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Chronic renal failure due to amyloid nephropathy caused by chronic infection after total hip replacement
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Hip Fx in the Elderly 2019
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A 75-year-old woman was admitted to our hospital because of proteinuria, pitting edema on the foot, and renal impairment. She had undergone total hip replacement (THR) for femoral neck fracture at the age of 66. Nine years later, she met with an accident during farming and was treated at an emergency hospital for severe general trauma. On the basis of systemic symptoms, she was diagnosed with nephrotic syndrome. Renal biopsy by Congo-red staining and electron microscopy revealed amyloid deposition on glomeruli, interstitium, and interlobar arteries. The amyloid was immunohistochemically identified as AA amyloidosis. The patient eventually required maintenance hemodialysis because of impaired renal function. AA amyloidosis is an unusual complication of intractable inflammation. Chronic infection with abscess occurred around the artificial hip joint following THR and possibly induced secondary amyloidosis. THR is a common and necessary procedure adopted for femoral neck fracture. Orthopedic surgeons should, however, carefully monitor the occurrence of chronic infection after THR because such an infection could lead to renal dysfunction and/or failure via AA amyloidosis in rare cases.
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What tissue bankers should know about the use of allograft meniscus in orthopaedics
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AMP (Acute Meniscal Pathology)
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The menisci of the knee are two crescent shaped cartilage shock absorbers sitting between the femur and the tibia, which act as load sharers and shock absorbers. Loss of a meniscus leads to a significant increase in the risk of developing arthritis in the knee. Replacement of a missing meniscus with allograft tissue can reduce symptoms and may potentially reduce the risk of future arthritis. Meniscal allograft transplantation is a complex surgical procedure with many outstanding issues, including 'what techniques should be used for processing and storing grafts?', 'how should the allografts be sized?' and 'what surgical implantation techniques might be most appropriate?' Further clinical research is needed and close collaboration between the users (surgeons) and the suppliers (tissue banks) is essential. This review explores the above subject in detail. [References: 61]
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All-polyethylene versus metal-backed and stemmed tibial components in cemented total knee arthroplasty. A prospective randomised RSA study
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Management of Hip Fractures in the Elderly
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We studied the quality of fixation of the tibial component using radiostereometric analysis (RSA) in 40 patients who had undergone a cemented Freeman-Samuelson total knee arthroplasty. They were prospectively randomised to either a stemmed metal-backed (MB) or non-stemmed all-polyethylene (AP) tibial component. The articulating geometry of the implants was identical, as was the operative technique and the postoperative regime. The study showed no complications of fixation using AP tibial components, and the migration was the same as that of their metal-backed counterparts. There was no bony collapse or increased subsidence of any part of the tibial component or increased incidence of radiolucent lines in the knees with AP components. Most AP implants were stable between one and two years after surgery, a finding known to be of positive prognostic significance when predicting future aseptic loosening
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Adherence to a Yoga Program in Older Women with Knee Osteoarthritis
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OAK 3 - Non-arthroplasty tx of OAK
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Yoga is beneficial for osteoarthritis (OA) management in older adults; however, adherence to yoga practice is unknown. The purposes of this secondary analysis were to examine: (1) yoga adherence during the intervention and follow-up periods; (2) the relationship between social cognitive theory (SCT) constructs and adherence; and (3) the impact of adherence on OA-related symptoms in 36 community-dwelling older women with knee OA. SCT was used as a framework to promote adherence to a yoga intervention program that included both group/homebased practices. Adherence to yoga was high during the intervention period but decreased over time. Although SCT was a useful framework for reducing attrition during the intervention, self-efficacy was the only construct that correlated with class attendance. Higher yoga adherence was correlated with improved symptoms, physical function, sleep quality, and quality of life. Yoga adherers were likely to be older, less educated, and had a lower body mass index than nonadherers.
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Responsiveness of SF-36 Health Survey and Patient Generated Index in people with chronic knee pain commenced on oral analgesia: analysis of data from a randomised controlled clinical trial
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OAK 3 - Non-arthroplasty tx of OAK
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PURPOSE: (1) To assess the responsiveness of the Short Form 36 Health Survey (SF-36) and Patient Generated Index (PGI) in people with knee pain who were given oral analgesics; and (2) to perform content analysis of the SF-36 and PGI aiming to identify differences between the instruments and causes of different responsiveness.
METHODS: An observational study nested within a randomised controlled trial comparing oral paracetamol, ibuprofen or a combination of the two in 884 community-derived people with chronic knee pain. Each participant was given the SF-36 and PGI questionnaires to fill out at baseline, day 10, week 7 and week 13 after commencement on analgesia. Responsiveness was measured as a standardised response mean from baseline, and contents of the instruments were analysed.
RESULTS: The PGI showed the greater responsiveness to analgesics than the SF-36 throughout the study period. Only the Bodily Pain Score of the SF-36 showed comparable responsiveness to the PGI. The standardised response mean of the PGI at 13 weeks was 0.61 (95% CI 0.51-0.72), and that of the Bodily Pain Score of the SF-36 was 0.49 (95% CI 0.39-0.58). Content analysis of the PGI identified multiple areas which are not represented in the SF-36 which may help explain its performance.
CONCLUSIONS: Overall the PGI is more responsive than the SF-36 to commonly used oral analgesics taken for knee pain. The PGI is able to elicit areas of individualised health-related quality of life which are not captured by the SF-36.
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Dental procedures as risk factors for prosthetic hip or knee infection: a hospital-based prospective case-control study
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PJI DX Updated Search
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BACKGROUND: The actual risk of prosthetic joint infection as a result of dental procedures and the role of antibiotic prophylaxis have not been defined. METHODS: To examine the association between dental procedures with or without antibiotic prophylaxis and prosthetic hip or knee infection, a prospective, single-center, case-control study for the period 2001-2006 was performed at a 1200-bed tertiary care hospital in Rochester, Minnesota. Case patients were patients hospitalized with total hip or knee infection. Control subjects were patients who underwent a total hip or knee arthroplasty but without a prosthetic joint infection who were hospitalized during the same period on the same orthopedic floor. Data regarding demographic features and potential risk factors were collected. Logistic regression was used to assess the association of variables with the odds of infection. RESULTS: A total of 339 case patients and 339 control subjects were enrolled in the study. There was no increased risk of prosthetic hip or knee infection for patients undergoing a high-risk or low-risk dental procedure who were not administered antibiotic prophylaxis (adjusted odds ratio [OR], 0.8; 95% confidence interval [CI], 0.4-1.6), compared with the risk for patients not undergoing a dental procedure (adjusted OR, 0.6; 95% CI, 0.4-1.1) respectively. Antibiotic prophylaxis in high-risk or low-risk dental procedures did not decrease the risk of subsequent total hip or knee infection (adjusted OR, 0.9 [95% CI, 0.5-1.6] and 1.2 [95% CI, 0.7-2.2], respectively). CONCLUSIONS: Dental procedures were not risk factors for subsequent total hip or knee infection. The use of antibiotic prophylaxis prior to dental procedures did not decrease the risk of subsequent total hip or knee infection
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Pediatric Supracondylar Humerus Fractures: AAOS Appropriate Use Criteria Versus Actual Management at a Pediatric Level 1 Trauma Center
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Pediatric Supracondylar Humerus Fracture 2020 Review
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OBJECTIVES: The purpose of this study was to characterize management of supracondylar humerus fractures (SCHFs) at a level 1 trauma center and identify factors contributing to divergence in management from American Academy of Orthopedic Surgeons (AAOS) the Appropriate Use Criteria (AUC) recommendations. METHODS: A query revealed 556 patients with diagnoses of SCHF between 2013 and 2015 at a pediatric level 1 trauma center. Patients were excluded if they were younger than 2 years of age, older than 12 years of age, were polytrauma patients, or if there was not sufficient clinical or radiographic documentation, resulting in 449 patients. Urgent/emergent intervention was defined as surgery within 8 hours of presentation. Binomial logistic regression assessed whether various factors predicted operative versus nonoperative management. RESULTS: Operative management was undertaken in 0/208 (0%) type I fractures, 61/106 (57.0%) type II fractures, and 135/135 (100%) type III fractures. Comparison with AUC recommendations revealed disagreement in 31% (138/449) of cases. Among 449 patients, 44 were treated nonoperatively despite AUC recommendations for operative treatment. All 44 of these patients were type II SCHFs managed nonoperatively. There were no definitive cases of malalignment or loss of alignment in these nonoperative cases. Factors predictive of operative management were anterior humeral line not intersecting the capitellum (odds ratio, 200; P<0.001) and increasing age (odds ratio, 1.53; P=0.024). The AUC more frequently recommended urgent/emergent operative intervention (148/449, 33.0%) than was performed at our pediatric level 1 trauma center (50/449, 11.1%). The majority of this disagreement (94/98, 95.9%) consisted of uncomplicated type III SCHF treated operatively in >8 hours. None of these patients developed compartment syndrome or required an open reduction. CONCLUSIONS: The American Academy of Orthopedic Surgeons AUC recommended operative and urgent/emergent intervention more frequently than was performed at a level 1 pediatric trauma center. Patient age and alignment of the anterior humeral line with the capitellum, though not specifically addressed in the AUC, were most predictive of operative versus nonoperative management at our institution.
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New role for an established drug? Bisphosphonates as potential anticancer agents
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MSTS 2018 - Femur Mets and MM
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As a result of their ability to effectively reduce the risk of skeletal-related events, bisphosphonates (BPs) were incorporated into clinical practice over a decade ago, leading to a new treatment paradigm for patients with skeletal involvement from advanced cancer. BPs are now a well-established treatment option in this setting. Our review of the literature found that in addition to maintaining bone health in patients with malignant bone lesions and patients at risk for cancer therapy-induced bone loss, emerging preclinical and clinical data suggest that BPs may also have anticancer activity. Later generation, nitrogen-containing BPs (N-BPs), such as zoledronic acid (ZOL), inhibit the mevalonate pathway, subsequently inhibiting a number of cellular functions in bone-resorbing osteoclasts. In addition, N-BPs inhibit cancer cell proliferation, viability, motility, invasion and angiogenesis; induce cancer cell apoptosis; and act in synergy with antineoplastic agents. N-BPs, especially ZOL, may be useful as anticancer agents. As evidence continues to emerge, another shift in cancer treatment paradigms, in which N-BPs are considered for their anticancer activity as well as palliative effects, may be approaching. © 2012 Macmillan Publishers Limited All rights reserved.
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The efficacy of external ultrasound-assisted liposuction: a randomized controlled trial
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Panniculectomy & Abdominoplasty CPG
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BACKGROUND: Use of high-intensity, high-frequency external ultrasound before liposuction has been reported to enhance the ease of fat extraction, increase the amount of fat extracted, and decrease patient discomfort during liposuction. OBJECTIVE: The purpose of this study was to compare the effect of application of high-intensity continuous wave ultrasound to extremely low-intensity ultrasound (placebo) prior to tumescent liposuction. METHODS: A total of 19 patients (25 sites) completed the double-blind study. We used a split treatment area design so that each patient could serve as their own control. After tumesing the treatment area, a 3 W/cm2 continuous wave 1 MHz ultrasound was applied for 10 minutes. The placebo control was treated with 0.3 W/cm2 1 MHz for 10 minutes. Traditional tumescent liposuction followed ultrasound application. Doctors completed a visual analog scale rating the following: rate of extraction, degree of resistance to cannula movement, and color of fat. Patients also completed a questionnaire after the procedure and at 1 month postoperatively. Histologic samples of the fat treated with external ultrasound were taken from two patients. RESULTS: In 14 of 19 patients the doctors graded either no difference between treatment and control sides or found a better response on the nontreated side in rate of fat removal and resistance to cannula advancement giving a P value of .0096. Only 5 of 19 aspirates were graded as differing in redness between treatment and control sides. Four of these were more red on the control side and one was more red on the treatment side. Therefore 15 of 19 had no better result with treatment, giving a P value of .0022. Seven patients graded the sensation during suctioning and/or postoperative course as better on the control side, four graded these variables as better on the treatment side, four showed no difference between the two sides, and four had mixed results. This gives only 4 of the 19 patients showing any advantage in treatment with a P value of .0022. CONCLUSION: When the placebo effect is eliminated, there is no advantage to the application of external ultrasound prior to liposuction.
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Association of lubricin concentration in synovial fluid and clinical status of osteoarthritic knee
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OAK 3 - Non-arthroplasty tx of OAK
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OBJECTIVES: Although lubricin plays a role in controlling inflammation and pain as well as being a mechanical lubricant, clinical relevance of lubricin concentration in synovial fluid (SF) is unknown. The purpose was to determine whether lubricin concentration in SF is associated with the clinical status of the knee.
METHODS: SF was obtained from 61 knee joints from patients who underwent any knee surgery with several stages of knee osteoarthritis. Lubricin/PRG4 concentration in SF was measured by enzyme-linked immunosorbent assay (ELISA). Clinical evaluations of the knee by the Kellgren and Lawrence (K-L) system, Knee Society Score (KSS), and the range of knee motion, and assessment of joint laxity were performed. Association of lubricin concentration in SF and these clinical factors was statistically analyzed.
RESULTS: There was no significant correlation between lubricin concentration in SF and age, sex, K-L grade, or KSS. However, lubricin concentration was significantly correlated with anteroposterior laxity (R = 0.50, p < 0.001), full flexion angle (R = 0.39, p < 0.01), and range of knee motion (R = 0.38, p < 0.01), but not full extension angle, varus laxity, or valgus laxity.
CONCLUSIONS: Lubricin concentration was correlated with joint flexibility, but not with clinical symptoms, including pain at that time.
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Oral care and bacteremia risk in mechanically ventilated adults
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Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures
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OBJECTIVE: Transient bacteremia occurs in healthy populations from toothbrushing. With the high incidence of bacteremia in the intensive care unit and toothbrushing as an oral care method, this study examined the incidence and clinical significance of transient bacteremia from toothbrushing in mechanically ventilated adults. METHODS: Prospective pre- and post-test with all subjects (N = 30) receiving a toothbrushing intervention twice per day (up to 48 hours). The planned microbial analysis used DNA typing to identify organisms from oral and blood cultures collected immediately before, 1 minute, and 30 minutes after the interventions. RESULTS: Seventeen percent of subjects had oral cultures that were positive for selected pathogens before the first toothbrushing intervention. None of the subjects had evidence of transient bacteremia by positive quantitative blood cultures before or after the toothbrushing interventions. Patient characteristics were not statistically significant predictors for systemic inflammatory response syndrome, length of hospital stay, or length of intubation. CONCLUSION: The toothbrushing intervention did not induce transient bacteremia in this patient population
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Osteo-core Plasty: A Minimally Invasive Approach for Subchondral Bone Marrow Lesions of the Knee
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Osteochondritis Dissecans 2020 Review
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"Bone marrow lesion" (BML) is a common term used to describe the presence of fluid in the bone marrow. Although various pathologies can cause BMLs seen on magnetic resonance imaging, in this Technical Note we focus on treating the lesions associated with osteoarthritis in the knee joint. The role of the subchondral bone in transferring loads within the knee joint, as well as in cartilage homeostasis, is well established. In addition, cartilage and subchondral bone are increasingly considered as an osteochondral unit, rather than as 2 separate structures. Knee osteoarthritis, along with insufficiency fracture, is one of the main indications for the treatment of painful BMLs. Nowadays, there is a growing interest in this field, and new approaches are being developed. Our technique can be defined as a surgical procedure aimed directly at pathology within the subchondral bone and is named "osteo-core plasty." It consists of 2 parts: The first is decompression of bone marrow to decrease intraosseous pressure, and the second is administration of bone marrow aspirate concentrate for better healing potential and bone autograft to deliver supportive tissue. It should be noted that the cause of BMLs must be known before this kind of treatment is performed.
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1 |
Pre-hospital dietary intake correlates with muscle mass at the time of fracture in older hip-fractured patients
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DoD PRF (Psychosocial RF)
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Background: Failure to meet an adequate dietary intake is involved in the pathogenesis of sarcopenia and osteoporosis, which in turn increase the risk for falls and fractures, respectively. Older people with hip fracture are often protein-malnourished at hospitalization. Whether low protein-energy intake is associated with muscle atrophy in hip-fractured patients is presently unknown. This information is necessary for the development of novel strategies to manage this especially vulnerable patient population. The aim of this study was, therefore, to explore the relationship between dietary intake and muscle mass in older hip-fractured patients. Methods: Analyses were conducted in hip-fractured elderly admitted to an orthopedic and trauma surgery ward (University Hospital). Muscle mass was estimated by bioelectrical impedance analysis within 24 h from admission. Dietary information was collected via 24-h dietary recall and nutrient intake calculated by a nutrition software. Results: Among 62 hip-fractured patients (mean age 84.6 ± 7.6 years, 84% women), the average energy intake was 929.2 ± 170.3 Kcal dayâ??1, with higher values reported by men (1.046.8 ± 231.4 Kcal dayâ??1) relative to women (906.5 ± 148.3 Kcal dayâ??1; p = 0.01). Absolute and normalized protein intake was 50.0 ± 13.5 g dayâ??1 and 0.88 ± 0.27 g kg (body weight)â??1 dayâ??1, respectively, with no gender differences. A positive correlation was determined between total energy intake and muscle mass (r = 0.384; p = 0.003). Similarly, protein and leucine consumption was positively correlated with muscle mass (r = 0.367 and 0.311, respectively; p = 0.005 for both). Conclusion: A low intake of calories, protein, and leucine is associated with reduced muscle mass in hip-fractured elderly. Given the relevance of sarcopenia as a risk factor for adverse outcomes in this patient population, our findings highlight the importance of a comprehensive dietary assessment for the detection of nutritional deficits predisposing to or aggravating muscle atrophy. (PsycINFO Database Record (c) 2016 APA, all rights reserved)
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Dkk-1-mediated inhibition of Wnt signaling in bone ameliorates osteoarthritis in mice
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OAK 3 - Non-arthroplasty tx of OAK
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Objective Wnt signaling is a master regulator of joint homeostasis, but its role in osteoarthritis (OA) remains unclear. This study was undertaken to characterize the activation of Wnt/β-catenin in knee joints of mice with OA and to assess how inhibiting this pathway in bone could affect cartilage. Methods OA was induced by partial meniscectomy in Topgal mice and in transgenic mice overexpressing Dkk-1 under the control of the 2.3-kb Col1a1 promoter (Col1a1-Dkk-1-Tg mice). Wnt/β-catenin activation was assessed by X-Gal staining at baseline and at weeks 4, 6, and 9. Cartilage and bone damage was analyzed in Col1a1-Dkk-1-Tg mice with OA at week 6. Primary chondrocytes and cartilage explants were used to assess the effect of Dkk-1 on cartilage catabolism. Results In meniscectomized Topgal mice, Wnt was mainly activated in osteocytes from the subchondral bone at week 6 after OA induction, as well as in osteophytes and synovium at week 4. Chondrocytes from damaged zones expressed X-Gal from week 4. Dkk-1 expression was high in chondrocytes in control mouse knees (mean ± SEM 84.2 ± 3.1%) but decreased greatly in knees of meniscectomized mice from week 4 (mean ± SEM 14.4 ± 3.8%). The OA score was lower in meniscectomized Col1a1-Dkk-1-Tg mice at week 6 compared with wild-type mice (5.1 ± 0.6 versus 8.4 ± 0.6; P = 0.002). Subchondral bone fraction and osteophyte volume were decreased. However, cartilage explants from Col1a1-Dkk-1-Tg mice showed proteoglycan loss and increased NITEGE expression. Expression of vascular endothelial growth factor (VEGF) was reduced in osteoblasts from Col1a1-Dkk-1-Tg mice, thereby decreasing expression of messenger RNA for matrix metalloproteinases in chondrocytes. Conclusion Wnt activation in OA affects the whole joint, particularly bone. Selective inhibition of this pathway in bone by Dkk-1 decreased OA severity through VEGF inhibition.
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Joint salvage for pathologic fracture of giant cell tumor of the lower extremity
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DoD LSA (Limb Salvage vs Amputation)
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Pathologic fracture through giant cell tumor is thought to be associated with higher rates of recurrence and poor functional outcome. We compared patients with and without pathologic fracture through giant cell tumor of weightbearing long bones. We retrospectively reviewed 139 patients with giant cell tumor of weightbearing long bones with (n = 43) and without (n = 96) pathologic fracture at presentation; the two groups had similar demographics. Joint salvage was successful in 84% of the fracture group and 96% of the nonfracture group. Five-year recurrence-free survival rates were comparable between the two groups (82.6% [95% confidence interval, 69.1-95.9%] in the fracture group and 77.9% [95% confidence interval, 67.7-88.1%] in the non-fracture group). There was a trend toward lower 5-year metastatic-free survival in the fracture group (94.7% [95% confidence interval, 87.3-100%]) than in the nonfracture group (97.3% [95% confidence interval, 93.5-100%]). Functional outcome was good and similar in the two groups. Arthrofibrosis was more common in the group with pathologic fracture. Joint salvage for patients with pathologic fractures through giant cell tumor of weightbearing bones is a reasonable option with functional outcomes and recurrence rates comparable to those of patients without fracture.
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Prosthetic advances
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DoD LSA (Limb Salvage vs Amputation)
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Much of the current prosthetic technology is based on developments that have taken place during or directly following times of war. These developments have evolved and improved over the years, and now there are many more available options to provide a comfortable, cosmetic, and highly functional prosthesis. Even so, problems with fit and function persist. Recent developments have addressed some of the limitations faced by some military amputees. On-board microprocessor-controlled joints are making prosthetic arms and legs more responsive to environmental barriers and easier to control by the user. Advances in surgical techniques will allow more intuitive control and secure attachment to the prosthesis. As surgical techniques progress and permeate into standard practice, more sophisticated powered prosthetic devices will become commonplace, helping to restore neuromuscular loss of function. Prognoses following amputation will certainly rise, factoring into the surgeon's decision to attempt to save a limb versus perform an amputation.
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A consensus statement on the European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis (ESCEO) algorithm for the management of knee osteoarthritis-From evidence-based medicine to the real-life setting
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AAHKS (4) Acetaminophen
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The European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis (ESCEO) published a treatment algorithm for the management of knee osteoarthritis (OA) in 2014, which provides practical guidance for the prioritization of interventions. Further analysis of real-world data for OA provides additional evidence in support of pharmacological interventions, in terms of management of OA pain and function, avoidance of adverse events, disease-modifying effects and long-term outcomes, e.g., delay of total joint replacement surgery, and pharmacoeconomic factors such as reduction in healthcare resource utilization. This article provides an updated assessment of the literature for selected interventions in OA, focusing on real-life data, with the aim of providing easy-to-follow advice on how to establish a treatment flow in patients with knee OA in primary care clinical practice, in support of the clinicians' individualized assessment of the patient. In step 1, background maintenance therapy with symptomatic slow-acting drugs for osteoarthritis (SYSADOAs) is recommended, for which high-quality evidence is provided only for the prescription formulations of patented crystalline glucosamine sulfate and chondroitin sulfate. Paracetamol may be added for rescue analgesia only, due to limited efficacy and increasing safety signals. Topical non-steroidal anti-inflammatory drugs (NSAIDs) may provide additional symptomatic treatment with the same degree of efficacy as oral NSAIDs without the systemic safety concerns. Oral NSAIDs maintain a central role in step 2 advanced management of persistent symptoms. However, oral NSAIDs are highly heterogeneous in terms of gastrointestinal and cardiovascular safety profile, and patient stratification with careful treatment selection is advocated to maximize the risk:benefit ratio. Intra-articular hyaluronic acid as a next step provides sustained clinical benefit with effects lasting up to 6 months after a short-course of weekly injections. As a last step before surgery, the slow titration of sustained-release tramadol, a weak opioid, affords sustained analgesia with improved tolerability.
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Infective endocarditis in the adult patient
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Dental Implant Infection
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Infective endocarditis (IE) is an uncommon disease with a high morbidity and mortality. The basic pathology involves adherence of microorganisms to areas of endothelial damage or associated implanted medical devices, such as prosthetic valves or pacemakers, resulting in localized infection and formation of vegetations. Complications include sepsis, secondary infections (e.g. spinal osteomyelitis), heart failure and embolization. Staphylococci, streptococci and enterococci are the predominant causes of IE. Blood cultures and echocardiography are key diagnostic tests, but a diagnosis of IE can still be difficult to establish. Cardiac computed tomography and positron emission tomography can also assist diagnosis. Serological tests, for some fastidious microorganisms, can be useful when blood cultures are negative. The modified Duke criteria can help in establishing the diagnosis but lack sensitivity, particularly when blood cultures are negative or transthoracic echocardiography images are non-diagnostic. Antibiotics are the mainstay of treatment, but surgical debridement and valve surgery are frequently required. Recent changes in antibiotic prophylaxis recommendations for those considered to be at risk of IE have greatly reduced the number of patients given antimicrobials by dental and other practitioners. This article summarizes how to diagnose IE and outlines current antibiotic treatment regimens.
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Incidence of perioperative arthroplasty complications in elderly patients and feasibility of screening perioperative stroke with NIHSS
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Surgical Management of Osteoarthritis of the Knee CPG
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In-hospital strokes account for 6.5-15%of total strokes. Half of them are perioperative. Thrombolysis and new antiplatelet drugs have significantly improved the prognosis of ischaemic strokes, but only 2-15% patients receive thrombolysis in time due to a short time window for use (6-12 h). Diagnosis of in-hospital stroke, especially perioperative, is complex. Nonneurological medical staff lack an identification tool; this results in patients exceeding the thrombolysis time window. NIHSS tests most neurological functions when stroke is present. It is easy to learn, quick toadminister, andthere is good agreement between neurologists and non-neurological medical staff. This study planned to prospectively investigate elderlypatientsundergoing arthroplasty todetect the incidence of perioperative complications. We evaluated patients using NIHSS to analyse screening feasibility for perioperative stroke and to facilitate a subsequent multi-centre investigation. We selected patients undergoing arthroplasty >60 yr old in Beijing Jishuitan Hospital. General information, previous history, and lab examination were recorded before operation. Surgeryandanaesthesiadataduringsurgeryandhaemodynamic data were recorded after operation. Medication was recorded before and after surgery and before discharge.NIHSSwas evaluatedbefore surgery,onpostoperativedays 1,2,and3,andbefore discharge. Patients were followed up by phone 6 months after surgery and assessed for independence and life quality using Barthel Index and EQ-5D. Data were analysed with SPSS 17.0. Average duration of surgery was 107.3 (44.1) min; this was mainly related to type of surgery. Surgeries with longest duration were total knee arthroplasty (TKA), total hip arthroplasty (THA), and shoulder joint replacement because of cancer, with an average duration of 201.2 (31.3) min. Surgeries with shorter duration are bilateral TKA, bilateral THA, knee joint rebuilding, hip joint rebuilding, and middle-size joint replacement of limbs, like shoulder, elbow, and ankle; average duration was 163.2 (40.7) min. Shortest duration surgeries include TKA, THA, and replacement of femoral head, capitulum radius, and metatarsophalangeal joints. Anaesthetic type was mainly related to operative site and patient status. Shoulder replacement and femoral head replacement (in elderly with fractured neck of femur) have the highest proportion of general anaesthesia, 59.2% and 60%, respectively. Hip joint replacement not due to fracture but arthroplasty has the lowest proportion of general anaesthesia. For example, the rate of general anaesthesia of bilateral THA and hip joint rebuilding is 14.3%. There were two patients who suffered perioperative stroke. The incidence is 0.39%. Referring to the records, patients' relatives and nurses realized abnormal symptomsatanearly stage of stroke. NIHSS score changed on the same day. NIHSS score increased as stroke symptoms worsened and decreased as they improved. For one patient, nurses applied neurological consultation two days later. It took neurologists 2 and 3 days separately from first consultation to confirming diagnosis. The specificity of NIHSS changing one score or one day is 85%. The specificity of changing more than 2 scores is 97%. The specificity of
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One-stage cementless revision arthroplasty for infected hip replacements
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PJI DX Updated Search
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We hypothesised that one-stage cementless revision hip arthroplasty may have advantages and a role in the treatment of selected patients with an infected hip replacement. We retrospectively reviewed all patients with an infected hip replacement treated with one-stage revision using cementless implants. Twelve patients were reviewed and followed up for at least three years (average: 7.2 years, range: 3.3-11.3 years) postoperatively. One recurrence of infection and one aseptic stem loosening were detected during follow-up. Grafted bone, which was used in eight patients, appeared to have united to host bone in all patients. The success rate of treatment was 83.3% when infection recurrence or component loosening were regarded as failure. One-stage revision hip arthroplasty using cementless implants appears to have a role in the treatment of carefully selected patients with an infected hip replacement if meticulous débridement is performed and appropriate antibiotics are properly used. é 2008 Springer-Verlag
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Physical activity and hip fracture: A population-based case-control study
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DoD PRF (Psychosocial RF)
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Background. A growing body of literature suggests that physical activity may be a protective factor against hip fracture. Methods. To study the association between hip fracture risk and recreational physical activity at various ages, changes in activity during adult life, occupational physical activity and how risks vary by adult weight change, we performed a population-based case-control study among postmenopausal women aged 50-81 years residing in six counties in Sweden in 1993-1995. The analysis consisted of 1327 women with hip fracture and 3262 randomly selected controls. Information on leisure physical activity before age 18, at 18-30 years and during recent years was based on a questionnaire. Data on occupational physical activity were collected through an independent classification of job titles obtained from record linkage with census data from 1960, 1970 and 1980. Results. There was a protective effect of recent leisure physical activity. Compared to women who reported no leisure activity, the odds ratios (OR) were 0.79 (95% CI: 0.62-1.00), 0.67 (95% CI: 0.54-0.84) and 0.48 (95% CI: 0.39-0.60) for women who exercised <1 h per week, 1-2 h per week, and 3+ h per week, respectively. These decreased OR were more pronounced in women who had lost weight after 18 years of age than in those who had gained weight. Women with high physical activity at both 18-30 years and during recent years did not have a stronger protection than those with isolated high activity late in life, after accounting for recent activity. Occupational physical activity was not associated with hip fracture risk in this study. Conclusion. Recent physical activity is protective against hip fracture. The protective effect is most pronounced in women who had lost weight after age 18.
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Treatment of carpal tunnel syndrome with alpha-lipoic acid
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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Carpal Tunnel Syndrome (CTS) is the most common peripheral mononeuropathy; its symptoms and functional limitations significantly penalize the daily activities and quality of life of many people. While surgery is reserved to most severe cases, the earlier stages of disease may be controlled by a pharmacological treatment aimed to "neuroprotection", i.e. to limiting and correcting the nerve damage. Our study was aimed to compare the efficacy of a fixed association of alpha-lipoic acid (ALA) 600 mg/die and gamma-linolenic acid (GLA) 360 mg/die, and a multivitamin B preparation (Vit B6 150 mg, Vit B1 100 mg, Vit B12 500 microg daily) for 90 days in 112 subjects with moderately severe CTS. Demographic, case-history and treatment efficacy data were collected; the Boston questionnaire was administered and the patients were evaluated by Hi-Ob scale and electro-myography. A significant reduction in both symptoms scores and functional impairment (Boston questionnaire) was observed in ALA/GLA group, while the multivitamin group experienced a slight improvement of symptoms and a deterioration of functional scores. Electromyography showed a statistically significant improvement with ALA/GLA, but not with the multivitamin product. The Hi-Ob scale showed significant efficacy of ALA/GLA in improving symptoms and functional impairment, while in the multivitamin group the improvement was significant, but less marked than in the ALA/GLA group. In conclusion, the fixed association of ALA and GLA proved to be a useful tool and may be proposed for controlling symptoms and improving the evolution of CTS, especially in the earlier stages of disease
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1 |
Adipose-derived stem cells in articular cartilage regeneration: current concepts and optimization strategies
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OAK 3 - Non-arthroplasty tx of OAK
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Knee osteoarthritis (KOA) is the most common progressive joint disorder associated with disability in the world. As a chronic disease, KOA has multifactorial etiology. However, the poor self-healing ability of the articular cartilage due to its intrinsic tissue hypovascularity and hypocellularity seems to be directly incriminated in the physio-pathological mechanism of KOA. While conventional therapies result in unfavorable clinical outcomes, regenerative cell therapies have shown great promise in articular cartilage regeneration. Adipose-derived stem cells (ASCs) appear to be an ideal alternative to bone-marrow derived stem cells (BMSCs) and autologous chondrocytes, due to their lower immunogenicity, richer source and easier acquisition. Since the first case report in 2011, ASCs have demonstrated safety and efficacy for articular cartilage regeneration in several phase I/II clinical trials. However, different levels of abnormality were found in the regenerated cartilage for most of the patients. A large portion of recent publications investigated different optimization strategies to improve the therapeutic function of ASCs, including cell source selection, preconditioning and co-delivery. Herein, we give an update on the latest research progress on ASCs, with a focus on the most promising optimization strategies for ASC-based therapy.
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Dynamic ultrasound assessment for monitoring of treatment of congenital dislocation of the hip
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Developmental Dysplasia of the Hip CPG
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Of the 7,827 babies born in Sheffield between March 1989 and August 1991, a total of 114 (1.4%) who had either clinical abnormality of the hip or high-risk factors for congenital dislocation of the hip (CDH) were examined by ultrasound at birth and at regular intervals. Dynamic ultrasound assessment of both hips was done to diagnose instability and to monitor the treatment. Abnormal findings were recorded in 55 babies at the first visit, and 31 of these subsequently required treatment with the Pavlik harness (3.9 per 1,000). Only one case of late CDH has been seen among the babies who were not examined by ultrasound. There were no cases of avascular necrosis in our series. Dynamic ultrasound examination of high-risk infants' hips is a reliable method of screening for CDH. Monitoring of hips treated with the Pavlik harness, by dynamic ultrasound examination, can identify failure to obtain a concentric reduction, and in such cases, splintage can be abandoned in favour of other modes of treatment. It can, therefore, reduce the chances of overtreatment and its associated complications
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The vascular network in the femoral head and neck after hip resurfacing
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Management of Hip Fractures in the Elderly
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The purpose of this study was to determine whether femoral neck fracture after cemented resurfacing hip arthroplasty (RHA) arises from intraosseous vascularity around the femoral head-neck junction. We implanted a replica of the femoral head component into osteoarthritic femoral heads and compared the intraosseous vascularity network between the femoral heads with and without the RHA procedure using microangiography through a retinacular artery with micro-computed tomography. Our results showed no significant difference in the vascularity around the femoral head-neck junction between the groups with and without the RHA procedure. These results suggest that deterioration of the intraosseous vascular network around the head-neck junction after RHA was not severe enough to induce complete avascularity
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Pulmonary hypertension with different etiology of forensic medicine - Eight cases
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Hip Fx in the Elderly 2019
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Purpose: In addressing complex cases with pulmonary hypertension (PH) no must omitted some situations encountered in forensic toxicology. Material and methods: We analyzed eight forensic cases presenting various degrees of pulmonary hypertension of different etiologies were subjected to forensic autopsy and then were taken lung fragments were processed histologically and stained HE, VG, Weigert, PAS-Alcian and Gomori. Results: The cases which were found pulmonary hypertension (PH) showed that gross aspects: type part of bronchopneumonia, atelectasis, acute pulmonary edema, more adherent with lobular mass, adherent and dry matter per section with areas of infarction. They correspond microscopically characteristic morphological aspects PH prolonged evolution, the presence of crystalline inclusions in polarized light with rectangular double refringency foreign body granulation (around vascular) reaction (addiction); with lumen mixoide embolism and histological aspects of major PH (mitral valve prosthesis); other intra-parenchimtous case with granulomatous chronic inflammation with foreign body giant cells (particles of talc) and another with aspects of adult respiratory distress histological type pneumoniae hyaline membrane, areas of hemorrhagic infarction and characteristic specifically diverse pulmonary vascular aspects encountered in PH. Conclusion: The degrees of PH set ranged from I to VI on the Heath-Edwards scale some are average and others being PH increase can be found in all histological grades of HP for every stage evolutionary scale pathogenesis.
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Investigation of Utility of Sonography in Early Management of Knee Pain Due to Traumatic Events
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AMP (Acute Meniscal Pathology)
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Background: Knee pain and related symptoms may come as a result of damage to one or more of the soft tissue structures that stabilize and cushion the knee joint. Trauma to the knee is the second most common occupational accident. Ultrasound has a significant role in patients presenting with knee joint trauma as sonography can detect haemarthrosis, tendon and muscle injuries. Methods: A descriptive observational study was conducted amongst 17 patients who underwent ultrasound imaging of the knee when they presented with knee pain following a traumatic episode at a tertiary care hospital in Delhi, NCR from July 2017 to March 2020. Ultrasound was performed using the technique described by Von Holsbeeck. Bilateral scans were taken for each patient for comparison. Examination was done with the patient supine, left and right lateral and prone positions. Results: A majority (65%) of the cases in our study were male, while six patients recruited were female. Sport-related knee injuries were the most common type, encountered in 12 patients (70.5%) while traffic and occupational-related knee injuries were encountered in the remaining 5 patients (29.5%). In the present study, the most frequent knee injuries were 8 ligamentous (47.0%), followed by 7 meniscal (41.1%), 2 osseous (11.7%), 1 tendinous (5.8%) and all patients had effusions. Among patients presenting with post-traumatic joint effusion, fluid was echogenic in twelve patients. Meniscal injury is seen in seven patients, while one case of quadriceps tendinosis seen secondary to repeated minor trauma seen as echogenic focus of calcification with acoustic shadowing. Two cases of fracture were diagnosed by the ultrasound. Conclusion: Sonography of the painful knee joint can diagnose all tendinous, bursal and synovial lesions. Most of meniscal and ligamentous lesions can be accurately depicted it.
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Efficacy of risedronate administration in osteoporotic postmenopausal women affected by inflammatory bowel disease
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Management of Hip Fractures in the Elderly
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Patients with inflammatory bowel disease (IBD) have frequently a bone mineral density (BMD) significantly lower than age-matched healthy subjects. The low BMD observed in IBD patients is related also to a higher incidence of bone fractures. In this prospective randomized study we evaluated the effect of 1-year risedronate administration on bone mass and turnover, and on vertebral fractures in osteoporotic postmenopausal women with IBD in remission. Ninety osteoporotic postmenopausal women were randomized to receive oral risedronate 35 mg/week (risedronate group) or placebo tablets (placebo group; one tab/week). The duration of treatment was 12 months. At entry and after treatment, lumbar spine and hip BMD, and serum osteocalcin (OC) and urinary deoxypyridinoline/creatinine ratio (DPD-Cr) levels were evaluated. Vertebral fractures were assessed from thoracic and lumbar lateral and anterior-posterior spinal radiographs taken at baseline, and from lateral spinal radiographs taken at the end of the study. At study entry, no difference between groups was also detected in BMD and in bone turnover markers. At the end of the study, lumbar spine, trochanter and femoral neck BMD was significantly ( p <0.05) higher in comparison with baseline in the risedronate group, whereas a significant ( p <0.05) decrease was observed in the placebo group. For the same visit, a significant ( p <0.05) difference in lumbar spine, trochanter and femoral neck BMD was detected between groups. After 12-month follow-up, serum OC and urinary DPD-Cr levels were significantly ( p <0.05) lower and higher in comparison with basal values in risedronate and placebo group, respectively. At the same time, a significant ( p <0.05) difference in serum OC and urinary DPD-Cr levels was observed between groups. Throughout the study, the incidence of vertebral fractures was significantly ( p <0.05) lower in the risedronate group than in the placebo group (12.5% vs 34.1%). The relative risk (RR) to develop a new vertebral fracture after 1 year of risedronate administration was of 0.36 (95% confidence interval, 0.14-0.85). In conclusion, risedronate administration is an effective anti-osteoporotic treatment in osteoporotic postmenopausal women with IBD in remission
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Early symptoms in the prodromal phase of delirium: a prospective cohort study in elderly patients undergoing hip surgery
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Management of Hip Fractures in the Elderly
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OBJECTIVES: The authors investigated prodromal delirium symptoms in elderly patients undergoing hip surgery. METHODS: This was a prospective cohort study in the setting of a large medical school-affiliated general hospital in Alkmaar, The Netherlands. Participants were patients undergoing hip surgery aged 70 and older at risk for delirium. Before surgery, patients were randomized to low-dose prophylactic haloperidol treatment or placebo. Daily assessments were based on patient interviews with the Mini-Mental State Examination and Digit Span test. The Delirium Rating Scale-Revised (DRS-R-98) was used to measure early symptoms during the prodromal phase before the onset of delirium. RESULTS: Data of 66 patients with delirium were compared with those of 35 at-risk patients who did not develop delirium: 14 of 66 patients (21%) had delirium on the day of surgery or early the day after, 32 of 66 (48%) on the second day, 14 of 66 on the third, and six of 66 (9%) on the fourth. The average DRS-R-98 total scores on day -4 to day -1 before delirium were 1.9 for the comparison group patients and 5.0, 4.3, 5.8, and 10.7 for patients with postoperative delirium. Multivariate analysis showed that the early symptoms memory impairments, incoherence, disorientation, and underlying somatic illness predict delirium. CONCLUSIONS: Most elderly patients undergoing hip surgery with postoperative delirium already have early symptoms in the prodromal phase of delirium. These findings are potentially useful for screening purposes and for optimizing prevention strategies targeted at reducing the incidence of postoperative delirium
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Mobile-bearing knee systems: ultra-high molecular weight polyethylene wear and design issues
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Surgical Management of Osteoarthritis of the Knee CPG
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In June 2004, the U.S. Food and Drug Administration Orthopaedic Advisory Panel recommended the reclassification of mobile-bearing knee systems for general use. This reflects the increasing use of mobile-bearing knee systems internationally, which is currently limited in the United States by regulatory requirement. Mobile-bearing knee systems are distinguished from conventional, fixed-plateau systems in that they allow dual-surface articulation between an ultra-high molecular weight polyethylene insert and metallic femoral and tibial tray components. Their in vivo success is dependent on patient selection, design, and material choice, as well as surgical precision during implantation. Laboratory and clinical experience extending over 25 years with individual systems suggests that mobile-bearing knee systems represent a viable treatment option for patients with knee arthrosis
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Association between changes in global femoral offset after total hip arthroplasty and function, quality of life, and abductor muscle strength
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PJI DX Updated Search
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Background and purpose - There is no consensus on the association between global femoral offset (FO) and outcome after total hip arthroplasty (THA). We assessed the association between FO and patients reported hip function, quality of life, and abductor muscle strength.Patients and methods - We included 250 patients with unilateral hip osteoarthritis who underwent a THA. Before the operation, the patients reported hip function was evaluated with the Western Ontario and McMaster Universities Osteoarthritis (WOMAC) index and quality of life was evaluated with EQ-5D. At 1-year follow-up, the same scores and also hip abductor muscle strength were measured. 222 patients were available for follow-up. These patients were divided into 3 groups according to the postoperative global FO of the operated hip compared to the contralateral hip, as measured on plain radiographs: the decreased FO group (more than 5 mm reduction), the restored FO group (within 5 mm restoration), and the increased FO group (more than 5 mm increment).Results - All 3 groups improved (p < 0.001). The crude results showed that the decreased FO group had a worse WOMAC index, less abductor muscle strength, and more use of walking AIDS. When we adjusted these results with possible confounding factors, only global FO reduction was statistically significantly associated with reduced abductor muscle strength. The incidence of residual hip pain and analgesics use was similar in the 3 groups.Interpretation - A reduction in global FO of more than 5 mm after THA appears to have a negative association with abductor muscle strength of the operated hip, and should therefore be avoided
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Concepts on correction of the musculoaponeurotic layer in abdominoplasty
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Panniculectomy & Abdominoplasty CPG
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The musculoaponeurotic layer of the abdominal wall should be corrected during abdominoplasty according to the specific deformity that the patient presents with. In this article, the anatomic basis of deformities and defects of the abdominal wall is described. Different degrees of deformities secondary to pregnancy are described as well as congenital muscle malposition. These conditions should be treated in specific ways so that the most efficient correction can be achieved and no recurrence will occur. In cases of associated incisional hernias, the 'components separation' technique can be considered for abdominal wall reconstruction and 2 alternative techniques of dissection of myoaponeurotic components are described for the correction of specific defects.
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Mortality in intertrochanteric fracture of the femoral neck
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Management of Hip Fractures in the Elderly
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The mortality during the first year after operation was studied in 209 patients with intertrochanteric fracture of the femoral neck, all treated with osteosynthesis. The excess mortality due to the fracture and operation proved to be about 20 per cent. Among the great majority of patients who did not have significant cardiac symptoms or signs despite their advanced age, the excess mortality was below 10 per cent. Among patients whose operative risk had been deemed increased due to heart disease, the excess mortality during the first year was about 50 per cent
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Distal forearm fractures in children. Complications and surgical indications
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DOD - Acute Comp Syndrome CPG
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Appropriate indications for operative management of pediatric distal forearm fractures include: 1. Compartment syndrome for fasciotomy. 2. Open fractures for irrigation and debridement. 3. Soft tissue/nerve entrapment. 4. Displaced intra-articular physeal fractures. 5. Displaced or angulated fractures when the patient is close to skeletal maturity. 6. Correction of physeal arrest with malalignment or malrotation. 7. Gross displacement with cosmetic deformity. [References: 36]
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Management of Gigantomastia: Outcomes of Superomedial Pedicle with Vertical Scar or Wise Pattern Skin Excision
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Reduction Mammoplasty for Female Breast Hypertrophy
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BACKGROUND: Gigantomastia is a rare condition characterized by excessive breast growth and can be physically and psychosocially disabling for the patient. Regarding management of gigantomastia, this study evaluates the outcomes of superomedial pedicle with vertical scar or wise pattern skin excision.
METHODS: A total of 425 patients who underwent reduction mammoplasty in our institution were reviewed. Forty eight reduction mammoplasty patients with resection weights greater than 1 kg per breast and treated with superomedial dermoglandular pedicle technique combined with vertical or wise-pattern skin excision were included.
RESULTS: The patients were between 19 and 66 years old, with an average of 41 years. Total weight of resection was between 1000 and 2600 g, with an average of 1384 grams for right breast and between 1000 and 3000g, with an average of 1434 grams for left breast. The secondary revisions and wound healing complications were extremely high in vertical scar group compared to wise pattern group (87,5% and 12,5%, respectively).
CONCLUSION: The authors concluded that superomedial dermoglandular pedicle in the addition of a wise pattern is an appropriate, safe and reliable method when dealing with significantly larger breasts (>1000g).
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Balance is an important predictive factor for quality of life and function after primary total knee replacement
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Surgical Management of Osteoarthritis of the Knee CPG
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We investigated the extent to which improved balance relative to pain relief correlates with the success of total knee replacement (TKR). A total of 81 patients were recruited to the study: 16 men (19.8%) and 65 women (80.2%). Of these, 62 patients (10 men, 52 women) with a mean age of 73 (57 to 83) underwent static and dynamic assessment of balance pre-operatively and one year post-operatively. The parameters of balance were quantified using commercially available and validated equipment. Motor function and self-reported outcome were also assessed. There was a significant improvement in dynamic balance (p < 0.001) one year after TKR, and better balance correlated with improved mobility, functional balance and increased health-related quality of life. As it seems that balance, and not only pain relief, influences the success of TKR, balance skills should be better addressed during the post-operative rehabilitation of patients who undergo TKR
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Leg position influences early blood loss and functional recovery following total knee arthroplasty: A randomized study
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PJI DX Updated Search
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BACKGROUND: Hidden blood loss is a major factor influencing functional recovery and quality of life in patients undergoing total knee arthroplasty. Special hip and knee flexion positions after have been reported to have promising results with respect to reducing perioperative blood loss. The purpose of this study was to determine the effect of postoperative leg position on blood loss and functional recovery after total knee arthroplasty. METHODS: We enrolled 46 consecutive patients with degenerative osteoarthritis of the knee in this prospective, randomized study. The patients were randomly allocated to a flexion or an extension group. In the flexion group, the affected leg was elevated by 60 degrees at the hip, and the knee was flexed by 60 degrees , while in the extension group, the affected knee was fully extended postoperatively. Blood loss, hemoglobin level, knee circumference and range of motion (ROM) were recorded to determine the influence of postoperative leg position on clinical outcomes. RESULTS: Although the transfusion rate was similar between the two groups (P > 0.05), other parameters related to blood loss (including calculated blood loss, hidden blood loss and postoperative knee circumference) were significantly lower in the flexion group than in the extension group (P < 0.05). After 6 weeks of rehabilitation, patients from the flexion group had gained a better ROM in the affected knee than had patients from the extension group (P = 0.04). At 6 months, however, the ROM of the affected knee was similar in both groups. The hospital stay was 1.9 days shorter in the flexion group than in the extension group. Wound infection rates were similar in both groups, and no proven case of deep vein thrombosis was observed in either group. CONCLUSIONS: Elevation of the hip by 60 degrees with 60 degrees knee flexion is an effective and simple method to reduce blood loss after primary unilateral total knee arthroplasty, and contributes to better recovery of the functional ROM in the early postoperative period
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Amoxycillin-resistant streptococci in dental plaque
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Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures
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This investigation was undertaken to study the prevalence of amoxycillin-resistant oral streptococci in normal healthy patients and patients with a cardiac condition, susceptible to infective endocarditis. Samples of supragingival dental plaque were collected from two test groups, children with congenital heart disease and adults with a history of rheumatic fever, and two control groups comprising normal healthy children and normal healthy adults. Bacteria from these samples were grown on a medium selective for oral streptococci, as well as on the same medium containing known concentrations of amoxycillin. The results indicate that a high percentage of rheumatic heart patients and children with congenital heart disease harboured amoxycillin-resistant oral streptococci. The level of amoxycillin resistance in the plaque of adults with rheumatic heart disease was significantly greater than in that of normal adults. In view of the high percentage of patients at risk harbouring amoxycillin-resistant streptococci, it is important that the individual clinical situation be monitored. Perhaps antibiotic sensitivity tests should be performed to select an appropriate antibiotic for prophylaxis of infective endocarditis
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Outcomes Of Distal Femur Fracture Treated With Dynamic Condylar Screw
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Hip Fx in the Elderly 2019
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BACKROUND: Implants for open reduction and internal fixation of distal femoral fracture includes angle blade plate, rush nails, enders nail and interlocking nails. But all these devices are technically demanding and less effective in providing inter-fragmentary compression in osteoporotic bones. These problems can be solved with dynamic condylar screw (DCS). The objective of the study was to determine the frequency of different outcomes of distal femoral fracture treated with dynamic condylar screw.
METHODS: This case series study was carried out in the Department of Trauma & Orthopaedics, Ayub Teaching Hospital Abbottabad from 1st October 2014 to August 2015, after approval of the ethical committee of the institution. Data of all patients with distal femoral fractures aged 20-70 years, recruited through emergency, OPD or consultant clinic collected on a pro forma. Standard treatment of trauma was given to the patients. Detailed history was taken including the past medical and surgical history. Detailed examination including air-way, breathing and circulation, general physical examination and abdomino-pelvic examination was done in each patient. Investigations including urinalysis, haemoglobin %, full blood count, X-ray (both AP and lateral view) of the involved femur (including hip and knee) was done.
RESULTS: Mean age of the patients was 43.18+/-14.647 ranging from 20 to 70 years. Mean duration of hospital stay in days was 2.21+/-1.111 ranging from 1 to 6 days. Patients' follow-up assessment after 4 months of surgery for union of femoral fracture treated with dynamic condylar screw was found in 96 (94.1%), wound infection was found in 7 (6.9%), knee stiffness was found in 21 (20.6%) and limb shortening was found in 7 (6.9%).
CONCLUSIONS: Dynamic condylar screw is an easy, scientifically less difficult and satisfying method of treatment for fra.ctures of femur.
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The Northwestern Abdominoplasty Scar Model: A Tool for High-Throughput Assessment of Scar Therapeutics
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Panniculectomy & Abdominoplasty CPG
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Significance: Scar management is an important concern in plastic surgery. Scar models that best mimic in vivo human scarring are essential for understanding scar development and progression, assessing the efficacy of therapeutics, and providing reliable and valid research outcomes. Recent Advances: In 2016, Lanier et al. proposed a new in vivo patient model, the Northwestern Abdominoplasty Scar Model, that overcomes the prior limitations of both animal and human models, with greater representativeness of the human scarring process, expedited recruitment, smaller sample requirements, and greater flexibility in the types and number of interventions that can be studied simultaneously. Critical Issues: Existing animal models suffer from limitations that impede generalization to human scars. Human scar studies are difficult to conduct and rarely used due to recruitment difficulties, ethical concerns regarding purposeful wounding, and inherent variability based on location, type of scar, and the heterogeneity of the host response between humans. Although overcoming many of these hurdles, the Northwestern Abdominoplasty Scar Model still has a few limitations. In addition, there remains a need for further study of and comparison between the Northwestern Abdominoplasty Scar Model and existing human and animal models, to inspire more widespread acceptance of a standardized human scar model. Future Directions: The Northwestern Abdominoplasty Scar Model is a critical stepping stone toward better human scar models. This model hopefully will inspire other in vivo patient models utilizing elective surgery to overcome recruitment and ethical concerns.
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Sleep disturbance and melatonin levels following traumatic brain injury
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DoD PRF (Psychosocial RF)
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OBJECTIVES: Sleep disturbances commonly follow traumatic brain injury (TBI) and contribute to ongoing disability. However, there are no conclusive findings regarding specific changes to sleep quality and sleep architecture measured using polysomnography. Possible causes of the sleep disturbances include disruption of circadian regulation of sleep-wakefulness, psychological distress, and a neuronal response to injury. We investigated sleep-wake disturbances and their underlying mechanisms in a TBI patient sample.
METHODS: This was an observational study comparing 23 patients with TBI (429.7 +/- 287.6 days post injury) and 23 age- and gender-matched healthy volunteers on polysomnographic sleep measures, salivary dim light melatonin onset (DLMO) time, and self-reported sleep quality, anxiety, and depression.
RESULTS: Patients with TBI reported higher anxiety and depressive symptoms and sleep disturbance than controls. Patients with TBI showed decreased sleep efficiency (SE) and increased wake after sleep onset (WASO). Although no significant group differences were found in sleep architecture, when anxiety and depression scores were controlled, patients with TBI showed higher amount of slow wave sleep. No differences in self-reported sleep timing or salivary DLMO time were found. However, patients with TBI showed significantly lower levels of evening melatonin production. Melatonin level was significantly correlated with REM sleep but not SE or WASO.
CONCLUSIONS: Reduced evening melatonin production may indicate disruption to circadian regulation of melatonin synthesis. The results suggest that there are at least 2 factors contributing to sleep disturbances in patients with traumatic brain injury. We propose that elevated depression is associated with reduced sleep quality, and increased slow wave sleep is attributed to the effects of mechanical brain damage.
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The efficacy and safety of methylprednisolone for pain control after total knee arthroplasty: A meta-analysis of randomized controlled trials
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AAHKS (2) Corticosteroids
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BACKGROUND: Pain management after arthroplasties has become a serious problem. We perform a meta-analysis from randomized controlled trial (RCTs) to examine the efficacy and safety of methylprednisolone in the setting of postoperative pain after total knee arthroplasty (TKA).
METHODS: We conduct electronic searches of Medline (1966 to October 2017), Embase (1980 to October 2017), ScienceDirect (1985 to October 2017) and the Web of Science (1995 to October 2017). Eligibility criteria: (1) Participants: Published studies enrolling adult human subjects with knee osteoarthritis who prepare for TKA are included in our study; (2) Interventions: The intervention groups receive methylprednisolone in the management of postoperative pain; (3) Comparisons: The control groups receive placebo; (4) Outcomes: The primary outcomes are visual analogue scale (VAS) scores and narcotic consumption. The secondary outcomes include adverse effects (gastrointestinal events and pruritus) and postoperative complications (deep venous thrombosis, pulmonary embolism and infection); (5) Study design: RCTs. Fixed/random effect model is adopted according to the heterogeneity tested by I<sup>2</sup> statistic. Stata 11.0 software is used to perform the meta-analyses.
RESULTS: Four RCTs involving 248 patients are included. The present meta-analysis indicates that there are significant differences between groups regarding pain score at 6h (WMD=-0.661, 95% CI: -1.152 to -0.171, P=0.008), 12h (WMD=-0.555, 95% CI: -1.091 to -0.018, P=0.043) and 24h (WMD=-0.648, 95% CI: -1.146 to -0.150, P=0.011) after TKA. Significant differences are found in terms of narcotic consumption at 6h (WMD=-3.453, 95% CI: -6.116 to -0.791, P=0.011), 12h (WMD=-5.138, 95% CI: -9.036 to -1.240, P=0.010) and 24h (WMD=-3.651, 95% CI: -5.909 to -1.393, P=0.002).
CONCLUSION: Methylprednisolone could significantly decrease postoperative pain score, narcotic consumption and opioid-related adverse effects after TKA. Further high-quality RCTs are still required to validate the results.
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Why is zoledronic acid (Z) superior to pamidronate (P) for bone metastases from breast cancer (BC) but equivalent in multiple myeloma (MM)
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MSTS 2018 - Femur Mets and MM
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No. 187]
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1 |
Free nipple graft reduction mammoplasty
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Reduction Mammoplasty for Female Breast Hypertrophy
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Free nipple graft reduction mammoplasty is the procedure of choice in patients with massive breast hypertrophy, or those high-risk patients less able to undergo a more extensive procedure. A major criticism of the technique is that it creates a flat, boxy breast that lacks projection. A technical modification of free nipple graft reduction mammoplasty is presented. In this modification, a central, bulky, superiorly based dermal-parenchymal flap extending from the "key-hole" site to the superior aspect of the areola is designed. After tailoring, this central flap is folded superiorly and secured beneath the medial and lateral flaps to create the bulk of the breast mound. This central flap can be accurately tailored to achieve the desired breast size and projection. The medial and lateral breast flaps do not create the breast mound, and are only contoured over the top of this central flap to complement the final breast form.
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Is arthroplasty preferable to internal fixation for the treatment of extracapsular fracture of the upper femur in the elderly?
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DoD SSI (Surgical Site Infections)
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INTRODUCTION: Although internal fixation is the reference treatment for extracapsular fracture of the upper femur, indications for arthroplasty are broadening, especially in unstable comminutive fracture in fragile bone. The present study hypothesis was that arthroplasty reduces early mortality and morbidity and provides better recovery of autonomy in over-80 year-old patients than does internal fixation.
MATERIAL AND METHODS: A prospective multicenter study was conducted on 8 sites. Internal fixation was systematically used in 5 centers; arthroplasty was used systematically in 1 center, and reserved for unstable fracture in 2 centers. A total of 697 patients aged over 80 years (mean age, 85+/-5 years), presenting with extracapsular fracture, were included; 521 were treated by internal fixation and 176 by arthroplasty. Results were studied on multivariate analysis of ASA score, blood loss, transfusion, and also of treatment modality as an independent factor for early (first 6 months) mortality and morbidity (mechanical, general and nutritional complications) and functional outcome (autonomy and dependence).
RESULTS: Overall mortality was 19.2%. Autonomy deteriorated in 56% of patients alive at 6 months and dependence worsened in 44%. Two percent of those managed by internal fixation underwent revision for disassembly (n=8) or infection (n=1). Eight percent of those managed by arthroplasty underwent revision for dislocation (n=4), implant loosening (n=3) or infection (n=7). On univariate analysis, mortality was higher in the arthroplasty group (25%) than with internal fixation (17%; P=0.002), as were blood loss (425+/-286mL versus 333+/-223mL; P<0.0001), transfusion rate (61% versus 32%; P<0.0001) and infection (4% versus 0.2%; P<0.001). On multivariate analysis, however, treatment modality no longer showed impact on mortality or on morbidity and autonomy at 6 months. Nutritional status was better conserved at 6 months following arthroplasty, but dependence worsened. Poor preoperative autonomy, ASA score, and nutritional status and time to treatment were independent factors for mortality. Transfusion, associated with onset of mechanical complications, significantly increased dependence.
CONCLUSION: Type of treatment had little impact on mortality, morbidity or functional outcome. Differences seemed more related to preoperative functional and nutritional status.
LEVEL OF EVIDENCE: III, prospective case-control study.
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The efficacy of tourniquet release in blood conservation after total knee arthroplasty
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Surgical Management of Osteoarthritis of the Knee CPG
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One hundred consecutive primary total knee arthroplasties performed by a single surgeon were prospectively randomized into two groups to study the effect of tourniquet release for hemostasis on postoperative blood loss and transfusion requirements. The two groups were comparable. Variables such as antiinflammatory drug use; anesthetic; soft-tissue release; and component fixation were analyzed. There was no significant difference between the groups in terms of perioperative blood loss, decrease in hemoglobin or hematocrit level, transfusion need, or incidence of wound or thromboembolic complications. Tourniquet release for hemostasis is not an effective means of limiting postoperative blood loss or reducing transfusion need after primary total knee arthroplasty
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Chronic low back pain in older adults: prevalence, reliability, and validity of physical examination findings
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Management of Hip Fractures in the Elderly
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OBJECTIVES: To develop a structured physical examination protocol that identifies common biomechanical and soft-tissue abnormalities for older adults with chronic low back pain (CLBP) that can be used as a triage tool for healthcare providers and to test the interobserver reliability and discriminant validity of this protocol.DESIGN: Cross-sectional survey and examination.SETTING: Older adult pain clinic.PARTICIPANTS: One hundred eleven community-dwelling adults aged 60 and older with CLBP and 20 who were pain-free.MEASUREMENTS: Clinical history for demographics, pain duration, previous lumbar surgery or advanced imaging, neurogenic claudication, and imaging clinically serious symptoms. Physical examination for scoliosis, functional leg length discrepancy, pain with lumbar movement, myofascial pain (paralumbar, piriformis, tensor fasciae latae (TFL)), regional bone pain (sacroiliac joint (SIJ), hip, vertebral body), and fibromyalgia.RESULTS: Scoliosis was prevalent in those with (77.5%) and without pain (60.0%), but prevalence of SIJ pain (84% vs 5%), fibromyalgia tender points (19% vs 0%), myofascial pain (96% vs 10%), and hip pain (48% vs 0%) was significantly different between groups (P < .001). Interrater reliability was excellent for SIJ pain (0.81), number of fibromyalgia tender points (0.84), and TFL pain (0.81); good for scoliosis (0.43), kyphosis (0.66), lumbar movement pain (0.75), piriformis pain (0.71), and hip disease by internal rotation (0.56); and marginal for leg length (0.00) and paravertebral pain (0.39).CONCLUSION: Biomechanical and soft tissue pathologies are common in older adults with CLBP, and many can be assessed reliably using a brief physical examination. Their recognition may save unnecessary healthcare expenditure and patient suffering
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Total hip arthroplasty in the treatment of degenerative disorders in rural and urban patients â?? A retrospective, randomised and controlled study
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Developmental Dysplasia of the Hip 2020 Review
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Introduction. Farming is hard work which may lead to overstrain and osteoarthritis of the hip and knee. Hip osteoarthritis has been rarely discussed in the Polish literature. Objective. The objective of the study was to determine the differences in hip osteoarthritis in urban and rural patients. The differences concern: prevalence, etiology, degree of degeneration and time spent in hospital. Materials and method. Hospital records of 200 patients were analysed who were divided into 2 groups. Group A consisted of 79 rural patients: 39 males (49.4%) and 40 females (50.6%), mean age 66.09 (±9.48), mean BMI â?? 27.26 (±4.47). Group B consisted of 121 urban patients: 51 males (42.1%), and 70 females (57.9%), mean age 67.74 (±8.88); mean BMI â?? 27.33 (±4.21). Results. There were no differences observed regarding hospitalization times, but statistically significant differences were noted concerning the causes of osteoarthritis in both the rural and urban patients. No statistically significant differences were found between the types of prosthetic implants. Conclusions. 1) There are no differences between rural and urban patients who received surgical treatment for hip osteoarthritis, although more patients operated upon were urban patients. 2) The degree of hip degeneration was greater in rural patients.
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Autologous platelet gel in total knee arthroplasty: a prospective randomized study
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PRP (Platelet-Rich Plasma)
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PURPOSE: Total knee arthroplasty (TKA) is often associated with major postoperative blood loss, postoperative pain, and impaired wound healing. The application of autologous platelet gel (APG), prepared from the buffy coat of a unit of autologous blood, has been advocated to improve haemostasis after surgery, to decrease perioperative blood loss, diminish postoperative pain and to enhance the wound healing process. This randomized controlled pilot study was developed to assess the effects of APG after total knee arthroplasty on blood loss, wound healing, pain, range of motion, and hospital stay. METHOD: A prospective, randomized observer blind controlled trial was performed. Forty patients with only osteoarthritis of the knee were scheduled to have a TKA, and they were randomized into two groups. Patients in the treatment group were all treated with the application of autologous platelet gel after the prosthesis was implanted. Patients in the control group were treated with the same protocol but no APG was used. RESULTS: Preoperative and postoperative Hb levels showed no significant difference and allogenic blood transfusions were not given in either group. Haematomas were significantly larger in the control group than in the platelet gel group (P = 0.03). The pain score at rest was higher in the control group on the 3rd day (P = 0.04). Wound healing disturbances were seen in four patients in the control group and in no patients in the APG group (n.s.). Range of motion of the knee was similar postoperatively. Hospital stay was 6.2 days in the APG and 7.5 days in the control group (n.s.). CONCLUSION: In this prospective randomized pilot study on APG in total knee arthroplasty, differences in favour of the use of platelet gel were found, but these were subjective evaluations, marginal in effect, or did not reach statistical significance. The use of drains might have decreased the concentration of delivered platelets and may have diminished the effect. However, in this study, a statistically significant clinically important effect in favour of platelet gel application was not found. Further studies with larger numbers of patients, and without the use of drains, are warranted to investigate the possible benefits of autologous platelet gel in total knee arthroplasty.
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Comparison of 3,000 and 5,000 IU aXa/day certoparin in the prevention of deep-vein thrombosis after total hip replacement
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PJI DX Updated Search
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Background: The aim was to investigate, whether 5,000 IUaXa/day certoparin lowers the incidence of deep vein thrombosis (DVT) in patients undergoing elective hip replacement surgery vs. 3,000 IUaXa/day. Double-blind, multicenter, randomised trial in 500 patients. Primary endpoint: incidence of symptomatic or asymptomatic DVT (bilateral ascending venography).Results: Mean age was 71 ñ 10 years with a higher prevalence of previous DVT (8vs.4%) and pulmonary embolism (PE) (4vs.1%) in the high dose group. Mean duration of surgery was 82 ñ 32 and 85 ñ 36 min. DVT was detected in 28 (11.1%) of the low dose and 35 (14.1%) of the high dose group (p = n.s.). Combined distal-proximal DVT was observed in 5 (2%) and 4 (1.6%) patients respectively. No difference in bleeding events was found.Conclusion: This trial confirms prior data showing that the conventional dosage of 3,000 IU aXa is effective and safe for the prevention of venous thromboembolic events after hip replacement surgery. é 2012 Bramlage et al.; licensee BioMed Central Ltd
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Evaluation of distal femoral rotational alignment with spiral ct scan before total knee arthroplasty (a study in iranian population)
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Pediatric Supracondylar Humerus Fracture 2020 Review
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Background: Evaluating the landmarks for rotation of the distal femur is a challenge for orthopedic surgeons. Although the posterior femoral condyle axis is a good landmark for surgeons, the surgical transepicondylar axis may be a better option with the help of preoperative CT scanning. The purpose of this study was to ascertain relationships among the axes' guiding distal femur rotational alignment in preoperative CT scans of Iranian patients who were candidates for total knee arthroplasty and the effects of age, gender, and knee alignment on these relationships. Methods: One hundred and eight cases who were admitted to two university hospitals for total knee arthroplasty were included in this study. The rotation of the distal femur was evaluated using single axial CT images through the femoral epicondyle. Four lines were drawn digitally in this view: anatomical and surgical transepicondylar axes, posterior condylar axis and the Whiteside anteroposterior line. The alignment of the extremity was evaluated in the standing alignment view. Then the angles were measured along these lines and their relationship was evaluated. Results: The mean angle between the anatomical transepicondylar axis and posterior condylar axis and between the surgical transepicondylar axis and posterior condylar axis were 5.9 ± 1.6 degrees and 1.6±1.7 degrees respectively. The mean angle between the Whiteside's anteroposterior line and the line perpendicular to the posterior condylar axis was 3.7±2.1 degrees. Significant differences existed between the two genders in these relationships. No significant correlation between the age of patients and angles of the distal femur was detected. The anatomical surgical transepicondylar axis was in 4.3 degrees external rotation in relation to the surgical transepicondylar axis. Conclusion: Preoperative CT scanning can help accurately determine rotational landmarks of the distal femur. If one of the reference axes cannot be determined, other reference axes can be used because of the good correlation between these landmarks.
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Perioperative complications of HINTEGRA total ankle replacement: our initial 50 cases
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DoD SSI (Surgical Site Infections)
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BACKGROUND: The purpose of the present study was to report the perioperative complications that occurred among our initial 50 consecutive cases of HINTEGRA total ankle replacement.
MATERIALS AND METHODS: This was a retrospective study of 50 cases composed of 30 men and 18 women of average age 57 years. Perioperative complications were used to compare the first 25 cases (Group A) with the subsequent 25 (Group B).
RESULTS: Perioperative complications occurred in 15 cases (60%) in Group A but in only five (20%) in Group B. No major wound complications requiring a soft-tissue coverage procedure were encountered. Minor wound complications occurred in three cases in each group which resolved with skin grafting or topical dressing changes. One deep infection occurred in Group A, which required implant removal and antibiotic impregnated spacer prior to revision TAR. Four patients sustained intraoperative malleolus fractures in Group A, but only one in Group B. Coronal malposition of the tibial component occurred in three cases in Group A and in two in Group B. Increased sagittal slope of the tibial component occurred in two cases in Group B and sagittal malposition of the talar component occurred in two cases in Group A. There were seven instances of anterior translation of the talar component with respect to the tibial component; four in Group A and three in Group B.
CONCLUSION: These results suggest that TAR has a steep learning curve. Moreover, knowledge of the perioperative complications of TAR may reduce the incidence of complications.
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Current trends in breast reduction
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Reduction Mammoplasty for Female Breast Hypertrophy
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Results of our study describe the long term effects of reduction mammaplasty. Many women with excessively small or large breasts have an altered personal self-image and often suffer from low self-esteem and other psychological stresses. This procedure is designed to reduce and reshape large breasts, and since the size, shape, and symmetry of a woman's breasts can have a profound effect on her mental and physical well-being it is important to observe the patient's long-term outcome. Currently, breast reduction surgery is safe, effective and beneficial to the patient. In Croatia, reduction mammoplasty is often excluded from the general health care plan. The distinction between "reconstructive" versus "cosmetic" breast surgery is very well defined by the American Society of Plastic Surgeons Board of Directors. Unfortunately, the Croatian Health Society has yet to standardize such a distinction. There is an imperative need for evidence-based selection criteria. We retrospectively analyzed data of 59 female patients suffering from symptomatic macromastia who underwent reduction mammaplasty over a 16 year period (1995 until 2011). Our aim was to compare and contrast the various techniques available for reduction mammaplasty and to determine, based on patient outcome and satisfaction, which technique is most suited for each patient. The results of our study generally reinforce the observation that reduction mammaplasty significantly provides improvements in health status, long-term quality of life, postsurgical breast appearance and significantly decrease physical symptoms of pain. A number of 59 consecutive cases were initially treated with the four different breast reduction techniques: inverted-T scat or Wisa pattern breast reduction, vertical reduction mammaplasty, simplified vertical reduction mammaplasty, inferior pedicle and free nipple graft techniques. The average clinical follow-up period was 6-months, and included 48 patients. The statistical analysis of the postoperative patient complications revealed a significant positive relationship in regards to smoking. The majority of these complications were wound related, with no significant relationship between patient complications and variables such as age, BMI, ASA score, resection weight of breast parenchyma, nipple elevation, duration of surgery, and type of pedicle. The higher number of complication correlated with a lower volume of parenchyma resection (rho=-0.321). Overall satisfaction with the new breast size (79%), appearance of the postoperative scars (87%), overall cosmetic outcome score (91%), overall outcome (100%), psychosocial outcome (46%), sexual outcome (85%), physical outcome (88%), satisfaction with preoperative information data (92%), and finally satisfaction with overall care process (96%) was calculated. As expected, the physical symptoms disappeared or were minimized in 88% of patients. Each method of breast reduction has its advantages and disadvantages. The surgeon should evaluate each patient's desires on the basis of her physical presentation. Breast reduction surgery increases the overall personal and social health; not only for the patient, but for their family and friends as well. It is an imperative that every surgeon is aware of this, in order to provide the highest level of care and quality to their patients.
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Incidence and risk factors for preoperative deep venous thrombosis in 314 consecutive patients undergoing surgery for spinal metastasis
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MSTS 2022 - Metastatic Disease of the Humerus
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Objective: The authors of this study aimed to identify the incidence of and risk factors for preoperative deep venous thrombosis (DVT) in patients undergoing surgical treatment for spinal metastases. Methods: Univariate analysis of patient age, sex, ethnicity, laboratory values, comorbidities, preoperative ambulatory status, histopathological classification, spinal level, and surgical details was performed. Factors significantly associated with DVT univariately were entered into a multivariate logistic regression model. Results: The authors identified 314 patients, of whom 232 (73.9%) were screened preoperatively for a DVT. Of those screened, 22 (9.48%) were diagnosed with a DVT. The screened patients were older (median 62 vs 55 years, p = 0.0008), but otherwise similar in baseline characteristics. Nonambulatory status, previous history of DVT, lower partial thromboplastin time, and lower hemoglobin level were statistically significant and independent factors associated with positive results of screening for a DVT. Results of screening were positive in only 6.4% of ambulatory patients in contrast to 24.4% of nonambulatory patients, yielding an odds ratio of 4.73 (95% CI 1.88-11.90). All of the patients who had positive screening results underwent preoperative placement of an inferior vena cava filter. Conclusions: Patients requiring surgery for spinal metastases represent a population with unique risks for venous thromboembolism. This study showed a 9.48% incidence of DVT in patients screened preoperatively. The highest rates of preoperative DVT were identified in nonambulatory patients, who were found to have a 4-fold increase in the likelihood of harboring a DVT. Understanding the preoperative thrombotic status may provide an opportunity for early intervention and risk stratification in this critically ill population.
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The subchondral bone plate
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AMP (Acute Meniscal Pathology)
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Pauwels (1965) and subsequent workers in the same field have shown that the distribution of the subchondral density within a joint surface can serve as a parametric measurement which reflects the main stress acting on a joint. Our own investigations on anatomical specimens have demonstrated that this subchondral mineralization does indeed show regular distribution patterns from which conclusions about the mechanical situation within an individual joint may be drawn. Since radiographical densitometry and histological methods are only available for determining the adaptive reaction of the bone to the particular mechanical situation in a joint after death, the information obtained applies only to an end situation and tells us nothing about the development of the changes with time. Furthermore, investigations carried out on human specimens by radiographical densitometry mostly apply to samples of a particular age, since such specimens can be acquired only from departments of pathology, forensic medicine or anatomy. The functional reactions of the bone tissue to repeated long-term changes in the loading--lengthy immobilization and subsequent remobilization, for instance, or heavy loading over a considerable period of time--cannot be followed by any ordinary method in experimental animals, since the death of the animal is a prerequisite for the precise quantitative examination of the bone tissue. This applies also to attempts to follow the process by means of animal experiments. CT OAM has been developed as a method which, based on CT, can provide a surface representation of the 3-D density distribution in the joints of living subjects. Comparative studies were carried out to establish and confirm the validity of the procedure. These have shown (1) that the results obtained from anatomical specimens are identical with those obtained in the living; (2) that secondary CT sections are suitable for evaluation and that the spectrum of joint surfaces examined can be extended to include the whole joint (if this were not so, effects caused by the apparatus--particularly the partial-volume effect--would render the procedure impossible); and finally (3) that the distribution of the Hounsfield density within the subchondral bone represents the distribution of the mineralization. The mineralization patterns found by us in different joints of normal subjects have shown that these patterns can be brought into line with current models of joint mechanics. The radiocarpal joint, for instance, has revealed the various types of loading occurring within physiological limits. Information has also been obtained about the age-related changes taking place in the hip, wrist and ankle joints. The increase of the total mineralization in gymnasts can be related to the qualitative and quantitative adaptation to an increased peak loading, and reduced mineralization to a lengthy reduction in use during, for instance, postoperative immobilization. In groups of patients with various diseases of mechanical origin (shoulder instability, malalignment of the main axis, defective repositioning of healed fractures, rupture of the rotator cuff, meniscectomy or rupture of the anterior cruciate ligament), a pattern of mineralization is found which is different from the normal picture. These findings reflect the abnormal mechanical situation. The mineralization pattern of the femoropatellar joint has revealed the differing etiologies of medial and lateral cartilage damage and the examination of patients with lunatomalacia has made it possible to recognize a genetic disposition. The postoperative comparison of the mineralization patterns of patients with genu varum who have undergone a correction osteotomy and the results of animal experiments on various procedures for reconstructing the anterior cruciate ligament or a primary replacement of the meniscus, have produced results which make it possible to judge the success or failure of the operation. (ABSTRACT TRUNCATED) [References: 373]
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Current meniscal allograft transplantation
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AMP (Acute Meniscal Pathology)
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Meniscal allograft transplantation is now gradually transforming from an interesting alternative in meniscal restoration algorithms to a reliable treatment of unicompartmental knee pain after meniscectomy. The past decade has allowed refinements in sizing, preservation, and fixation of the meniscal allograft. Current techniques focus on adherence to biomechanical principles in attempting to duplicate the force transfer of an intact meniscal tibial plateau construct. Although intermediate term outcome results are promising in regards to pain relief, the long term objective of articular cartilage preservation remains a goal. Copyright © 2004 by Lippincott Williams & Wilkins.
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Carpal tunnel syndrome: a case-control study evaluating its relationship with body mass index and hand and wrist measurements
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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This case-control study investigated the associations between the body mass index (BMI), hand and wrist measurements and carpal tunnel syndrome (CTS). The hands and wrists of 50 patients with CTS and 50 age- and sex-matched controls were measured. The right and left wrist indices (wrist depth/wrist width) were significantly greater in CTS patients (mean = 0.71. SD = 0.04) than in the controls (mean = 0.69 SD = 0.04). The hand index (hand length/palm width) and BMI were not significantly different in the two groups. The hand, but not the wrist, index was found to correlate with the BMI. These results provide some support for a causative association between wrist morphometry, as measured by the wrist index, and CTS, but this difference is too small to be of diagnostic value in clinical or epidemiological practice. The results could also suggest that the previously reported association between CTS and the hand index may be secondary to differences in the BMI
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Complex distal radius fractures in young patients. Comparison between external fixator and volar plate
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Distal Radius Fractures
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BACKGROUND: Distal radius fractures in young, workingâ?age patients are frequent and are associated with potential disability in case of inappropriate treatment. Our hypothesis is that there is no difference between patients treated with a volar plate and those treated with closed reduction and external fixation. METHODS: We studied 69 patients with complex distal radius fractures. They were prospectively and randomly assigned to treatment with a volar plate or an external fixator: they were followedâ?up and assessed at one year using two scales, the Visual Analog Scale (VAS) and the McDermid et al. Functionality Scale. RESULTS: Both groups showed good results at one year. Measurements in the pain Visual Analog Scale and disability measured with the McDermid et al. scale were not statistically significant. Higher scores mean greater disability. Scores above 20 were considered as failures. We found 2 cases with complications in the F group; one with material dislodgement and one with malunion, without significant differences. CONCLUSIONS: Both treatments show good results in the mediumâ?term; no differences were found between both groups regarding pain and residual disability. Complications were few and they were addressed conservatively; they were less frequent with open reduction and internal fixation. When ranges of motion and the complication rate were compared, the volar plate showed a statistically significant difference in a decreased complication risk.
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Shoulder Conditions: Clavicle and Acromioclavicular Joint Conditions
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Pediatric Supracondylar Humerus Fracture 2020 Review
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The clavicle is the most commonly fractured bone, and the most frequently fractured part of the clavicle is the middle third (ie, midshaft). X-ray usually is the first-line imaging modality for clavicle injuries. Conservative management is preferred for patients with uncomplicated and nondisplaced clavicular fractures. Typically, immobilization should last 4 weeks, then range-of-motion exercises should begin after 4 weeks, with full return to activities by 12 weeks. Distal clavicle osteolysis is a relatively uncommon pathologic bone resorption that occurs with repetitive overhead activities. Conservative management includes activity modification, nonsteroidal anti-inflammatory drugs, and injection. Surgical options also are available. Acute acromioclavicular (AC) joint injuries usually are the result of a direct blow to the superolateral shoulder with the humerus in adduction. The Rockwood classification system of AC joint injuries describes types I to VI, classified by the ligaments injured and degree of displacement. Low-grade AC joint injuries (ie, types I to III) typically can be managed nonsurgically, whereas high-grade injuries are managed with surgery. Osteoarthrosis of the AC joint manifests similarly to distal clavicle osteolysis and may be posttraumatic or idiopathic. Osteoarthrosis typically is managed with activity modification, nonsteroidal anti-inflammatory drugs, and injections but also may be managed surgically.
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First eye cataract surgery and hospitalization from injuries due to a fall: A population-based study
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Management of Hip Fractures in the Elderly
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Objectives To assess the association between first eye cataract surgery and hospitalization from injuries due to a fall in older adults at the population level. Design Retrospective population-based study. Setting Western Australian Hospital Morbidity Data System and Western Australian mortality data. Participants Six hundred individuals aged 60 and older hospitalized from injuries due to a fall between 2004 and 2008 in Western Australia. Measurements Hospital admission from injuries due to a fall. Results Of the 15,295 individuals who underwent cataract surgery in one eye only, 600 (3.9%) were involved in 625 hospital admissions from injuries due to a fall 1 year before (n = 273) or 1 year after (n = 352) first eye cataract surgery; 30% of these hospitalizations were for femoral neck fractures. Poisson generalized estimating equations confirmed 27% more (adjusted risk ratio = 1.27, 95% confidence interval = 1.04-1.56 P =.02) hospitalizations from injuries due to a fall in the year after first eye cataract surgery than in the year before. Conclusion First eye cataract surgery was associated with more hospital admissions from injuries due to a fall in the year after cataract surgery than in the year before. Further research is needed to determine the underlying causes and reasons. (copyright) 2012, Copyright the Authors Journal compilation (copyright) 2012, The American Geriatrics Society
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Favorable results after total wrist arthroplasty
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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Background and purpose During the past 40 years, several attempts have been made with total wrist arthroplasty to avoid fusion in severely destroyed wrists. The results have often been disappointing. There is only modest clinical documentation due to the small number of patients (especially non-rheumatoid cases) and short follow-up times. Here we report a multicenter series using a third-generation implant with a minimum follow-up time of 5 years. Methods In 2012, data were retrieved from a registry of consecutive wrist operations at 7 centers with units specialized in hand surgery, between 2003 and 2007. The wrists had been reviewed annually and analysis was done on the latest follow-up data. Results 60 patients had been operated (5 bilaterally), 5 wrists had been revised, and 52 were available for follow-up (with the revised cases excluded). The pain scores, QuickDASH scores, ulnar flexion, and supination for the whole group were statistically significantly better at follow-up. There were no statistically significant differences between the rheumatoid and the non-rheumatoid patients except for motion, which was better in the non-rheumatoid group. The motion obtained depended on the preoperative motion. Implant survival was 0.9 at 5-9 years. Interpretation The clinical results in terms of pain, motion, strength, and function were similar to those in previous reports. The implant survival was 0.9 at 9 years, both in rheumatoid and non-rheumatoid cases, which is an important improvement compared to the earlier generations of total wrist arthroplasty. (copyright) 2011 Nordic Orthopaedic Federation
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Triplex US in the diagnosis of asymptomatic deep venous thrombosis
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Management of Hip Fractures in the Elderly
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PURPOSE: To evaluate the accuracy of triplex ultrasound (TUS) compared with venography as a screening test for deep venous thrombosis (DVT), and to evaluate interobserver variation in the interpretation of the venographic studies. MATERIAL AND METHODS: A total of 133 postoperative hip fracture patients, asymptomatic of DVT, were prospectively examined with TUS and venography. All venograms were reviewed blindly and in case of disagreement a consensus was arrived at. RESULTS: The incidence of DVT was 20%, with isolated calf vein thrombi in 63% of the cases. There were 7 false-negative and one false-positive result/s at TUS, with a sensitivity of 74%, specificity of 99% and accuracy of 97%. The kappa values ranged from 0.58 to 0.82. The false-negative results were all caused by missed calf vein thrombi in technically inadequate examinations. At sonography 2% of vein segments were noninterpretable, compared to 29% at venography. CONCLUSION: Venous US is less sensitive as a test for DVT in this study of asymptomatic patients than in earlier studies on symptomatic patients. Still, sonographic screening of high-risk patients would be both effective and cost effective. Fresh thrombi may cause a false-negative compression test
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Median mixed and sensory nerve conduction studies in carpal tunnel syndrome
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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OBJECTIVE: To assess the sensitivities and specificities of velocity differences between median mixed nerve conduction across the wrist (Medmxpw) and (I) median mixed nerve conduction in the forearm (Medmxf) and (II) palm to D2 sensory conduction (MedpD2). DESIGN AND METHODS: We prospectively studied 67 limbs of patients with clinically definite carpal tunnel syndrome (CTS). Medmxf and Medmxpw were performed by stimulating the median nerve at the elbow and palm respectively and recording at the proximal wrist crease. We also compared conventional median sensory (D2-wrist) and mixed (palm-wrist) tests in all patients. Thirty limbs of asymptomatic subjects served as normal controls and 21 limbs of subjects with other neuropathies served as diseased controls; control data was collected prospectively. RESULTS: The sensitivity of the MedpD2-Medmxpw difference (0.87) was significantly greater than that of the Medmxf-Medmxpw difference (0.61, P < 0.001). Both tests were similar and highly specific (0.98 and 0.96, respectively). CONCLUSIONS: The MedpD2-Medmxpw study is among the most sensitive and specific electrophysiologic tests for CTS
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Effect of time-to-surgery on in-house mortality during orthogeriatric treatment following hip fracture: A retrospective analysis of prospectively collected data from 16,236 patients of the AltersTraumaRegister DGU R
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Hip Fx in the Elderly 2019
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BACKGROUND: Time-to-surgery in geriatric hip fractures remains of interest. The majority of the literature reports a significantly decreased mortality rate after early surgery. Nevertheless, there are some studies presenting no effect of time-to-surgery on mortality. The body of literature addressing the effect of an orthogeriatric co-management is growing. Here we investigate the effect of time-to-surgery on in-house mortality in a group of patients treated under the best possible conditions in certified orthogeriatric treatment units.
METHODS: We conducted a retrospective cohort registry analysis from prospectively collected data of the AltersTraumaRegister DGU R. Data were analyzed univariably, and the association of early surgery with in-house mortality was assessed with multivariable logistic regression while controlling for specified patient characteristics. Additionally, propensity score matching for time-to-surgery was applied to examine its effect on the in-house mortality rate.
FINDINGS: A total of 15,099 patients met the inclusion criteria. The median age was 85 years (IQR 80-89), and 72.1% were female. The overall in-house mortality rate was 5.5%. Most (71.2%) of the patients were treated within 24 h, and 91.6% within 48 h. Neither the multivariable logistic regression model nor the propensity score matching indicated that early surgery was associated with a decreased mortality rate. The most important indicators for mortality were ASA >= 3 [Odds ratio (OR) 3.4, 95% confidence interval (CI) 2.35-5.11], fracture event during inpatient stay (OR 2.6, 95% CI 1.48-4.3), ISAR >= 2 (OR 1.88, 95% CI 1.33-2.76), and male gender (OR 1.71, 95% CI 1.39-2.09).
INTERPRETATION: Our results suggest that for those patients, who were treated in an orthogeriatric co-management under the best possible conditions, there are no significant differences regarding in-house mortality rate between the time-to-surgery intervals of 24 and 48 h or slightly above. This and the comparatively small number of patients who underwent surgery after 24 h show that an extension of the pre-surgery interval, justified by an orthogeriatric treatment team, will not be detrimental to the affected patients.
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Ultrasound-Guided Prolotherapy with Polydeoxyribonucleotide for Painful Rotator Cuff Tendinopathy
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Trial Systematic Review Project
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Background. Rotator cuff tendinopathy is a primary cause of shoulder pain and dysfunction. Several effective nonsurgical treatment methods have been described for chronic rotator cuff tendinopathy. Prolotherapy with polydeoxyribonucleotide (PDRN), which consists of active deoxyribonucleotide polymers that stimulate tissue repair, is a nonsurgical regenerative injection that may be a viable treatment option. The objective of this study was to assess the efficacy of PDRN in the treatment of chronic rotator cuff tendinopathy. Method. The records of patients with chronic rotator cuff tendinopathy (n=131) were reviewed retrospectively, and the patients treated with PDRN prolotherapy (n=32) were selected. We measured the main outcome of the shoulder pain and disability index score on a numerical rating scale of average shoulder pain. Results. Compared with baseline data, significant improvements in the shoulder pain and disability index and pain visual analog scale scores were demonstrated at one week after the end of treatment, and at one month and three months later. Conclusions. PDRN prolotherapy may improve the conservative treatment of painful rotator cuff tendinopathy for a specific subset of patients.
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Dynamic definition mini-lipoabdominoplasty combining multilayer liposculpture, fat grafting, and muscular plication
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Panniculectomy & Abdominoplasty CPG
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BACKGROUND: There is a select group of women for whom mini-abdominoplasty techniques combined with 3-dimensional liposculpture and fat grafting can effectively correct postpartum deformities. OBJECTIVE: The authors describe a multilayer and 360-degree approach, dynamic definition mini-abdominoplasty (DDM), to create athletic definition and contour and to restore a feminine appearance postpartum. METHODS: A total of 181 consecutive women ages 20 to 56 years underwent DDM between January 2005 and May 2012. Patients who were a minimum of 6 months postpartum and in good health, with a body mass index below 30, were considered for inclusion in the study. Fat grafting was performed in select cases in the buttocks, deltoids, and/or calves. A satisfaction index (SI) was estimated based on patient survey responses. RESULTS: An overall SI of 91.5% was achieved. No major complications were reported. Twenty-nine minor complications included postoperative anemia, seroma, and infection in the surgical wound. In most patients, the postpartum abdomen was restored to an aesthetic and even athletic appearance. Athletic definition to the rectus, arms, trunk, thighs, and buttocks was also achieved. No burns or flap necrosis were reported. CONCLUSIONS: Dynamic definition mini-abdominoplasty is safe and reproducible. It serves as a viable alternative to a full abdominoplasty in selected cases and for women who wish to restore an athletic and feminine appearance after childbirth. LEVEL OF EVIDENCE: 4.
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A new dimension to outcome: application of the Bath Ankylosing Spondylitis Radiology Index
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Management of Hip Fractures in the Elderly
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Our aim was to develop a reproducible and simple radiological scoring system for ankylosing spondylitis (AS) to use in cross sectional and prospective studies. Regarding validation of the BASRI (Bath Ankylosing Spondylitis Radiology Index), radiographs of 470 patients with AS were scored using the New York criteria for the sacroiliac joints. The lumbar and cervical spine, and hips were similarly graded 0-4. These scores were added together to give BASRI-t (total) and if the hips are excluded to give BASRI-s (spine). Radiographs of 188 patients were used to test reproducibility. Blinded radiographs of 89 non-AS patients were included randomly to assess disease specificity. Sensitivity to change was assessed using 177 radiographs from 40 patients. Regarding the cross sectional study, 2200 radiographs of 550 (104 F:446 M) patients were randomly selected and scored using BASRI. The frequency distribution of BASRI-t and BASRI-s were plotted using a probit plot. Inter and intraobservation showed between 73 and 82% and 73 and 88% complete agreement, with specificity of 0.78-0.89, suggesting scores are disease-specific. Sensitivity to change became apparent at 2 years (p<0.05). Scoring required 30 seconds to complete. BASRI-t was found to be normally distributed using a probit plot. The mean BASRI scores (total, spinal, hip) increased with disease duration. The correlation, however, was poor (r=0.293, 0.347, 0.263, respectively). Those with hip involvement had more severe spinal disease (p<0.0001). Men had more severe spinal disease than women (p<0.0001). We conclude BASRI is a reliable and rapid method to grade radiographic changes in AS. Using this scoring system it can be seen that AS is a slowly progressive disease with much individual variation. Hip patients have more severe spinal disease than those without hip involvement and men have more severe spinal disease than women
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The 5 and 11 Factor Modified Frailty Indices are Equally Effective at Outcome Prediction Using TQIP
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Hip Fx in the Elderly 2019
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BACKGROUND: The 5-factor modified frailty index (mFI-5) and the 11-factor modified frailty index (mFI-11) are equally effective in predicting adverse outcomes in the American College of Surgeons National Surgical Quality Improvement Program database. The similarly structured American College of Surgeons Trauma Quality Improvement Program (TQIP) database has not been studied with these two frailty indices. We hypothesized that the mFI-5 and mFI-11 could similarly predict adverse outcomes with TQIP data.
METHODS: The mFI-5 and mFI-11 were calculated for each patient comprising our institutional TQIP registry (2016-2018). Spearman rho was calculated to assess correlations between the two indices across multiple predefined TQIP patient cohorts. Complications were stratified by frailty score for each index. Multivariable logistic regression models adjusting for age, Glasgow Coma Scale score, and Injury Severity Score were created to assess each mFI's association with any complication and discharge dispositions (home, facility, and expired).
RESULTS: There were 8467 patients. Spearman rho was >0.9 (P < 0.0001) for all patient cohorts except elderly, elderly blunt multisystem, and isolated hip fractures. Increasing frailty scores for both mFIs were associated with greater rates of acute kidney injury (P < 0.0001), myocardial infarction (P < 0.001), severe sepsis (P < 0.05), unplanned return to the intensive care unit (P < 0.0001), and unplanned intubation (P < 0.0001). On separate multivariable logistic regressions, the mFI-5 and mFI-11 were each predictive of any complication (P < 0.0001) and a facility discharge (P < 0.001). Neither the mFI-5 nor the mFI-11 were associated with mortality (P > 0.05).
CONCLUSIONS: The mFI-5 and mFI-11 are highly correlated across several TQIP patient cohorts. They also are both predictive of complications and discharge dispositions; however, neither index can predict mortality. Given its ease of use, the mFI-5 may be a better option for identifying frail patients and predicting adverse outcomes at the point of care in trauma.
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Extensor mechanism repair failure with use of bidirectional barbed suture in total knee arthroplasty
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Surgical Management of Osteoarthritis of the Knee CPG
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Total knee arthroplasty (TKA) continues to advance as innovative devices become available. #2 PDO Quill SRS (Angiotech, Reading, Pa) bidirectional barbed suture was used for 161 primary TKAs at our facility. We report on 3 separate cases of extensor mechanism repair failure after primary TKA in which a barbed suture was used for extensor mechanism closure. Before the implementation of this device, there were no reported failures in 385 primary TKAs. We recommend that surgeons who use this device for extensor mechanism repair of a medial parapatellar arthrotomy in TKA exercise caution when operating on patients with morbid obesity, diabetes, and rheumatoid arthritis. We have discontinued use of the bidirectional barbed suture until more definitive large orthopedic studies establish its efficacy and safety
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0 |
Achromatic doublet intraocular lens for full aberration correction
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Upper Eyelid and Brow Surgery
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A doublet intraocular lens optimized for both chromatic and monochromatic aberration correction in pseudophakic eyes is presented. Ray-tracing techniques were applied to design the lens in white light within a chromatic eye model. Combinations of two materials, already commonly used in intraocular lenses, as acrylic and silicone, were used. Iterative optimization algorithms were employed to correct for longitudinal chromatic aberration, spherical aberration and off-axis aberrations within 10 degrees of visual field. The performance of this lens was compared with a standard single-material aspheric intraocular lens. Near full aberration correction was achieved with the doublet intraocular lens. The modulation transfer function and Strehl ratio were superior for the doublet lens. Through-focus calculations were also conducted showing better optical quality for the doublet. Real higher-order aberrations from normal eyes were incorporated in the model to evaluate the effect on the doublet intraocular lens performance. Results showed that the doublet lens preserved its benefits under realistic conditions. This doublet intraocular lens should provide patients with a better quality of vision after it is further developed in terms of manufacturing and surgical limitations.
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0 |
Suture Anchor Refixation of Meniscal Root Tears Without an Additional Portal
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OAK 3 - Non-arthroplasty tx of OAK
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The biomechanical consequences of a tear of the posterior root of the medial meniscus are comparable to that of a complete meniscectomy. The integrity of the meniscal roots is crucial to enable the important function of load sharing and shock absorption. An untreated root tear leads to extrusion and loss of function of the meniscus causing early degenerative arthritis of the respective knee compartment. Meniscal root repair can be achieved by 2 main techniques: indirect fixation using pullout sutures through a transtibial tunnel with extracortical fixation and direct fixation using suture anchors. Pullout sutures are prone to elongation or abrasion of the suture material due to the length of the bone tunnel. Current suture anchor techniques are challenging as they require an additional posterior portal with higher risk of damage to neurovascular structures. Even with the use of specially designed curved passing devices, secure insertion of the anchor is difficult. We present a technique for suture anchor refixation of the posterior root of the medial meniscus without the need for an additional posterior portal.
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1 |
Osteoarthritis year in review 2017: rehabilitation and outcomes
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OAK 3 - Non-arthroplasty tx of OAK
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OBJECTIVE: The purpose of this systematic review was to describe studies examining rehabilitation for people with osteoarthritis (OA) and to summarize findings from selected key systematic reviews (SRs) and randomized controlled trials (RCTs).
DESIGN: A systematic search was performed using Pubmed, Embase and Cochrane databases from April 1<sup>st</sup> 2016 to May 15<sup>th</sup> 2017 using the terms 'osteoarthritis', 'randomized controlled trial', and 'systematic review'. Inclusion criteria were: clinically or radiologically diagnosed patients with OA, rehabilitation treatment, RCT or SRs. A selection of the included studies is discussed based on study quality and perceived importance to the field; including those that are innovative, inform the direction of the field or generate controversy. Methodological quality of the included studies was assessed using the PEDro-scale for RCTs and the Amstar guideline for SRs.
RESULTS: From 1211 articles, 80 articles met the eligibility criteria including 21 SRs and 61 RCTs. The median of the methodological quality of the SRs and RCTs was 7 (2-9) and 6 (3-10), respectively. The studies were grouped into several themes, covering the most important rehabilitation fields.
CONCLUSIONS: Striking is the small number of studies investigating another joint (18%) than the knee (82%). Exercise is the most common treatment evaluated and should be accompanied with education to effectuate a behavioural change in physical activity of people with OA. No new insights in the field of braces (or orthoses) and in the field of acupuncture were found.
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0 |
Bone histology at autopsy and matched bone scintigraphy findings in patients with hormone refractory prostate cancer: the effect of bisphosphonate therapy on bone scintigraphy results
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MSTS 2018 - Femur Mets and MM
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Bisphosphonates (BisP) are non-metabolized compounds with high bone affinity used in bone metastasis diagnosis and treatment. Currently, BisP are used to treat hypercalcemia of malignancy as well as to prevent, minimize, or delay skeletal morbidity. These compounds have a long half-life in bone. Thus long-term BisP treatment might saturate bone and interfere with a single-dose scanning agent used for bone scintigraphy when visualizing bone metastases. In an effort to answer this question, this study evaluated the concordance of histology and Technetium99 methylene diophosphonate (Tc99 MDP) bone scintigraphy in the diagnosis of bone metastases in prostate cancer patients. We assessed the concordance of findings between bone scintigraphy and histology using 188 bone biopsies from 11 autopsied patients who died with metastatic prostate cancer, 5 of whom were treated with pamidronate for 2 to 13 months before death. Overall agreement between histology and bone scintigraphy was 84%, 86% in non-pamidronate-treated patients and 82% in pamidronate-treated patients. Scintigraphic bone metastases without histological metastasis (false negatives = 12.7%) were observed in 24 anatomic locations; half of these were in one patient who had been treated with pamidronate and had no histological bone response to the carcinoma. There were only 4 sites where a positive bone scan was not associated with histologic metastasis (false positives = 2.21%). There was no statistical difference between the treated and non-treated group for concordance, specificity, sensitivity, positive and negative predictive values of bone scintigraphy and prevalence of histological abnormality. Long-term pamidronate treatment of prostate cancer bone metastases does not generally affect the ability to detect bone metastases with Tc99 MDP bone scintigraphy.
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0 |
In-hospital mortality and unintentional falls among older adults in the United States
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Hip Fx in the Elderly 2019
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Purpose of the Study: To estimate the odds of death associated with documented unintentional falls and acute care hospitalization among older adults in the United States. Design and Method: Data were abstracted from the 2005 Nationwide Inpatient Sample (NIS) and odds of death were modeled using logistic regression. Results: The age 65 and older fall rate per 1,000 discharges was 53.0 while the mortality rate for those who fell was 33.2. Older-old (odds ration [OR] = 2.93; confidence interval [CI] = [2.50, 3.43]), men (OR = 1.64, CI = [1.54, 1.75]), and non-White (OR = 1.09; CI = [1.01, 1.19]) had higher odds of death compared to younger-old, women, and Whites. Additional comorbidity (OR = 3.41, CI = [3.05, 3.82]), dehydration (OR = 1.14; CI = [1.05, 1.25]) and intracranial fractures (OR = 4.46; CI = [4.02, 4.95]) resulted in greater odds of death. Implications: Among older adults who experienced a fall and hospitalization, odds of mortality appear influenced by factors beyond injury severity related to falling. Additional research is necessary to delineate the mechanisms behind these phenomena to inform the public about falls-prevention programs. © The Author(s) 2012.
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Management of osteoarthritis of the knee by primary care physicians
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AAHKS (4) Acetaminophen
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BACKGROUND: Most patients with osteoarthritis (OA) are treated by primary care physicians (in this article, primary care physicians are family physicians and general internists).
OBJECTIVE: To describe and compare the self-reported practice patterns of family physicians and general internists for the evaluation and management of severe OA of the knee, including factors that might influence referral for total knee replacement.
DESIGN, SETTING, AND PARTICIPANTS: A survey was developed and mailed to randomly selected community family physicians and general internists practicing in Indiana.
MAIN OUTCOME MEASURE: Self-reported physician practice patterns regarding OA of the knee.
RESULTS: Physical examination was the most common method of evaluating OA of the knee. Family physicians were more likely to examine for crepitation, joint stability, and quadriceps muscle strength than were general internists (P<.05). Patients with OA of the knee treated by family physicians were more likely to receive nonsteroidal anti-inflammatory drugs or oral corticosteroids and were less likely to receive aspirin, acetaminophen, or narcotics compared with patients treated by general internists. Six patient characteristics were rated as positive factors favoring a referral for possible total knee replacement, 8 characteristics were rated as negative, and 5 were rated as not a factor in the decision about referral.
CONCLUSIONS: Results from this study suggest that additional research is needed to determine the evaluative techniques for OA of the knee that provide the most useful information for management decisions, the management techniques that maximize patient outcomes, and the criteria that should be used to select patients who would benefit most from referral for possible total knee replacement.
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Incidence of positive intraoperative allograft cultures used in knee ligament reconstruction
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Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures
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Soft-tissue allografts are valuable options in knee ligament reconstructive surgery. The purpose of this study was to determine the risk of soft-tissue contamination before implantation and the occurrence of infection after implantation in patients who received soft-tissue allografts for knee reconstructive procedures. A retrospective review of medical records was performed for patients who had undergone knee ligament surgery with allograft tissues at one institution between 1993 and 2004. Cultures were positive in 6 (5.7%) of 105 cases. Coagulase-negative Staphylococcus was the most common organism. None of these patients developed postoperative infections. The culture-positive group had a longer period of joint effusion postoperatively, compared with the culture-negative group (14.2 weeks versus 9.6 weeks). Patients with positive cultures required no additional treatment other than close observation
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0 |
Treatment of multiple myeloma with etidronate: results of a multicentre double-blind study. Groupe d'Etudes et de Recherches sur le Myelome (GERM)
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MSTS 2018 - Femur Mets and MM
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OBJECTIVES: Because osteoclastic bone resorption is stimulated in multiple myeloma, we evaluated the efficacy of etidronate in this disease, in a multicentre controlled study.
METHODS: Ninety-four previously untreated patients with stage II or III multiple myeloma received, in addition to the same chemotherapy, 10 mg/kg/day etidronate per os (n = 49) or placebo (n = 45) for 4 months. The evaluation was clinical (pain, Karnofsky, survival), biological and radiological. Forty-one patients had iliac bone biopsy before the treatment and 34 patients also at the end of the study. Histologic bone parameters were compared with 49 normal controls.
RESULTS: No statistical difference was found between etidronate and placebo treated patients for clinical, biological and radiological parameters. Compared with controls, pretreatment biopsies showed markedly increased bone resorption and decreased trabecular bone volume. Bone resorption decreased significantly in patients with etidronate compared with those with placebo (p < 0.05).
CONCLUSION: Though we found no clinical, biological and radiological difference with placebo, etidronate inhibited the increased bone resorption in multiple myeloma.
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1 |
Choice of desflurane or propofol for the maintenance of general anesthesia does not affect the risk of periprocedural myocardial damage in patients undergoing transfemoral transcatheter aortic valve implantation
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Hip Fx in the Elderly 2019
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Purpose: This study aimed to reveal whether the occurrence of periprocedural myocardial damage (PMD) decreases in patients who received volatile anesthetics to maintain general anesthesia compared with those who received propofol during transcatheter aortic valve implantation (TAVI). Methods: We included one hundred and forty adult patients who underwent transfemoral TAVI under general anesthesia from January 2015 to March 2017 in this single-center retrospective review. We compared the rate of patients who developed PMD between those who received desflurane (Group D, n = 72) and propofol (Group P, n = 68) for anesthetic maintenance. PMD was represented by the peak levels of creatine kinase myocardial band (CK-MB) and troponin I within 72 h following the procedure and defined as an increase >5 times in CK-MB or >15 times in troponin I compared with the institutional upper reference limits. Further analysis was performed to identify the independent predictors of PMD. Results: There was no significant difference in the rate of PMD between groups (Group D 72.2% to Group P 70.6%, P = 0.85) or levels of CK-MB (Group D 7.85 [1.3â??72.7] ng/mL to Group P 8.45 [1.8â??49.7] ng/mL; P = 0.59) and troponin I (Group D 1.061 [0.050â??10.8] ng/mL to Group P 1.214 [0.036â??29.0] ng/mL; P = 0.97). The risk of PMD was higher in patients with more intraprocedural blood loss (odds ratio 1.49 per 100 mL, P = 0.048) and lower in those with an implanted permanent pacemaker (odds ratio 0.17; P = 0.02). Conclusions: Desflurane does not appear to be more cardioprotective than propofol when used for anesthetic maintenance in patients undergoing transfemoral TAVI.
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Vertical Sculpted Pillar Reduction Mammaplasty in 317 Patients: Technique, Complications, and BREAST-Q Outcomes
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Panniculectomy & Abdominoplasty CPG
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Background The senior author (JCG) has described the vertical sculpted pillar breast reduction. Objectives This manuscript aimed to compare this technique's safety profile to other established techniques via complication rate reporting. Few studies have utilized the BREAST-Q for long-term outcomes reporting in bilateral reduction mammaplasty patients. BREAST-Q outcome comparisons, between cosmetic and insurance-based breast reduction cohorts, have not been previously reported. Methods A retrospective chart review was performed on patients who underwent reduction mammaplasty using the vertical sculpted pillar technique. The BREAST-Q postoperative reduction mammaplasty module was administered. Complication rates and outcomes data were compared among patient cohorts distinguished by pedicle, scar pattern, and payor population. Statistically significant differences were set at P <. 05. Results Compared to the superior pedicle, use of the superomedial pedicle statistically increased rates of postoperative fat necrosis in this series. Complication rates did not differ among scar patterns, but use of a J, L-shaped, or short-T scar decreased the need for secondary/revisional surgery. Cosmetic and insurance-based outcomes did not differ in any domain of the postoperative reduction mammaplasty BREAST-Q module. Conclusions Complications data for the vertical sculpted pillar reduction mammaplasty were comparable to published results for other techniques. Complication rates are unaffected by scar pattern. Superomedial pedicle selection and larger insurance-based reductions may predispose to statistically significant increases in fat necrosis compared to use of the superior pedicle. Payor source neither affects the majority of complication rates, nor BREAST-Q satisfaction and quality of life domains. This information can be used to improve management of expectations during the preoperative consultation process. Level of Evidence 4 Therapeutic .
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1 |
Motor unit number estimation and motor unit action potential analysis in carpal tunnel syndrome
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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OBJECTIVE: To evaluate the clinical significance of motor unit number estimation (MUNE) and quantitative analysis of motor unit action potential (MUAP) in carpal tunnel syndrome (CTS) according to electrophysiologic severity, ultrasonographic measurement and clinical symptoms. METHOD: We evaluated 78 wrists of 45 patients, who had been diagnosed with CTS and 42 wrists of 21 healthy controls. Median nerve conduction studies, amplitude and duration of MUAP, and the MUNE of the abductor pollicis brevis were measured. The cross sectional area (CSA) of the median nerve at the pisiform and distal radioulnar joint level was determined by high resolution ultrasonography. Clinical symptom of CTS was assessed using the Boston Carpal Tunnel Questionnaire (BCTQ). RESULTS: The MUNE, the amplitude and the duration of MUAP of the CTS group were significantly different from those found in the control group. The area under the ROC curve was 0.944 for MUNE, 0.923 for MUAP amplitude and 0.953 for MUAP duration. MUNE had a negative correlation with electrophysiologic stage of CTS, amplitude and duration of MUAP, CSA at pisiform level, and the score of BCTQ. The amplitude and duration of MUAP had a positive correlation with the score of BCTQ. The electrophysiologic stage was correlated with amplitude but not with the duration of MUAP. CONCLUSION: MUNE, amplitude and duration of MUAP are useful tests for diagnosis of CTS. In addition, the MUNE serves as a good indicator of CTS severity
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0 |
Immediate intramedullary flexible nailing of open pediatric tibial shaft fractures
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DoD SSI (Surgical Site Infections)
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BACKGROUND: Flexible nailing has become the preferred implant for pediatric patients with tibial shaft fractures that require operative fixation. Immediate definitive fracture fixation with flexible nails in patients with high-energy, open fractures has not been examined. The purpose of our study was to determine if immediate flexible nailing of open pediatric tibial shaft fractures is safe and efficacious from a bone healing, wound, and infectious standpoint.
METHODS: A retrospective review of 26 tibial shaft fractures consecutively treated with flexible nailing at our institution from 2003 to 2010 was performed. Age, mechanism of injury, associated injuries, presence of compartment syndrome, antibiotic administration, systemic insults, time to union, as well as bone healing (nonunion, delayed union, malunion, leg length discrepancy, growth arrest), wound, and infectious complications were collected. Comparisons were made between patients with open fractures and those with closed fractures.
RESULTS: We identified 14 patients with open fractures and a control group of 12 patients with closed injuries who underwent flexible nailing. Patients with open fractures were more likely to have polytraumatic injuries (71.0% vs. 25.0%, P = 0.04). There was no difference (P = 1.0) in the rates of compartment syndrome (open = 14.0%, closed = 17.0%) between the 2 groups. Systemic complications (pulmonary compromise and increased intracranial pressure) were noted in 2 patients who underwent immediate nailing of their open fractures; both of whom had closed head injuries. There was no difference (P = 1.0) in the rates of wound/infectious complications between the open (7.0%) and closed (4.0%) fractures groups, with no cases of wound breakdown or osteomyelitis. There was an increased rate (P = 0.02) of bone healing complications in the open fracture group (21.0% vs. 4.0%); all in patients with Gustilo type 2 or 3 injuries. All patients achieved radiographic union at final follow-up.
CONCLUSIONS: Immediate flexible nailing of open pediatric tibial shaft fractures can be safely performed with minimal risk of wound or infectious complications. Clinicians should understand that prolonged bone healing (particularly in Gustilo type 2 or 3 injuries) should be expected in patients who undergo immediate flexible nailing of their open fractures. Open tibial shaft fractures are high-energy injuries, and should be seen as surrogate markers of polytrauma in the pediatric population. The risk of compartment syndrome is high regardless of whether a patient has a closed or open tibia fracture, and caution should be used in performing flexible nailing in patients who may have closed head injury due to a risk of systemic complications.
LEVEL OF EVIDENCE: Level III, therapeutic study, retrospective cohort.
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0 |
Carpal tunnel syndrome and motor vehicle accidents
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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Carpal tunnel syndrome can result from acute injury, as indicated by a retrospective study. Symptoms of carpal tunnel syndrome developed in 96 patients within 2 months after an automobile accident. Forty-four (46%) of these 96 patients underwent carpal tunnel release. It is postulated that the mechanism of injury is blunt trauma from the steering wheel or dashboard
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0 |
Salvaging the Infected Breast Tissue Expander: A Standardized Multidisciplinary Approach
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PJI DX Updated Search
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BACKGROUND: Infections of breast tissue expander (TE) are complex, often requiring TE removal and hospitalization, which can delay further adjuvant therapy and add to the overall costs of breast reconstruction. Therefore, to reduce the rate of TE removal, hospitalization, and costs, we created a standardized same-day multidisciplinary outpatient quality improvement protocol for diagnosing and treating patients with early signs of TE infection. METHODS: We prospectively evaluated 26 consecutive patients who developed a surgical site infection between February 2013 and April 2014. On the same day, patients were seen in the Plastic Surgery and Infectious Diseases clinics, underwent breast ultrasonography with or without periprosthetic fluid aspiration, and were prescribed a standardized empiric oral or intravenous antimicrobial regimen active against biofilm-embedded microorganisms. All patients were managed as per our established treatment algorithm and were followed up for a minimum of 1 year. RESULTS: TEs were salvaged in 19 of 26 patients (73%). Compared with TE-salvaged patients, TE-explanted patients had a shorter median time to infection (20 vs 40 days; P = 0.09), a significantly higher median temperature at initial presentation [99.8 degrees F; interquartile range (IQR) = 2.1 vs 98.3 degrees F; IQR = 0.4 degrees F; P = 0.01], and a significantly longer median antimicrobial treatment duration (28 days; IQR = 27 vs 21 days; IQR = 14 days; P = 0.05). The TE salvage rates of patients whose specimen cultures yielded no microbial growth, Staphylococcus species, and Pseudomonas were 92%, 75%, and 0%, respectively. Patients who had developed a deep-seated pocket infection were significantly more likely than those with superficial cellulitis to undergo TE explantation (P = 0.021). CONCLUSIONS: Our same-day multidisciplinary diagnostic and treatment algorithm not only yielded a TE salvage rate higher than those previously reported but also decreased the rate of hospitalization, decreased overall costs, and identified several clinical scenarios in which TE explantation was likely
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Postoperative pain management after total knee arthroplasty in elderly patients: treatment options
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AAHKS (8) Anesthetic Infiltration
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Total knee arthroplasty (TKA) is a common surgical procedure in the elderly and is associated with severe pain after surgery and a high incidence of chronic pain. Several factors are associated with severe acute pain after surgery, including psychological factors and severe preoperative pain. Good acute pain control can be provided with multimodal analgesia, including regional anesthesia techniques. Studies have demonstrated that poor acute pain control after TKA is strongly associated with development of chronic pain, and this emphasizes the importance of attention to good acute pain control after TKA. Pain after discharge from hospital after TKA is currently poorly managed, and this is an area where increased resources need to be focused to improve early pain control. This is particularly as patients are often discharged home within 4-5 days after surgery. Chronic pain after TKA in the elderly can be managed with both pharmacological and non-pharmacological techniques. After excluding treatable causes of pain, the simplest approach is with the use of acetaminophen combined with a short course of non-steroidal anti-inflammatory drugs (NSAIDs). Careful titration of opioid analgesics can also be helpful with other adjuvants such as the antidepressants or antiepileptic medications used especially for patients with neuropathic pain. Topical agents may provide benefit and are associated with fewer systemic side effects than oral administration. Complementary or psychological therapies may be beneficial for those patients who have failed other options or have depression associated with chronic pain.
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0 |
Risk of SARS-CoV-2 transmission to medical staff and patients from an exposure to a COVID-19-positive ophthalmologist
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Coronavirus Disease 2019 (COVID-19)
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PURPOSE: To evaluate the risk of transmission of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) after exposure to a COVID-19+ physician in a retina clinic. METHODS: A retrospective observational study. Records of 142 patients and 11 staff members from a single retina clinic that were exposed to a COVID-19+ ophthalmologist were reviewed. All 153 individuals were placed in quarantine for 14 days. They were contacted after the quarantine period to inquire about symptoms consistent with COVID-19, and the results of diagnostic test for SARS-CoV-2 when performed. RESULTS: All patients (nâ??=â??142) were contacted successfully. The mean age was 72.8â??±â??13.6 years; 54.2% (nâ??=â??77) were females. Twenty-three patients (16.2%) were exposed during an ophthalmic exam, 111 (78.2%) during intraocular injection, 4 (2.8%) underwent exam and injection, 3 (2.1%) underwent surgery, and one patient (0.7%) had laser photocoagulation. Half of the patients (50%; nâ??=â??71) were in contact with the COVID-19+ physician while he was symptomatic. Forty-four patients (31%) wore a mask on the day of their visit. 11.3% (nâ??=â??16) of the patients, and all involved staff had been tested for the virus and all were negative. One patient (0.7%) reported transient cough and sore throat, and the remaining 141 (99.3%) patients and 11 (100%) staff did not develop symptoms. CONCLUSIONS: Low risk for SARS-CoV-2 transmission in the ophthalmic setting was observed when universal safety measures such as social distancing, meticulous hand hygiene, enlarged breath shields, and mask wear during procedures were taken.
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0 |
Extensor mechanism allografts in total knee arthroplasty
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DoD LSA (Limb Salvage vs Amputation)
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Forty knees in 40 patients who had a chronic extensor mechanism disruption after knee arthroplasty underwent extensor mechanism allograft placement to restore extensor function. Thirteen knees were infected previously and 11 knees did not respond to previous attempts at direct extensor repair or reconstruction. Two patients died and two patients underwent above the knee amputation because of recurrent infection. The final group of 36 patients was studied for a mean followup of 3.6 years (range, 2-10 years). Clinical evaluations were performed using a modified Knee Society scoring system. The average range of motion in the entire group of patients was 1.4 degrees extension to 98 degrees flexion. The average extensor lag was 13 degrees in 15 of 36 patients. There were eight extensor allograft ruptures, which were treated by repeat extensor allograft placement. The average knee scores for function improved from 37 points preoperatively to 68 points postoperatively. Despite these initial ruptures, 34 of 36 patients had a successful clinical result. These results support the use of this technique for complete extensor mechanism loss after knee arthroplasty when direct repair is unfavorable.
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0 |
Use of protective eyewear in U.S. children: Results from the National Health Interview Survey
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DoD PRF (Psychosocial RF)
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Purpose: To study use of protective eyewear in children who participated in activities that can cause eye injury. Methods: National Health Interview Survey (NHIS) data from 2002 were used to analyze protective eyewear use by children who participated in activities that can cause eye injury. Weighted percentages and 95% confidence intervals (CI) of the sociodemographic characteristics of children who wore protective eyewear were analyzed. Odds ratios (OR) were estimated in logistic regression models. Results: In the 2002 NHIS, 3,901 children aged 6-17 years (51% of interviewed children) participated in activities that can cause eye injury, but while doing so, only 14.5% of children wore protective eyewear. After controlling for potentially confounding effects of study variables, females were less likely to wear protective eyewear than males (OR = 0.61; 95% CI: 0.48-0.76) and children aged 12-17 years were more likely to wear protective eyewear than children aged 6-8 years (12-14 year olds: OR = 1.72, 95% CI: 1.20-2.46; 15-17 year olds: OR = 1.60; 95% CI: 1.11-2.31). Race/ethnicity, parent's education, family structure, poverty status, and region of United States residence did not have significant influence on protective eyewear use. Conclusions: To achieve the Healthy People 2010 objective of 20% of children using protective eyewear in recreational activities and hazardous situations around the home, intervention/education programs must continue to be improved and implemented. Copyright © 2007 Informa Healthcare.
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0 |
A randomized comparative evaluation of two approaches for posterior lumbar plexus block using real time ultrasound guidance-a pilot study
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Surgical Management of Osteoarthritis of the Knee CPG
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Introduction: Lumbar plexus block (LPB) is a well accepted method for post operative analgesia in patients undergoing lower limb surgery. Karmakar et al reported an approach using an paramedian in-plane ultrasound probe in a case series of 5 patients. They found it impossible to visualize the whole path of the needle while using real-time ultrasound due to the plexus depth and steep angle of insertion. Capdevila et al described an approach contacting the transverse process and advancing inferior to it. We add off-plane ultrasound guidance to this approach to position the needle on the transverse process with the probe in transverse axis. Adding USS allows visualization of needle tip location with hydro-location and estimation of depth of deeper structures. Methods: 19 patients undergoing total knee arthroplasty were randomized to receive one of the two approaches. We hypothesized that off-plane needle insertion for lumbar plexus would be quicker and woulf result in higher success rate compared to an in-plane approach. Block onset was checked every 5 minutes for 30 minutes. Pain scores were collected for 48 hours. Patients were followed up at one week. Results: 19patients underwent randomization. Demographic data were similar between groups: (Table presented) Visualization of the lumbar plexus and adjacent structures while in-plane could be clear but was frequently challenging, requiring 40% of the in-plane blocks to be converted to off-plane. (Figure presented) There were no significant difference in procedure times, block success rates or postoperative verbal reported pain scores (VRS) between the two groups. No adverse events occurred. (Table presented) Discussion: Visualization of anatomical structures was frequently difficult. Despite this pain scores were low. Due to the steep needle angle and plexus depth, visualization of the needle tip is likely to remain a challenge in a significant proportion of patients. The off-plane approach can be viewed as a useful extension of the nerve-stimulator technique
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Clinical phase I/II trial of SVF therapy for cartilage regeneration: a cellular therapy with novel 3D MRI imaging for evaluating chondral defect of knee osteoarthritis
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AMP (Acute Meniscal Pathology)
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Background: The clinical applications of stromal vascular fraction (SVF) therapy for osteoarthritis (OA) have attracted academic and clinical attention. However, data of the effects of stromal vascular fraction therapy on regeneration of degenerated cartilage are limited in the literature. Meanwhile, there is a great need for a simple and non-invasive evaluation method to analyze the changes of joint cartilage qualitatively and quantitatively in clinical trials. This study entitled “stromal vascular fraction Therapy for Human Knee Osteoarthritis” was registered in ClinicalTrial.gov # NCT05019378. Materials and Methods: We designed and conducted a single center, open labeled clinical phase I/II study, and 6 osteoarthritis patients with both knee cartilage defect I-II were enrolled in this study. The two knees of each patient were randomly assigned to autologous stromal vascular fraction treatment group or non-treatment control group to evaluate the safety and therapeutic effect of stromal vascular fraction therapy for human knee osteoarthritis. We have also established a novel protocol to provide 3D MRI imaging for human knee cartilage enabling us to qualitatively and quantitatively evaluate cartilage degeneration and regeneration in this study. Results: The qualitative and quantitative evaluation of 3D Magnetic Resonance Imaging (MRI) imaging of knee cartilage demonstrated that the stromal vascular fraction therapy reduced the cartilage defects; and significant increase of cartilage value both in defect cartilage area and whole cartilage area of treated group and significant increase of thickness and area of both femoral and tibia cartilage in vertical sections of the stromal vascular fraction treated Group at 12 and 24 W post treatment in cartilage defect I-II osteoarthritis patients. Conclusion: This clinical phase I/II study indicated that stromal vascular fraction therapy is a safe clinical procedure and provided evidence that the stromal vascular fraction therapy significantly facilitated cartilage regeneration, opening the opportunity to a phase III trial investigating authentic efficacy of the procedure. This study is the first qualitative and quantitative evaluation of the efficacy of autologous stromal vascular fraction cellular therapy on cartilage regeneration. Through early and definite diagnosis of knee osteoarthritis patients, and providing safe and efficient therapy to facilitate cartilage regeneration, we will be able to control or reverse cartilage degeneration and completely change the epidemiology of osteoarthritis worldwide.
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Warm needle acupuncture vs. needle acupuncture for osteoarthritis of the knee: A pilot study protocol
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OAK 3 - Non-arthroplasty tx of OAK
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Introduction Acupuncture has been shown to have clinically relevant benefits for chronic pain. However, interpretation of the results and whether they are due to the placebo effect remains contested. As a complex physical intervention acupuncture presents particular problems in clinical research that seeks to identify a specific effect. The existing evidence mosaic can be enhanced by randomised controlled trials that investigate the specific efficacy of different components of acupuncture. This study investigates the specific efficacy of the conducted heat in warm needle acupuncture. Methods The study is a randomised, controlled, parallel-group 2-armed clinical trial. It is designed so that the outcome administrator, participants and primary acupuncturist will be blinded to group allocation. Analysis The primary outcome measures WOMAC® NRS 3.1 score and SF 36 are both considered interval variables and provided the distribution of changes is normally distributed the change in score will be analysed using t-test. The information obtained from interviews with participants will be thematically analysed. Discussion Compromises from acupuncture in practice have been made in order to devise procedures that can investigate the specific efficacy of the conducted heat of warm needle acupuncture. The way in which these compromises may impact on interpretation of the results is discussed.
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Prognostic factors in lateral epicondylitis: a randomized trial with one-year follow-up in 266 new cases treated with minimal occupational intervention or the usual approach in general practice
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The Treatment of Pediatric Supracondylar Humerus Fractures AUC
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OBJECTIVES: To determine whether minimal intervention by occupational specialists involving information about the disorder, encouragement to stay active and instruction in graded self-performed exercises could enhance the prognosis of lateral epicondylitis compared with the treatment usually given in general practice, to quantify workplace factors associated with the prognosis, and to consider treatments given in general practice. METHODS: A randomized controlled trial was performed in a cohort of 266 consecutive new cases of lateral epicondylitis diagnosed in general practice. Workplace factors were assessed with questionnaires at the time of inclusion, and patients completed follow-ups at 3, 6 and 12 months. Status at 1 yr was assessed as overall improvement and pain reduction compared with the time of diagnosis. General practitioners (GPs) registered the treatments given for both cases and controls during follow-up. Numbers of contacts with GPs and physiotherapists were obtained from the National Health Insurance registry. Prognostic factors were analysed by multiple logistic regression analysis. RESULTS: After 1 yr, 83% of cases showed improvement in the condition, but the intervention was found to have had no advantage. Poor overall improvement was associated with employment in manual jobs [odds ratio (OR) 3.0, 95% confidence interval (CI) 1.0-8.7], a high level of physical strain at work (OR 8.5, CI 1.0-74.7) and a high level of pain at baseline (OR 2.3, CI 1.0-5.3). Pain reduction less than 50% was associated with manual jobs (OR 2.3, CI 1.1-5.1), high physical strain at work (OR 3.6, CI 1.0-12.9), high baseline distress (OR 1.9, CI 1.0-4.0) and tennis elbow on the dominant side (OR 3.1, CI 1.4-6.8). The intervention group received less treatment and fewer treatment modalities, but the intervention was not followed by a reduction in the number of visits to GPs and physiotherapist clinics during 12 months of follow-up. CONCLUSIONS: Poor prognosis at 1 yr of follow-up for lateral epicondylitis was related to manual work and high baseline pain, whilst no relation was found between the type of medical treatment given/chosen and prognosis. This may have implications for the future management of lateral epicondylitis in terms of a greater focus on interaction with the workplace regarding job modification to reduce physical demands during recovery
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Predictors of physical activity in colorectal cancer survivors after participation in a telephone-delivered multiple health behavior change intervention
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DoD PRF (Psychosocial RF)
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PURPOSE: Physical activity improves the health outcomes of colorectal cancer (CRC) survivors, yet few are exercising at levels known to yield health benefits. Baseline demographic, clinical, behavioral, and psychosocial predictors of physical activity at 12 months were investigated in CRC survivors.
METHODS: Participants were CRC survivors (n=410) who completed a 12-month multiple health behavior change intervention trial (CanChange). The outcome variable was 12 month sufficient physical activity (>=150 min of moderate-vigorous physical activity/week). Baseline predictors included demographics and clinical variables, health behaviors, and psychosocial variables.
RESULTS: Multivariate linear regression revealed that baseline sufficient physical activity (p<0.001), unemployment (p=0.004), private health insurance (p=0.040), higher cancer-specific quality of life (p=0.031) and higher post-traumatic growth (p=0.008) were independent predictors of sufficient physical activity at 12 months. The model explained 28.6% of the variance.
CONCLUSIONS: Assessment of demographics, health behaviors, and psychosocial functioning following a diagnosis of CRC may help to develop effective physical activity programs.
IMPLICATIONS FOR CANCER SURVIVORS: Understanding the demographic, behavioral and psychosocial determinants of physical activity may facilitate the development and delivery of effective public health interventions designed to promote long term behavior change.
Trial registration: Actrn12608000399392.
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A simple technique for removing a locking compression plate with a stripped locking screw
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The Treatment of Pediatric Supracondylar Humerus Fractures AUC
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We use a straightforward technique to remove a locking compression plate and a screw with a stripped hexagonal recess. If the hexagonal recess of the screw had been stripped during attempts at screw removal using a conical extraction device, we perform the following procedure after loosening the contact surface between the bone and the plate. Using a larger drill bit, another hole is drilled immediately adjacent to the screw through the nonlocking portion of the combination hole. The plate is struck along the line connecting the screw to the newly formed hole. Using an elevator, leverage force is then applied to the plate, which can be removed with the stripped screw attached. This technique can be used to remove plates with several stripped screws and does not require any special tools. Copyright (copyright) 2012 by Lippincott Williams &Wilkins
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1 |
An evidence-based review of enhanced recovery interventions in knee replacement surgery
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AAHKS (8) Anesthetic Infiltration
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INTRODUCTION: Total knee replacement (TKR) is a very common surgical procedure. Improved pain management techniques, surgical practices and the introduction of novel interventions have enhanced the patient's postoperative experience after TKR. Safe, efficient pathways are needed to address the increasing need for knee arthroplasty in the UK. Enhanced recovery programmes can help to reduce hospital stays following knee replacements while maintaining patient safety and satisfaction. This review outlines common evidence-based pre, intra and postoperative interventions in use in enhanced recovery protocols following TKR.
METHODS: A thorough literature search of the electronic healthcare databases (MEDLINE(), EmbaseTM and the Cochrane Library) was conducted to identify articles and studies concerned with enhanced recovery and fast track pathways for TKR.
RESULTS: A literature review revealed several non-operative and operative interventions that are effective in enhanced recovery following TKR including preoperative patient education, pre-emptive and local infiltration analgesia, preoperative nutrition, neuromuscular electrical stimulation, pulsed electromagnetic fields, perioperative rehabilitation, modern wound dressings, different standard surgical techniques, minimally invasive surgery and computer assisted surgery.
CONCLUSIONS: Enhanced recovery programmes require a multidisciplinary team of dedicated professionals, principally involving preoperative education, multimodal pain control and accelerated rehabilitation; this will be boosted if combined with minimally invasive surgery. The current economic climate and restricted healthcare budget further necessitate brief hospitalisation while minimising costs. These non-operative interventions are the way forward to achieve such requirements.
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0 |
The perceptions of pediatricians regarding their self-efficacy in child neglect and abuse
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DoD PRF (Psychosocial RF)
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Child abuse is one of the most severe forms of childhood trauma which has pervasive and long-lasting effects on children, their families, and the society. These effects, impairing the development of the victims, extend far beyond childhood into adolescence and adulthood. Pediatricians are the most common group of clinicians who encounter abused children immediately. Therefore, it is important for a pediatrician to be aware of the symptoms of abuse and neglect, and to feel sufficient about reporting in order to release and prevent the trauma. We aimed to assess awareness and self-efficacy about recognizing, diagnosing and reporting. Pediatricians completed the questionnaire created by the researchers. There were differences about pediatricians' perception of self-efficacy and approach to abuse. Pediatricians experience difficulties about the diagnosis of child abuse and neglect through the process from examination to reporting.
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Effect of exercise therapy compared with arthroscopic surgery on knee muscle strength and functional performance in middle-aged patients with degenerative meniscus tears: a 3-mo follow-up of a randomized controlled trial
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AMP (Acute Meniscal Pathology)
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OBJECTIVE: The aim of this study was to compare the effect of a 12-wk exercise therapy program and arthroscopic partial meniscectomy on knee strength and functional performance in middle-aged patients with degenerative meniscus tears.
DESIGN: A total of 82 patients (mean age, 49 yrs; 35% women) with a symptomatic, unilateral, magnetic resonance imaging-verified degenerative meniscus tear and no or mild radiographic osteoarthritis were randomly assigned to a supervised neuromuscular and strength exercise program or arthroscopic partial meniscectomy. Outcomes assessed 3 mos after intervention initiation were isokinetic knee muscle strength, lower extremity performance, and self-reported global rating of change.
RESULTS: Mean difference in isokinetic knee extension peak torque between the two groups was 16% (95% confidence interval, 7.1-24.0) (P < 0.0001), favoring the exercise group. Patients in the exercise group improved isokinetic knee extension peak by a mean of 25 Nm (range, 18-33 Nm) from baseline to follow-up. Furthermore, patients assigned to exercise therapy showed statistically significant improvements (P <= 0.002) in all other measured variables, with moderate to large effect sizes (0.5-1.3). Patients reported a similar and positive effect of both interventions.
CONCLUSION: A 12-wk supervised exercise therapy program yielded clinically relevant and statistically significant improvement in isokinetic quadriceps strength immediately after completion of the program, as compared with treatment with arthroscopic partial meniscectomy.
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Mosaicplasty for the treatment of articular defects of the knee and ankle
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Surgical Management of Osteoarthritis of the Knee CPG
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Efficacious treatment of full-thickness cartilage defects of the weightbearing surfaces is a multifaceted challenge for the orthopaedic surgeon. Autologous osteochondral transplantation represents one solution: to bring about a hyaline or hyalinelike repair of the defected area. The current authors discuss the experimental background and their 8 years of clinical experience with the autologous osteochondral mosaicplasty. Several series of animal studies and subsequent clinical practice have confirmed the survival of the transplanted hyaline cartilage. Hyaline cartilage and fibrocartilage fill the donor sites located on the nonweightbearing surfaces and surfaces that bear less weight. Clinical scores, imaging techniques, control arthroscopies, histologic examination of biopsy samples, and cartilage stiffness measurements were used to evaluate the clinical outcomes and quality of the transplanted cartilage. According to these investigations, femoral condylar implantations have shown good to excellent results in 92%, tibial resurfacing in 88%, patellar and/or trochlear mosaicplasties in 81%, and talar procedures in 94% of patients. The Bandi score showed long-term donor site disturbances in 3% of patients. Fifty-eight of the 68 control arthroscopies had good gliding surfaces, histologically-proven survival of the transplanted hyaline cartilage, and fibrocartilage covering of the donor sites. In the entire series, there were four deep infections and 34 painful hemarthroses after surgery. A multicentric, comparative, prospective evaluation of 413 arthroscopic resurfacing procedures (mosaicplasty, Pridie drilling, abrasion arthroplasty, and microfracture cases in homogenized subgroups) showed that mosaicplasty gave a more favorable clinical outcome in the long-term followup, than the other three techniques. Intermediate-term evaluation of the femoral condylar implantations (3-6-years followup) and talar mosaicplasties (3-7-years followup) confirmed the durability of the early results. From these encouraging results from an increasingly large series and similar results from other centers, it seems that autologous osteochondral mosaicplasty may be a viable alternative treatment of localized fullthickness cartilage damage of the weightbearing surfaces of the knee and other weightbearing synovial joints
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Principles of external fixation and supplementary techniques in distal radius fractures
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Distal Radius Fractures
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External fixation for fractures of the distal radius has been used for almost 80 years. The main objective is to gain reduction and maintain the reduction throughout the treatment period. Several fixator concepts are available and selection is based on the complexity of the injury to be treated as well as the surgeon's experience. Periarticular application of the fixator with immediate use of the wrist joint is recommended whenever possible. For intra-articular fractures, transarticular application is advisable. External fixtion in complex fractures has to be supplemented by bone grafting, fixation wires and stabilization of the radioulnar joint. Associated injuries in distal radius fractures need to be identified and treated. The possible complications of external fixation and the means to prevent them are discussed. External fixation of the distal radius has found its place as an established method in treating certain types of this common fracture.
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Treatment Options After Failed Distal Radial Fracture Treatment (Salvage Procedures)
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Distal Radius Fractures
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The vast majority of distal radius fractures respond well to either nonsurgical or surgical treatment methods. Several fracture patterns, however, are known to be problematic. Failure to recognize their particular intricacies may result in the formation of fracture nonunions, malunions, wrist arthritis, and/or carpal instability. The aforementioned consequences of failed treatment often require salvage techniques to improve upper extremity function. Techniques for limiting complications associated with surgical fracture management are presented in an algorithmic format to assist the treating physician. Indications and contra-indications of each technique are reviewed, and our preferred methods and surgical pearls are presented. © 2009 Elsevier Inc. All rights reserved.
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Passenger seating position and the risk of passenger death or injury in traffic crashes
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DoD PRF (Psychosocial RF)
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Objective: To estimate the association of passenger seat position with the risk of death and serious injury for passengers in traffic crashes. Methods: Using 1993-2000 data from the National Highway Traffic Safety Administration's Crashworthiness Data System (CDS), the risk ratio for death and serious injury was estimated for rear seat passengers compared with front seat passengers in motor vehicle crashes. Results: The adjusted risk ratio for death of passengers in the rear seat in a crash was 0.61 (95% confidence interval [CI] 0.46-0.81). Rear seat passenger position was also associated with a decrease in the risk of death and serious injury compared with the front seat passenger position: risk ratio=0.67 (95% CI 0.57-0.78). Conclusion: We estimated that the rear seat passenger position may reduce the risk of death in a motor vehicle crash by about 39% and reduce the risk of death or serious injury in a crash by 33%, compared with the front seat passenger position. If the associations that we report are causal, sitting in the rear seat, compared with the front seat, may prevent about 4 in 10 passenger deaths, or 3 in 10 passenger deaths and injuries, that might otherwise occur. (PsycINFO Database Record (c) 2018 APA, all rights reserved)
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