. In addition, 12 cases of ORIF and 4 cases of osteotomy reported in the previous studies were also reviewed. The HMCF nonunion can heal after ORIF, but the indication and the optimal techniques need to be clarified. Supracondylar osteotomy alone is an effective and safe treatment option to improve the functional and cosmetic outcomes of HMCF nonunion.
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0 |
Novel biological approaches to the intra-articular treatment of osteoarthritis
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AAHKS (2) Corticosteroids
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Osteoarthritis is common, incurable and difficult to treat. Because osteoarthritis is symptomatic only in a limited number of weight-bearing joints and lacks obvious extra-articular manifestations, it is well suited to local therapy administered by intra-articular injection. Several biologically based, local therapies of this type are either in clinical use or in development. Intra-articular injections of hyaluronic acid are widely used, but are highly controversial because their mode of action is unclear and clinical trials have provided contradictory results. The conclusions of meta-analyses are also discordant. An alternative therapy, based on the intra-articular injection of autologous conditioned serum, is used in Europe. This product, known as Orthokine®, is generated by incubating venous blood with etched glass beads. In this way, peripheral blood leukocytes produce elevated amounts of the interleukin-1 receptor antagonist and other anti-inflammatory mediators that are recovered in the serum. Considerable symptomatic relief has been reported in clinical trials of this product. Alternatively, instead of injecting a heterogeneous, incompletely characterized mixture of native molecules into the joint, it is possible to inject recombinant growth factors and cytokine antagonists. None of these are in routine clinical use, but promising preliminary human trials have been performed with insulin-like growth factor-1 and the interleukin-1 receptor antagonist. It is possible that sustained intra-articular production of such factors could be achieved by gene transfer. Although gene therapy for osteoarthritis is not yet a clinical reality, the first human trial should begin next year. © 2005 Adis Data Information BV. All rights reserved.
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Abdominal Etching
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Panniculectomy & Abdominoplasty CPG
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Abdominal etching techniques are used to improve the aesthetics of the abdominal region, providing patients an athletic physique, using liposuction and fat redistribution. Based on the anatomy of fat layers, lipocontouring for deep fat liposuction and superficial fat liposculpting for superficial fat liposuction are proposed. The degree of abdominal etching is controlled by the surgeon through the extent of lipocontouring and superficial fat liposculpting. Therefore, we propose the classification of low-, medium-, and high-definition abdominal etching levels. This article offers a comprehensive description of the authors' technique, including preoperative assessment, intraoperative procedure, and postoperative care for patients undergoing abdominal etching.
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0 |
Early results of a new rotating hinge knee implant
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OAK 3 - Non-arthroplasty tx of OAK
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Background. Indication for rotating hinge (RH) total knee arthroplasty (TKA) includes primary and revision cases, with contradictory results. The aim of this study was to report prospective early results of a new modular rotating hinge TKA (EnduRo). For this implant several new design features and a new bearing material (carbon-fiber reinforced poly-ether-ether-ketone) have been developed. Furthermore, we tried to establish a new classification of failure modes for revision TKA. Methods. 152 EnduRo rotating-hinge prostheses were implanted in two centers. In 90 patients a primary implantation has been performed and 62 patients were revision cases. Knee Society Score (KSS), Western Ontario and McMaster Osteoarthritis Index (WOMAC), Oxford Knee Score (OKS), and Range of motion (ROM) were assessed before surgery, 3 months postoperatively, 12 months postoperatively, and annually thereafter. We defined 3 types of complications: Type 1, infection; type 2, periprosthetic complications; type 3, implant failures. Results. KSS, WOMAC, OKS, and ROM revealed significant improvements between the preoperative and the follow-up investigations. There were 14 complications (9.2%) leading to revision surgery, predominantly type 2. Conclusion. Our study shows excellent clinical results of the EnduRo TKA. Furthermore, no premature material failure or unusual biological response to the new bearing material could be detected. © 2014 Alexander Giurea et al.
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0 |
The effect of neuraxial blocks on surgical blood loss and blood transfusion requirements: a meta-analysis
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AAHKS (9/10) Regional Nerve Blocks
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PURPOSE: The aim of this study was to evaluate the effect of neuraxial blocks on surgical blood losses and on the number of patients requiring blood transfusion.
METHODS: A search of the American National Library of Medicine's PubMed up to November 12, 2004, was performed. Twenty-four studies could be kept for analysis.
RESULTS: Regional anesthesia reduced the number of transfused patients for total hip replacement (P = 0.0009) and spinal fusion (P = 0.04). A reduction of measured blood loss that did not lead to a reduction in the number of transfused patients was also found for fractured hip surgery (P < 0.0001), lumbar disk surgery (P = 0.01), peripheral vascular surgery (P = 0.03), retropubic prostatectomy (P = 0.02), cesarean section (P < 0.0001), and bowel surgery (P = 0.0008). In summary neuraxial blocks have a clear and definite effect on surgical blood loss, but this effect do not usually lead to a reduction in the number of transfused patients except for patients undergoing total hip replacement and spinal fusion.
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0 |
A feasibility study of zoledronic acid combined with carboplatin/nedaplatin plus paclitaxel in patients with non-small cell lung cancer with bone metastases
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MSTS 2018 - Femur Mets and MM
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Aims and background. Although zoledronic acid (ZOL) has been reported to inhibit bonemetastasis fromlung cancer, the optimumchemotherapy regimen in combination with ZOL has not yet been determined. Methods and study design. Eighteen patients having non-small cell lung cancer (NSCLC) with bone metastasis who received carboplatin/nedaplatin plus paclitaxel combined with ZOL (4mg every 28 days) were enrolled to investigate the feasibility of this treatment. The efficacy was evaluated by the percentage of patients at 9 months who were receiving radiation therapy, the time to first radiation treatment, and quality of life. Adverse effects were also evaluated. Results. Only 3 among 18 patients received radiation therapy for bone metastases during the 9 months of the study. ZOL seems to prolong the median time to the first radiation treatment andmaintain the quality of life regarding pain and activity status. No patients discontinued the treatment, although grade 3 or 4 treatment-related adverse effects occurred in 8 patients. Conclusions. ZOL combined with carboplatin/nedaplatin plus paclitaxel is an effective and tolerable treatment for NSCLC with bone metastases.
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0 |
Efficacy and safety of pirarubicin plus capecitabine versus pirarubicin plus cyclophosphamide in Chinese node-negative breast cancer patients: a 4-year open-label, randomized, controlled study
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MSTS 2018 - Femur Mets and MM
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This study aimed to evaluate the efficacy and safety of adjuvant chemotherapy with pirarubicin plus capecitabine (AX regimen) in Chinese node-negative breast cancer (BCa) patients. Two hundred eighty Chinese pT1-2N0M0 BCa patients under 70Â years of age were equally and randomly assigned to receive four cycles of adjuvant therapy with the AX regimen or pirarubicin and cyclophosphamide (AC regimen) between January 2010 and May 2011. End points included overall survival (OS), disease-free survival (DFS), chemotherapy-induced toxicities, and quality of life (QoL). The 4-year DFS (AX vs. AC, 93.6 vs. 92.9Â %, PÂ =Â 0.761) and OS (97.1 vs. 96.4Â %, PÂ =Â 0.965) were similar between the two treatment arms. The AX group, compared to the AC group, experienced significantly less frequent grade III/IV vomiting (11.4 vs. 26.4Â %, PÂ <Â 0.001), whereas the incidence of other grade III/IV chemotherapy-associated toxicities was comparable between the two groups (all P values >0.05). Use of the AX regimen was associated with significantly higher QoL scores in the domains of physical, role, and social functions than the AC regimen (P values <0.05), although the two regimens were similar in the domains of emotional and cognitive functions (all P values >0.05). In comparison with the AC regimen, AX adjuvant chemotherapy is equally beneficial for node-negative BCa patients younger than 70Â years with respect to OS and DFS. The AX regimen is primarily advantageous over the AC regimen based on less frequent severe toxicities and better health-related QoL.
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0 |
Pressure sores and hip fractures
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Management of Hip Fractures in the Elderly
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Development of pressure sores during hospital admission causes morbidity and distress to the patient, increases strain on nursing resources, delaying discharge and possibly increasing mortality. A hip fracture in elderly patients is a known high-risk factor for development of pressure sores. We aimed to determine the current incidence of pressure sores and identify those factors which were associated with an increased risk of pressure sores. We retrospectively analysed prospectively collected data of 4654 consecutive patients admitted to a single unit. One hundred and seventy-eight (3.8%) of our patients developed pressure sores. Patient factors that increased the risk of pressure sores were increased age, diabetes mellitus, a lower mental test score, a lower mobility score, a higher ASA score, lower admission haemoglobin and an intra-operative drop in blood pressure. The risk was higher in patients with an extracapsular neck of femur fracture and patients with an increased time interval between admission to hospital and surgery. Our studies indicate that while co-morbidities constitute a substantial risk in an elderly population, the increase in incidence of pressure sores can be reduced by minimising delays to surgery
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0 |
The clinical effect of plateletâ??rich plasma prepared through different activation methods on patients with knee osteoarthritis
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OAK 3 - Non-arthroplasty tx of OAK
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Aim: Intra-articular application of platelet rich plasma (PRP) can be an alternative treatment method for knee osteoarthritis. The objective of this study was to compare the activation methods of platelet rich plasma before intraarticular application. Material and Method: A total 51 patients (76 knees) was randomly selected into two groups. In group 1, activation of PRP was managed by adding calcium chloride (CaCl). In group 2, activation of PRP was managed by keeping the solution at -70° degrees for 24 hours after preparation and immersed in water at 37°C for a period of 5 minutes for complete dissolution. Then PRP was applied. The patients were assessed with VAS and WOMAC pain scores both baseline and after 2nd, 6th and 12th months of the treatment. Results: VAS and WOMAC pain scores were significantly higher at baseline compared to the results obtained at the 2nd, 6th and 12th months (p=0.06). Following 2nd, 6th and 12th months a gradual downward tendency was seen in both scores, even though no significant difference was found between the groups after 2nd, 6th and 12th months. Discussion: Patients received some clinical benefits from both activation methods. There is no significant difference between activating PRP by CaCl or -70°C which compared in terms of clinical benefits. Therefore, blood storage at -70ºC may be preferred primary due to no need for additional material such as CaCl.
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The useful of us in diagnosis of carpal tunnel syndrome in diabetics: A proposal for new reference values
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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Background Carpal Tunnel Syndrome (CTS) is a neural affection that in diabetic patients can be associated with polyneuropathy (DP). In rheumatologists's practice, ultrasonography represents a useful tool in the study of median nerve entrapment pathology since increased median nerve Cross-section area (CSA) at the carpal tunnel is considered both sensitive and specific in diagnosis of CTS(1,2). However, previous studies on diabetics showed a diffuse increase of peripheral nerve CSA in patients with DP (3), making standard reference values for general population not applicable in these patients. Objectives The aim of this study was to assess median nerve CSA cut-off values for the diagnosis of CTS in a population of diabetic patients, with or without polyneuropathy. Methods We enrolled all consecutive diabetic patients, regardless the presence of CTS or DP symptoms but without other risk factors for neuropathy, who reached the Diabetology Clinic of this hospital in November 2012 for routine controls. Patients underwent median nerve conduction study (EMG) of the symptomatic hand or the dominant one-if asymptomatic for CTS. For the diagnosis of DP were also assessed tibial, peroneal and sural nerve. CSA measurement of the median nerve was performed at the tunnel inlet. ROC curves were employed to determine the optimal cut-off values for ultrasonographic CSA in all patients and in subgroups with or without DP. EMG was considered the gold standard for diagnosis of CTS. Results 39 patients (20 female), mean age 64yo (range 27-83yo, SD 12,47), were enrolled. Mean duration of disease was 18,6 y (range 1-64y, SD 13,39). Mean values of median CSA in the cohort and in patients with and without DP were respectively 11,23 mm(2) (SD 2,6), 12,4 mm(2) (SD 2,7) and 10,5mm(2) (SD 2,26). ROC analysis showed the following CSAs as the best values for sensitivity and specificity: total cohort 11,5 mm(2) (61,5% sensitivity and a 85% specificity - AUC 0,796), patients with DP 12mm(2) (sensitivity 69% with a 100% specificity, AUC 0,846), 10,5mm(2) in patients without DP (sensitivity 61%, specificity 64%, AUC 0,734). The standard cut-off value for the general population of 10,5mm(2) yielded in our patients the following results: total cohort 65% and 62%, diabetes with DP 60% and 50% and diabetes without DP 61% and 64% of sensitivity and specificity respectively. Conclusions In patients with diabetes and DP US CSA cut-off values for diagnosis of CTS should be raised to obtain a better sensitivity and specificity while for patients with diabetes but without DP the same cut-off values of the general population can be used. For patients with diabetes but uncertain about the presence of DP, the optimal cut-off is 11,5mm(2)
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1 |
Determination of sensitive electrophysiologic parameters at follow-up of different steroid treatments of carpal tunnel syndrome
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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Nonsurgical treatment for carpal tunnel syndrome (CTS) is frequently offered to those with mild to moderate symptoms. However, the most sensitive electrophysiological parameters at follow-up, and most effective type of different methods of steroid treatment for CTS, remain unknown. The aim of this study was to compare the efficacy of local corticosteroid injection, phonophoresis, and iontophoresis for the treatment of CTS, and to evaluate the most sensitive electrophysiologic parameters at the follow-up visit. Different conservative treatments were applied in this prospective study. Fifty-six hands of 31 patients were randomly treated with local steroid injection, iontophoresis, or phonophoresis with 2- and 4-month follow-up visits. Conventional and new neurophysiologic sensorimotor nerve conduction parameters for CTS diagnosis were performed on the initial visit and at 2 and 4 months after treatment. The local steroid injection group showed a significant improvement in the mean nerve conduction parameters after the second and fourth months when compared with basal values, whereas no significant changes except the difference between the median and ulnar distal latency to the fourth digit (D4M-D4U), difference between sensory median distal latency to second digit and ulnar distal latency to the fifth digit (D2M-D5U), and median motor distal latency were observed in the iontophoresis and phonophoresis groups. At the end of follow-up period, the most sensitive parameters were D4M-D4U and D2M-D5U; the D4M-D4U was improved 60% in the injection group, 33% in iontophoresis group, and 39% in phonophoresis group, and the improvement of the D2M-D5U was 70%, 28%, and 28%, respectively, in the injection, iontophoresis, and phonophoresis groups. These findings show that steroid injection is superior to iontophoresis and phonophoresis in the treatment of CTS, and that the most sensitive neurophysiologic parameters in follow-up are D4M-D4U and D2M-D5U, being the objective measures of the outcome of CTS treatment
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1 |
Coronal patellar osteotomy of the external facet combined with the release of the lateral retinaculum improves the clinical outcomes of isolated lateral release in lateral knee compartment syndrome
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DOD - Acute Comp Syndrome CPG
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OBJECTIVE: To describe a novel coronal osteotomy of the external facet of the patella, and to evaluate if the outcomes of the treatment of lateral knee compartment syndrome (LKCS) with this osteotomy, combined with the release of the external lateral retinaculum, are better than the isolated lateral retinacular release.
MATERIAL AND METHODS: A prospective study with a 2 year follow up that included 70 patients diagnosed with LKCS, distributed into 2 groups. The first group included 50 patients on whom the lateral retinacular release combined with osteotomy was performed, and a second group on whom an isolated retinacular release was performed. Measurements were made using the Werner functional scale before the surgery and at 3, 12, and 24 months follow-up.
RESULTS: There were significant differences in the overall functional state between the two groups after the surgery (better in the osteotomy group at all the intervals, P<.05). The improvement, which was progressive up to 12 months, was slightly less at 24 months, although the values were still better than the pre-surgical ones in both groups. Pain was the variable that showed most improvement. The patients with LKCS with degenerative signs showed a benefit in all cases.
CONCLUSION: The results demonstrate that the described patellar osteotomy technique, combined with lateral retinacular release, significantly improves the pain and the functional scale score of patients with LKCS after 2 years of follow-up, to a greater extent than isolated lateral retinacular release, including those in which there was evidence of degenerative signs.
Copyright © 2016 SECOT. Publicado por Elsevier Espana, S.L.U. All rights reserved.
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Histological alterations after irradiation of cartilage using Ho:YAG laser
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AMP (Acute Meniscal Pathology)
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OBJECTIVE: The authors carried out an experimental study to evaluate the histological alterations after irradiation of cartilage using Holmium:YAG (Ho:YAG) laser VersaPulse Select 60 watts and Infra Tome Delivery Systems 30 degrees Handpiece (spot size at fiber tip 0.4 mm; Coherent Medical, Palo Alto, CA).
BACKGROUND DATA: Recently, some authors reported cases with articular cartilage damage following arthroscopic laser surgery in the knee joint for the treatment of articular cartilage or meniscal pathology.
MATERIALS AND METHODS: The cartilage specimens immersed in saline were exposed to Ho:YAG laser irradiation. The laser wavelength was 2.1 microm, and pulse duration was 250 microsec. Power settings were 0.2-1 joules per pulse and 10-15 Hz. Total laser energy used in these procedures was 1.5 K joules. During the procedures, the handpiece was used at an angle of 30 degrees and at a distance of 1 mm.
RESULTS: Electron microscopic evaluation demonstrated that the ultrastructure of the cartilage is preserved in both experiment and control groups.
CONCLUSION: When Ho:YAG laser is used in optimal dosage (optimal joule and Hertz) with optimal technique (keeping the handpiece at an appropriate angle and distance) and avoiding overtreatment, it does not cause cartilage damage.
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0 |
Transdermal androgen therapy to augment EPO in the treatment of anemia of chronic renal disease
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Management of Hip Fractures in the Elderly
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(bullet) Background: Hypogonadism and anemia are common comorbid conditions in dialysis patients. Testosterone replacement may improve such clinical parameters as anemia, sarcopenia, and low libido. Additionally, by increasing hemoglobin levels, testosterone replacement may allow for a dose reduction in recombinant human erythropoietin (rHuEPO), thereby reducing cost. Methods: This phase IV, single-center, placebo-controlled, double-blind study assessed the effect of transdermal testosterone on serum testosterone levels, rHuEPO dose required to maintain hemoglobin level, bone mineral content, lean body mass and fat content, cholesterol level, sexual function, and mood. Forty hypogonadal male hemodialysis patients who were administered rHuEPO were randomly assigned to 100 mg of topical 1% testosterone gel (Testim; Auxilium Pharmaceuticals, Norristown, PA) or placebo, applied daily for 6 months. Results: Forty men with a mean age of 56 years and baseline serum testosterone level less than 300 ng/dL (<10.4 nmol/L) participated in this trial. In men assigned to administration of transdermal testosterone, there was an increase beyond that in the placebo group in mean serum testosterone (77.1 ng/dL [2.7 nmol/L]), dihydrotestosterone (DHT; 0.8 nmol/L), and estradiol levels (6.3 pg/mL [23.0 pmol/L]) and a decrease in mean serum luteinizing hormone levels (-3.1 IU/L). Compared with subjects administered placebo, participants on testosterone replacement therapy did not show an appreciable change in rHuEPO dose (mean difference adjusted for baseline values, 12.6 U/kg/wk; P = 0.73), bone mineral density, lean body mass or fat content, cholesterol level, sexual function, or mood. Conclusion: Daily administration of 100 mg of topical 1% testosterone gel for 6 months failed to significantly increase serum testosterone or DHT levels in hypogonadal men with end-stage renal disease. Treatment with transdermal testosterone did not impact on rHuEPO requirement or clinical parameters in this small placebo-controlled study. Greater serum testosterone levels may be required to show clinical benefit in men with end-stage renal disease. (copyright) 2006 by the National Kidney Foundation, Inc
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0 |
Effects of robotic therapy on motor impairment and recovery in chronic stroke
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The Treatment of Pediatric Supracondylar Humerus Fractures AUC
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OBJECTIVE: To examine whether robotic therapy can reduce motor impairment and enhance recovery of the hemiparetic arm in persons with chronic stroke. DESIGN: Pre-posttest design. SETTING: Rehabilitation hospital, outpatient care. PARTICIPANTS: Volunteer sample of 20 persons diagnosed with a single, unilateral stroke within the past 1 to 5 years, with persistent hemiparesis. INTERVENTIONS: Robotic therapy was provided 3 times weekly for 6 weeks. Subjects able to reach robot targets were randomly assigned to sensorimotor or progressive-resistive robotic therapy groups. Robotic therapy consisted of goal-directed, planar reaching tasks to exercise the hemiparetic shoulder and elbow. MAIN OUTCOME MEASURES: The Modified Ashworth Scale, Fugl-Meyer test of upper-extremity function, Motor Status Scale (MSS) score, and Medical Research Council motor power score. RESULTS: Evaluations by a single blinded therapist revealed statistically significant gains from admission to discharge (P<.05) on the Fugl-Meyer test, MSS score, and motor power score. Secondary analyses revealed group differences: the progressive-resistive therapy group experienced nonspecific improvements on wrist and hand MSS scores that were not observed in the sensorimotor group. CONCLUSIONS: Robotic therapy may complement other treatment approaches by reducing motor impairment in persons with moderate to severe chronic impairments
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0 |
Compliance with the Eastern Association for the Surgery of Trauma guidelines for prophylactic antibiotics after open extremity fracture
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DoD SSI (Surgical Site Infections)
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CONTEXT: Prophylactic antibiotics, paired with wound care and surgical intervention, is considered the standard of care for patients with open fracture. Guidelines from the Eastern Association for the Surgery of Trauma (EAST) recommend specific prophylactic antimicrobial therapy based on the type of open fracture.
AIMS: We quantified adherence to EAST guideline recommendations and documented the incidence of infection in patients with open fracture.
SETTINGS AND DESIGN: A retrospective, observational study of all patients with open fracture admitted to our facility from January 2004 to December 2008 was conducted.
MATERIALS AND METHODS: Patients were divided into compliant and noncompliant groups according to the EAST guideline recommendations. Compliance was defined as an appropriate spectrum of therapy for guideline suggested duration. We assessed for surgical and non-surgical site infections, and morbidity outcomes.
STATISTICAL ANALYSIS: Nominal data were explored using summary measures. Continuous variables were compared using the Student t-test or the Mann-Whitney U-test. Dichotomous data were compared using chi(2) statistic or Fisher's exact test.
RESULTS: The final analysis included 214 patients. Prophylactic antibiotics were guideline compliant in 28.5% of patients, and ranged from 10.0% in type 3b fractures to 52.7% in type 1 fractures. The most common reason for non-compliance was the use of guideline recommended coverage that exceeded the suggested duration (71.2%). Patients who received non-compliant therapy required prolonged hospital lengths of stay (6 vs. 3 days, P = 0.0001). The overall incidence of infection was similar regardless of guideline compliance (17.0% vs. 11.5%, P = 0.313).
CONCLUSIONS: Prophylactic antibiotics for open fracture frequently exceeded guideline recommendations in duration and spectrum of coverage, especially in more severe fracture types. Non-compliance with EAST recommendations was associated with increased in-hospital morbidity.
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0 |
Population based study on patients with traumatic brain injury suggests increased risk of dementia
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DoD PRF (Psychosocial RF)
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Objective: The relationship between traumatic brain injury (TBI) and the risk of dementia remains controversial. This population based study was designed to estimate and compare the risk of dementia in TBI and non-TBI individuals during the 5 year period after TBI. Methods: This study was a retrospective cohort study. Data were obtained from the Longitudinal Health Insurance Database 2000. We included 44 925 patients receiving ambulatory or hospital care and 224 625 non-TBI patients; patients were matched for sex, age and year of index use of healthcare. Patients <15 years of age and those admitted to the intensive care unit were excluded. Each individual was studied for 5 years to identify the subsequent development of dementia. Data were analysed by Cox proportional hazard regression. Results: During the 5 year follow-up period, 1196 TBI (2.66%) and 224 625 non-TBI patients (1.53%) patients developed dementia. During the 5 year follow-up period, TBI was independently associated with a 1.68 (range 1.57-1.80) times greater risk of dementia after adjusting for sociodemographic characteristics and selected comorbidities. Conclusions: The findings of this study suggest an increased risk of dementia among individuals with TBI. We suggest the need for more intensive medical monitoring and health education in individuals with TBI.
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Comparison study of bone strength of the proximal femur with and without hip osteoarthritis by computed tomography-based finite element analysis
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Hip Fx in the Elderly 2019
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Proximal femoral fractures are common in elderly osteoporosis patients; however, its prevalence is clinically rare in hip fracture patients with hip osteoarthritis (OA). This study aimed to evaluate bone strength of the proximal femur with or without hip OA and proximal femoral fracture risk using computed tomography (CT)-based finite element analysis (FEA). A retrospective analysis was done on CT data of 20 patients who underwent total hip arthroplasty for unilateral hip OA. Furthermore, the fracture load between OA and contralateral sides was compared and the association between fracture load and risk factor was analyzed. The fracture load was significantly higher in the OA side than that in the contralateral side (3819.5 ± 1557.8 N vs. 3224.5 ± 943.7 N, respectively; P = 0.0405). There was no significant difference in fracture load between OA and the contralateral side in Kellgrenâ??Lawrence (KL)-3 and KL-4 grade, but the KL-4 fracture load tends to be high (P = 0.2461 and P = 0.0527, respectively). Moreover, there was no significant association between fracture load and OA severity or age. The study findings may assist in predicting bone strength and proximal femur fracture risk. The results of this FEA study indicate the bone strength of the proximal femur was affected by the severity of the osteoarthritis.
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0 |
Hyperthermic isolated limb perfusion in locally advanced limb soft tissue sarcoma: A 24-year single-centre experience
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DOD - Acute Comp Syndrome CPG
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Background: Hyperthermic isolated limb perfusion (HILP) is a locoregional treatment aimed at avoiding amputation in patients with advanced extremity soft tissue sarcomas (STS). Over the last 25 years, HILP procedure has been implemented to maximise its therapeutic ratio. Methods: A retrospective analysis including 117 patients who underwent HILP from 1989 to 2013 was performed. Three different drug schedules were applied: 1) doxorubicin (n = 47), 2) high dose (3-4 mg) tumour necrosis factor-alpha (TNF-α) plus doxorubicin (n = 30), 3) low dose (1 mg) TNF-α plus melphalan (L-PAM) (n = 40). Tumour response was evaluated by MRI or CT and surgical specimens. Toxicity and local progression-free survival (LPFS) were also evaluated. Results: In total 92 (78.6%) patients had primary, 25 (21.4%) had recurrent and 17 (14.5%) had metastatic disease. The subjects in the three groups were homogeneous for clinical-pathological features. Pathological response was complete in 55 patients (47%), partial in 35 (29.9%), regardless of drug schedule (p = 0.501) and tumour presentation (p = 0.094). Wieberdink III-V toxicity was registered in 19.1%, 20% and 2.5% of patients, respectively (p < 0.051). Twenty-eight patients (23.9%) received adjuvant radiotherapy with no relevant toxicity. Five-year LPFS was 81.6% and 74.2% in patients with primary or recurrent disease, respectively (p = 0.652). After a median follow-up of 36.5 months, the limb sparing rate was 77.8%. Conclusions: HILP performed with different drugs was equally active, either in primary, recurrent or metastatic STS, providing effective limb sparing and durable local control. Low dose TNF-α plus L-PAM had the most favourable toxicity profile. Adjuvant radiotherapy was not associated with relevant toxicity.
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1 |
Efficacy and safety of tranexamic acid in geriatric hip fracture with hemiarthroplasty: a retrospective cohort study
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Hip Fx in the Elderly 2019
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BACKGROUND: Geriatric hip fracture patients are particularly susceptible to blood loss and venous thromboembolism (VTE) during hemiarthroplasty, yet relatively few studies have examined the safety and efficacy of tranexamic acid (TXA) in these patients.
METHODS: This cohort study of hip fracture patients (>=65 years) undergoing hemiarthroplasty between January 2013 and September 2016 involved 289 patients who received 15 mg/kg TXA prior to surgery and 320 who received no TXA. All patients underwent a fast-track program including nutrition, blood, and pain management; VTE prophylaxis; early mobilization; and early intake. The primary outcome was red cell transfusion requirement. Secondary outcomes included blood loss, hemoglobin (Hb) level, VTE, adverse events and length of hospital stay. Multivariate logistic regression and meta-analysis of the literature were also performed to control for confounding factors and identify risk factors of red cell transfusion.
RESULTS: The proportion of patients receiving at least 1 U of erythrocytes was significantly lower in the TXA group (8.65%) than in the control group (24.06%, OR 0.299, p < 0.001). Mean Hb level was significantly higher in the TXA group on postoperative day 1 (111.70 +/- 18.40 vs 107.29 +/- 18.70 g/L, p = 0.008) and postoperative day 3 (108.16 +/- 17.25 vs 104.22 +/- 15.16 g/L, p = 0.005). A significantly higher proportion of TXA patients began to ambulate within 24 h after surgery (37.02% vs 26.25%, p = 0.004), and their length of hospitalization was significantly shorter (11.82 +/- 4.39 vs 15.96 +/- 7.30 days, p = 0.003). TXA did not increase risk of DVT (OR 0.70, 95%CI 0.25 to 1.97). Logistic regression showed that, after adjusting for covariates, TXA was associated with 62% lower risk of red blood cell transfusion (0.327, 95%CI 0.214 to 0.696), and a similar result was obtained in meta-analysis of unadjusted data from the present study and the literature (OR 0.33, 95%CI 0.25 to 0.43).
CONCLUSION: TXA appears to be safe and effective for reducing blood loss and red blood cell transfusion in geriatric hip fracture patients undergoing fast-track hemiarthroplasty.
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0 |
Psoas compartment block for lower extremity surgery: a meta-analysis
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Surgical Management of Osteoarthritis of the Knee CPG
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Psoas compartment block (PCB) is a potentially useful but controversial technique for lower limb surgery. We have conducted a systematic review of the efficacy and safety of PCB for anaesthesia and postoperative analgesia for hip and knee surgery. Relevant studies were identified within PubMed, EMBASE, and the Cochrane Library. The main outcome measure for anaesthesia was anaesthetic efficacy. For postoperative analgesia, the severity of postoperative pain was compared. The data were subjected to meta-analysis using relative risks with 95% confidence intervals (95% CI) for dichotomous variables and weighted mean differences with 95% CI for continuous variables. Thirty publications were included. PCB is an effective intervention for analgesia after hip and knee surgery. It appears superior to opioids for pain relief after hip surgery. This analgesic benefit may be extended beyond 8 h by the use of a catheter technique. Compared with Winnie's 3-in-1 block, PCB is associated with more consistent block of the obturator nerve. PCB may be an alternative to postoperative neuraxial block. Although PCB combined with sciatic nerve block and sedation is an effective technique for minor knee surgery, there is currently insufficient data to recommend the use of this approach for hip and major knee surgery. PCB is a safe and effective alternative for analgesia after hip and knee surgery. More research is required to define its role in the intraoperative setting and confirm potentially beneficial effects on variables such as perioperative haemodynamics and blood loss
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Computed tomographic evaluation of component position on dislocation after total hip arthroplasty
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Management of Hip Fractures in the Elderly
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True proper position after total hip arthroplasty was determined by measuring the cup and stem anteversion using computed tomography. We compared 20 dislocated hips (14 posterior and 6 anterior) with 18 non-dislocated hips. Both the cup anteversion and the stem anteversion showed no differences among the groups. The sum of cup and stem anteversion in posterior dislocated hips was significantly lesser than that in non-dislocated hips and the sum in anterior dislocated hips was significantly greater than that in non-dislocated hips. These results suggested even if the cup alone or the stem alone is at proper position, dislocation might occur
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Evaluation of Clinical Results and Complications of Structural Allograft Reconstruction after Bone Tumor Surgery
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Pediatric Supracondylar Humerus Fracture 2020 Review
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BACKGROUND: Massive bone allograft is an option in cases of limb preservation and reconstruction after massive benign and malignant bone tumor resection. The purpose of this study was to analyze the outcome of these procedures at Imam Reza Hospital, Mashhad University of Medical Sciences. METHODS: In this study, 113 cases have been presented. Eleven cases were excluded (patients has a traumatic defect or they passed away before the completion of the study's two-year follow up period). Each patient completed a questionnaire, went through a physical examination and, if indicated, X-ray information was collected. The patients were divided into three groups: chemotherapy, chemotherapy plus radiation therapy, and no-adjuvant-therapy. RESULTS: Fifty-four cases were male and the mean age was 24.5±5.39. The number of cases and indications for surgery were: 33 cases of aggressive benign tumors or low grade malignant bone tumors (large bone defects) including 16 germ cell tumors, eight aneurysmal bone cysts, five low grade osteosarcomas, and four chondrosarcomas. Another 69 cases were high-grade malignant bone tumors including 42 osteosarcomas, 21 Ewing's sarcoma, and six other high grade osteosarcomas. Patients were divided into three groups: the first group received no adjuvant therapy, the second group received chemotherapy, and the third group received chemotherapy plus radiotherapy. The location of tumors were as follows: eight cases in the pelvic bone, 12 in the proximal femur, 18 in the femoral shaft, 36 in the distal femur, 12 in the proximal tibia, and 16 in the humeral bone. The 12 cases of proximal femoral defects were reconstructed by allograft composite prosthesis, 18 diaphyseal defects with intercalary allograft, and 36 distal femoral defects were reconstructed using osteoarticular allograft. The rate of deep infection was 7:8% (eight patients) and in this regard, we found a significant difference among the three groups, such that most cases of infection occurred in the adjuvant chemotherapy plus radiation therapy group. Allograft fracture occurred in six patients and prevalence was the same in all groups. Only in six cases of radio-chemotherapy nonunion occurred, so we used autogenous bone graft for union. Local recurrence was observed in six patients: three belonged to the adjuvant chemotherapy group and the other three were in the chemo-radiotherapy group; no significant difference was observed between these two groups. However, there was a significant difference between these two and the group that received no adjuvant therapy. Also, there were 11 cases of metastases and Restriction of knee joint motion occurred in 48 cases of osteo-cartilaginous grafts of the distal femur and proximal tibia. CONCLUSION: Although structural allograft is an appropriate choice in limb reconstruction after massive resection of involved tissues in malignant and invasive bone tumors, the risk of complications such as nonunion and infection in massive allograft increases in cases of adjuvant (chemotherapy and radiotherapy) modalities of treatment. Whereas the rate of tumor recurrence, metastasis, and restrictions in range of motion during a short term follow up after implantation showed no significant difference among the evaluated groups. Consequently, further attention and constant periodic visits of the patients and checking for local recurrence and distant metastasis should be done after surgery.
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Early Postoperative CT Scan Provides Prognostic Data on Clinical Outcomes of Fresh Osteochondral Transplantation of the Knee
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AMP (Acute Meniscal Pathology)
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BACKGROUND: There is a lack of information regarding the ability of imaging studies to predict clinical outcomes after fresh osteochondral allograft (FOCA) transplantation of the knee.
PURPOSE: To determine the value of computed tomography (CT) scans to predict the clinical outcome of FOCA transplantation using the assessment computed tomography osteochondral allograft (ACTOCA) score.
STUDY DESIGN: Cohort study; Level of evidence, 3.
METHODS: We prospectively collected data from all consecutive patients who underwent FOCA transplantation for osteochondral knee lesions at one institution between August 2017 and August 2019. All patients were followed up for a minimum of 2 years. CT scans performed 6 months after surgery were evaluated by a musculoskeletal radiologist using the ACTOCA scoring system. The radiologist was blinded to the patient's medical history. Clinical outcomes were assessed preoperatively and at 12 and 30 months postoperatively using the International Knee Documentation Committee (IKDC) score, the Kujala score, the Tegner activity scale, and the Western Ontario Meniscal Evaluation Tool (WOMET) score.
RESULTS: A total of 38 cases were included. The ACTOCA score at 6 months after surgery showed a statistically significant correlation with clinical results at 12 and 30 months. The correlation was better at 30 months, showing a high negative correlation with the IKDC score (-0.663) and a moderate negative correlation with the Kujala, WOMET, and Tegner scores (-0.593; -0.547, and -0.593, respectively) (P < .001).
CONCLUSION: A statistically significant correlation between the mean ACTOCA score on CT scans at 6 months and the clinical results measured by the IKDC, Kujala, WOMET, and Tegner scores at 30 months confirmed the predictive value of the ACTOCA score for use in clinical practice.
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TNF-alpha and sTNF-RII Are Associated with Pain Following Hip Fracture Surgery in Older Adults
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Hip Fx in the Elderly 2019
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Objective: To explore whether plasma inflammatory mediators on postoperative day 3 (POD3) are associated with pain scores in older adults after hip fracture surgery.
Design: Cross-sectional study.
Setting: Mount Sinai Hospital, New York, New York.
Subjects: Forty patients age 60 years or older who presented with acute hip fracture at Mount Sinai Hospital between November 2011 and April 2013.
Methods: Plasma levels of six inflammatory mediators of the nuclear factor kappa B pathway were measured using blood collected on POD3. Self-reported pain scores (i.e., pain with resting, walking, and transferring) were assessed at baseline (prefracture) and on POD3. Linear regression models using log-transformed data were performed to determine associations between inflammatory mediators and postoperative pain.
Results: Interleukin 18 (IL-18) was positively associated with POD3 resting pain score in the unadjusted model (beta = 0.66, P = 0.03). Tumor necrosis factor alpha (TNF-alpha) and soluble TNF receptor II (sTNF-RII) were positively associated with POD3 resting pain score in the adjusted model (beta = 0.99, P = 0.03, and beta = 0.86, P = 0.04, respectively). Moreover, TNF-alpha was positively associated with POD3 walking pain score in the adjusted model (beta = 1.59, P = 0.05). Pain with transferring was not associated with these inflammatory mediators.
Conclusions: These findings suggest that TNF-alpha and its receptors may influence pain following hip fracture. Further study of the TNF-alpha pathway may inform future clinical applications that monitor and treat pain in the vulnerable elderly who are unable to accurately report pain.
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Comparative effectiveness of a complex Ayurvedic treatment and conventional standard care in osteoarthritis of the knee--study protocol for a randomized controlled trial
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OAK 3 - Non-arthroplasty tx of OAK
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BACKGROUND: Traditional Indian Ayurvedic medicine uses complex treatment approaches, including manual therapies, lifestyle and nutritional advice, dietary supplements, medication, yoga, and purification techniques. Ayurvedic strategies are often used to treat osteoarthritis (OA) of the knee; however, no systematic data are available on their effectiveness in comparison with standard care. The aim of this study is to evaluate the effectiveness of complex Ayurvedic treatment in comparison with conventional methods of treating OA symptoms in patients with knee osteoarthritis.
METHODS AND DESIGN: In a prospective, multicenter, randomized controlled trial, 150 patients between 40 and 70 years, diagnosed with osteoarthritis of the knee, following American College of Rheumatology criteria and an average pain intensity of >=40 mm on a 100 mm visual analog scale in the affected knee at baseline will be randomized into two groups. In the Ayurveda group, treatment will include tailored combinations of manual treatments, massages, dietary and lifestyle advice, consideration of selected foods, nutritional supplements, yoga posture advice, and knee massage. Patients in the conventional group will receive self-care advice, pain medication, weight-loss advice (if overweight), and physiotherapy following current international guidelines. Both groups will receive 15 treatment sessions over 12 weeks. Outcomes will be evaluated after 6 and 12 weeks and 6 and 12 months. The primary endpoint is a change in the score on the Western Ontario and McMaster University Osteoarthritis Index (WOMAC) after 12 weeks. Secondary outcome measurements will use WOMAC subscales, a pain disability index, a visual analog scale for pain and sleep quality, a pain experience scale, a quality-of-life index, a profile of mood states, and Likert scales for patient satisfaction, patient diaries, and safety. Using an adapted PRECIS scale, the trial was identified as lying mainly in the middle of the efficacy-effectiveness continuum.
DISCUSSION: This trial is the first to compare the effectiveness of a complex Ayurvedic intervention with a complex conventional intervention in a Western medical setting in patients with knee osteoarthritis. During the trial design, aspects of efficacy and effectiveness were discussed. The resulting design is a compromise between rigor and pragmatism.
Trial registration: Nct01225133.
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An acupuncture needle remaining in a lung for 17 years: case study and review
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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The case of a 67-year-old patient with an acupuncture needle remaining in his left lung is described. This foreign body was a remnant of a procedure performed by a doctor 17 years previously for osteoarthritic back pain. On the basis of this case, a review was performed of literature available in the PubMed database dealing with acupuncture needles remaining in a patient's body. A total of 25 articles were found. The articles describe needles found in the bladder, shoulder girdle, spinal cord, right ventricle, L5 nerve root, medulla oblongata, skin, carpal tunnel, nuchal and occipital area, calf and paraspinal muscle. Migration of needle fragments to the liver, pancreas, stomach, colon, breast, kidney, muscles, and spinal cord has been reported in the literature. In cases where patients were operated on, the needles were removed without subsequent complications and the patients recovered fully
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Resection of primary mediastinal non-seminomatous germ cell tumors: A 28-year experience at memorial sloan-kettering cancer center
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MSTS 2022 - Metastatic Disease of the Humerus
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Introduction: Surgical resection of residual tumor mass in responders to platinum-based chemotherapy has evolved as the preferred treatment of primary mediastinal nonseminomatous germ cell tumors (PMNGCTs). We reviewed a single institution's operative experience with these rare tumors. Methods: We reviewed charts of patients resected for PMNGCT at Memorial Sloan-Kettering Cancer Center between July 1980 and April 2008. Analyses included Kaplan-Meier survival with univariate log-rank comparisons and Cox multivariate regression. Results: Fifty-seven patients were identified and followed up for a median of 5.3 years. Fifty-four of them received platinum-based preoperative chemotherapy, and 28 (49%) had limited stage I/II disease. Preoperative tumor markers normalized or decreased in 79% of patients. The most common surgical approach was anterolateral thoracotomy with partial sternotomy ("hemiclamshell," 38.6%). An R0 resection was achieved in 91% of the patients with a major morbidity of 17.5% and no postoperative deaths. The median overall survival was 31.5 months. Factors correlating with better survival on univariate analyses were necrosis or teratoma versus residual cancer on final pathology (p = 0.001), R0 resection (p = 0.03), normalized or decreased postchemotherapy/preoperative tumor markers (p < 0.001), normalized postoperative tumor markers (p = 0.004), stage I/II disease (p = 0.03), and surgery after 2000 versus 1980-1999 (p = 0.01). An exploratory multivariate analysis suggests that normalized or decreased postchemotherapy/preoperative tumor markers is the strongest independent predictor of improved survival. Conclusions: In a cohort of PMNGCT patients in which 91% of the patients underwent complete posttherapy resection, response to chemotherapy, measured by normalized or decreased preoperative tumor markers, was the strongest predictor of improved survival. Copyright © 2011 by the International Association for the Study of Lung Cancer.
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MRI in knee osteoarthritis. Application in diet intervention
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OAK 3 - Non-arthroplasty tx of OAK
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This thesis examines two main hypotheses: 1. Obese knee osteoarthritis (KOA) patients can achieve symptomatic improvements following diet intervention regardless of their level of structural damage and overall joint malfunctioning: 2. Rapid weight-loss in obese patients with KOA will lead to improvements in KOA related pathology that can be assessed and evaluated by MRI. Data for the studies were obtained from obese KOA patients who were recruited for a 16 week diet intervention trial, the CAROT-trial (ClinicalTrials.gov identification no.: NCT00655941). Inclusion criteria were age >= 50 years, BMI >= 30 kg/square metro plus symptomatic and verified KOA. Patients underwent a 16 weeks dietary programme with formula products and counselling. Baseline and week 16 assessments included clinical examinations, MRI and CR of the most symptomatic knee, muscle strength tests, gait analyses, blood samples and collection of patient-reported outcomes with a variety of generic and specific health status questionnaires. MRI scans were graded by the BLOKS and CR was analysed by measuring the mJSW and grading the knee as described by KL. 388 possible subjects were pre-screened, 192 were enrolled. Following the 16 weeks diet intervention 175 patients remained in the study. 187 (97%) MRI scans were completed at baseline, 172 (98 %) MRI scans obtained at week 16 and this left the study with 169 (97%) patients with complete MRI datasets at week 16. No statistical significant differences were detected between baseline characteristics of all the initially included patients (n = 192) and the 169 patients included in the per protocol analyses performed in study III (p < 0.05). In order to apply BLOKS, an extensive MRI scoring system, in study II and III we examined the inter- and intra-observer reliability of the various BLOKS items in study I.
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Total Hip Replacement Versus Open Reduction and Internal Fixation of Displaced Femoral Neck Fractures: A Randomized Long-Term Follow-up Study
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Management of Hip Fractures in the Elderly
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BACKGROUND: Clinical trials with short and intermediate-term follow-up have demonstrated superior results for total hip replacement as compared with internal fixation with regard to hip function and the need for secondary surgery in elderly patients with a displaced intracapsular femoral neck fracture. The aim of the present study was to compare the results of total hip replacement with those of internal fixation over a long-term follow-up period of seventeen years. METHODS: We enrolled 100 patients who had sustained a femoral neck fracture in a single-center, randomized controlled trial; all patients had had a healthy hip before the injury. The study group included seventy-nine women and twenty-one men with a mean age of seventy-eight years (range, sixty-five to ninety years). The subjects were randomly assigned to either total hip replacement (the arthroplasty group) (n = 43) or internal fixation (the control group) (n = 57). The primary end point was hip function, evaluated with use of the Harris hip score. Secondary end points included mortality, reoperations, gait speed, and activities of daily life. Follow-up evaluations were performed at three months and at one, two, four, eleven, and seventeen years. RESULTS: The Harris hip score was higher in the total hip arthroplasty group, with a mean difference of 14.7 points (95% confidence interval, 9.2 to 20.1 points; p < 0.001 [analysis of covariance]) during the study period. We found no difference in mortality between the two groups. Four patients (9%) in the total hip replacement group and twenty-two patients (39%) in the internal fixation group had undergone a major reoperation (relative risk, 0.24; 95% confidence interval, 0.09 to 0.64). The overall reoperation rate was 23% (ten of forty-three) in the total hip replacement group and 53% (thirty of fifty-seven) in the internal fixation group (relative risk, 0.44; 95% confidence interval, 0.24 to 0.80). The results related to gait speed and activities of daily living favored the arthroplasty group during the first year. CONCLUSIONS: Over a period of seventeen years in a group of healthy, elderly patients with a displaced femoral neck fracture, total hip replacement provided better hip function and significantly fewer reoperations compared with internal fixation without increasing mortality. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence
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Primary prevention of glucocorticoid-induced osteoporosis with intravenous pamidronate and calcium: a prospective controlled 1-year study comparing a single infusion, an infusion given once every 3 months, and calcium alone
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AAHKS (2) Corticosteroids
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The aim of this study was to compare the action of two regimens of intravenous (iv) pamidronate in the primary prevention of glucocorticoid-induced osteoporosis (GC-OP). The primary purpose of the study was to determine whether any differences in bone mineral density (BMD) appeared after 1 year. A secondary endpoint aimed at assessing the remodeling parameters in order to better understand the mechanisms of action of the various regimens. Thirty-two patients, who required first-time, long-term glucocorticoid therapy at a daily dose of at least 10 mg of prednisolone, were studied. Simultaneously with the initiation of their glucocorticoid treatment, patients also were randomly allocated to receive a single iv infusion of 90 mg of pamidronate at the start (group A); a first infusion of 90 mg of pamidronate followed, subsequently, by an iv infusion of 30 mg pamidronate every 3 months (group B); and a daily 800-mg elemental calcium supplement given as calcium carbonate (group C), which also was taken by patients in groups A and B. Patients were matched for starting glucocorticoid doses, sex, menopausal status, and hormonal replacement therapy. Lumbar spine and hip (total and subregions) BMDs were measured at the outset and repeated at 6-month intervals by dual-energy X-ray absorptiometry (DXA; Hologic QDR-2000). Bone turnover was assessed by measurement of total and bone-specific serum alkaline phosphatase activity (B-ALP), serum osteocalcin (OC), and serum C-telopeptide cross-links of type I collagen (CTX). After 1 year, the mean BMD changes for groups A, B, and C were, respectively, 1.7, 2.3, and -4.6% at the lumbar spine; 1.2, 1.2, and -3.1% at the femoral neck; 1.0, 2.6, and -2.2% for the total hip region. No difference was observed between pamidronate regimens but a highly significant difference was observed between both pamidronate regimens and the control group at the lumbar spine (p < 0.001), at the femoral neck (p < 0.01), and for the total hip (p < 0.05). A significant decrease of serum C-telopeptide was observed, after 3 months, in groups A and B (p = 0.029), but a sustained decrease of bone resorption over time was observed only in group B. As far as BMD evolution over 1 year was concerned, iv pamidronate, given either as a single infusion or once every 3 months, effectively achieved primary prevention of GC-OP.
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The Impact of COVID-19 on Bariatric Surgery: Re-Defining Psychosocial Care
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Coronavirus Disease 2019 (COVID-19)
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The global outbreak of novel coronavirus disease (COVID-19) has had a tremendous psychological impact on individuals around the world. Individuals with obesity are susceptible to distress and psychological sequalae secondary to this pandemic, which can have detrimental effects on obesity management. In particular, individuals undergoing bariatric surgery could experience increased emotional distress resulting in increased eating psychopathology, mental health exacerbation and difficulties with self-management. Addressing these challenges requires novel approaches to re-defining psychosocial care before and after bariatric surgery. Emerging evidence suggests the remote delivery of care using virtual care models, including mobile and online modalities, could extend the reach of psychosocial services to individuals after bariatric surgery and mitigate weight regain or impairment in quality of life. Due to this pandemic, the rapid integration of virtual psychosocial care in bariatric surgery programs to address patients' needs will create new opportunities for clinical and implementation science research.
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The wait for total hip replacement in patients with osteoarthritis
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Surgical Management of Osteoarthritis of the Knee CPG
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OBJECTIVES: We documented the following components of waiting time for total hip replacement (THR): first surgical consultation, date of decision to operate and date of surgery. We then explored whether these intervals differed by age, sex, occupation or quality-of-life score. METHODS: We used a cross-sectional design and collected the primary data from patients 2 to 4 weeks before they underwent THR. Trained interviewers administered the Medical Outcomes Study Short Form-36 and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), which included data on event dates, conservative treatment, demographic information and quality of life. We illustrated waiting times, quality of life and past use of conservative treatment (i.e., cane, exercise, physiotherapy) with descriptive statistics (mean [standard deviation] or median [intraquartile range]) for continuous variables and with percentages for categorical variables. We plotted KaplanMeier graphs for each waiting time component and employed log-rank analysis to determine whether any of these delays differed by age, sex, occupation or disability. We also performed a Cox regression to adjust for all covariates simultaneously. RESULTS: The median wait from surgical consultation to decision to operate was 0 months. There was no difference between age, sex or occupation. The median wait from decision to operate to the date of surgery was 6 months and did not differ by age, sex or occupation. However, subjects with more severe symptoms (WOMAC) underwent surgery earlier than did those with less severe disease. CONCLUSION: Although neither of the waiting time components were associated with age, sex or occupation, patients with more severe symptoms appear to be prioritized for surgery
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Musculoskeletal function and quality of life in elderly patients after a subtrochanteric femoral fracture treated with a cephalomedullary nail
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Management of Hip Fractures in the Elderly
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OBJECTIVES: To report the musculoskeletal function and health-related quality of life in elderly patients after a subtrochanteric fracture treated with a single lag screw cephalomedullary nail. DESIGN: Prospective cohort study with a minimum 1-year follow-up. SETTING: University hospital. PATIENTS: Fifty-three patients, mean age 82 years (range, 61-94 years), with a subtrochanteric fracture of the femur. INTERVENTION: Fixation with a long Gamma cephalomedullary nail. MAIN OUTCOME MEASUREMENTS: Reoperation rate, musculoskeletal function (Short Musculoskeletal Function Assessment), and health-related quality of life (EuroQol-5D). RESULTS: Six patients (11%) were reoperated on, five as a result of technical failures and one as a result of an ipsilateral fracture of the distal femur. The Short Musculoskeletal Function Assessment Dysfunction Index increased from 18 before the fracture to 46 at 4 months and 43 at 12 months. The corresponding values for the Short Musculoskeletal Function Assessment Bother Index were 10 before the fracture and 43 and 40 at 4 and 12 months (P < 0.001 between follow-ups and before fracture for both indices). The EuroQol-5Dindex score decreased from 0.85 to 0.49 at 4 months and remained at almost the same level at 12 months, 0.52 (P < 0.001 between follow-ups and before fracture). CONCLUSIONS: A subtrochanteric fracture treated with a single lag screw cephalomedullary nail had a substantial negative impact on the patient's musculoskeletal function according to the Short Musculoskeletal Function Assessment as well as on the patient's health-related quality of life. However, the need for revision surgery was comparatively low
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21 year follow up of a DIEP (deep inferior epigastric perforator) flap: a tale of a "nulltiple"
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Panniculectomy & Abdominoplasty CPG
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Since the first description of "The free abdominoplasty flap for breast reconstruction" by Hans Holmstrom in 1979, [see Ref. 1] the use of lower abdominal tissue has revolutionised reconstruction of the breast. DIEP (deep inferior epigastric perforator) free flap offers an abundance of reconstructive material, aesthetically-pleasing results and limited donor site morbidity. We report our first case of breast reconstruction with what presently is known as DIEP flap, performed in 1991 at St. Andrew's Centre for Plastic Surgery and Burns in Essex, The United Kingdom and the recent follow up results. We also discuss the historical events surrounding the evolution of this unpublished case and other documented cases.
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Optimization of perioperative management of proximal femoral fracture in the elderly
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Hip Fx in the Elderly 2019
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Proximal femoral fracture in elderly subjects is a major event that is life-threatening in the medium-to-long term. Advanced age, male gender and number of comorbidities largely account for high mortality and require geriatric expertise. Protein-energy malnutrition and bone demineralization increase mortality. Mortality can, on the other hand, be reduced by acting on two variables accessible to medical intervention: daily activities and nutritional status. Functional and neurocognitive assessment allow the risk of dependency to be evaluated, and global geriatric work-up can prevent sudden breakdown of homeostasis. In the emergency setting, pain is to be alleviated, polymedication and anticoagulation therapy checked, and instability (notably cardiac and pulmonary) and confusion syndrome screened for on geriatric and anesthesiologic opinions. Surgery should be implemented without delay, within 48hours of admission, preferably using multimodal anesthesia. The technique should be geared to allow early weight-bearing and mobilization. The most comprehensive care plan involves team-work between emergency physicians, surgeons, orthopedic specialists, anesthesiologists, geriatricians, pharmacists, rehabilitation specialists and nursing staff, to reduce mortality and readmission and improve functional results. Post-fracture coordination seeks to prevent falls and further fractures and to treat bone demineralization.
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Outcomes of free vascularized fibular flaps for the treatment of radiation-associated femoral nonunions
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Hip Fx in the Elderly 2019
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INTRODUCTION: Nonunion is a known complication following fracture in the setting of radiotherapy. Free vascularized fibular (FVF) flaps have been used successfully in the treatment of segmental bone defects; however, their efficacy in the treatment of radiated nonunions is limited. The purpose of the study was to evaluate the outcome following FVFG for radiation-associated femoral fracture nonunions.
METHODS: 23 (11 male and 12 female; mean age 60+/-12 years) patients underwent FVF for radiation-associated femoral fracture nonunions. The most common indication for radiotherapy was soft tissue sarcomas (n=16). The mean follow-up was 5+/-4 years. Mean radiation dose was 51+/-14Gy at a mean of 11+/-3 years prior to FVF. The mean FVF length was 17+/-4cm and placed commonly with an intramedullary nail (n=18).
RESULTS: First time union was 52% (n=12) following additional bone grafting, the overall union was 78% (n=18) at a mean of 13+/-6 months. Musculoskeletal Tumor Society scores improved from 30% preoperatively to 73% at latest follow-up (p<0.0001). Five fractures failed to unite; 3 were converted to proximal femoral replacements.
CONCLUSIONS: FVF are a reasonable treatment option for radiation-associated femoral fracture nonunions, providing a union rate of 78% and an improvement in functional outcome.
LEVEL OF EVIDENCE: Therapeutic Level IV.
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Efficacy of Surgical Tenodesis for Treatment of Distal Semitendinosus Hamstring Tendon Injuries
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AMP (Acute Meniscal Pathology)
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Background: Understanding the optimal management of distal semitendinosus hamstring injuries is critical for reducing pain, restoring preinjury function, maintaining knee stability, improving hamstring muscle strength, and minimizing the risk of complications and recurrence. To our knowledge, the outcomes of surgical tenodesis for distal semitendinosus hamstring injuries have not been previously reported. Hypothesis: Surgical tenodesis for injuries of the semitendinosus would enable return to preinjury level of sport with low risk of recurrence. Study Design: Case series; Level of evidence, 4. Methods: This prospective single-surgeon study included 13 professional athletes (12 men, 1 woman; mean age, 32 ± 8.2 years; mean body mass index, 26.7 ± 3.9 kg/m2) undergoing treatment for distal semitendinosus hamstring injuries with primary tenodesis to the distal semimembranosus. Indications for surgical tenodesis included distal semitendinosus tendon avulsion injury (n = 8) or residual tendon instability and hamstring weakness after semitendinosus graft harvest for anterior cruciate ligament reconstruction (n = 5). All study patients underwent a standardized postoperative rehabilitation program. The primary outcome was defined as time for return to sporting activity. Secondary outcomes were patient satisfaction, injury recurrence, and complications. The mean follow-up time was 17 months (range, 12-24 months) from date of surgery. Results: All study patients returned to their preinjury level of sporting activity. The mean time from the surgical intervention to return to full sporting activity was 15 ± 4.6 weeks. At 1-year follow-up, all study patients were still participating at their preinjury level of sporting activity, and 12 patients (92%) were very satisfied and 1 patient (8%) was satisfied about the outcomes of their surgery. No study patients had recurrence of the primary injury. No surgical complications, injury recurrence, or reoperations were observed within the follow-up period. Conclusion: Early return to sporting activity was seen after surgical tenodesis for distal semitendinosus hamstring injuries after acute trauma or residual symptoms following previous hamstring graft harvest, with high levels of patient satisfaction and low risk of recurrence at short-term follow-up.
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Evaluation of the quality of life and risk of suicide
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DoD PRF (Psychosocial RF)
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OBJECTIVE: To identify the socio-demographic profiles, suicidal ideation, the presence of mental disorders and the quality of life of patients using mental health services in Arapiraca, Alagoas, Brazil.
METHOD: Interviews were conducted in family health units and the Psychosocial Attention Center. The sample included 202 mental disorder patients with a risk of suicide attempts, 207 mental disorder patients without a risk of suicide attempts and 196 controls. This study used an identification questionnaire, the abbreviated World Health Organization Quality of Life questionnaire, Beck's Suicidal Ideation Scale and the Mini International Neuropsychiatric Interview.
RESULTS: Patients who had a mental disorder and a risk of suicide attempts tended to be single, had less education and lower family income, were not working and showed lower scores in quality of life domains; 73 of these patients had suicidal ideation in the previous week. Depressive disorders, manic episodes, hypomanic episodes, social phobias, obsessive compulsive disorder, post-traumatic stress disorder, psychotic syndromes and generalized anxiety disorder were more frequent and statistically significant for patients at risk for suicide attempts.
CONCLUSION: The management of patients with a risk of suicide attempts must focus on individual patients because this risk is directly linked to changes in quality of life and the improvement of these patients' prognosis.
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1 |
Arthroscopic modified Mason-Allen technique for large U- or L-shaped rotator cuff tears
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Trial Systematic Review Project
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PURPOSE: While a conventional single- or double-row repair technique could be applied for repair of C-shaped tears, a different surgical strategy should be considered for repair of U- or L-shaped tears because they typically have complex patterns with anterior, posterior, or both mobile leaves. This study was performed to examine the outcomes of the modified Mason-Allen technique for footprint restoration in the treatment of large U- or L-shaped rotator cuff tears.
METHODS: Thirty-two patients who underwent an arthroscopic modified Mason-Allen technique for large U- or L-shaped rotator cuff tears between January 2012 and December 2013 were included in this study. Margin convergence was first performed to reduce the tear gap and tension, and then, an arthroscopic Mason-Allen technique was performed to restore the rotator cuff footprint in a side-to-end repair fashion. All patients were evaluated preoperatively and for a minimum of 2 years of follow-up with a visual analog scale (VAS) for pain, Constant score, and ultrasonography.
RESULTS: There was significant improvement in all VAS and Constant scores compared with the preoperative values (P < 0.001). Functional results by Constant scores included 9 cases that were classified as excellent, 11 cases as good, 8 cases as fair, and 2 cases as poor. Binary logistic regression analysis revealed that heavy work, pseudoparalysis, joint space narrowing, fatty degeneration of the SST and IST, and a positive tangent sign were found to significantly correlate with functional outcomes. Multivariable logistic regression analysis revealed that only fatty degeneration of the SST was a risk factor for fair/poor clinical outcomes. Complications occurred in 5 of the 32 patients (15.6 %), and the reoperation rate due to complications was 6.3 % (2 of 32 patients).
CONCLUSIONS: An arthroscopic modified Mason-Allen technique was sufficient to restore the footprint of the rotator cuff in our data. Overall satisfactory results were achieved in most patients, with the exception of those with severe fatty degeneration. An arthroscopic modified Mason-Allen technique could be an effective and reliable alternative for patients with large U- or L-shaped rotator cuff tears.
LEVEL OF EVIDENCE: Case Series, Therapeutic Level IV.
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Total knee arthroplasty: good agreement of clinical severity scores between patients and consultants
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Surgical Management of Osteoarthritis of the Knee CPG
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BACKGROUND: Nearly 20,000 patients per year in the UK receive total knee arthroplasty (TKA). One of the problems faced by the health services of many developed countries is the length of time patients spend waiting for elective treatment. We therefore report the results of a study in which the Salisbury Priority Scoring System (SPSS) was used by both the surgeon and their patients to ascertain whether there were differences between the surgeon generated and patient generated Salisbury Priority Scores. METHODS: The Salisbury Priority Scoring System (SPSS) was used to assign relative priority to patients with knee osteoarthritis as part of a randomised controlled trial comparing the standard medial parapatellar approach versus the sub-vastus approach in TKA. The operating surgeons and each patient completed the SPSS at the same pre-assessment clinic. The SPSS assesses four criteria, namely progression of disease, pain or distress, disability or dependence on others, and loss of usual occupation. Crosstabs and agreement measures (Cohen's kappa) were performed. RESULTS: Overall, the four SPSS criteria showed a kappa value of 0.526, 0.796, 0.813, and 0.820, respectively, showing moderate to very good agreement between the patient and the operating consultant. Male patients showed better agreement than female patients. CONCLUSION: The Salisbury Priority Scoring System is a good means of assessing patients' needs in relation to elective surgery, with high agreement between the patient and the operating surgeon
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0 |
Use of Acellular Dermal Matrices in One-stage Implant-based Breast Reconstruction
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Acellular Dermal Matrix
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Implant-based breast reconstruction is the most common choice in breast cancer patients. Recently,the acellular dermal matrix (ADM) technique has been widely used in implant-based breast reconstruction in the western countries. This article briefly reviews the biological characteristics,history,types,surgical techniques,and postoperative complications of ADM.
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0 |
Bone Marrow-Derived and Adipose-Derived Mesenchymal Stem Cell Therapy in Primary Knee Osteoarthritis: A Narrative Review
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BMAC (Bone Marrow Aspirate Concentrate)
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Regenerative medicine in the context of musculoskeletal injury is a broad term that offers potential therapeutic solutions to restore or repair damaged tissue. The current focus in recent literature and clinical practice has been on cell based therapy. In particular, much attention has been centered on autologous bone marrow concentrate and adipose-derived mesenchymal stem cells (MSCs) for cartilage and tendon disorders. This article provides an overview of MSC-derived therapy and offers a comprehensive review of adipose- and bone marrow-derived MSC therapy in primary knee osteoarthritis. LEVEL OF EVIDENCE: IV.
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0 |
Occult renal cell carcinoma with acrometastasis and ipsilateral juxta-articular knee lesions mimicking acute inflammation
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PJI DX Updated Search
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Generally, skeletal peripheral metastases below the elbow and the knee are rare. Skeletal metastases to the hand or foot are very rare; but when they do it may be a revealing clinical finding. Purely lytic lesions are commonly seen in metastases from lung, renal, and thyroid tumors, but they are also known to occur in primary myeloma, brown tumor and lymphomas. A 70-year-old man was brought to the emergency department with acute painful swelling involving his right hand and the right knee. Due to significant accompanying soft tissue swellings cellulitis, acute osteomyelitis and gouty arthropathy were included in the initial differential diagnosis. Radiographs showed pure lytic bony lesion with complete disappearance of lower two third of the second metacarpal, trapezium and trapezoid bones of the right hand along with a lytic subarticular lesion of medial condyle of ipsilateral femur. Chest X-ray (CXR) was normal but sonography of the abdomen readily demonstrated a large renal mass, later confirmed at biopsy as renal cell carcinoma (RCC). Clinicians should be cognizant of the strong association between digital acrometastases and renal cell carcinoma in male patients with normal CXR findings. In suspected hand acrometastasis associated with a soft tissue component outside the contours of normal bone, screening the abdomen by sonography should be done prior to bone biopsy and before costly or time-consuming investigations are offered. Metastatic RCC should be included in the differential diagnosis of all unilateral expansile bony lesions of the digit. It is particularly important if such lesion/lesions are accompanied by local inflammation. Screening the abdomen by sonography may be of particular value in such elderly male patient when Chest X-ray shows no abnormality
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0 |
Improving Cost-efficiency in Bilateral Direct-to-Implant Reconstructions with Acellular Dermal Matrix
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Acellular Dermal Matrix
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The use of acellular dermal matrix (ADM) for bilateral breast reconstruction has increased in recent years. Detection of BCRA mutation and therefore bilateral risk-reduction mastectomy is one of the main reasons for this increase. High cost of ADM is considered a major drawback for its use. The authors present a new technique which allows the use of only one unit of ADM for both breasts. After assessing the viability of the skin of mastectomy flaps, a musculofascial pocket formed superiorly by pectoralis major, laterally by serratus fascia and inferiorly by rectus fascia, is performed. Then, the ADM is divided in two halves. We propose two different ways to divide the matrix, cutting it vertically or diagonally in two. The way in which the matrix should be cut depends on the distensibility of the pocket. Afterwards, the implant is inserted and the exposed area of the implant is covered by the ADM sutured to the edges of the musculofascial pocket. Using only one ADM unit for bilateral reconstruction, the procedure becomes not only more cost-effective but also can reduce complications such as seroma, rippling, wrinkling, and visibility by means of a better coverage with lesser foreign body load. Furthermore, the lesser the matrix used, the faster the integration is achieved.
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0 |
Compartment syndrome in ipsilateral humerus and forearm fractures in children
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The Treatment of Pediatric Supracondylar Humerus Fractures AUC
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Ipsilateral fractures of the humerus and forearm are uncommon injuries in children. The incidence of compartment syndrome in association with these fractures is controversial. The authors reviewed 978 consecutive children admitted to the hospital with upper extremity long bone fractures during a 13-year period. Forty-three children with ipsilateral fractures of the humerus and forearm were identified. Of 33 children with a supracondylar humerus fracture and ipsilateral forearm fracture, three children (7%) had compartment syndrome develop and required forearm fasciotomies. All three cases of compartment syndrome occurred among nine children with ipsilateral displaced extension supracondylar humerus and displaced forearm fractures; the incidence of compartment syndrome was 33% in this group. These findings suggest that children who sustain a displaced extension supracondylar humerus fracture and displaced forearm fracture are at significant risk for compartment syndrome. These children should be monitored closely during the perioperative period for signs and symptoms of increasing intracompartmental pressures in the forearm
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1 |
Closed suction drains do not increase the blood transfusion rates in patients undergoing total knee arthroplasty
|
Surgical Management of Osteoarthritis of the Knee CPG
|
We aim to determine whether the presence of a drain increases the actual blood transfusion rates in patients undergoing primary total knee arthroplasty (TKA). A retrospective review was performed on two consecutive groups of patients who underwent primary TKA: group 1 including 100 patients who underwent TKA and had one deep closed suction drain; group 2 including 100 patients who underwent TKA and had no drain. Blood transfusions were given post-operatively on the basis of clinical need without a pre-determined haemoglobin trigger factor. Group 1 drained a mean of 692 ml (range 150-1500) of blood in 48 h. The mean fall in haemoglobin at 48 h post-operatively was 3.26 g/dl in group 1 and 3.33 g/dl in group 2. Nine patients in group 1 and seven patients in group 2 required a blood transfusion; this was not statistically significant (P=0.79). Transfusion of primary TKA patients on the basis of clinical need can result in post-operative transfusion rates of 8%. The presence of a drain does not increase the transfusion rates of patients undergoing primary TKA. (copyright) 2006 Springer-Verlag
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0 |
Differences in reconstruction of the anatomy with modern adjustable compared to second-generation shoulder prosthesis
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Glenohumeral Joint OA
|
Reconstruction of the anatomy of the proximal humerus is a prerequisite to achieving good long-term clinical results after shoulder arthroplasty. Modern, adjustable prostheses have greater flexibility of inclination, retroversion, and medial and dorsal offset in comparison with older prostheses. Such improvements should allow for better reconstruction of the centre of rotation compared to older prostheses. Reconstruction of the humeral head centre was assessed in 106 modern adjustable (Affinis) and 47 second-generation prostheses. All reconstructions were compared both to the preoperative state and the unoperated shoulder. To describe the pre- and postoperative states, the geometry and position of the humeral head in relation to the glenoid were analysed on patient radiographs. Applying the defined parameters, modern adjustable prostheses showed better reconstruction than second generation prostheses. Parameter values measured in reconstructions using fourth generation prostheses were comparable to those of the unoperated shoulder, but differed significantly from the preoperative state. Second generation prostheses, in contrast, only show non-specific differences in parameter values. This suggests that an approximate reconstruction of normal anatomy can be achieved using a modern fourth generation prosthesis. Reconstruction of the complex anatomy of the proximal humerus is significantly better with modern adjustable prostheses compared to second generation prostheses. Improved clinical outcome can therefore be predicted in a functional and intact rotator cuff. The advantage of using modern prostheses systems over older models is clearly demonstrated in this study.
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0 |
Trauma-focused cognitive behaviour therapy and exercise for chronic whiplash: protocol of a randomised, controlled trial
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DoD PRF (Psychosocial RF)
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INTRODUCTION: As a consequence of a road traffic crash, persistent pain and disability following whiplash injury are common and incur substantial personal and economic costs. Up to 50% of people who experience a whiplash injury will never fully recover and up to 30% will remain moderately to severely disabled by the condition. The reason as to why symptoms persist past the acute to sub-acute stage and become chronic is unclear, but likely results from complex interactions between structural injury, physical impairments, and psychological and psychosocial factors. Psychological responses related to the traumatic event itself are becoming an increasingly recognised factor in the whiplash condition. Despite this recognition, there is limited knowledge regarding the effectiveness of psychological interventions, either delivered alone or in combination with physiotherapy, in reducing the physical and pain-related psychological factors of chronic whiplash. Pilot study results have shown positive results for the use of trauma-focused cognitive behaviour therapy to treat psychological factors, pain and disability in individuals with chronic whiplash. The results have indicated that a combined approach could not only reduce psychological symptoms, but also pain and disability.
AIMS: The primary aim of this randomised, controlled trial is to investigate the effectiveness of combined trauma-focused cognitive behavioural therapy, delivered by a psychologist, and physiotherapy exercise to decrease pain and disability of individuals with chronic whiplash and post-traumatic stress disorder (PTSD). The trial also aims to investigate the effectiveness of the combined therapy in decreasing post-traumatic stress symptoms, anxiety and depression.
PARTICIPANTS AND SETTING: A total of 108 participants with chronic whiplash-associated disorder (WAD) grade II of > 3 months and < 5 years duration and PTSD (diagnosed with the Clinician Administered PTSD Scale (CAPS) according to the DSM-5) will be recruited for the study. Participants will be assessed via phone screening and in person at a university research laboratory. Interventions will take place in southeast Queensland, Australia and southern Denmark.
INTERVENTION: Psychological therapy will be delivered once a week over 10 weeks, with participants randomly assigned to either trauma-focused cognitive behavioural therapy or supportive therapy, both delivered by a clinical psychologist. Participants will then receive ten sessions of evidence-based physiotherapy exercise delivered over a 6-week period.
OUTCOME MEASURES: The primary outcome measure is neck disability (Neck Disability Index). Secondary outcomes focus on: pain intensity; presence and severity of PTSD (CAPS V and PTSD Checklist 5); psychological distress (Depression, Anxiety Stress Scale 21); patient perceived functionality (SF-12, Tampa Scale of Kinesiophobia, and Patient-Specific Functional Scale); and pain-specific self-efficacy and catastrophising (Pain Self-Efficacy Questionnaire and Pain Catastrophizing Scale). After psychotherapy (10 weeks after randomisation) and physiotherapy (16 weeks after randomisation), as well as at the 6-month and 12-month follow-ups, a blind assessor will measure the outcomes.
ANALYSIS: All analyses will be conducted on an intention-to-treat basis. The primary and secondary outcomes that are measured will be analysed using linear mixed and logistic regression models. Any effect of site (Australia or Denmark) will be evaluated by including a site-by-treatment group-by-time interaction term in the mixed models analyses. Effect modification will only be assessed for the primary outcome of the Neck Disability Index.
DISCUSSION: This study will provide a definitive evaluation of the effects of adding trauma-focused cognitive behaviour therapy to physiotherapy exercise for individuals with chronic WAD and PTSD. This study is likely to influence the clinical management of whiplash injury and will have immediate clinical applicability in Australia, Denmark and the wider international community. The study will also have implications for both health and insurance policy makers in their decision-making regarding treatment options and funding.
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0 |
Fixed flexion deformity and total knee arthroplasty
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Surgical Management of Osteoarthritis of the Knee CPG
|
Fixed flexion deformities are common in osteoarthritic knees that are indicated for total knee arthroplasty. The lack of full extension at the knee results in a greater force of quadriceps contracture and energy expenditure. It also results in slower walking velocity and abnormal gait mechanics, overloading the contralateral limb. Residual flexion contractures after TKA have been associated with poorer functional scores and outcomes. Although some flexion contractures may resolve with time after surgery, a substantial percentage will become permanent. Therefore, it is essential to correct fixed flexion deformities at the time of TKA, and be vigilant in the post-operative course to maintain the correction. Surgical techniques to address pre-operative flexion contractures include: adequate bone resection, ligament releases, removal of posterior osteophytes, and posterior capsular releases. Post-operatively, extension can be maintained with focused physiotherapy, a specially modified continuous passive motion machine, a contralateral heel lift, and splinting
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1 |
A prospective magnetic resonance imaging study of the incidence of posterolateral and multiple ligament injuries in acute knee injuries presenting with a hemarthrosis
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Anterior Cruciate Ligament Injuries CPG
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PURPOSE: The purpose of this study was to determine whether the incidence of posterolateral knee injuries, as well as other concurrent knee ligament injuries, could be obtained from a prospective evaluation of magnetic resonance imaging scans in patients with an acute knee injury with a hemarthrosis. METHODS: We prospectively documented all patients with acute (within 30 days) knee injuries with a hemarthrosis over a 90-day period who underwent 1.5-T magnetic resonance imaging at a large referral imaging facility with 6 sites, effectively covering a large metropolitan area. The anterior cruciate ligament, superficial medial collateral ligament, and posterior cruciate ligament (PCL) and the following individual structures of the posterolateral corner were evaluated for high-grade injury: fibular collateral ligament, popliteus tendon, and popliteofibular ligament. RESULTS: Out of 331 consecutive acute knee injuries with a hemarthrosis, 265 ligament injuries occurred in 187 patients (56%). Of these 187 patients with ligament injuries, 126 had isolated ligament injuries and 61 (33%) had combined multiple ligament injuries. Of the 187 patients with knee ligament injuries, 83 (44%) had isolated anterior cruciate ligament tears, 28 (15%) had isolated superficial medial collateral ligament tears, 11 (5%) had isolated PCL tears, and 4 (2.1%) had isolated posterolateral knee tears. Of the patients with posterolateral knee structure injuries, 87% (26/30) had multiple ligament injuries, with the overall incidence of posterolateral knee injuries among all knee ligament injuries being 16% and among all acute knee injuries with a hemarthrosis being 9.1%. Of the 27 patients with PCL tears, 16 (52%) had combined multiple ligament injuries. CONCLUSIONS: This study shows that in this population, the incidence of posterolateral knee injuries in patients with acute knee ligament injuries with a hemarthrosis was 9.1%. It also verified that most PCL and posterolateral corner injuries occur in combination with other ligament injuries. LEVEL OF EVIDENCE: Level II, development of diagnostic criteria on the basis of consecutive patients with a universally applied gold standard
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0 |
Visual outcome of surgically managed pituitary adenomas followed-up at the Yaounde Central Hospital
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Upper Eyelid and Brow Surgery
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INTRODUCTION: Pituitary adenomas are benign brain tumours arising from the adenohypophysis; representing 10-15% of all intra-cranial tumours. Despite improved management, they are still related to high morbidity. Visual impairment is a common presentation and visual field defects representing 37-96%. We aimed at describing the clinical presentation of operated patients and their visual outcome. METHODS: We conducted a cross-sectional study for 6 months at the Yaounde Central Hospital's Neurosurgery, Endocrinology and Ophthalmology departments. We included all patients with histopathological confirmation, having pre-operative visual assessment and operated from January 2010 to June 2016. RESULTS: Twenty-five participants (50 eyes) were enrolled. Three subtypes of pituitary adenomas were identified: Non-functional pituitary adenomas (64%) > Somatotropinomas (20%) > Prolactinomas (16%). All cases were macroadenomas. The median duration of symptoms was 14 months. All participants presented with vision impairment and 80% with headaches. Craniotomy was used in 88% of cases. The temporal hemifield was the most quantitatively affected; 76% of eyes presented with visual acuity (VA) < 6/12 and 24% of eyes a visual acuity >/=6/12. Thirty percent of eyes presented with optic atrophy; cranial nerve III palsy was the most observed. The Mean deviation (MD), an automated visual field index, improved though non-significant and 16% of eyes had a normal visual field printout after surgery. Left eye mean deviation improved significantly (p = 0.04). After surgery, there was a mild improvement of VA with 62% of eyes having a VA< 6/12 and 38% a VA >/=6/12. There was no ophthalmoplaegia after surgery. Long delay before diagnosis significantly jeopardizes pre-operative and post-operative visual acuity (r = 0.5; p = 0.01). CONCLUSION: Quantitative vision parameters comparison are suggestive of a potential improvement of vision. This conclusion will be better ascertained on a large-scale sample size. Long delay before diagnosis is associated to poor visual outcome.
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0 |
Tranexamic acid reduces blood loss and financial cost in primary total hip and knee replacement surgery
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OAK 3 - Non-arthroplasty tx of OAK
|
Background: Blood conservation strategies have been developed to diminish blood transfusion requirements in patients undergoing hip or knee replacement surgery. Tranexamic acid (TA) is an inexpensive antifibrinolytic agent that is little used in orthopaedic surgery due to the absence of standardised optimal administration regimens. Hypothesis: Blood transfusion requirements and induced costs can be diminished by using TA according to a standardised administration protocol in a large cohort of patients. Materials and methods: A retrospective study in patients who underwent joint replacement surgery by a single surgeon compared two periods, 2007-2008 without TA and 2008-2009 with TA. The 451 included patients underwent primary unilateral hip (n=261) or knee (n=190) replacement for osteoarthritis. Standardised protocols were used for surgery and anaesthesia. TA was given intravenously in a dose of 1g (i.e., 15mg/kg) at incision and wound closure then at 6-hour intervals for 24hours. Blood losses were estimated using the Mercuriali formula. Haemoglobin on D -1 and D 8 and the number and volume of autologous (from intra-operative blood salvage) and homologous blood transfusions were collected. The costs of TA, blood salvage systems, and homologous blood units were recorded. The two groups were compared using Student's test, Wilcoxon's test, and the Khi2 test, and multivariate analyses were performed. Values of p less than 0.05 were considered significant. Results: TA use was associated with a significant decrease in the homologous blood transfusion rate (from 4% to 0%) and with 38% and 68% reductions in the rate and volume of autologous blood transfusions, respectively, due to a 34% decrease in blood losses. After taking into account the additional cost of TA therapy, there was a 25% reduction in the cost of the blood conservation strategy. Conclusion: TA therapy abolished the need for homologous blood transfusion and induced no notable side effects. TA therapy decreased the amount of blood salvaged intra-operatively, allowing a more rational use of the blood salvage system and decreasing the cost of anaesthesia. Level of evidence: IV. Retrospective case-control. © 2012.
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0 |
Outcomes after Total Hip Arthroplasty Using a Cementless S-ROM Modular Stem for Patients with High Hip Dislocation Secondary to Hip Pyogenic Arthritis
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Developmental Dysplasia of the Hip 2020 Review
|
OBJECTIVE: To evaluate the midterm results of the cementless S-ROM modular femoral stem used with subtrochanteric transverse shortening osteotomy for the treatment of high hip dislocation secondary to hip pyogenic arthritis. METHODS: We retrospectively reviewed the data of 49 patients (49 hips) with an average infection quiescent period of 37.4â??years who underwent cementless total hip arthroplasty (THA) with simultaneous subtrochanteric transverse shortening osteotomy from July 2008 to June 2012. There were 23 men and 26 women with a mean age of 44.3â??years at the time of surgery. The following clinical outcomes were evaluated: the Western Ontario and McMaster Universities Arthritis Index (WOMAC) score, Harris hip score (HSS), modified Merle d'Aubigne-Postel hip (MAP) score, low back pain visual analog scale score, 12-item short-form health survey questionnaire score, limp, and Trendelenburg sign. Radiographic outcomes and complications were also evaluated. RESULTS: The mean follow-up period was 8.7â??years (range, 5.5-10â??years). No infection recurrence was observed after THA. The average HSS significantly improved from 45.0 to 84.8. The WOMAC score improved from 70.1â??±â??3.5 (range, 65-76) to 43.1â??±â??13.4 (range, 21-67). The modified MAP score improved from 5.9â??±â??1.9 (range, 3-9) to 14.3â??±â??2.4 (range, 11-18). The low back pain visual analog scale score, 12-item short-form health survey questionnaire score, limp, and Trendelenburg sign also improved significantly. The average limb length discrepancy decreased from 39.6â??mm (range, 30-55â??mm) to 7.2â??mm (range, 0-22â??mm). Two patients had temporary sciatic nerve paralysis but recovered within 6â??months without any functional defects; one had an intraoperative fracture fixed by cerclage wires. One hip required revision surgery because of femoral stem aseptic loosening. CONCLUSIONS: The cementless S-ROM modular femoral stem used with subtrochanteric transverse shortening osteotomy is safe and effective for high hip dislocation secondary to pyogenic arthritis and provides satisfactory midterm results. Significant improvements in clinical function were observed, as were high rates of stable fixation of the cementless implant, restoration of more normal limb lengths, and a low incidence of complications.
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0 |
Femoral head osteonecrosis after bone marrow transplantation
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Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures
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Thirty-five patients with bilateral osteonecrosis of the femoral head after bone marrow transplantation were reviewed retrospectively. The median age at the time of transplantation was 26 years. The first symptoms occurred within 2 years of transplantation. At presentation, 18 of the patients reported pain in both hips, 17 had symmetric radiographic lesions, and 39 of the hips had collapsed. Medical treatment was indicated initially. At the final examination before surgery (median, 3.5 years), 31 patients had bilateral hip pain, 22 patients had symmetric radiographic lesions, and 56 of the hips had collapsed. Fifty-seven of the hips required surgery, including one open drainage, four core decompressions, six cup arthroplasties, and 46 primary total hip replacements. Six hips (four core decompressions; two cups) later underwent total hip replacement revision, and a deep infection developed in one. By considering the requirement of a total hip replacement as a failure of conservative treatment, the rate of survival of the femoral head was 30% 5 years after the transplant. There was no significant difference between the Ficat grades, except for Grade 0, which showed a higher survival rate. The study of the specific features of the osteonecrosis may lead to the recommendation of primary total hip arthroplasty after failure of the medical treatment
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0 |
Determining Stability in Posterior Wall Acetabular Fractures
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Hip Fx in the Elderly 2019
|
OBJECTIVES: To determine if the radiographic parameters of femoral head coverage by the intact posterior wall, acetabular version, and location of the fracture or a history of dislocation were determinates of hip stability in patients with posterior wall acetabular fractures.
DESIGN: Retrospective review.
SETTING: Level I trauma hospital.
PATIENTS: One hundred eighty-five consecutive patients with isolated unilateral posterior wall (OTA 62-A1) acetabular fractures.
INTERVENTION: Patients underwent dynamic stress fluoroscopic examination under general anesthesia to determine hip stability.
MAIN OUTCOME MEASUREMENTS: A number of radiographic measurements were performed, and an examination under anesthesia served as a standard to compare stable versus unstable hips.
RESULTS: Examination under anesthesia (EUA) determined 116 hips to be stable and 22 hips as unstable. Moed and Keith method of wall size measurements and cranial exit point of fracture was statistically different between stable and unstable hips. Twenty-three percent of the unstable hips had wall sizes less than 20%. Average cranial exit point of fracture from dome was 5.0 mm in the unstable group and 9.5 mm in the stable group, and fractures that extend into the dome demonstrate a statistically significant increase in hip instability.
CONCLUSIONS: Determination of hip stability can be challenging in patients with posterior wall acetabular fractures. Our data suggest that the location of the exit point of the fracture in relation to the dome of the acetabulum is a radiographic marker that can be used to aid physician in determining stability, and wall sizes less than 20% is not a reliable indicator of stability.
LEVEL OF EVIDENCE: Diagnostic Level II. See Instructions for Authors for a complete description of levels of evidence.
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0 |
Programmed Multidrug Delivery Based on Bio-Inspired Capsule-Integrated Nanocoatings for Infected Bone Defect Treatment
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DoD SSI (Surgical Site Infections)
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Infection and delayed wound healing are two major serious complications related to traumatic injuries and cause a significant burden to patients and society. Most currently available drug delivery materials typically carry a single drug, lack protection from drug loading, and face challenges in on-demand and precisely controlled drug release. Here, we report a flower (Cirsium arvense)-inspired capsule-integrated multilayer nanofilm (FICIF), synthesized using a layer-by-layer self-assembly, for programmed multiple drug co-delivery for trauma (open fracture as an example) treatments. Our approach allows polypeptide multilayer nanofilms and innovative impregnated capsules to assemble hierarchical reservoirs with specific drug binding sites, shielding protection capability, and ordered packing structures. The resultant FICIF nanocarriers enable sustained and on-demand co-delivery of a unique immune-tuning cytokine (interleukin 12p70) and a growth factor (bone morphogenetic protein 2) in clinical use, resulting in extraordinary anti-infection (3 orders of magnitude improved bacterial killing) and bone regeneration (5 times enhanced bone healing) in treating infected rat femur fractures. The successful synthesis of these biomimetic high-performance delivery nanocoatings is expected to serve as a source of inspiration for the development of biomaterials for various clinical applications.
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