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Do physicians' implicit views of African Americans affect clinical decision making?
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Surgical Management of Osteoarthritis of the Knee CPG
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BACKGROUND: Total knee replacement (TKR) is a cost-effective treatment option for severe osteoarthritis (OA). While prevalence of OA is higher among blacks than whites, TKR rates are lower among blacks. Physicians' implicit preferences might explain racial differences in TKR recommendation. The objective of this study was to evaluate whether the magnitude of implicit racial bias predicts physician recommendation of TKR for black and white patients with OA and to assess the effectiveness of a web-based instrument as an intervention to decrease the effect of implicit racial bias on physician recommendation of TKR. METHODS: In this web-based study, 543 family and internal medicine physicians were given a scenario describing either a black or white patient with severe OA refractory to medical treatment. Questionnaires evaluating the likelihood of recommending TKR, perceived medical cooperativeness, and measures of implicit racial bias were administered. The main outcome measures included TKR recommendation, implicit racial preference, and medical cooperativeness stereotypes measured with implicit association tests. RESULTS: Subjects displayed a strong implicit preference for whites over blacks (P < .0001) and associated "medically cooperative" with whites over blacks (P < .0001). Physicians reported significantly greater liking for whites over blacks (P < .0001) and reported believing whites were more medically cooperative than blacks (P < .0001). Participants reported providing similar care for white and black patients (P = .10) but agreed that subconscious biases could influence their treatment decisions (P < .0001). There was no significant difference in the rate of recommendation for TKR when the patient was black (47%) versus white (38%) (P = .439), and neither implicit nor explicit racial biases predicted differential treatment recommendations by race (all P > .06). Although participants were more likely to recommend TKR when completing the implicit association test before the decision, patient race was not significant in the association (P = .960). CONCLUSIONS: Physicians possessed explicit and implicit racial biases, but those biases did not predict treatment recommendations. Clinicians' biases about the medical cooperativeness of blacks versus whites, however, may have influenced treatment decisions
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The Short Term Effect of Hot Packs and Whirlpool for Increasing Total Active Motion at the Wrist
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Distal Radius Fractures
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This study investigates the short term effect of hot packs versus whirlpool and exercise for patients with distal radius fracture (DRF) during a therapy visit. Patients with recently healed DRF are randomized into two groups, with one group receiving hot packs during therapy and the other immersing the arm in a whirlpool for 3 consecutive therapy visits. Measurements of wrist and forearm range of motion, and volume of the hand are recorded before and immediately after heat for each visit, effectively creating six measurement time points. Change scores are recorded for range of motion and for volume, and analyzed using MANOVA to determine differences between groups.
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A pilot randomized control trial of aerobic cycling before total knee arthroplasty
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Surgical Management of Osteoarthritis of the Knee CPG
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Purpose: The main purpose of the study was to determine if a full trial of an aerobic cycling program for pre TKA (total knee arthroplasty) patients was feasible, by assessing recruitment, safety, ability to cycle, program adherence and aerobic benefit. Secondary objectives were to estimate sample size for a future full trial and conduct an exploratory assessment for change in outcome measures (pain, physical function, quality of life) from pre to post intervention to post surgery. Methods: The trial was a pilot study with a prospective, randomized control design. In order to be eligible for the study, patients had to meet the following inclusion criteria: have a primary diagnosis of OA of the knee and be on awaiting list for TKA in the Calgary Health Region, agree to attend multiple fitness assessments and a thrice per week, on-site cycling program over 10 weeks before surgery. Patients that were randomized to the exercise group enrolled in an aerobic cycling program to attend three cycling sessions per week over 10 weeks before their surgical date. Each of the cycling sessions was 30 minutes in duration, with 5 minutes used for awarm-up period at the start and 5 minutes as a cool-down period at the 25 minute mark. The middle 20 minuteswas an aerobic exercise period where patients cycled at an intensity that could improve cardiorespiratory fitness (70-85% of their heart rate maximum). Results: A total of 21 pre TKA patients (12 exercise group, 9 control group) were enrolled in the study. Therewere no statistically significant differences in the baseline demographics, baseline questionnaires or VO2 max bike results, between the exercise and control groups. The percentage recruited was 8.3% (21/254). The ineligible patients (n = 295), had a mean age of 67.8 (9.7) and 61% female. The mean age of declined eligible patients (n = 233)was 64.7(8.4) and 54% were females. Only 1/9 patients in the control groupwas unable to complete their post intervention submaximal bike test due to knee pain. For patients in the exercise group, there were no adverse events due to the cycling sessions that caused patients to cease cycling or seek medical attention. Pacing in the cycling sessions was an initial problem in 3/12 exercise group patients who needed the first three to seven sessions to achieve the required intensity of the exercise program. A total of 38/360 sessions were missed amongst the 12 participants with an overall attendance rate of 89%. A paired t test demonstrated a statistically significant improvement in VO2 max for the exercise group from pre to post intervention. There was no difference in mean V02 max between groups from pre to post intervention (post mean VO2max, E:25.3 (plus or minus) 6.30, C: 23.9 (plus or minus) 11.06, p = .754). Repeated measures ANOVA revealed a significant change in mean WOMAC pain (F(2,31)=10.26, p (less-than or equal to) .001) and physical function (F(2,31)=11.17, p (less-than or equal to) .001) scores and SF-36 pcs score (F(2,30)=5.53, p = .009) over time but no group effect. Further assessment revealed a significant improvement in these scores from pre surgery to three months post TKA (WOMAC subscales, p (less-than or equal to) .001, SF-36, p = .004). Although the difference in mean WOMAC physical function scores between the exercise and control group widened (by 7 points) from pre to post intervention, this change was not statistically significant. Conclusions: In this study, it was demonstrated that patients without heart disease and younger than age 80, can safely undertake an aerobic cycling program before TKA surgery. If severe knee OA patients can tolerate aerobic cycling, then this mode of exercise has potential to assist in reduction of weight and improvement of overall health and well-being. Further exploration with a larger sample size, possibly in a multi-centre trial, would be necessary to determine possible pain and physical function benefits from aerobic cycling, before or after knee replacement surgery
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Influence of low back pain on total knee arthroplasty outcome
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OAK 3 - Non-arthroplasty tx of OAK
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Background: Preoperative pain and functional status are strong determinants of postsurgical success in total knee arthroplasty. Patients suffering chronic pain from other coexistent musculoskeletal problems may respond differently postoperatively, with potentially poorer outcomes after surgery. The aim of the study was to determine the influence of low back pain on the outcome of total knee replacement surgery. Methods: All patients completed Oxford Knee Scores (OKS), American Knee Society Scores (AKSS) and SF-12 (both physical and mental components). Patients were divided into those with (n=40) and without a documented history of low back pain (n=305). Results: OKS, AKSS and SF-12 physical scores were significantly worse for patients with low back pain at 24. months following surgery. The mental component of the SF-12 measure demonstrated a significant improvement in median mental health post-operatively for patients with no current history of low back pain. In contrast the group with low back pain showed no improvement in mental health scores post-operatively. Conclusion: This study demonstrates that symptomatic low back pain influences functional outcome after total knee arthroplasty surgery and that patients with low back pain show limited or no improvement in mental health post-operatively. © 2013 Elsevier B.V.
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Race and ethnic variation in proximal femur structure and BMD among older men
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Management of Hip Fractures in the Elderly
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Femoral neck dimensions and vBMD from QCT were compared among 3,305 black, Asian, Hispanic, and white men >or=65 yr of age. All had similar stature-adjusted mean femoral neck volume, but black and Asian men had thicker cortices and higher trabecular vBMD, which may increase bone strength. INTRODUCTION: Hip fracture rates among elderly U.S. black and Asian men are lower than rates among white men. Structural characteristics or volumetric BMD (vBMD), which confer advantages for femoral neck bone strength, may vary by race/ethnicity. However, this topic has not been studied in detail. MATERIALS AND METHODS: In a cross-sectional study, dimensions and vBMD in the femoral neck and shaft were obtained from QCT scans among 3,305 men >or=65 yr of age in the Osteoporotic Fractures in Men (MrOS) study. Femoral neck measures were cross-sectional area; integral, cortical, and medullary volumes and integral, cortical, and trabecular vBMD. Shaft measures were cross-sectional, cortical, and medullary areas and cortical vBMD. Self-reported race/ethnicity was classified as black, Asian, Hispanic, or white. We used multivariable linear regression models with adjustment for age, height, and body mass index to compare means of the outcome measures in black, Asian, and Hispanic men to those in whites. RESULTS: All groups had similar femoral neck integral volume. Among black and Asian men, mean cortical volume as a percent of integral volume was 6% greater, integral vBMD was 6-10% greater, and trabecular vBMD was 33-36% greater than means among whites. Shaft cross-sectional area was similar among blacks, but smaller among Asians, compared with whites. However, mean shaft cortical area was greater among blacks but similar among Asians and whites, resulting in mean cortical thickness being 5% greater among black and Asian men. Blacks also had greater mean cortical vBMD in both the femoral neck and shaft. CONCLUSIONS: Black and Asian men >or=65 yr of age have features in the proximal femur that may confer advantages for bone strength. Specifically, greater cortical thickness and higher trabecular vBMD among black and Asian men could help explain the lower hip fracture rates in these populations. Discerning the mechanisms underlying these differences could provide advances for the prevention and treatment of osteoporosis
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Orthopaedic manifestations of mucolipidosis III: an illustrative case
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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The musculoskeletal manifestations of mucolipidosis III include short stature, claw hands, carpal tunnel syndrome, and limited joint mobility. This article presents a series of complex orthopaedic problems, including avascular necrosis of the talus, encountered in one such patient whose presentation had initially given the impression of a mild form of the disease
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[High dosage vitamin E therapy in patients with activated arthrosis]
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Management of Hip Fractures in the Elderly
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The known antiphlogistic in vitro effect of vitamin E was tested in a double-blind randomized study in patients with osteoarthritis. Fifty-three in-patients with osteoarthritis of the hip (n = 34) or the knee (n = 19) were treated for 3 weeks with 400 mg vitamin E (d-alpha-tocopherolacetate, V, n = 26) or 50 mg Diclofenac (D, n = 27) three times daily. A standardized therapeutic exercise program was performed; local therapy was not permitted. There were no significant differences in the efficacy of the two drugs, although one patient of the V-group refused further treatment after 8 days because of inefficacy. V reduced or abolished the pain at rest in 77% (D in 85%), the pain on pressure in 67% (D in 50%), and the pain on movement in 62% (D in 63%). Both treatments appeared to be equally effective in reducing the circumference of the knee joints (p = 0.001) and the walking time (p less than 0.001) and in increasing the joint mobility (p less than 0.002). Patients (n = 11) with a plasma-alpha-tocopherol increase higher than two standard deviations of the mean value at onset (greater than 25.2 mg/l) seemed to have a more pronounced reduction of pain (eight out of 11 patients) compared with four out of 11 patients with a moderate increase of vitamin E. Side effects occurred in two out of 26 patients with V (7.7%), and in 25.9% during D-treatment. One patient with D therefore stopped the therapy after 9 days.(ABSTRACT TRUNCATED AT 250 WORDS)
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Skeletal manifestations of hydatid disease in Serbia: demographic distribution, site involvement, radiological findings, and complications
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MSTS 2022 - Metastatic Disease of the Humerus
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Although Serbia is recognized as an endemic country for echinococcosis, no information about precise incidence in humans has been available. The aim of this study was to investigate the skeletal manifestations of hydatid disease in Serbia. This retrospective study was conducted by reviewing the medical database of Institute for Pathology (Faculty of Medicine in Belgrade), a reference institution for bone pathology in Serbia. We reported a total of 41 patients with bone cystic echinococcosis (CE) during the study period. The mean age of 41 patients was 40.9+/-18.8 years. In 39% of patients, the fracture line was the only visible radiological sign, followed by cyst and tumefaction. The spine was the most commonly involved skeletal site (55.8%), followed by the femur (18.6%), pelvis (13.9%), humerus (7.0%), rib (2.3%), and tibia (2.3%). Pain was the symptom in 41.5% of patients, while some patients demonstrated complications such as paraplegia (22.0%), pathologic fracture (48.8%), and scoliosis (9.8%). The pathological fracture most frequently affected the spine (75.0%) followed by the femur (20.0%) and tibia (5.0%). However, 19.5% of patients didn't develop any complication or symptom. In this study, we showed that bone CE is not uncommon in Serbian population. As reported in the literature, therapy of bone CE is controversial and its results are poor. In order to improve the therapy outcome, early diagnosis, before symptoms and complications occur, can be contributive.
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Fibroma of the flexor tendon presenting as carpal tunnel syndrome and trigger finger
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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This article examines a rare association of carpal tunnel syndrome and trigger finger produced by a single flexor tendon tumor. Examination and treatment is also discussed
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Limb salvage and prosthetic joint reconstruction for low-grade and selected high-grade sarcomas of bone after wide resection and replacement by autoclaved [corrected] autogeneic grafts
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The Treatment of Pediatric Supracondylar Humerus Fractures AUC
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Wide resection is an acceptable alternative to amputation for the management of primary sarcomas of the long bones or pelvis. The resected bone can be debrided of gross tumor tissue, autoclaved, and then replaced over intramedullary fixation to reconstruct the limb anatomically. The procedure can be combined with prosthetic reconstruction of adjacent joints with sufficient strength to allow early unprotected weight-bearing. Resection and replacement for 28 low-grade (G1) and 14 selected high-grade (G2) sarcomas were performed in 42 patients. The hemipelvis was resected and replaced four times, the proximal or distal femur 28 times, the proximal or distal tibia eight times, and the proximal humerus two times. Replacement of an adjacent joint, most commonly using a long-stemmed hip or knee prosthesis, was accomplished in 33 patients. All patients had been followed for a minimum of two years, nine months after treatment. The mean follow-up period is four years, ten months. Six individuals, all with high-grade sarcomas, developed tumor-related complications. Two evidenced a local recurrence of tumor, and four developed distant metastases. None of the patients with low-grade sarcomas developed a recurrence or metastases. Fifteen patients suffered complications unrelated to tumor control; 13 required reoperation, including two who required amputations for persistent pseudoarthrosis and graft infection, respectively. There was one other infection, successfully eradicated by drainage followed by local and systemic antibiotics. Due to mechanical failure or loosening, six patients were treated by successful revision of their joint arthroplasties. Two years after initial surgery, five patients had failures of union at the graft-host junction. Four healed after cancellous grafting and one was revised to a custom prosthesis. There were no late fatigue fractures of the grafts. The technique does not compromise the margins for adequate tumor resection. It preserves a graft strong enough to support a joint arthroplasty and to allow early weight-bearing with a low risk of pseudarthrosis or late fatigue fracture
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Ipriflavone-treatment of senile osteoporosis: results of a multicenter, double-blind clinical trial of 2 years
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Distal Radius Fractures
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Eightyâ?four out of 100 enrolled female patients affected by osteoporosis completed a doubleâ?blind, randomized trial, using ipriflavone (IP) in a dose of 3 x 200 mg/day (41 patients) or placebo (P)(43 patients). All patients received 1 g/day oral calcium supplementation. Inclusion criteria were: age over 65 years; at least one vertebral fracture in the past; bone mineral density measured at the distal tenth of the radius lower than the normal average â?2 x S.D. The trial period was between June 1990 and November 1993. Patients of the IP group showed a significant increase in bone mineral density (P < 0.05) compared with the starting values during the whole study period. Pain decreased rapidly, intake of analgesics dropped, and often significant decreases in calciuria, hydroxyprolinuria, alkaline phospatase, osteocalcin and parathormone values were observed. Only two new fractures occurred during the trial in the IP group. Patients of the P group at the end of the study displayed decreased bone mineral densities (P < 0.05), increased pain, greater consumption of analgesics, and often significant increases in the bone metabolism parameters listed for the IP group. In the
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Osteosarcoma of the jaw: Challenges in the diagnosis and treatment
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MSTS 2022 - Metastatic Disease of the Humerus
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PURPOSE: Osteosarcomas rarely affect jaw bones. Patients are usually older than those who suffer long bone sarcomas, with a rare incidence of metastasis. This is suggestive of a different pattern of behavior compared with long bone sarcomas. This study aimed to present NCI, Cairo University experience in treating patients diagnosed with osteosarcomas of the jaw, including the diagnostic challenges and treatment outcome.
PATIENTS AND METHODS: This is a retrospective case series study of all cases of osteosarcomas of mandible and maxilla that were treated at the NCI, in the period between 2006 and 2013. Patients' data, including demographic data, various clinical presentations, results of investigations, treatment modalities performed and outcomes, were collected from hospital records kept in the Biostatistics Department at NCI.
RESULTS: Records showed 21 cases of osteosarcoma of the jaw. The mandible was affected in 15 cases, the maxilla in six. Two cases had sun-ray periosteal reactions. Erroneous biopsy results were found in 4 cases compared with final pathology reports of surgical resections. All cases underwent surgical resections, with 8 cases having positive margins. The median follow-up period was 19.3months (range 0.3-98.0months). The cumulative disease-free survival (DFS) was 27.5% and the median DFS was 72months. The cumulative overall survival at end of the study was 77.4%.
CONCLUSIONS: Osteosarcoma of the jaw is challenging both to diagnose and manage. This is due to the high incidence of mistakes in biopsy results, rare specific radiological features and difficulties in proper resection due to proximity to vital structures.
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Expression analysis of cystatin C and M in laser-capture microdissectioned human breast cancer cells--a preliminary study
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MSTS 2018 - Femur Mets and MM
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Cathepsins B and L, implicated in the progression of malignant tumors, are regulated by a family of endogenous inhibitors referred to as the cystatins. Cystatin M was identified by differential display as down-regulated gene in metastatic breast cancer cells. However, this finding has yet to be confirmed in clinical breast cancer specimens. Our objective is to examine the expression levels of cystatins C, M, and cathepsins B and L mRNA in breast cancer cells isolated by laser capture microdissection. The mRNA and protein levels of cathepsin B, L, and cystatin C and M in breast cancer specimens were determined utilizing laser capture microdissection/RT-PCR, Western blotting, and immunohistochemical methods. Expression levels of either cystatin M or C were not significantly different between lymph node-positive and -negative breast carcinomas. Increased expression levels of both cystatin M and C correlated significantly with larger tumor size. Cystatin M mRNA was detected by in situ hybridization in both primary and metastatic breast cancer cells. Our findings are at variance with a previous report proposing a metastasis suppressive function for cystatin M. Therefore, additional studies in a larger series with adequate follow-up are necessary to elucidate the biologic significance of cystatin M expression in breast cancer metastasis.
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Functional outcome and quality of life after the surgical treatment for diffuse-type giant-cell tumour around the knee: a retrospective analysis of 30 patients
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OAK 3 - Non-arthroplasty tx of OAK
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We retrospectively reviewed 30 patients with a diffuse-type giant-cell tumour (Dt-GCT) (previously known as pigmented villonodular synovitis) around the knee in order to assess the influence of the type of surgery on the functional outcome and quality of life (QOL). Between 1980 and 2001, 15 of these tumours had been treated primarily at our tertiary referral centre and 15 had been referred from elsewhere with recurrent lesions. The mean follow-up was 64 months (24 to 393). Functional outcome and QOL were assessed with range of movement and the Knee injury and Osteoarthritis Outcome Score (KOOS), the Musculoskeletal Tumour Society (MSTS) score, the Toronto Extremity Salvage Score (TESS) and the SF-36 questionnaire. There was recurrence in four of 14 patients treated initially by open synovectomy. Local control was achieved after a second operation in 13 of 14 (93%). Recurrence occurred in 15 of 16 patients treated initially by arthroscopic synovectomy. These patients underwent a mean of 1.8 arthroscopies (one to eight) before open synovectomy. This achieved local control in 8 of 15 (53%) after the first synovectomy and in 12 of 15 (80%) after two. The functional outcome and QOL of patients who had undergone primary arthroscopic synovectomy and its attendant subsequent surgical procedures were compared with those who had had a primary open synovectomy using the following measures: range of movement (114 versus 127; p = 0.03); KOOS (48 versus 71; p = 0.003); MSTS (19 versus 24; p = 0.02); TESS (75 versus 86; p = 0.03); and SF-36 (62 versus 80; p = 0.01). Those who had undergone open synovectomy needed fewer subsequent operations. Most patients who had been referred with a recurrence had undergone an initial arthroscopic synovectomy followed by multiple further synovectomies. At the final follow-up of eight years (2 to 32), these patients had impaired function and QOL compared with those who had undergone open synovectomy initially. We conclude that the natural history of Dt-GCT in patients who are treated by arthroscopic synovectomy has an unfavourable outcome, and that primary open synovectomy should be undertaken to prevent recurrence or residual disease.
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Osteoporosis in the aging male
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Management of Hip Fractures in the Elderly
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Based on data from the Third National Health and Nutrition Examination Survey, about 1-2 million males in the U.S. have osteoporosis and another 8-13 million have osteopenia, when using male cutoffs for bone mineral density readings. Osteoporosis tends to develop later in life in men, and the incidence of osteoporosis-related fractures is lower in men compared to women. However, the mortality attributed to hip fractures is twice as high in men as in women. Although there are multiple factors that have been linked to the development of osteoporosis in men, 50% of the cases can be attributed to one of three major causes: excessive alcohol consumption, glucocorticoid excess (endogenous or exogenous), and hypogonadism. There is an ongoing debate on whether it will be best to use gender-specific reference values of bone mass or the female reference values to diagnose osteoporosis in men. The International Society for Clinical Densitometry recommended that male osteoporosis should be defined as a bone mineral density T-score of -2.5 or below the normal mean for men. At the present time, only alendronate and teriparatide are currently approved by the Food and Drug Administration for the treatment of male osteoporosis
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Fragility fractures of the ankle in the frail elderly patient: treatment with a long calcaneotalotibial nail
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PJI DX Updated Search
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Conventional methods of treating ankle fractures in the elderly are associated with high rates of complication. We describe the results of treating these injuries in 48 frail elderly patients with a long calcaneotalotibial nail. The mean age of the group was 82 years (61 to 96) and 41 (85%) were women. All were frail, with multiple medical comorbidities and their mean American Society of Anaesthesiologists score was 3 (3 to 4). None could walk independently before their operation. All the fractures were displaced and unstable; the majority (94%, 45 of 48) were low-energy injuries and 40% (19 of 48) were open. The overall mortality at six months was 35%. Of the surviving patients, 90% returned to their pre-injury level of function. The mean pre- and post-operative Olerud and Molander questionnaire scores were 62 and 57 respectively. Complications included superficial infection (4%, two of 48); deep infection (2%, one of 48); a broken or loose distal locking screw (6%, three of 48); valgus malunion (4%, two of 48); and one below-knee amputation following an unsuccessful vascular operation. There were no cases of nonunion, nail breakage or peri-prosthetic fracture. A calcaneotalotibial nail is an excellent device for treating an unstable fracture of the ankle in the frail elderly patient. It allows the patient to mobilise immediately and minimises the risk of bone or wound problems. A long nail which crosses the isthmus of the tibia avoids the risk of peri-prosthetic fracture associated with shorter devices
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Meniscal repair and replacement
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OAK 3 - Non-arthroplasty tx of OAK
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Viewed for many years as just vestigial organs, a lack of appreciation of the importance of the menisci led to the widespread practice of total meniscectomy. The realization that removal of these important structures leads to accelerated arthritis took some time. It is now recognized that the menisci play an important role in load distribution, joint stability and lubrication, protecting the joint surfaces from degenerative change. As awareness of the true importance of these important structures has increased, and so has the understanding of different patterns of meniscal injury and the interaction of additional factors, such as alignment and ligamentous stability, in determining long-term meniscal and knee function. This has led to an integrated approach to meniscal surgery as part of an overall strategy to preserve and restore knee function, incorporating a shift towards meniscal preserving surgery whenever possible. This article will review knee anatomy and biomechanics as a basis for understanding the mechanism and classification of meniscal tears and associated injuries. Assessment, surgical decision-making and repair techniques, including the role of biological augmentation to increase the scope of repairable injuries, will also be reviewed. Options to reconstruct the meniscus using meniscal allograft transplantation for patients with symptomatic meniscal deficiency will be discussed.
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Patient education before hip or knee arthroplasty lowers length of stay
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Surgical Management of Osteoarthritis of the Knee CPG
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From April 2006 to May 2007, 261 patients undergoing primary unilateral total hip arthroplasty or total knee arthroplasty were offered voluntary participation in a one-on-one preoperative educational program. Length of stay (LOS) and inpatient data were monitored and recorded, prospectively. Education participants enjoyed a significantly shorter LOS than nonparticipants for both total hip arthroplasty (3.1 +/- 0.8 days vs 3.9 +/- 1.4 days; P = .0001) and total knee arthroplasty (3.1 +/- 0.9 days vs 4.1 +/- 1.9 days; P = .001)
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Lower leg replantation--decision-making, treatment, and long-term results
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DoD LSA (Limb Salvage vs Amputation)
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OBJECT: The aim of this article is to review the results of replantation at the lower leg after total and subtotal amputation injury. Although subtotal and total lower leg amputations have been successfully replanted in the past, nowadays there is a common opinion that these operations do not justify their efforts, and therefore most of those patients are amputated. METHODS: To clarify this hypothesis we carried out an extensive literature research. The following criteria were evaluated: 1) survival rate, 2) individual motor and sensory functions and global lower extremity function judged according to the classification of Chen, 3) socioeconomic aspects (operation time, number of operations per patient, time of hospitalization, and return to normal life), and 4) number and nature of local and/or systemic complications. RESULTS: The success rate of lower leg amputation, which only means perfect restoration of viability, is reported between 62.5% and 100%. Using Chen's classification the functional results can be given as follows: A "functional extremity" (grade I and grade II) can be reconstructed in 82.6% to 92.7%. A non-functional extremity (grade III and grade IV) will result in one tenth to one fifth of cases. Complications can be classified in local or systemic and occur depending on the quality of the decision-making process. CONCLUSION: Our results as well as those of other large series show that lower leg replantation is still worthwhile in a well selected patient group, contrary to what is believed by an increasing number of orthopaedic and trauma surgeons.
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Accuracy of synovial fluid analysis compared to histology for the identification of calcium pyrophosphate crystals: an ancillary study of the OMERACT US Working Group - CPPD subgroup
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AMP (Acute Meniscal Pathology)
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The aim of this study was to evaluate the accuracy of synovial fluid analysis in the identification of calcium pyrophosphate dihydrate crystals compared to microscopic analysis of joint tissues as the reference standard. This is an ancillary study of an international, multicentre cross-sectional study performed by the calcium pyrophosphate deposition disease (CPPD) subgroup of the OMERACT Ultrasound working group. Consecutive patients with knee osteoarthritis (OA) waiting for total knee replacement surgery were enrolled in the study from 2 participating centres in Mexico and Romania. During the surgical procedures, synovial fluid, menisci and hyaline cartilage were collected and analysed within 48 hours from surgery under transmitted light microscopy and compensated polarised light microscopy for the presence/absence of calcium pyrophosphate crystals. All slides were analysed by expert examiners on site, blinded to other findings. A dichotomic score (absence/ presence) was used for scoring both synovial fluid and tissues. Microscopic analysis of knee tissues was considered the gold standard. Sensitivity, specificity, accuracy, positive and negative predictive values of synovial fluid analysis in the identification of calcium pyrophosphate crystals were calculated. 15 patients (53% female, mean age 68 yo +/- 8.4) with OA of grade 3 or 4 according to Kellgren-Lawrence scoring were enrolled. 12 patients (80%) were positive for calcium pyrophosphate crystals at the synovial fluid analysis and 14 (93%) at the tissue microscopic analysis. The overall diagnostic accuracy of synovial fluid analysis compared with histology for CPPD was 87%, with a sensitivity of 86% and a specificity of 100%, the positive predictive value was 100% and the negative predictive value was 33%. In conclusion synovial fluid analysis proved to be an accurate test for the identification of calcium pyrophosphate dihydrate crystals in patients with advanced OA.
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Peroxisome proliferator activated receptor a activation counteracts interleukin 1B induced cytokine production by infrapatellar fat pad
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Surgical Management of Osteoarthritis of the Knee CPG
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Purpose: The infrapatellar fat pad (IPFP) is located in the knee joint, closely to the cartilage and synovial layer. It contains adipocytes, nerve fibers, macrophages and other immune cells capable of producing cytokines that can influence the osteoarthritis (OA) etiopathogenesis. Peroxisome proliferator activated receptor a (PPAR(alpha)) is a nuclear receptor type I and member of the superfamily of ligand-dependent transcription factors, regulating the transcription of target genes by binding retinoid X receptor. PPAR(alpha) agonists such as fibrates are used in clinical practice as lipid lowering drugs and are also known to exert anti-inflammatory effects on various tissues. We hypothesized that the IPFP is involved in the OA process by producing cytokines and that the production can be altered by pro- and antiinflammatory stimuli. Methods:
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Fresh Osteochondral Allograft Transplantation for Treatment of Articular Cartilage Defects of the Knee
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Osteochondritis Dissecans 2020 Review
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Articular cartilage damage of the knee can cause severe morbidity. Owing to its avascular nature, articular cartilage has limited potential for self-healing and increased propensity to progress to osteoarthritis. Treatment of large, full-thickness cartilage defects is still a challenge for orthopaedic surgeons but has recently achieved high success rates with the use of osteochondral allografts. This article details our technique of osteochondral allograft transplantation for the treatment of articular cartilage defects of the knee.
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Isolated dorsal dislocation of the lunate
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Distal Radius Fractures
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Lunate dislocations are well described in the volar direction as part of the perilunate dislocation, sometimes together with fractures of the other carpal bones or distal radius, as described by the anatomical studies of Mayfield [1]. It is a result of disruption of the complex inter-carpal and radiocarpal ligaments that hold the well conforming carpus in their normal position. Given the strength of these structures a significant trauma is required to cause them to fail.However, we present a case of a patient who not only presented with relatively trivial trauma that resulted in a lunate dislocation, but it was also in the dorsal direction and not associated with any fracture or neurological compromise. In addition, she presented several days after her injury.We treated her with closed manipulation and percutaneous K-wire fixation followed by a short period of immobilisation in a Plaster-of-Paris cast, with rapid return to full duties at work.As many volar lunate dislocations may be missed at presentation, we suggest that in patients with relatively trivial trauma there should also be a suspicion of the lunate dislocating dorsally, which may be treated successfully without the aggressive open surgery usually required in volar perilunate dislocations.
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Moving social work norms via theater for senior farmers
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DoD PRF (Psychosocial RF)
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Problem: Senior farmers have a 2.6-fold risk of fatal injury compared to their younger counterparts. Usual educational interventions have resulted in limited success in reducing injury. Method: An innovative strategy, didactic readers theater, was piloted. Farmers' stories provided the foundation for the scripts. The approach incorporated adult learning strategies based on Ajzen's Theory of Planned Behavior. The intervention was marketed as a â??dinner theaterâ? to farm couples. Three short socio-novels (plays) were presented by local farmers who served as actors. Following each play participants completed a reaction form and participated in a short discussion about the play's content. One week later a phone survey was completed that tapped further reaction to the content and behavior changes. Results: Thirty-three farm household individuals (including 16 couples) participated. Participants expressed favorable reaction to the intervention. Within one week post intervention, 42% had made safety changes and 67% were â??thinking about/intendingâ? to make changes. Discussion: The use of real stories contributed to the success of this intervention. Farmers identified with the stories and began to think and talk about the impact that aging exerts on their health and safety. Interaction among the group identified work modifications which empowered the farmers to make positive changes in their own work behavior. Summary: Educational interventions with farmers have met with limited success in reducing farm-related injuries. Moreover, few interventions have utilized the family unit. This novel program, incorporating local organizations and using limited financial resources, resulted in swift behavior changes. Practical applications: Total Worker Health includes not only the worker, but also the family. Interventions that include family units should be considered when possible. This format is effective, easily adapted to local issues, can be delivered using existing infrastructure, and is acceptable to the farm community. It is currently being tested on a larger scale. (PsycINFO Database Record (c) 2017 APA, all rights reserved)
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0 |
Development of an Osteoarthritis (OA) Care Plan to Improve Process and Quality of OA Treatment Decisions
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OAK 3 - Non-arthroplasty tx of OAK
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The investigators propose to prospectively randomize orthopedists, with their patients, to receive (or not) a realâ?time, webâ?based system intervention: the OA Care plan. The OA Care plan will include individualized, patientâ?centric information: (1) trended patientâ?reported OA pain and function, (2) tailored estimates of likely TJR benefits and risks based on a contemporary US cohort of 25,000 TJR patients (FORCEâ?TJR Registry), (3) evidenceâ?based information for nonâ?operative care, and (4) individual patient goals. Specific Aims include: Aim 1. Patients and their Caregivers/Trusted Others will refine the design, content, and usability of a realâ?time, webâ?based individual OA Care plan to guide TJR and nonâ?operative OA care decisions. Aim 2. Randomize 40 orthopedists, and their patients, to receive the OA Care plan at the time of orthopedic consultation (intervention) vs. usual care (control) and compare (a) OA care decision process and quality and (b) quality of OA care as measured by pain relief and functional gain in the two arms at 6 and 12 months after the decision, and assess the impact of decision quality on quality of OA care. Aim 3. Randomize 54 orthopedists, and their patients, to receive the OA Care plan plus peer, family, and primary care physician support (OA Care plan+Support; intervention) vs. the OA Care plan alone and compare the quality of OA care decision and quality of care (pain relief, functional gain) in the two arms. Based on the components of the Chronic Care Model, this technologyâ?delivered, individualized OA Care plan will enable patients and clinicians to make treatment decisions based on patient symptoms, goals, and comparative effectiveness evidence. The investigators hypothesize that OA Care plan users, as compared to usual care, will report greater decision quality for both TJR or nonâ?operative care, and better quality of care (less OA pain, greater function). Further, the investigators anticipate incremental effectiveness of the OA Care plan+Support (peer, family, and primary care support) on the same outcomes. Study results will guide future OA Care plan implementation to assure optimal healthcare for patients with advanced knee and hip OA. Finally, lessons learned from the evaluation of this automated patientâ?centric decision support system can be extended beyond OA and TJR to other elective surgical procedures to engage informed patients to make optimal individual decisions.
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0 |
The effectiveness of pulsed electrical stimulation (E-PES) in the management of osteoarthritis of the knee: a protocol for a randomised controlled trial
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OAK 3 - Non-arthroplasty tx of OAK
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BACKGROUND: Osteoarthritis (OA) of the knee is one of the main causes of musculoskeletal disability in the western world. Current available management options provide symptomatic relief (exercise and selfâ?management, medication and surgery) but do not, in general, address the disease process itself. Moreover, adverse effects and complications with some of these interventions (medication and surgery) and the presence of coâ?morbidities commonly restrict their use. There is clearly a need to investigate treatments that are more widely applicable for symptom management and which may also directly address the disease process itself. In two randomised controlled trials of four and 12 weeks duration, pulsed electrical stimulation was shown to be effective in managing the symptoms of OA of the knee. Laboratory and animal studies demonstrate the capacity of externally applied electric and electromagnetic fields to positively affect chondrocyte proliferation and extracellular matrix protein production. This latter evidence provides strong theoretical support for the use of electrical stimulation to maintain and repair cartilage in the clinical setting and highlights its potential as a diseaseâ?modifying modality. METHODS/DESIGN: A doubleâ?blind, randomised, placeboâ?controlled, repeated measures trial to examine the effectiveness of pulsed electrical stimulation in providing symptomatic relief for people with OA of the knee over 26 weeks. Seventy people will be recruited and information regarding age, gender, body mass index and medication use will be recorded. The population will be stratified for age, gender and baseline pain levels. Outcome measures will include pain (100 mm VAS and WOMAC 3.1), function (WOMAC 3.1), stiffness (WOMAC 3.1), patient global assessment (100 mm VAS) and quality of life (SFâ?36). These outcomes will be measured at baseline, four, 16 and 26 weeks. Activity levels will be measured at baseline and 16 weeks using accelerometers and the Human Activity Profile questionnaire. A patient global perceived effect scale (11â?point Likert) will be completed at 16 and 26 weeks. DISCUSSION: This paper describes the protocol for a randomised, doubleâ?blind, placeboâ?controlled trial that will contribute to the evidence regarding the use of subâ?sensory pulsed electrical stimulation in the management of OA of the knee. TRIAL REGISTRATION: Australian Clinical Trials Registry ACTRN12607000492459.
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0 |
Arthroscopic Technique for Isolated Posterolateral Rotational Instability of the Knee
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AMP (Acute Meniscal Pathology)
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Isolated posterolateral corner injury is an uncommon injury that could be a source of unexplained knee pain and dysfunction. Most of these patients present instability caused by concomitant ligament injuries. Numerous studies have shown open approach posterolateral repair or reconstruction surgeries to restore posterolateral rotational stability. Still, there is a certain population of patients who present posterolateral rotation instability without significant injury to the fibular collateral ligament, popliteal fibular ligament, and popliteus tendon. The posterolateral capsular ligament is critical to provide posterolateral rotation stability. In this Technical Note, with video, we show a completely arthroscopic approach to stabilize the posterolateral corner, by stabilizing the posterior lateral joint capsule with the lateral meniscus attached to the rim of the lateral tibial plateau.
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0 |
Treatment of newly diagnosed multiple myeloma
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MSTS 2018 - Femur Mets and MM
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Multiple myeloma (MM) is the second most common oncohematologic disease. Most patients are older than 65 years at diagnosis, and different therapeutic options are available depending on the age of the patient. For those younger than 65 years, autologous stem cell transplantation is the standard of care, whereas in older patients the better choice is conventional chemotherapy. The introduction of thalidomide, bortezomib, and lenalidomide, which target MM cells and the bone marrow microenvironment, has changed the therapeutic options in newly diagnosed patients with MM. Copyright © 2008 by Current Medicine Group LLC.
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Dentistry and endocarditis
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Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures
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Bacterial endocarditis (BE), a rare heart infection caused by a bacteremia, has frequently been blamed on but rarely caused by dental procedures. Viridans group streptococci are found abundantly in the mouth and the gingival sulcus but have been surpassed by staphylococci as the leading cause of BE. Antibiotic prophylaxis has been recommended before dental procedures in patients at risk for BE, but it remains controversial because studies have failed to show that antibiotic prophylaxis is an effective preventive for BE or that dental procedures are an important cause of BE. The risks and costs of antibiotic prophylaxis, including antibiotic resistance, cross-reactions with other drugs, allergy, anaphylaxis, and even death, may exceed the benefits in preventing BE. The rationale for the use of antibiotic prophylaxis to prevent BE allegedly caused by dental procedure bacteremias must be seriously reexamined based on recent evidence, particularly the absolute risk rates for endocarditis after a given dental procedure. Copyright (copyright) 2005 by Current Science Inc
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0 |
The fine structure of ducts and subareolar ducts in the resting gland of the female breast
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Reduction Mammoplasty for Female Breast Hypertrophy
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This is the study of the breast tissue of 2 young women subjected to a reduction mastoplasty. In transverse section ducts had longitudinal folds, some of which were solid ridges of cells. Four distinctive cell types were distinguished; epithelial cells, lymphocyte type cells, basal clear cells and myoepithelial cells. The epithelium was unilayered multiple at folds, and similar in general morphology to the terminal ductal lobular unit. Well developed terminal bars may prevent cellular disruption during contraction, and apical cytoplasmic vesicles represent possible secretory material. Basal cytoplasmic bodies may represent transport of secretory products into or from the periductal stroma. Intranuclear vesicles may also be linked to secretory activity. The myoepithelium was well differentiated with numerous cytoplasmic filaments and 9+0 cilia, forming a discontinuous layer around the epithelium. The basal lamnina was generally multilayered. The capillaries were 1-5 μm in diameter laying exterior to the delimiting fibroblasts of the epithelial stromal junction.
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0 |
Geriatric fractures about the hip: divergent patterns in the proximal femur, acetabulum, and pelvis
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Hip Fx in the Elderly 2019
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Geriatric acetabular, pelvis, and subtrochanteric femur fractures are poorly understood and rapidly growing clinical problems. The purpose of this study was to describe the epidemiologic trends of these injuries as compared with traditional fragility fractures about the hip. From 1993 to 2010, the Nationwide Inpatient Sample (NIS) recorded more than 600 million Medicare-paid hospital discharges. This retrospective study used the NIS to compare patients with acetabular fractures (n=87,771), pelvic fractures (n=522,831), and subtrochanteric fractures (n=170,872) with patients with traditional hip fractures (intertrochanteric and femoral neck, n=3,495,742) with regard to annual trends over an 18-year period in incidence, length of hospital stay, hospital mortality, transfers from acute care institutions, and hospital charges. Traditional hip fractures peaked in 1996 and declined by 25.7% by 2010. During the same 18-year period, geriatric acetabular fractures increased by 67%, subtrochanteric femur fractures increased by 42%, and pelvic fractures increased by 24%. Hospital charges, when controlling for inflation, increased roughly 50% for all fracture types. Furthermore, transfers from outside acute care hospitals for definitive management stayed elevated for acetabular fractures as compared with traditional hip fractures, suggesting a greater need for tertiary care of acetabular fractures. Geriatric acetabular fractures are rapidly increasing, whereas traditional hip fractures continue to decline. Patients with these injuries are more likely to be transferred from their hospital of presentation to another acute care institution, possibly increasing costs and complications. This is likely related to their complexity and the lack of consensus regarding optimal management.
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0 |
Population-based prospective study on the incidence of osteoporosis-associated fractures in a German population of 200,413 inhabitants
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Distal Radius Fractures
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BACKGROUND: A limited body of data is available with regard to the incidence of osteoporotic fractures in Germany. Most of the data published thus far have been derived from hospital records or health insurance settlements. The aim of the present study was to prospectively register four types of fractures in an urban population. The data we obtained were compared with the results of retrospective analysis procedures in order to determine the differences and underlying errors.
METHODS: An urban population of 200 413 residents was investigated prospectively with regard to osteoporosis-associated fractures over a period of 12 months. All fractures were recorded and confirmed on radiographs. The results of this analysis were compared with the data from the Statistical Bureau and the International Classification of Disease (ICD) registers of the hospitals.
RESULTS: A total of 979 fractures occurred during the period of investigation. The most common type was the distal radius fracture (395; 197.1 per 100 000). The retrospective detected data of the Statistical Bureau were 31, 56% lower than the actual number of fractures. A retrospective analysis of fractures based on the ICD registers of the hospitals revealed an over-registration rate of 26.67%.
CONCLUSIONS: Retrospective methods of fracture registration do not provide sufficiently reliable data.
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0 |
Factors predisposing to periprosthetic fracture after hip arthroplasty: a case (n = 31)-control study
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Management of Hip Fractures in the Elderly
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We compared retrospectively 31 patients with a periprosthetic fracture to 31 patients in a control group. The Finnish Arthroplasty Register was used to count all periprosthetic fractures treated by revision arthroplasty in Finland and in Tampere University Hospital district during the years 1990-1999. We used the date of the previous operation to find the control group patients operated on at the same time in the same hospital district. No other selection or matching criteria were used. The type of prosthesis, complications, age, BMI, cementation and primary diagnosis were compared. We found that patients who had a fracture as the primary diagnosis ran a 4.4 (95%CI = 1.4-14) times higher risk of periprosthetic fracture than those operated on for other reasons
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0 |
Internal fixation for osteochondritis dissecans of the knee
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Diagnosis and Treatment of Osteochondritis Dissecans AUC
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Eight knees of seven patients with osteochondritis dissecans of the knee underwent internal fixation of the fragments. The affected location was the medial femoral condyle in four knees, the lateral femoral condyle in one knee and the patellar groove in three knees. At the time of surgery, patient age ranged from 13 to 20 years (mean 16.9 years). Open reduction and internal fixation of the unstable fragments was performed with autologous bone pegs in one knee. In the other seven knees, the procedures were carried out with biodegradable poly-L-lactide pins. At a mean follow-up of 5 years (range 4-6.8 years), seven fragments were united, whereas one knee required arthroscopic removal of the loose fragment. Neither effusion nor synovitis was noticed in any of the patients treated with biodegradable pins. The technique is simple and provides satisfactory results, suggesting a valid option for the treatment of osteochondral defects where possible
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1 |
Periprosthetic fractures associated with primary total shoulder arthroplasty and primary humeral head replacement: A thirty-three-year study
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Glenohumeral Joint OA
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Background: The objective of this study was to assess the frequency of, and risk factors for, periprosthetic fractures during and after shoulder arthroplasty. Methods: All adults treated with a primary total shoulder arthroplasty or humeral head replacement at the Mayo Clinic Medical Center from 1976 to 2008 were identified. Periprosthetic fractures were validated by medical record review. Univariate and multivariable-adjusted logistic regression analyses were used to assess the association of demographic factors (age, sex, and body mass index [BMI]), underlying diagnosis, implant fixation (cemented or uncemented), American Society of Anesthesiologists (ASA) class, and comorbidity as assessed with the Deyo-Charlson index. Results: The cohort consisted of 2207 patients treated with a total of 2588 primary total shoulder arthroplasties and 1349 patients treated with 1431 humeral head replacements. Seventy-two medical-record-confirmed periprosthetic fractures occurred in association with the total shoulder arthroplasties. These consisted of forty-seven intraoperative fractures (forty humeral fractures, five glenoid fractures, and two fractures for which the site was unclear) and twenty-five postoperative fractures (twenty humeral fractures, three glenoid fractures, and two fractures for which the site was unclear). There were thirty-three fractures associated with the humeral head replacements. Fifteen were intraoperative (eight humeral fractures and seven glenoid fractures), and eighteen were postoperative (sixteen humeral fractures and two glenoid fractures). In the multivariable regression analysis of the total shoulder arthroplasties, female sex (odds ratio [OR], 4.19; 95% confidence interval [CI], 1.82 to 9.62; p < 0.001; a 2.4% rate for women versus 0.6% for men) and the underlying diagnosis (p = 0.04; posttraumatic arthritis: OR, 2.55; 95% CI, 0.92 to 7.12) were associated with a significantly higher risk of intraoperative humeral fracture in general, and female sex was associated with the risk of intraoperative humeral shaft fracture (OR, infinity; p < 0.001). In combined analyses of all patients (treated with either total shoulder arthroplasty or humeral head replacement), a higher Deyo-Charlson index was significantly associated with an increased risk of postoperative periprosthetic humeral shaft fracture (OR, 1.27; 95% CI, 1.11 to 1.45); p < 0.001), after adjusting for the type of surgery (total shoulder arthroplasty or humeral head replacement). Conclusions: The overall risk of periprosthetic fractures after total shoulder arthroplasty or humeral head replacement was low. Women had a significantly higher risk of intraoperative humeral shaft fracture. The underlying diagnosis (especially posttraumatic arthritis) was significantly associated with the risk of intraoperative humeral fracture, and comorbidity was significantly associated with the risk of postoperative humeral shaft fracture. Level of Evidence: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence. Copyright © 2012 by The Journal of Bone and Joint Surgery, Incorporated.
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0 |
Nonsurgical Management of Osteoarthritis Knee Pain in the Older Adult: An Update
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AAHKS (4) Acetaminophen
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Symptomatic knee osteoarthritis is a common complaint of many elderly patients in primary care offices. For those unable or unwilling to undergo knee replacement, the primary practitionersâ?? understanding of the strengths and weaknesses of the available treatment modalities for pain relief is critical to successful in-office counseling and expectation management. Treatment requires a multimodal approach of nonpharmacologic and pharmacologic therapies to achieve a maximal clinical benefit. The focus of this review is on the nonsurgical options for treatment of knee osteoarthritis in patients aged 65 and older.
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0 |
Community-based study to estimate prevalence and burden of illness of rheumatic diseases in Cuba: a COPCORD study
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HipFx Supplemental Cost Analysis
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OBJECTIVE: To estimate the prevalence, burden of illness, and help-seeking behavior of patients with musculoskeletal complaints and provide point prevalence estimates of osteoarthritis, low back pain, fibromyalgia, rheumatoid arthritis, gout, and bone fractures not related to trauma among the adult population in a urban community in Havana City. METHODS: Home survey of adults validated against physical examination. Forty-eight trained family doctors and 3 rheumatologists supervised the interviews and confirmed diagnoses. Family doctors applied a validated Community Oriented Program for the Control of Rheumatic Diseases core questionnaire. A diagnosis using American College of Rheumatology criteria was established. Analysis was based on descriptive statistics and point prevalence estimates with 95% confidence intervals (CIs) of most common diseases and associated disability rate. RESULTS: One thousand two hundred thirty-eight men and 1917 women were included. Prevalence of musculoskeletal pain was estimated in 43.9% (95% CI: 42.2-45.7). The knees were the most affected area (11.7%; 95% CI: 10.6-12) followed by low back pain (11.6%; 95% CI: 10.5-12.8). Point prevalence and 95% CI were as follows: osteoarthritis, 20.4% (95% CI: 19-21.8); gout, 0.38% (95% CI: 0.2-0.6); fibromyalgia, 0.22% (95% CI: 0.09-0.4); systemic lupus erythematosus, 0.06% (95% CI: 0.01-0.25); spondyloarthropathies, 0.19% (95% CI: 0.07-0.4); and rheumatoid arthritis,1.24% (95% CI: 0.8-1.7). Bone fractures not related to trauma were found in 1.14%, hip fracture being the most common (30.5%). Most patients were seen by the general practitioner (65.4%) and 6.2% described some disability. CONCLUSIONS: Musculoskeletal pain is highly prevalent in Cuba. Prevalence estimates are similar to those described in other surveys except for rheumatoid arthritis that seems more prevalent in Cuba and fibromyalgia less prevalent
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0 |
The effects on surgery stress of preoperative oral carbohydrate intake of knee and hip replacement surgery
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Surgical Management of Osteoarthritis of the Knee CPG
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In recent years, are developed a special carbohydrate drink that administer before elective surgery for patients cause and cause accelerate gastric emptying, relieve anxiety due to hunger, prevent hypoglycemia and to improve patient comfort. In this study, was investigated the effects of preoperative oral fluid intake of carbohydrates on stress responses to surgery. Current study compared the reponses to surgical stress of two group patients who administered oral carbohydrate drinks or not. One of the groups were fasted and the others were fed with only carbohydrate drinks two times before surgery. Two groups were compared to the effectiveness of oral carbohydrate intake on surgical procedure and complications. Demographic features and operation characteristics of the patients were similar. There was no significant difference between the groups regarding to Heart Rate, systolic blood pressure, diastolic blood pressure, and form the mean blood pressure values. Basal requirement of the groups who administered oral glucose and water, were met by about 1200 ml fluid intake. Hemodinamic responses of the patients underwent starvation have no difference. It is likely that basal requirement of those patients were met by the fluid released from the depletion of glycogen stores during the starvation. Conclusively, surgical stres is a complex procedure and may be effected by various factors which known or unknown. For the patients undergoing knee and hip replacement procedures, the effect of preoperative oral carbohydrate intake on surgical stress relieved by anesthesia have no significant difference between the groups in terms of preoerative or postoperative cortisol levels, Heart Rate values, insulin levels and glucose levels. Further investigations are necessary to support this result
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0 |
Preliminary results of Miller-Galante uncemented total knee arthroplasty
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Surgical Management of Osteoarthritis of the Knee CPG
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From July 1984 through February 1986, a total of 46 knees were placed in 42 patients. The average age of all patients was 58 years (range, 32 to 68). Osteoarthritis was the diagnosis in 38 knees, traumatic arthritis in 5, and rheumatoid arthritis in 3. During follow up, averaging 3.6 years (range, 2.0 to 4.5), the total knee score based on a modified Hospital for Special Surgery knee rating scale improved from a preoperative average of 59 to 93 postoperatively. Radiographically, partial radiolucencies (less than 1 mm) were present in at least one view in 72% of the knees in which the interface was well visualized. No radiolucencies were progressive. Complications occurred mainly in the patellar components, as 17% of metal-backed uncemented patellae required revision to cemented non-metal backed components. There were no deep infections. The authors remain cautiously optimistic while awaiting long-term follow up
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1 |
A prospective study of antibiotic efficacy in preventing infection in reduction mammaplasty
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Reduction Mammoplasty for Female Breast Hypertrophy
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BACKGROUND: The role of prophylactic antibiotics in reduction mammaplasty remains controversial. However, most surgeons choose to use antibiotics. In addition to cost and potential allergic reactions, unnecessary administration of antibiotics can suppress host natural flora and produce resistant organisms.
METHODS: Fifty patients were sequentially assigned to one of three study limbs: (1) no antibiotics, (2) preoperative antibiotics only, or (3) preoperative and postoperative antibiotics. The study was designed to include approximately 17 patients in each group. Cephalosporin antibiotics were used unless there was any question of allergy, in which case an alternative antibiotic regimen was used. Preoperative data collected on patients included age, body mass index, history of diabetes mellitus, peripheral vascular disease, previous breast surgery, steroid therapy, and tobacco use. Operative data included specimen weight, operative time, estimated blood loss, prolonged intraoperative hypotension, adjunctive axillary and breast tail liposuction, and intraoperative breast tissue culture.
RESULTS: The patient population in the three limbs of the study was similar. Thus, there was no significant difference among the groups insofar as the preoperative data were concerned (p > 0.20): age, body mass index, diabetes mellitus, peripheral vascular disease, previous breast surgery, and steroid or tobacco use. Furthermore, no significant difference (p > 0.12) was noted among intraoperative data in the three groups: specimen weight, operative time, estimated blood loss, prolonged hypotension, adjunctive breast liposuction, and positive bacterial culture from intraoperative breast tissue samples. Ninety percent of positive intraoperative breast tissue cultures revealed Staphylococcus epidermidis. Using strict criteria, the infection rate ranged from 19 to 20 percent. There was no significant difference (p > 0.91) in rate of infection among the three study limbs. There was, however, a significant reduction (p = 0.002) in delayed wound healing in the group that received preoperative antibiotics only. Among the studied risk factors for infection, only positive intraoperative culture of breast tissue was significant (p = 0.008) for development of infection. There was a significant association between delayed wound healing and infection (p = 0.003).
CONCLUSIONS: This prospective study did not find that prophylactic antibiotics in reduction mammaplasty have an effect on infection; however, a single preoperative dose significantly improved wound healing.
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0 |
Can a single dose of 300 mg of pregabalin reach acute antihyperalgesic levels in the central nervous system?
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AAHKS (9/10) Regional Nerve Blocks
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BACKGROUND AND OBJECTIVES: Central spinal cord sensitization can occur during surgery and may lead to persistent pain after surgery. Pregabalin has been shown to decrease central sensitization in experimental pain paradigms, and so the same antihyperalgesic effect of pregabalin may occur during and immediately after surgery. Our study investigated whether a single 300-mg dose of pregabalin in patients has sufficient central nervous system bioavailability to be useful under acute conditions where brain or spinal cord excitability may lead to long-term disease, such as chronic pain.
METHODS: Nine patients undergoing primary total knee replacement received pregabalin 300 mg orally, 1 hr before surgery. An intrathecal catheter was inserted for anesthesia, postoperative analgesic drug administration, and cerebrospinal fluid (CSF) sampling. Blood and CSF were then simultaneously sampled at 2, 4, 6, 8, and 24 hrs after oral pregabalin administration. Pregabalin concentration in plasma and CSF was measured using a validated high-pressure liquid chromatography assay.
RESULTS: By 2 hrs after pregabalin administration, the CSF pregabalin concentration is high enough (0.115 mug/mL) to have anticonvulsant activity, and by 6 hrs after pregabalin administration, the CSF pregabalin level is high enough (0.359 mug/mL) to reduce central nervous system hypersensitivity. The median time to peak pregabalin concentration in CSF was at 8 hrs. The pregabalin CSF/plasma based on area under the curve (AUC[0-24 hrs]) was 0.098 +/- 0.016, and for AUC[0-], the ratio was 0.176 +/- 0.064.
CONCLUSIONS: Sufficient central nervous system drug concentrations are reached after oral administration of pregabalin, suggesting that postoperative pain hypersensitivity can be reduced. Decreasing this acute brain or spinal cord excitability may prevent chronic pain from developing after surgery.
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1 |
Modified hybrid fixator for high-energy Schatzker V and VI tibial plateau fractures
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DoD SSI (Surgical Site Infections)
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High-energy tibial plateau fractures associated with severe soft tissue injury are difficult to manage. The risk of wound complications following open reduction and internal fixation is notably high owing to extensive soft tissue dissection. Alternatively, application of hybrid external fixator minimizes soft tissue dissection and provides adequate fracture stabilization to allow early range of motion and correction of any mal-alignment. With this technique, soft tissue complications particularly surgical site infections are expected to be significantly reduced. This prospective study aims to determine the effectiveness of a modified hybrid external fixator in the management of high-energy tibial plateau fractures. Thirty-three patients with high-energy Schatzker V and VI tibial plateau fracture with severe soft tissue injury precluding formal open reduction were enrolled into the study. The fixator was a construct combining the Ilizarov ring with a monolateral external fixator. The results-bony union, range of motion, and associated complications of the treatment-were assessed. All fractures united within an average time of 14 weeks. Neither loss of reduction nor surgical site wound breakdown/osteomyelitis was noted. Eight patients developed superficial pin track infection and one septic arthritis of the knee joint. Hybrid external fixation is a safe option for complex high-energy tibial plateau fractures by simultaneously providing adequate fracture stabilization and protection of soft tissue healing to achieve bony union. The complication is mainly related to pin tract infection.
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1 |
LiDCO-based fluid management in patients undergoing hip fracture surgery under spinal anaesthesia: a randomized trial and systematic review
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Hip Fx in the Elderly 2019
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BACKGROUND: Hip fracture is a condition with high mortality and morbidity in elderly frail patients. Intraoperative fluid optimization may be associated with benefit in this population. We investigated whether intraoperative fluid management using pulse-contour analysis cardiac monitoring, compared with standard care in patients undergoing spinal anaesthesia, would provide benefits in terms of reduced time until medically fit for discharge and postoperative complications.
METHODS: Patients undergoing surgical repair of fractured neck of femur, aged >60 yr, receiving spinal anaesthesia were enrolled in this single-centre, blinded, randomized, parallel group trial. Patients were allocated to either anaesthetist-directed fluid therapy or a pulse-contour-guided fluid optimization strategy using colloid (Gelofusine) boluses to optimize stroke volume. The primary outcome was time until medically fit for discharge. Secondary outcomes included postoperative complications, mobility, and mortality. We updated a systematic review to include relevant trials to 2014.
RESULTS: We recruited 130 patients. Time until medically fit for discharge was similar in both groups, mean [95% confidence interval (CI)] 12.2 (11.1-13.5) vs 13.1 (11.9-14.5) days (P=0.31), as was total length of stay 14.2 (12.9-15.8) vs 15.3 (13.8-17.2) days (P=0.32). There were no significant differences in complications, function, or mortality. An updated meta-analysis (four studies, 355 patients) found non-significant reduction in early mortality [relative risk 0.66 (0.24-1.79)] and in-hospital complications [relative risk 0.80 (0.61-1.05)].
CONCLUSIONS: Goal-directed fluid therapy during hip fracture repair under spinal anaesthesia does not result in a significant reduction in length of stay or postoperative complications. There is insufficient evidence to either support or discount its routine use.
Clinical trial registration: Isrctn88284896.
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1 |
Outcomes of tibia shaft fractures caused by low energy gunshot wounds
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DoD SSI (Surgical Site Infections)
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BACKGROUND: The purpose of this project was to compare the rates of infections, nonunions, malunions, and secondary operations in tibia fractures resultant from low energy GSWs versus those seen in open and closed tibia fractures resultant from blunt trauma. A secondary objective was to assess the utility of using the traditional Gustilo-Anderson classification system for open fractures to describe fractures secondary to low energy GSW.
METHODS: A retrospective review of 327 patients with tibia shaft fractures was conducted at our level I trauma center. Patients underwent a variety of interventions depending on their injury. Standard fixation techniques were utilized. Outcome measures include: mechanism of injury, rates of superficial and deep infection, nonunion, malunion, and secondary operations.
RESULTS: Deep infection after low energy GSW tibia fractures was uncommon and seen in only 2.3% of patients. Rates of infection after low energy GSWs were similar to low and high energy closed tibia fractures resultant from blunt trauma, but significantly less than that seen in open type II (25%, p<0.05), type IIIA (19.5%, p<0.05), and type IIIB fractures (47%, p<0.01). There were no nonunions following GSW fractures, versus 3.7% after closed tibia fractures from blunt trauma (p=0.2). Nonunions were more common after open fractures from blunt trauma (11%, p<0.05) versus GSWs. Differences in infection and nonunion were associated with more secondary operations (18%, p<0.01) in the open tibia fracture group compared with GSWs (2.3%) and closed fractures (7.9% p=0.19).
CONCLUSIONS: While GSWs are traditionally thought of as open injuries, low energy GSW tibia fractures had a low rate of infection and no nonunions, and resulted in a reoperation rate similar to closed blunt tibia shaft fractures and significantly lower than open tibia fractures.
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1 |
Panniculectomy and the separation-of-parts hernia repair: a solution for the large infraumbilical hernia in the obese patient
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Panniculectomy & Abdominoplasty CPG
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BACKGROUND: Infraumbilical hernias in the obese are problematic in terms of achieving adequate exposure and eventual wound healing. Simultaneous panniculectomy with separation-of-parts hernia repair is one approach to this reconstructive issue, but the feasibility of such a combination is untested. METHODS: Twenty-four simultaneous panniculectomy and separation-of-parts hernia repairs performed by the senior surgeon over a 6-year period are presented. Patients were analyzed by preoperative, intraoperative, and postoperative parameters. Complications were grouped into major and minor categories. RESULTS: Average patient body mass index was 39 (range, 29 to 57). Twenty of 24 (83 percent) of the hernias were recurrent on initial presentation. Almost one-half of the cases were contaminated (46 percent), marked by the presence of a preoperative wound (29 percent) or concurrent gastrointestinal procedure (17 percent). In 25 percent of cases, a preexisting laparotomy scar necessitated a vertical reopening of the abdominal skin, raising the stakes for postoperative wound breakdown. Despite these findings, major/minor wound complications (12.5 percent/33 percent) and additional surgery rates (17 percent) were relatively low considering this morbidly obese population. Postoperative wound complications, hernia recurrence, and reoperation rates were significantly increased among those patients whose body mass index exceeded 35(p < 0.05). All hernia recurrences (n = 4) were corrected definitively with a secondary direct repair. Mean follow-up was 10 months (range, 3 to 60 months). CONCLUSION: The separation-of-parts hernia repair in combination with pannus resection can be performed safely in obese patients, with complication rates comparable to those reported in the literature. This combined procedure has become the authors' procedure of choice in these difficult clinical situations.
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0 |
Magnetic resonance imaging of the knee
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AMP (Acute Meniscal Pathology)
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Knee pain is frequently seen in patients of all ages, with a wide range of possible aetiologies. Magnetic resonance imaging (MRI) of the knee is a common diagnostic examination performed for detecting and characterising acute and chronic internal derangement injuries of the knee and helps guide patient management. This article reviews the current clinical practice of MRI evaluation and interpretation of meniscal, ligamentous, cartilaginous, and synovial disorders within the knee that are commonly encountered.
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0 |
The epidemiology of femoral neck fractures in Jerusalem. A prospective study (1967-1971)
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Management of Hip Fractures in the Elderly
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A prospective study of 570 patients with fracture of the upper end of the femur was carried out between 1967 and 1971 in Jerusalem. Of three distinct ethnic groupings, Western or Ashkenazi females and Eastern or Sephardi males produced the highest incidence of fractured neck of the femur proportional to their makeup in the population at risk. No explanation for this is forthcoming as both groups are of differing sex and race. The age and sex incidence of these fractures in the Eastern and Western ethnic groups in this city showed a distinct resemblance to their geographicaly counterparts in other studies. There is an interesting seasonal pattern of incidence of fractures in females and correlation with increased physical activity during the three special holiday periods
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0 |
Obesity has no adverse effect on the outcome of unicompartmental knee replacement at a minimum follow-up of seven years
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OAK 3 - Non-arthroplasty tx of OAK
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The significance of weight in the indications for unicompartmental knee replacement (UKR) is unclear. Our hypothesis was that weight does not affect the long-term rate of survival of UKRs. We undertook a retrospective study of 212 UKRs at a mean follow-up of 12 years (7 to 22). The patients were distributed according to body mass index (BMI; < vs >= 30 kg/m(2)) and weight (< vs >= 82 kg). Kaplan-Meier survivorship analysis was performed and ten-year survival rates were compared between the sub-groups. Multimodal regression analysis determined the impact of the various theoretical contraindications on the long-term rate of survival of UKR. The ten-year rates of survival were similar in the two weight subgroups (>= 82 kg: 93.5% (95% confidence interval (CI) 66.5 to 96.3); < 82 kg: 92.5% (95% CI 82.5 to 94.1)) and also in the two BMI subgroups (>= 30 kg/m(2): 92% (95% CI 82.5 to 95.3); < 30 kg/m(2): 94% (95% CI 78.4 to 95.9)). Multimodal regression analysis revealed that weight plays a part in reducing the risk of revision with a relative risk of 0.387, although this did not reach statistical significance (p = 0.662). The results relating weight and BMI to the clinical outcome were not statistically significant. Thus, this study confirms that weight does not influence the long-term rate of survival of UKR.
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0 |
Dorsally displaced fractures of the distal radius: a critical appraisal of the DRAFFT (distal radius acute fracture fixation trial) study
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Distal Radius Fractures
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The results of the DRAFFT (distal radius acute fracture fixation trial) study, which compared volar plating with Kirschner (K-) wire fixation for dorsally displaced fractures of the distal radius, were published in August 2014. The use of K-wires to treat these fractures is now increasing, with a concomitant decline in the use of volar locking plates. We provide a critical appraisal of the DRAFFT study and question whether surgeons have been unduly influenced by its headline conclusions.
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0 |
[A clinical evaluation of chest wall reconstruction]
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Acellular Dermal Matrix
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From April 1987 to June 1995, we performed the chest wall reconstruction in 13 cases of 25 ones who had chest wall resection. The clinical records of these 13 patients were reviewed as follows. The histological diagnosis of these cases were direct invasion by primary lung cancer in 13 cases, malignant tumor of the chest wall in 5 cases, benign tumor or inflammation of the chest wall in 4 cases, local recurrence of the breast cancer and post operative radiation ulcer in each 1 case respectively, and mediastinal peripheral nerve sheath tumor in 1 case. Full diagnosis of the mediastinal malignant tumors were Ewing' sarcoma, chondrosarcoma, malignant lymphoma, malignant fibrous histiocytoma and eosinophilic granuloma in each 1 case respectively. The total number of resected ribs was 10 (bilateral 5 ribs with sternal body) in 1 case, 4 in 1 case, 3 in 6 cases, 2 in 2 cases and 1 in 4 cases. The following statement shows our methods of chest wall reconstructions. We treated one case with wide anterior chest wall resection, we treated by the Marlex-resin sandwich, 4 cases with 4 or 3 ribs of anterior or lateral chest wall, by sheets of Marlex mesh in layers, 3 cases with 3 ribs of posterior site, 1 case with 2 ribs and 4 cases with one rib, these 7 cases treated by cross sutures. And, we treated another 2 cases by pedicle omental flap and major pectoral muscle in each case respectively. The Marlex-resin sandwich has easy fixation and excellent stability, but it has also foreign body reaction. Therefore our case needed to remove of sandwich 10 months later for cellulitis and infection after the operation. Recently we use mostly sheets of Marlex mesh in layers, for the reconstruction of the chest wall with 3 or more rib's defect, but if it is more small defect, we use the cross suture method. The cross suture is very easy and effective method to maintain the stability of small chest wall defect.
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Correlations between serum adipocytokine concentrations, disease stage, radiological status and total body fat content in the patients with primary knee osteoarthritis
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OAK 3 - Non-arthroplasty tx of OAK
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PURPOSE: The study was designed to investigate whether serum concentrations of leptin, resistin and adiponectin in obese and normal-weight patients with primary knee osteoarthritis (OA) correlate with clinical and radiological stages of the disease and percentage of total body fat.
METHODS: Seventy-three patients with knee OA, divided into obese and normal-weight groups, were clinically evaluated according to the Knee Society Score (KSS), and radiologically assessed using Kellgren and Lawrence scale. The percentage of total body fat and some anthropometric data were also given. Serum leptin, resistin and adiponectin concentrations were measured by Elisa and were correlated with the clinical, radiological and anthropometric parameters.
RESULTS: Leptin concentrations were significantly higher (p = 0.001) in the obese patients and positively correlated (R = 0.63) with radiologically assessed OA grade, but only in the normal-weight group. Resistin and adiponectin concentrations were identical in obese and normal-weight patients and negatively correlated (R = -0.41) with the clinical status of obese patients. In both groups, percentage of total body fat positively correlated (R = 0.29 and R = 0.53 for obese and normal-weight respectively) with radiologically assessed OA grade. However, no correlations were found with clinical status of the patients.
CONCLUSIONS: It was found that in the obese patients with knee OA, increased percentage of total body fat and elevated serum leptin concentration might favour the advancement of clinical but not radiologically assessed changes in the joint structures, while in normal-weight patients it correlates only with radiologically assessed changes but does not affect to an appreciable extent the clinical status of the patients.
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1 |
Efficacy of combined ozone and platelet-rich-plasma treatment versus platelet-rich-plasma treatment alone in early stage knee osteoarthritis
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OAK 3 - Non-arthroplasty tx of OAK
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BACKGROUND: Osteoarthritis (OA) is a chronic disease most often occurring in knee joints, leading to pain of varying severity and deterioration in daily living activities.
OBJECTIVE: To compare efficacy of platelet-rich-plasma (PRP) versus PRP in combination with ozone gas injection in patients with early stage knee OA.
METHODS: Retrospective data of patients who received PRP alone (n= 45) or combined treatment (PRP + ozone, n= 35) injection was analyzed. Patients were evaluated using the visual analogue scale (VAS) and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores.
RESULTS: In both PRP alone and combined treatment groups, post-treatment VAS and WOMAC scores at month 1, month 3, and month 6 showed a significant reduction compared to pre-treatment scores (p< 0.001). Physical function and total WOMAC scores as well as VAS scores at post-treatment month 3 were significantly lower in the combined treatment group compared to the PRP alone group. Moreover, in the combined treatment group, VAS scores on Day 10 and hyper-inflammation at the injection site was significantly lower than the PRP alone group.
CONCLUSION: In general, similar efficacy was observed between treatment with PRP alone and treatment with PRP in combination with ozone. However, patients receiving ozone treatment are less likely to experience post-injection pain and are more likely to recover faster when compared to patients receiving PRP treatment alone.
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0 |
Association study of MMP8 gene in osteoarthritis
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OAK 3 - Non-arthroplasty tx of OAK
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OBJECTIVES: Osteoarthritis (OA) is a joint disease common in the elderly. There is a prior functional evidence for different matrix metalloproteinases (MMPs), such as MMP8 and MMP9, having a role in the breakdown of cartilage extracellular matrix in OA. Thus, we analyzed whether the common genetic variants of MMP8 and MMP9 contribute to the risk of OA.
MATERIALS AND METHODS: In total, 13 common tagging single-nucleotide polymorphisms (SNPs) were studied in a discovery knee OA cohort of 185 cases and 895 controls. For validation, two knee OA replication cohorts and two hand OA replication cohorts were studied (altogether 1369 OA cases, 4445 controls in the five cohorts). The chi(2) test for individual study cohorts and Cochran-Mantel-Haenszel test for combined meta-analysis were calculated using Plink.
RESULTS: The rs1940475 SNP in MMP8 showed suggestive association in the discovery cohort (OR = 0.721, 95% CI 0.575-0.906; p = 0.005). Other knee and hand OA replication study cohorts showed similar trend for the predisposing allele without reaching statistical significance in independent replication cohorts nor in their meta-analysis (p > 0.05). Meta-analysis of all five hand and knee OA study cohorts yielded a p-value of 0.027 (OR = 0.904, 95% CI 0.826-0.989).
CONCLUSIONS: Initial analysis of the MMP8 gene showed suggestive association between rs1940475 and knee OA, but the finding did not replicate in other study cohorts, even though the trend for predisposing allele was similar in all five cohorts. MMP-8 is a good biological candidate for OA, but our study did not find common variants with significant association in the gene.
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0 |
Continuous epidural analgesia after total knee arthroplasty: bupivacaine vs ropivacaine [abstract]
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Surgical Management of Osteoarthritis of the Knee CPG
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European Society of Anaesthesiologists Annual Congress, Amsterdam, The Netherlands, 29 May-1 June 1999
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1 |
Survivorship Analysis and Clinical Outcomes of Transtibial Pullout Repair for Medial Meniscus Posterior Root Tears: A 5- to 10-Year Follow-up Study
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AMP (Acute Meniscal Pathology)
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PURPOSE: This study investigated the clinical outcomes and mid- to long-term survival rates in patients undergoing transtibial pullout repair of medial meniscus posterior root tears (MMPRTs) after a minimum follow-up of 5 years.
METHODS: Between 2005 and 2011, patients with MMPRTs who had been followed for at least 5 years after undergoing transtibial pullout repair were recruited. Participants were identified using medical records and information in a prospectively collected database. Clinical outcomes were assessed based on a comparison of patient preoperative Lysholm scores and their scores at the final follow-up. A Kaplan-Meier survival analysis was used to investigate the survival rates of repair procedures. Clinical failures were defined as cases requiring conversion to total knee arthroplasty (TKA) or having final Lysholm score <65 or less than their preoperative scores.
RESULTS: Overall, 91 patients (mean age, 58.7 +/- 9.7 years) were included: the mean follow-up duration was 84.8 +/- 13.8 months. Among these patients, the mean Lysholm score improved significantly from 51.8 +/- 7.9 preoperatively to 83.0 +/- 11.1 at the final follow-up (P < .001). Overall, 4 patients failed due to conversion to TKA (n = 1) or having final Lysholm scores <65 or less than the preoperative scores (n = 3). The overall Kaplan-Meier probabilities of survival after repair were 99% at 5 years, 98% at 6 years, 95% at 7 years, and 92% at 8 years.
CONCLUSIONS: Among patients with MMPRTs, transtibial pullout repair demonstrated a high clinical survival rate and the patients demonstrated clinical improvement, based on mid- and long-term follow-up examinations.
LEVEL OF EVIDENCE: Level IV, retrospective uncontrolled case series.
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0 |
Enhanced recovery program for hip and knee replacement reduces death rate: A study of 4,500 consecutive primary hip and knee replacements
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AAHKS (5) Gabapentinoids
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Background and purpose: Multimodal techniques can aid early rehabilitation and discharge of patients following primary joint replacement. We hypothesized that this not only reduces the economic burden of joint replacement by reducing length of stay, but also helps in reduction of early complications. Patients and methods: We evaluated 4,500 consecutive unselected total hip replacements and total knee replacements regarding length of hospital stay, mortality, and perioperative complications. The first 3,000 underwent a traditional protocol while the other 1,500 underwent an enhanced recovery protocol involving behavioral, pharmacological, and procedural modifications. Results: There was a reduction in 30-day death rate (0.5% to 0.1%, p = 0.02) and 90-day death rate (0.8% to 0.2%, p = 0.01). The median length of stay decreased from 6 days to 3 days (p < 0.001), resulting in a saving of 5,418 bed days. Requirement for blood transfusion was reduced (23% to 9.8%, p < 0.001). There was a trend of a reduced rate of 30-day myocardial infarction (0.8% to 0.5%. p = 0 .2) and stroke (0.5% to 0.2%, p = 0.2). The 60-day deep vein thrombosis figures (0.8% to 0.6%, p = 0.5) and pulmonary embolism figures (1.2% to 1.1%, p = 0.9) were similar. Re-admission rate remained unchanged during the period of the study (4.7% to 4.8%, p = 0.8). Interpretation: This large observational study of unselected consecutive hip and knee arthroplasty patients shows a substantial reduction in death rate, reduced length of stay, and reduced transfusion requirements after the introduction of a multimodal enhanced recovery protocol. © 2011 Nordic Orthopaedic Federation.
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1 |
Ultrasonic investigation of the hip in newborns in the diagnosis of congenital hip dislocation: classification and results of a screening program
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Developmental Dysplasia of the Hip CPG
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The method of ultrasonic examination of the hip is described, the latest updated Graf classification is explained, and the results of a prospective screening program are described. One thousand four hundred and sixty newborn infants were examined by ultrasound and clinically by independent observers. The distribution of the ultrasound types was determined. Recommendations are given for the use of ultrasonic investigation of the hip for groups at risk in the neonatal period
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0 |
Incidence and clinical implications of stent fractures of the Xpert self-expanding nitinol stent in infrainguinal arteries
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DoD LSA (Limb Salvage vs Amputation)
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Background: Different stents in infrainguinal arteries have recently been associated with stent fractures and unfavorable clinical outcome,although data is limited regarding fractures of the Xpert selfexpanding nitinol stent. Thus, purpose of the present investigation was to evaluate its incidence and clinical implications in lower limb arteries. Patients and methods: Fifty-three consecutive patients (53 limbs) with peripheral arterial disease underwent secondary Xpert stent implantation due to suboptimal primary balloon angioplasty (PTA). Median age was 76 years. Stent fractures were evaluated by plain X-ray at median follow-up of 16 months.Stent patency was assessed by duplex ultrasound and sustained clinical improvement was defined as improvement of the ABI of � 0.10 together with improvement of at least one Rutherford class above the baseline finding throughout follow-up. Results: Median length of femoropopliteal and infrapopliteal lesion was 3.0 and 2.3 cm, respectively. Sixtyfive stents were implanted in 43 limbs with femoropopliteal and 10 stents in 10 limbs with infrapopliteal lesion, respectively. Stent fractures occurred in 3 of 43 limbs (7.0%) of patients with femoropopliteal lesion with stent-based fracture rate of 4.6%. All fractured stents showed multiple struts fractures and occurred in the distal and middle superficial femoral artery.No stent fracture was observed in infrapopliteal lesions. The fractured stents were not associated with any clinical deterioration. Sustained clinical improvement was 71.0% and 54.6% for femoropopliteal and infrapopliteal lesions, respectively. Stent patency assessed by duplex was 65.2 and 63.9% for femoropopliteal and infrapopliteal lesions, respectively. Conclusions: Fractures of the Xpert stent were seldom and not associated with unfavorable clinical outcome at midterm follow-up. © 2009 by Verlag Hans Huber, Hogrefe AG, Bern.
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0 |
Intraarticular fractures of the distal humerus in the adult
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The Treatment of Pediatric Supracondylar Humerus Fractures AUC
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Intraarticular fractures of the distal humerus are notoriously difficult to treat. Three basic treatment methods are available: closed reduction, traction, and open treatment. In the past, functional results with all these methods generally have been poor because of disabling limitations of elbow motion. Thirteen adult patients were treated by open reduction and application of medial and lateral buttress plates providing rigid internal fixation and early motion. The patients were evaluated for range of motion, infection, nerve injury, avascular necrosis, myositis ossificans, varus/valgus deformity, pain, instability, weakness, and degenerative changes. Ten of the 13 patients were available for follow-up study for an average of two years. Nine of the ten achieved good or excellent results. Based on these observations, the treatment of choice is internal fixation with dual plates combined with early active postoperative motion
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0 |
O-linked N-acetylglucosamine (O-GlcNAc) protein modification is increased in the cartilage of patients with knee osteoarthritis
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OAK 3 - Non-arthroplasty tx of OAK
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OBJECTIVE: There is increasing evidence that the addition of O-linked N-acetylglucosamine (O-GlcNAc) to proteins plays an important role in cell signaling pathways. In chondrocytes, accumulation of O-GlcNAc-modified proteins induces hypertrophic differentiation. Osteoarthritis (OA) is characterized by cartilage degradation, and hypertrophic-like changes in hyaline chondrocytes. However, the mechanisms responsible for these changes have not been described. Our aim was to study whether O-GlcNAcylation and the enzymes responsible for this modification are dysregulated in the cartilage of patients with knee OA and whether interleukin-1 could induce these modifications in cultured human OA chondrocytes (HOC).
DESIGN: Human cartilage was obtained from patients with knee OA and from age and sex-matched healthy donors. HOC were cultured and stimulated with the catabolic cytokine IL-1alpha. Global protein O-GlcNAcylation and the synthesis of the key enzymes responsible for this modification, O-GlcNAc transferase (OGT) and O-GlcNAcase (OGA), were assessed by western blot.
RESULTS: OA was associated with a 4-fold increase in the global O-GlcNAcylation in the cartilage. OA cartilage showed a re-distribution of the OGT and OGA isoforms, with a net increase in the presence of both enzymes, in comparison to healthy cartilage. In HOC, IL-1alpha stimulation rapidly increased O-GlcNAcylation and OGT and OGA synthesis.
CONCLUSIONS: Our results indicate that a proinflammatory milieu could favor the accumulation of O-GlcNAcylated proteins in OA cartilage, together with the dysregulation of the enzymes responsible for this modification. The increase in O-GlcNAcylation could be responsible, at least partially, for the re-expression of hypertrophic differentiation markers that have been observed in OA.
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0 |
The antioxidant and non-antioxidant contributions of vitamin E in vitamin E blended ultra-high molecular weight polyethylene for total knee replacement
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PJI DX Updated Search
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Vitamin E (VE) blended ultra-high molecular weight polyethylene (UHMWPE) has been developed in Japan as a material for use in total knee replacement (TKR). Various results have demonstrated that VE blended UHMWPE reduces the incidence of delamination failure and lowers the amount of wear produced during knee simulator testing. It was also found that wear particles from VE blended UHMWPE elicited a reduced biological response compared to conventional UHMWPE. A great deal of research concerning vitamin E (VE) stabilized ultrahigh molecular weight polyethylene (UHMWPE) has focused on VE's effects as an antioxidant and its ability to prevent the oxidative degradation of UHMWPE chains. However, other chemical and mechanical changes have been observed in VE blended UHMWPE that are unrelated to the oxidative protection that VE provides. This paper provides a general review of VE blended UHMWPE, with a particular focus on the non-antioxidant effects of VE. The potential application of VE blended UHMWPE in total hip replacement (THR), along with the differences in loading conditions between the knee and the hip are also discussed
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0 |
Haemophilus aphrophilus endocarditis after tongue piercing
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Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures
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Piercing invades subcutaneous areas and has a high potential for infectious complications. The number of case reports of endocarditis associated with piercing is increasing. We studied a 25-year-old man with a pierced tongue, who arrived at Memorial Health University Medical Center with fever, chills, rigors, and shortness of breath of 6 days' duration and had an aortic valvuloplasty for correction of congenital aortic stenosis
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0 |
Evidence that ORF3 at the Streptococcus parasanguis fimA locus encodes a thiol-specific antioxidant
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Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures
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Streptococcus parasanguis is a primary colonizer of dental plaque and a major player in subacute bacterial endocarditis. In the present study, the authors report that an ORF (ORF3) located 77 bp downstream of the fimA operon on the S. parasanguis FW213 chromosome complements an Escherichia coli thiol peroxidase (tpx) mutation in glutamine synthetase (GS) protection assays and that GS is protected by the ORF3 gene product in S. parasanguis cell extracts. In addition, the putative streptococcal peroxidase (Tpx(Sp)) protects S. parasanguis from stress caused by H2O2 and is induced by oxygen, as revealed by Northern blot analysis. Taken collectively, these findings support a thiol-dependent antioxidant activity for Tpx in S. parasanguis
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0 |
Prosthetic hip joint infection caused by Listeria monocytogenes
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Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures
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The authors report an unusual case of prosthetic hip joint infection caused by Listeria monocytogenes. The patient, an 87-year-old lady who had undergone a right total hip replacement 10 years previously, presented with pain and restriction of hip motion three weeks after an episode of abdominal pain. Aspiration of the joint yielded a dark fluid, from which Listeria Monocytogenes type 4-b was isolated. Blood cultures remained negative. After prolonged antibiotic therapy, symptoms gradually resolved. A few months later, pain recurred with radiological signs of loosening of the femoral component. Onestage revision arthroplasty was performed combined with antibiotic treatment. The patient remains asymptomatic at one year follow-up. Laboratory data and xray control are normal. Prosthetic hip joint infection with Listeria monocytogenes is uncommon; few cases have been reported. The literature review shows that prolonged antibiotic therapy alone may be used in patients for whom removal of the prosthesis is not desirable, although revision arthroplasty or prosthesis removal remains necessary in the other cases
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0 |
The segmental tibial fracture
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DoD SSI (Surgical Site Infections)
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A series of 31 segmental tibial fractures is reported. Eighty-four percent of the patients sustained multiple trauma and 80% of these were open fractures. The series includes treatment with 20 external fixators, seven unreamed intramedullary nails, two casts, and two amputations. Complications included a 48% incidence of elevated compartment pressures necessitating fasciotomy. Despite rapid early decompression, there was a 19% incidence of residual motor and sensory deficit. Other complications observed were a 35% incidence of wound infection, nonunion, and malunion. Eighty-one percent of delayed or nonunions occurred at the distal fracture site. Intramedullary nailing produced the fewest complications. The segmental tibial fracture is at high risk for complications. Close observation of the limb for high compartment pressures is advisable. Treatment for compartment syndrome includes prompt decompression and stabilization of the fracture and, as indicated, intramedullary rods without preliminary reaming.
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0 |
Primary oromandibular reconstruction using free flaps and thorp plates in cancer patients: a 5-year experience
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DoD SSI (Surgical Site Infections)
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BACKGROUND: Low-profile second-generation THORP titanium plates combined with soft tissues free flaps (forearm or TRAM) can be used for oromandibular reconstruction in patients with SCC in advanced stage (stage III-IV).
METHODS: To evaluate long-term stability and possible complications of this reconstructive technique, we recorded, retrospectively, data of 25 patients with posterolateral oromandibular defects after tumor resection collected during a 5-year period.
RESULTS: All free flaps were successfully transferred, although eight patients were initially seen with delayed hardware-related reconstructive complications: plate exposure in four patients and plate fracture in four patients.
CONCLUSIONS: Nowadays, the state-of-the-art treatment for mandibular defects is primary bone reconstruction with bone free flaps, but in selected cases (elderly patients, poor performance status, posterolateral oromandibular defects, soft tissue defects much more important than bone defects) the association with THORP plate-soft tissue free flaps represents a good reconstructive choice.
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0 |
Fixion nails for humeral fractures
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The Treatment of Pediatric Supracondylar Humerus Fractures AUC
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Humeral fractures in the setting of multi-trauma are usually managed with internal fixation. We prospectively followed nine patients treated with an expandable nail (Fixion, DiscoTech, Medical Technologies, Herzliya, Israel), until union. Internal fixation rapidly stabilises the injured limb, and the lack of distal cross-bolting in this device markedly reduced our operative time. There were no complications in our series and there was evidence of clinical and radiological union within 6 months. We found the nail easy to use and effective in this clinical setting
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0 |
The clinical and immunological assessment of frozen bone allografts
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BMAC (Bone Marrow Aspirate Concentrate)
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The clinical results of bone allografts, previously frozen at -70° were reviewed. This revealed satisfactory results in most cases, especially when the grafts were employed in areas of high osteogenic potential, for example with Cloward body infusions (27 fusions/27 cases) or when grafting crush fractures in metaphysical bone (eg. Lateral tibial plateau). Immunological studies for humeral antibody were carried out with the complement dependent cytotoxicity test and the antibody dependent cell cytotoxicity test. The target cells were fibroblasts from the bone graft donors and were grown under sterile conditions. No evidence of antibody formation was seen in any of the tests. This contrasted with our work with fresh unfrozen osteochondral allografts, used for biologically resurfacing osteoarthritic joints. These grafts are known to be immunogenic and are transplanted ater tissue typing but without matching. In these cases high levels of antibody formed specifically against donor antigens, were demonstrated. These antibodies were noted to arise by the second week and were demonstrable for several months post operatively.
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1 |
A Current Review of the Meniscus Imaging: Proposition of a Useful Tool for Its Radiologic Analysis
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AMP (Acute Meniscal Pathology)
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The main objective of this review was to present a synthesis of the current literature in order to provide a useful tool to clinician in radiologic analysis of the meniscus. All anatomical descriptions were clearly illustrated by MRI, arthroscopy, and/or drawings. The value of standard radiography is extremely limited for the assessment of meniscal injuries but may be indicated to obtain a differential diagnosis such as osteoarthritis. Ultrasound is rarely used as a diagnostic tool for meniscal pathologies and its accuracy is operator-dependent. CT arthrography with multiplanar reconstructions can detect meniscus tears that are not visible on MRI. This technique is also useful in case of MRI contraindications, in postoperative assessment of meniscal sutures and the condition of cartilage covering the articular surfaces. MRI is the most accurate and less invasive method for diagnosing meniscal lesions. MRI allows confirming and characterizing the meniscal lesion, the type, the extension, its association with a cyst, the meniscal extrusion, and assessing cartilage and subchondral bone. New 3D-MRI in three dimensions with isotropic resolution allows the creation of multiplanar reformatted images to obtain from an acquisition in one sectional plane reconstructions in other spatial planes. 3D MRI should further improve the diagnosis of meniscal tears.
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0 |
Additional treatment in chronic pain syndrome due to hip and knee arthritis with the selective serotonin reuptake inhibitor fluvoxamine (Fevarin
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OAK 3 - Non-arthroplasty tx of OAK
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OBJECTIVE: The aim of this study was to investigate the effectiveness and safety of the selective serotonin reuptake inhibitor fluvoxamine (Flevarin) in patients with a chronic pain syndrome due to hip and knee arthritis. METHODS: We prospectively investigated 60 patients in a singleâ?centre doubleâ?blind study. The group was divided into two groups (M1 fluvoxamine; M2 placebo) each containing 30 patients, age ranging from 30 to 80 years. During treatment results were evaluated using several scales once at the beginning (V1) followed by weekly evaluations (V1â?V8) and one final investigation at the end of treatment (V9). The investigated medication consisted of 50â?150 mg fluvoxamine. In addition other drugs such as NSAID were administered (diclofenac, piroxicam, ibuprofen). RESULTS: Both groups (M1 and M2) showed a reduction of pain during treatment using the visual analogue scale (VAS). However, no statistical difference was found between both groups concerning pain reduction at any time. A significant pain relief was monitored in the patients of the M1 group towards the end of treatment. Concerning the daily impairment because of pain measured by the Griss scale an improvement was seen in 70 % of the patients receiving fluvoxamine versus 44 % in patients receiving placebo. Additionally, an improvement in the M1 group was seen in the WOMAC scale and in factors such as pain, stiffness and mobility compared to the M2 group. Using the CGI scale, 56.6 % of the M1 group compared to 37.9 % of the M2 group were stating that their overall status had improved "much" or "very much" at the end of the treatment (V9). A depression had been excluded in all patients. No statistical differences were seen in the Bf scale (von Zerssen) during all evaluations (V1 to V9). During the whole study 127 side effects were registered in 49 patients. None of the 5 severe events were related to the investigated drug. CONCLUSION: Considering the good effects in combination with very few side effects, a positive costâ?effectiveness relation for the usage of fluvoxamine can be stated in patients with chronic pain syndrome due to hip and knee arthritis.
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0 |
Gynaecomastia surgery in the Netherlands: What, why, who, where
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Panniculectomy & Abdominoplasty CPG
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Gynaecomastia, breast enlargement in men, is common in all age groups. It is operated on by plastic surgeons, general surgeons and paediatric surgeons. It is therefore possible that there is a difference in the populations treated, the indications for surgery and the management used by the different practitioners. We performed a survey in order to assess the approach to treatment of gynaecomastia by the different disciplines. An electronic survey questionnaire was sent to members of the Dutch societies of surgery, paediatric surgery and plastic surgery. We received 105 responses from plastic surgeons, 95 from general surgeons and 15 from paediatric surgeons, representing respective response rates of 38.7%, 23.8% and 42.8%. Plastic surgeons operated on gynaecomastia most frequently. The diagnostic criteria and workup were similar for all disciplines, although general surgeons used more imaging. There was a difference in the side operated on. General surgeons and paediatric surgeons operated mainly on unilateral cases (74% and 52%), while plastic surgeons operated mainly on bilateral cases (85%). Pharmaceutical treatment with Tamoxifen was reported only by general surgeons (13%). All disciplines used mainly the periareolar incision. Plastic surgeons reported more often the use of other surgical approaches as well as adjunctive liposuction and they did not always submit tissue for pathological examination. Perioperative antibiotics, drains and pressure garments were not always used. All disciplines agreed that the most common complication was bleeding, followed by seroma, infection, insufficient results, inverted nipple and nipple necrosis. This survey highlights some differences in the practice of gynaecomastia surgery. The findings appear to point to the fact that the indications are different, being more aesthetic in the case of plastic surgeons. The results of this survey are important in establishing the standard of care and may be helpful for setting guidelines. © 2014 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
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0 |
Tosic external fixator in the management of proximal tibial fractures in adults
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DOD - Acute Comp Syndrome CPG
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This retrospective clinical study assessed proximal tibial fractures managed with the Tosic external fixator. Nineteen patients with 21 proximal tibial fractures treated with the Tosic external fixator between July 1997 and October 1998 comprised the study population. Eleven fractures were graded as 41A2, 3 fractures as 41A3, 4 fractures as 41C1, and 3 fractures as 41C2. Fourteen fractures were closed, and 7 fractures were open. Average time to healing was 17 weeks. No revision of fixation was needed. There were five cases of pin tract infection. Average range of knee motion was 2°-135°. These results indicate the Tosic external fixator is an efficient and simple way to treat proximal tibial metaphyseal fractures.
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0 |
Unilateral versus bilateral primary knee osteoarthritis: Relation to the Western Ontario McMaster Universities Osteoarthritis Index (WOMAC), C-reactive protein and radiological assessment in Egyptian patients
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OAK 3 - Non-arthroplasty tx of OAK
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Aim of the work: To study the differences between unilateral and bilateral knee osteoarthritis (KOA) patients in relation to the Western Ontario McMaster Universities Osteoarthritis Index (WOMAC), C-reactive protein (CRP) and radiological assessment. Patients and methods: The study included 80 primary KOA patients subgrouped into those with unilateral or bilateral condition according to the X-ray. WOMAC scale and body mass index (BMI), waist (WC) and thigh (TC) circumferences were measured. The CRP and lipid profile were evaluated and plain X-ray knees assessed by Kellgren and Lawerence (KL) grade. Results: Patients mean age was 50 ± 9.8 years, disease duration 4 ± 3 years and were 61 females and 19 males. Mean BMI was 32 ± 6.6, WC 96 ± 20 cm, TC 56 ± 11.5 cm, WOMAC 43 ± 14 and KL grade 2 ± 0.9. Unilateral knee was detected in 28 (35%) and was bilateral in 52 (65%) patients. Highest pain was detected in female patients on using stairs and was significant on weight-bearing (p = 0.004), but going downstairs and the KL grade were significantly more in males (p = 0.004 and p = 0.03 respectively). The WOMAC pain subscale items and KL grading were significantly increased in patients with bilateral KOA. The WOMAC significantly correlated with the BMI, WC, TC, lipid profile and KL grade (p < 0.0001 for all). On regression, only the disease duration and cholesterol levels were predictors of WOMAC score (β = 0.2, p = 0.04 and β = 0.29, p = 0.03 respectively). Conclusions: Pain on weight bearing in females and bending activities especially going downstairs (in males) appears early with primary KOA. Bilateral involvement is more painful with more radiographic severity.
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0 |
Current role of emergency ultrasound of the chest
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MSTS 2022 - Metastatic Disease of the Humerus
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Objective: Chest sonography has gained clinical significance in the diagnosis of various pulmonary, pleural, cardiac, and mediastinal emergency conditions. Therefore, the current role of emergency ultrasound are assessed. Data Source: A systematic literature search of MEDLINE database was performed to identify all studies dealing with transthoracic sonography/chest ultrasound in combination with pulmonary embolism, pneumothorax, pneumonia, pleural effusion, pulmonary edema, and lung contusion. The relevant sonographic studies between 1988 and 2010 were evaluated. Conclusions: The noninvasive ultrasound-based diagnosis is relatively portable permitting the technique to be performed at any time, in any place, and on any patient, an ideal method for emergency conditions. Sonography allows immediate diagnosis of pulmonary embolism, pneumothorax, pneumonia, pleural effusion as well as rib fracture, and it provides a basis for further diagnostic- and treatment-related decisions. The key sonographic features associated with these most common emergency chest diseases are illustrated herein. Copyright © 2011 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins.
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0 |
Childhood trauma and diurnal cortisol disruption in fibromyalgia syndrome
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DoD PRF (Psychosocial RF)
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Adults with fibromyalgia syndrome report high rates of childhood trauma. Neuroendocrine abnormalities have also been noted in this population. Exploratory analyses tested relationships between retrospective reports of childhood trauma and diurnal salivary cortisol patterns among 85 women with fibromyalgia. Subjects with fibromyalgia completed self-reports of childhood physical, sexual and emotional abuse, as well as emotional and physical neglect. Recent major life events, current perceptions of stress, and depressive symptoms were also assessed. Salivary cortisol was collected six times per day for two consecutive days to assess diurnal rhythm, awakening response and mean cortisol levels. Hierarchical regression analyses were performed, controlling for age, relevant medications, life events, perceived stress, and depressive symptoms. Childhood physical abuse predicted flattened diurnal cortisol rhythms as well as greater cortisol responses to awakening. Sexual abuse was a second predictor of increased awakening cortisol responses. Patients with a history of trauma had markedly low levels of cortisol at the time of first awakening, partly explaining the results. These findings suggest that severe traumatic experiences in childhood may be a factor of adult neuroendocrine dysregulation among fibromyalgia sufferers. Trauma history should be evaluated and psychosocial intervention may be indicated as a component of treatment for fibromyalgia.
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1 |
5 year experience with lower lip cancer
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Reconstruction After Skin Cancer
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Retrospective study of 189 cases of lower lip cancer treated from 1996-2000 is done. There were 69% males and 31% females. Median age was 66.8 years. 84.4% of patients were with tumors stage I-II. Surgical treatment was performed in 83.6% of patients. In all operated cases was squamous cell carcinoma as verrucous tumor in 17.4%, as exophytic in 46% and as ulcerative in 36.6%. There were different methods of local excision, primary reconstruction and neck dissection depending from stage. In the patient group with clinically negative neck at the first attendance (170 patients) delayed cervical metastases developed in 6 patients (3.5%). Recurrence at the primary site developed in 11.3% of patients and was associated with large tumor size and low cancer differentiation. Survival rate at 5-year follow-up was 95% for patients with I stage, 89.7% for II stage and 37% for III and IV stage patients or mean for all group 83.7%. Diagnosis and treatment of actinic cheilitis also is discussed.
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0 |
The association between toe grip strength and osteoarthritis of the knee in Japanese women: A multicenter cross-sectional study
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OAK 3 - Non-arthroplasty tx of OAK
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We evaluated the relationship between altered foot function and knee osteoarthritis through a specific comparison of toe grip strength in older women with and without knee osteoarthritis.
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0 |
Contemporary bone loss options: Rebuild, reinforce, and augment
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PJI DX Updated Search
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Bone loss is commonly encountered during revision total knee arthroplasty (TKA). Small defects can be adequately managed with cement filling (with or without screws), modular prosthetic augments, and morselized allograft. For larger defects, cancellous impaction grafting and structural allografts have traditionally been utilized. More recently, highly porous tantalum cones and titanium sleeves have been designed to achieve axial and rotational stability in the metaphysis and subsequent biologic fixation. Sleeves are linked to one type of prosthesis, whereas cones are unlinked and can be used with any implant design. Multiple studies have demonstrated excellent survivorship and radiographic osseointegration at mid-term follow-up. This article provides a review of contemporary methods of bone loss management with a focus on highly porous metals and an emphasis on the authors' preferred method for managing the severe bone loss in revision TKA
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0 |
Interventions for treating wrist fractures in children
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Distal Radius Fractures
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Background: Wrist fractures, involving the distal radius, are the most common fractures in children. Most are buckle fractures, which are stable fractures, unlike greenstick and other usually displaced fractures. There is considerable variation in practice, such as the extent of immobilisation for buckle fractures and use of surgery for seriously displaced fractures. Objectives: To assess the effects (benefits and harms) of interventions for common distal radius fractures in children, including skeletally immature adolescents. Search methods: We searched the Cochrane Bone, Joint and Muscle Trauma Group's Specialised Register, the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, trial registries and reference lists to May 2018. Selection criteria: We included randomised controlled trials (RCTs) and quasi-RCTs comparing interventions for treating distal radius fractures in children. We sought data on physical function, treatment failure, adverse events, time to return to normal activities (recovery time), wrist pain, and child (and parent) satisfaction. Data collection and analysis: At least two review authors independently performed study screening and selection, 'Risk of bias' assessment and data extraction. We pooled data where appropriate and used GRADE for assessing the quality of evidence for each outcome. Main results: Of the 30 included studies, 21 were RCTs, seven were quasi-RCTs and two did not describe their randomisation method. Overall, 2930 children were recruited. Typically, trials included more male children and reported mean ages between 8 and 10 years. Eight studies recruited buckle fractures, five recruited buckle and other stable fractures, three recruited minimally displaced fractures and 14 recruited displaced fractures, typically requiring closed reduction, typically requiring closed reduction. All studies were at high risk of bias, mainly reflecting lack of blinding. The studies made 14 comparisons. Below we consider five prespecified comparisons: Removable splint versus below-elbow cast for predominantly buckle fractures (6 studies, 695 children)One study (66 children) reported similar Modified Activities Scale for Kids - Performance scores (0 to 100; no disability) at four weeks (median scores: splint 99.04; cast 99.11); low-quality evidence. Thirteen children needed a change or reapplication of device (splint 5/225; cast 8/219; 4 studies); very low-quality evidence. One study (87 children) reported no refractures at six months. One study (50 children) found no between-group difference in pain during treatment; very low-quality evidence. Evidence was absent (recovery time), insufficient (children with minor complications) or contradictory (child or parent satisfaction). Two studies estimated lower healthcare costs for removable splints. Soft or elasticated bandage versus below-elbow cast for buckle or similar fractures (4 studies, 273 children)One study (53 children) reported more children had no or only limited disability at four weeks in the bandage group; very low-quality evidence. Eight children changed device or extended immobilisation for delayed union (bandage 5/90; cast 3/91; 3 studies); very low-quality evidence. Two studies (139 children) reported no serious adverse events at four weeks. Evidence was absent, insufficient or contradictory for recovery time, wrist pain, children with minor complications, and child and parent satisfaction. More bandage-group participants found their treatment convenient (39 children). Removal of casts at home by parents versus at the hospital fracture clinic by clinicians (2 studies, 404 children, mainly buckle fractures) One study (233 children) found full restoration of physical function at four weeks; low-quality evidence. There were five treatment changes (home 4/197; hospital 1/200; 2 studies; very low-quality evidence). One study found no serious adverse effects at six months (288 children). Recovery time and number of children with minor complications were not reported. There was no evidence of a difference in pain at four weeks (233 children); low-quality evidence. One study (80 children) found greater parental satisfaction in the home group; low-quality evidence. One UK study found lower healthcare costs for home removal. Below-elbow versus above-elbow casts for displaced or unstable both-bone fractures (4 studies, 399 children) Short-term physical function data were unavailable but very low-quality evidence indicated less dependency when using below-elbow casts. One study (66 children with minimally displaced both-bone fractures) found little difference in ABILHAND-Kids scores (0 to 42; no problems) (mean scores: below-elbow 40.7; above-elbow 41.8); very low-quality evidence. Overall treatment failure data are unavailable, but nine of the 11 remanipulations or secondary reductions (366 children, 4 studies) were in the above-elbow group; very low-quality evidence. There was no refracture or compartment syndrome at six months (215 children; 2 studies). Recovery time and overall numbers of children with minor complications were not reported. There was little difference in requiring physiotherapy for stiffness (179 children, 2 studies); very low-quality evidence. One study (85 children) found less pain at one week for below-elbow casts; low-quality evidence. One study found treatment with an above-elbow cast cost three times more in Nepal. Surgical fixation with percutaneous wiring and cast immobilisation versus cast immobilisation alone after closed reduction of displaced fractures (5 studies, 323 children) Where reported, above-elbow casts were used. Short-term functional outcome data were unavailable. One study (123 children) reported similar ABILHAND-Kids scores indicating normal physical function at six months (mean scores: surgery 41.9; cast only 41.4); low-quality evidence. There were fewer treatment failures, defined as early or problematic removal of wires or remanipulation for early loss in position, after surgery (surgery 20/124; cast only 41/129; 4 studies; very low-quality evidence). Similarly, there were fewer serious advents after surgery (surgery 28/124; cast only 43/129; 4 studies; very low-quality evidence). Recovery time, wrist pain, and satisfaction were not reported. There was lower referral for physiotherapy for stiffness after surgery (1 study); very low-quality evidence. One USA study found similar treatment costs in both groups. Authors' conclusions: Where available, the quality of the RCT-based evidence on interventions for treating wrist fractures in children is low or very low. However, there is reassuring evidence of a full return to previous function with no serious adverse events, including refracture, for correctly-diagnosed buckle fractures, whatever the treatment used. The review findings are consistent with the move away from cast immobilisation for these injuries. High-quality evidence is needed to address key treatment uncertainties; notably, some priority topics are already being tested in ongoing multicentre trials, such as FORCE.
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0 |
Breast cancer at bone metastatic sites: Recent discoveries and treatment targets
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MSTS 2018 - Femur Mets and MM
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Breast carcinoma is the most common cancer of women. Bones are often involved with breast carcinoma metastases with the resulting morbidity and reduced quality of life. Breast cancer cells arriving at bone tissues mount supportive microenvironment by recruiting and modulating the activity of several host tissue cell types including the specialized bone cells osteoblasts and osteoclasts. Pathologically activated osteoclasts produce osteolytic lesions associated with bone pain, pathological fractures, cord compression and other complications of metastatic breast carcinoma at bone. Over the last decade there has been enormous growth of knowledge in the field of osteoclasts biology both in the physiological state and in the tumor microenvironment. This knowledge allowed the development and implementation of several targeted therapeutics that expanded the armamentarium of the oncologists dealing with the metastases-associated osteolytic disease. While the interactions of cancer cells with resident bone cells at the established metastatic gross lesions are well-studied, the preclinical events that underlie the progression of disseminated tumor cells into micrometastases and then into clinically-overt macrometastases are just starting to be uncovered. In this review, we discuss the established information and the most recent discoveries in the pathogenesis of osteolytic metastases of breast cancer, as well as the corresponding investigational drugs that have been introduced into clinical development. © 2011 The International CCN Society.
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0 |
The effect of obesity on mechanical failure after total knee arthroplasty
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PJI DX Updated Search
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"Increased aseptic tibial failures in patients with a BMI >/=35 and well-aligned total knee arthroplasties" published in The Journal of Arthroplasty on July 2, 2015 draws the conclusion that the risk of revision total knee arthroplasties (TKA) due to aseptic tibial component loosening is two times greater in patients with a BMI >/=35 kg/m(2), independent of age or limb alignment. This result confirms that obese patients are at a higher risk of mechanical complications after performing TKA, independently from the risk of infection. This study suggests that the management of obese patients for TKA must be meticulous, careful, and should inspire from great bone deformations in valgus of varus when choosing implants
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0 |
Manipulation under anesthesia for post traumatic stiff knee-pearls, pitfalls and risk factors for failure
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DoD SSI (Surgical Site Infections)
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Background Stiffness is common following fractures around knee. Manipulation under anesthesia (MUA) is the initial noninvasive procedure usually performed for such patients. Though MUA has been extensively evaluated for knee arthroplasty, there is paucity of literature regarding its benefits in trauma cases. The purpose of this study was to define the role of manipulation in post traumatic stiff knees. Methods Hospital inpatient and outpatient records from January 2010 to June 2014 were retrospectively reviewed to identify patients undergoing MUA at our institution. Patients with more than one year follow up and adequate data were included. Clinical and radiographic parameters were analyzed to assess outcomes, complications, effect of timing on flexion gain as well as identify risk factors associated with failure. Results Out of 45 patients undergoing manipulation, 41 patients with 48 knees (34 unilateral and 7 bilateral) met inclusion criteria. Thirty six manipulations were successful while 3 were abandoned due to tight tissues and 9 developed complications.Successful MUA resulted in immediate gain of 62.36° of flexion which decreased to 49.86° at 1year. There was statistically significant loss of flexion of 12.5° over a year (p value 0.0013). Arc of motion improved from 48.5° to 106.1° at 1 year (p value <0.0001). Significant improvement was also seen in extension and fixed flexion deformity (p value <0.0001). No significant difference could be detected between early (<3 months) and late (>3 months) groups with respect to outcomes (p value 0.883)or complications (p value 0.3193). Failed group had significantly lower pre MUA flexion and pre MUA range of motion (p value 0.003). Univariate analysis showed that extensor mechanism ruptures during injury (p value <0.0001) and knees with Flexion <40° (p value 0.0022) or ROM<30° (p value 0.0002) were significantly associated with failures. Conclusion MUA is a suitable non invasive treatment option for post traumatic stiffness. There is no effect of timing on outcome and late manipulation also results in good outcome. Extensor mechanism rupture and pre manipulation ROM < 30° or flexion <40° are associated with failure and such cases should be considered for alternative options for better outcome.
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0 |
Combined Doppler and B-mode sonography in carpal tunnel syndrome
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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An intraoperatively enlarged engorged median nerve has been described as typical of patients with carpal tunnel syndrome (CTS). Although many studies of CTS have addressed median nerve enlargement, little is known about the usefulness of Doppler methods in detecting median nerve engorgement combined with nerve cross-sectional area (CSA). In a retrospective study of hands referred for evaluation of possible CTS, patients were clinically graded into Highly-likely or Indeterminate CTS. Nerve conduction studies (NCS), CSA, and Doppler analysis were compared. Median nerve blood flow was detected in 29 of 30 Highly-likely CTS hands (mean 13.3m/s (8.2) SD) and in 25 of 30 with Indeterminate CTS (mean 8.5m/s (4.5) SD). These were significantly higher than our laboratory normal values (mean 1.9 m/s (2.8) SD). Raised intraneural blood flow showed the highest test sensitivity in diagnosing Highly-likely carpal tunnel syndrome (83%) and combined with CSA reached 90%. NCS sensitivity was 83%. In the group of Indeterminate CTS, combined blood flow and CSA showed abnormality in 77% and NCS 47%. All nerve conduction parameters and median nerve cross sectional area showed linear correlation to intraneural blood flow velocity (P<0.05; Spearman's r=0.362 to 0.264). This study suggests that adding measures of intraneural blood flow to CSA further improves the sonographic evaluation of CTS and may be of particular use in patients with negative NCS
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0 |
Safety and effectiveness profile of raloxifene in long-term, prospective, postmarketing surveillance
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Management of Hip Fractures in the Elderly
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This large-scale postmarketing surveillance of raloxifene (60 mg/day) was conducted to assess the safety and effectiveness of raloxifene for long-term use in postmenopausal Japanese women with osteoporosis. The baseline examination included 6,967 women (mean age, 70.4 years). Participants completed observation after 6, 12, 24, and 36 months of therapy. Adverse drug reactions (ADR) were reported in 776 participants (11.14 %), with a total of 87 serious ADR cases occurring in 76 participants (1.09 %). The most frequently reported ADRs were edema peripheral (45/6,967, 0.65 %) and venous thromboembolism (11/6,967, 0.16 %). Of the 6,967 participants, 2,784 were included in the effectiveness analysis. Lumbar spine bone mineral density (BMD) increased significantly (p < 0.001, paired t test) compared with baseline at 6, 12, 24, and 36 months (2.51 %, 2.85 %, 4.76 %, and 3.51 %, respectively). Significant decreases in serum and urinary cross-linked amino-terminal telopeptide of type I collagen (NTX) and urinary deoxypyridinoline levels from baseline were observed at 3 months, followed by a significant decrease of serum bone alkaline phosphatase at 6 months [p < 0.001 for all comparisons except serum NTX (p = 0.011), Wilcoxon signed-rank test]. Early reductions in the biochemical markers of bone turnover (BTM) observed at 3 months with raloxifene treatment correlated negatively with subsequent increases in lumbar spine BMD at 1 year (r = -0.347, p = 0.008). The incidence of any new clinical fractures within 3 years was 1.18 % (82/6,967 participants). In summary, no new signals in safety were observed in the daily use of raloxifene. Moreover, the effectiveness profile of raloxifene was confirmed in practical use by this large-scale, long-term, postmarketing surveillance. (copyright) 2012 The Japanese Society for Bone and Mineral Research and Springer
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1 |
Complications of Volar Plating of Distal Radius Fractures: A Systematic Review
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Distal Radius Fractures
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Background In recent years, there has been an increased utilization of volar locking plate fixation of distal radius fractures (DRFs). However, reported long-term complication rates with this technique remain unclear. Purpose The purpose of this systematic review was to investigate the pooled incidence of complications associated with volar locking plating of DRF. Methods A search of the Scopus database was performed from 2006 through 2016. Studies were considered eligible if they had a diagnosis of a DRF and were treated with a volar locking plate with an average of 12 months or longer follow-up. Results The literature search yielded 633 citations, with 55 eligible for inclusion in the review (total n = 3,911). An overall complication rate of 15% was identified, with 5% representing major complications requiring reoperation. The most common complication types identified included nerve dysfunction (5.7%), tendon injury (3.5%), and hardware-related issues (1.6%). Conclusion Nerve complications were reportedly higher than tendon and hardware-related complications combined. However, despite varying complication rates in the literature, this systematic review reveals an overall low complication rate associated with volar locking plating of DRF.
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0 |
Outcomes of root canal treatment and restoration, implant-supported single crowns, fixed partial dentures, and extraction without replacement: a systematic review
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DoD PRF (Psychosocial RF)
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STATEMENT OF PROBLEM: Dentists and patients are regularly confronted by a difficult treatment question: should a tooth be saved through root canal treatment and restoration (RCT), be extracted without any tooth replacement, be replaced with a fixed partial denture (FPD) or an implant-supported single crown (ISC)?
PURPOSE: The purpose of this systematic review was to compare the outcomes, benefits, and harms of endodontic care and restoration compared to extraction and placement of ISCs, FPDs, or extraction without tooth replacement.
MATERIAL AND METHODS: Searches performed in MEDLINE, Cochrane, and EMBASE databases were enriched by hand searches, citation mining, and expert recommendation. Evidence tables were developed following quality and inclusion criteria assessment. Pooled and weighted mean success and survival rates, with associated confidence intervals, were calculated for single implant crowns, fixed partial dentures, and initial nonsurgical root canal treatments. Data related to extraction without tooth replacement and psychosocial outcomes were evaluated by a narrative review due to literature limitations.
RESULTS: The 143 selected studies varied considerably in design, success definition, assessment methods, operator type, and sample size. Direct comparison of treatment types was extremely rare. Limited psychosocial data revealed the traumatic effect of loss of visible teeth. Economic data were largely absent. Success rates for ISCs were higher than for RCTs and FPDs, respectively; however, success criteria differed greatly among treatment types, rendering direct comparison of success rates futile. Long-term survival rates for ISCs and RCTs were similar and superior to those for FPDs.
CONCLUSIONS: Lack of comparative studies with similar outcomes criteria with comparable time intervals limited comparison of these treatments. ISC and RCT treatments resulted in superior long-term survival, compared to FPDs. Limited data suggested that extraction without replacement resulted in inferior psychosocial outcomes compared to alternatives. Long-term, prospective clinical trials with large sample sizes and clearly defined outcomes criteria are needed. [References: 201]
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0 |
Actinobacillus actinomycetemcomitans isolated from a case of cutaneous botryomycosis
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Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures
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Cutaneous botryomycosis is an uncommon chronic suppurative bacterial skin infection that can mimic a fungal infection both clinically and histopathologically. Causative bacteria, most commonly Staphylococcus aureus, aggregate to form characteristic granules. We report the case of a 52-year-old black man who developed cutaneous botryomycosis of the hand following trauma. Routine bacterial cultures grew S aureus and Actinobacillus actinomycetemcomitans, a fastidious gram-negative bacillus known to cause periodontal disease, endocarditis, and actinomycosislike soft tissue infections. Despite culture-proven eradication of S aureus with long-term appropriate antibiotic therapy, the lesion, resolved only after fluoroquinolone treatment directed against A. actinomycetemcomitans, suggesting that A. actinomycetemcomitans was of etiologic significance
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0 |
Composite grafting of the maxillary sinus for placement of endosteal implants. A preliminary report of 48 patients
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Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures
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The maxillary sinuses in 48 patients were grafted with dense, non-resorbable hydroxylapatite (HA) particles combined with autologous, cancellous bone. After 3 months of healing, HA-coated titanium endosteal implants were placed in the maxilla, and following an additional 3-5 month healing period, the dentitions were restored with various prostheses. Of the 267 maxillary implants placed, 18 (6.4%) failed. Thirteen (6.4%) of the 203 implants placed in the grafted floor of the sinus failed, and 5 (7.8%) of the 64 implants placed in the anterior maxilla failed. Simultaneous lateral and anterior onlay grafting of the alveolar process with the same composite graft material was required in 36 (75%) patients because the width of the alveolar process was considered insufficient for placement of endosseous implants. The mean follow-up period was 17 months (range 12-32). Results from this preliminary study indicate that composite grafting of the maxillary sinus with onlay grafting of the alveolar ridge will provide the bony structure necessary for placement of endosseous implants. Further follow-up of these patients is necessary to determine the long-term stability of this technique; however, these results are promising
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Perioperative infection rate in patients with osteosarcomas treated with resection and prosthetic reconstruction
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PJI DX Updated Search
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BACKGROUND: The incidence of perioperative infection after segmental tumor endoprosthetic replacement in previous reports varies from a high of 7.4% to a low of 2.6%. Appropriate antibiotic use for this group is unknown and controversial, whereas the relationship of antibiotic use and perioperative infection is unclear. QUESTIONS/PURPOSES: We determined the incidence of perioperative infection in patients with osteosarcoma treated with segmental prosthetic replacement using a standard perioperative antibiotic regimen and the incidence of late infections and wound complications. PATIENTS AND METHODS: We retrospectively reviewed the records of 53 patients with osteosarcoma undergoing segmental prosthetic replacements from 1993 to 2008. There were 30 males and 23 females ranging from 10 to 78 years of age. All patients were given intraoperative antibiotics (intravenous cefazolin), continued for 3 days postoperatively and then given orally for 5 days. Patients who were allergic to penicillin or cefazolin were given vancomycin followed by clindamycin. A perioperative infection was defined as a deep infection within 2 months after prosthetic reconstruction. The minimum followup was 1 year (range, 1-15 years). RESULTS: We identified one confirmed perioperative prosthetic infection (1/53; 1.9%) (Enterobacter cloacae and methicillin-resistant Staphylococcus) in a 78-year-old woman after proximal tibial replacement, gastrocnemius flap, and skin graft. Her infection was controlled with debridement, drainage, and intravenous antibiotics. Three patients had late infections, two of which were culture negative. Four patients had wound complications that required further surgery. CONCLUSION: The antibiotic regimen we used is longer than that recommended for patients having routine total joint arthroplasty. Its appropriateness will require comparison with alternate regimens, including those of shorter duration. LEVEL OF EVIDENCE: Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence
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1 |
Immediate effects of foot orthoses on pain during functional tasks in people with patellofemoral osteoarthritis: A cross-over, proof-of-concept study
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OAK 3 - Non-arthroplasty tx of OAK
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BACKGROUND: The purpose of the study was to determine whether prefabricated foot orthoses immediately reduce pain during functional tasks in people with patellofemoral osteoarthritis, compared to flat insoles and shoes alone.
METHODS: Eighteen people with predominant lateral patellofemoral osteoarthritis (nine women; mean [SD] age 59 [10]years; body mass index 27.9 [3.2]kg/m<sup>2</sup>) performed functional tasks wearing running sandals, and then wearing foot orthoses and flat insoles (random order). Participants rated knee pain during each task (11-point numerical rating scales), ease of performance and knee stability (five-point Likert scales), and comfort (100mm visual analogue scales).
RESULTS: Compared to shoes alone, foot orthoses (p=0.002; median difference 1.5 [IQR 3]) and flat insoles (p<0.001; 2 [3]) significantly reduced pain during step-downs; foot orthoses reduced pain during walking (p=0.008; 1 [1.25]); and flat insoles reduced pain during stair ambulation (p=0.001; 1 [1.75]). No significant differences between foot orthoses and flat insoles were observed for pain severity, ease of performance or knee stability. Foot orthoses were less comfortable than flat insoles and shoes alone (p<0.05).
CONCLUSIONS: In people with patellofemoral osteoarthritis, immediate pain-relieving effects of prefabricated, contoured foot orthoses are equivalent to flat insoles. Further studies should investigate whether similar outcomes occur with longer-term wear or different orthosis designs.
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0 |
Correlation of neoplasms with incidence and localization of skeletal metastases: An analysis of 1,355 diphosphonate bone scans
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MSTS 2018 - Femur Mets and MM
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A total of 1,355 patients from clinical trails with the 99mTc-labeled bone agent, Osteoscan (99mTc-Sn -EHDP), has shown a higher incidence of skeletal abnormalities than previously reported. Overall in this study, 60% of bone scans were abnormal in patients with nonosseous neoplasms. Carcinoma of breast, lung, and prostate yielded 67%, 64%, and 62% skeletal involvement, respectively. Over 50% of all the skeletal abnormalities for the neoplastic indications were detected in the thorax and vertebra while the skull, pelvis, and extremities accounted for 22%, 38%, and 34%, respectively.
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0 |
Effects of increased intra-abdominal pressure in severe obesity
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DoD - ACS - Interrater Reliability
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This article gives an overview, citing animal and clinical studies, of the effects of increased intra-abdominal pressure (IAP) in severe obesity. Animal studies demonstrate that increased IAP increases pleural pressure, cardiac filling pressures, femoral venous pressure, renal venous pressure, systemic blood pressure, and vascular resistance, renin and aldosterone levels, and intracranial pressure. Thus, the comorbidities presumed secondary to increased IAP in obese patients include congestive heart failure, hypoventilation, venous stasis ulcers, gastroesophageal reflux, urinary stress incontinence, incisional hernia, pseudotumor cerebri, proteinuria, and systemic hypertension. [References: 32]
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0 |
Potential involvement of adipocyte insulin resistance in obesity-associated up-regulation of adipocyte lysophospholipase D/autotaxin expression
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Panniculectomy & Abdominoplasty CPG
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AIMS/HYPOTHESIS: Autotaxin is a lysophospholipase D that is secreted by adipocytes and whose expression is substantially up-regulated in obese, diabetic db/db mice. The aim of the present study was to depict the physiopathological and cellular mechanisms involved in regulation of adipocyte autotaxin expression. METHODS: Autotaxin mRNAs were quantified in adipose tissue from db/db mice (obese and highly diabetic type 2), gold-thioglucose-treated (GTG) mice (highly obese and moderately diabetic type 2), high-fat diet-fed (HFD) mice (obese and moderately diabetic type 2), streptozotocin-treated mice (thin and diabetic type 1), and massively obese humans with glucose intolerance. RESULTS: When compared to non-obese controls, autotaxin expression in db/db mice was significantly increased, but not in GTG, HFD, or streptozotocin-treated mice. During db/db mice development, up-regulation of autotaxin occurred only 3 weeks after the emergence of hyperinsulinaemia, and simultaneously with the emergence of hyperglycaaemia. Adipocytes from db/db mice exhibited a stronger impairment of insulin-stimulated glucose uptake than non-obese and HFD-induced obese mice. Autotaxin expression was up-regulated by treatment with TNFalpha (insulin resistance-promoting cytokine), and down-regulated by rosiglitazone treatment (insulin-sensitising compound) in 3T3F442A adipocytes. Finally, adipose tissue autotaxin expression was significantly up-regulated in patients exhibiting both insulin resistance and impaired glucose tolerance. CONCLUSIONS/INTERPRETATION: The present work demonstrates the existence of a db/db-specific up-regulation of adipocyte autotaxin expression, which could be related to the severe type 2 diabetes phenotype and adipocyte insulin resistance, rather than excess adiposity in itself. It also showed that type 2 diabetes in humans is also associated with up-regulation of adipocyte autotaxin expression.
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0 |
Bortezomib overcomes cell-adhesion-mediated drug resistance through downregulation of VLA-4 expression in multiple myeloma
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MSTS 2018 - Femur Mets and MM
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Multiple myeloma (MM) is incurable, mainly because of cell adhesion-mediated drug resistance (CAM-DR). In this study, we performed functional screening using short hairpin RNA (shRNA) to define the molecule(s) responsible for CAM-DR of MM. Using four bona fide myeloma cell lines (KHM-1B, KMS12-BM, RPMI8226 and U266) and primary myeloma cells, we identified CD29 (beta1-integrin), CD44, CD49d (alpha4-integrin, a subunit of VLA-4), CD54 (intercellular adhesion molecule-1 (ICAM-1)), CD138 (syndecan-1) and CD184 (CXC chemokine receptor-4 (CXCR4)) as major adhesion molecules expressed on MM. shRNA-mediated knockdown of CD49d but not CD44, CD54, CD138 and CD184 significantly reversed CAM-DR of myeloma cells to bortezomib, vincristine, doxorubicin and dexamethasone. Experiments using blocking antibodies yielded almost identical results. Bortezomib was relatively resistant to CAM-DR because of its ability to specifically downregulate CD49d expression. This property was unique to bortezomib and was not observed in other anti-myeloma drugs. Pretreatment with bortezomib was able to ameliorate CAM-DR of myeloma cells to vincristine and dexamethasone. These results suggest that VLA-4 plays a critical role in CAM-DR of MM cells. The combination of bortezomib with conventional anti-myeloma drugs may be effective in overcoming CAM-DR of MM.
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Panobinostat, a pan-histone deacetylase inhibitor: Rationale for and application to treatment of multiple myeloma
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MSTS 2018 - Femur Mets and MM
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Histone deacetylase inhibitors (HDACis) have emerged as novel therapeutic agents for cancer. Currently, four HDACis are approved by the Food and Drug Administration (FDA) to treat various hematologic malignancies. Panobinostat (LBH-589, trade name Farydak®, developed and marketed by Novartis) is a potent pan-HDACi with demonstrated anticancer activities against multiple myeloma, a B-cell malignancy, at a low nanomolar range in preclinical settings, and in 2015 was granted FDA approval for the treatment of relapsed and refractory multiple myeloma. Here, we review the development of HDACis, the unique features of panobinostat, and the rationale for developing panobinostat in a combination setting for the treatment of multiple myeloma. We also review the completed and ongoing clinical trials testing the efficacy of panobinostat in combination therapies and highlight future therapeutically relevant strategies.
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18F-FDG PET/CT for the prediction and detection of local recurrence after radiofrequency ablation of malignant lung lesions
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MSTS AUC - Based on ACR Lit Review
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UNLABELLED: The utility of (18)F-FDG PET/CT for response assessment in malignant lung tumors treated with radiofrequency ablation (RFA) and for the detection and prediction of local recurrence was investigated. METHODS: Between December 17, 2003, and April 9, 2008, 68 consecutive patients (mean age, 68 y) with 94 pulmonary lesions, including metastases (n = 38) and primary lung cancers (n = 44), underwent RFA. Because of inadequate imaging follow-up in 12 patients, only 82 lesions were analyzed (CT scans, n = 82; (18)F-FDG PET/CT scans, n = 62). The median follow-up was 25 mo (range, 12-66 mo). A baseline study was defined as (18)F-FDG PET/CT performed no more than 3 mo before RFA. The first postablation scan was defined as PET/CT performed between 1 and 4 mo after RFA; additional follow-up studies were obtained in some cases between 6 and 12 mo after RFA. The unidimensional maximum diameter of the lesion was recorded on a pretherapy diagnostic CT scan or on the CT component of a pretherapy (18)F-FDG PET/CT scan, whichever was obtained most recently, using lung windows. Maximum standardized uptake values (SUVs) were recorded for all lesions imaged by (18)F-FDG PET/CT. (18)F-FDG uptake patterns on post-RFA scans were classified as favorable or unfavorable. Survival and recurrence probabilities were estimated using the Kaplan-Meier method. Uni- and multivariate analyses were also performed. RESULTS: Before RFA, factors predicting greater local recurrence-free survival included initial lesion size less than 3 cm (P = 0.01) and SUV less than 8 (P = 0.02), although the latter was not an independent predictor in multivariate analysis. Treated metastases recurred less often than treated primary lung cancers (P = 0.03). Important post-RFA factors that related to reduced recurrence-free survival included an unfavorable uptake pattern (P < 0.01), post-RFA SUV (P < 0.01), and an increase in SUV over time after ablation (P = 0.05). CONCLUSION: (18)F-FDG PET/CT parameters on both preablation and postablation scans may predict local recurrence in patients treated with RFA for lung metastases and primary lung cancers
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Perioperative complication rate of one-stage bilateral total hip arthroplasty using the direct anterior approach
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Hip Fx in the Elderly 2019
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BACKGROUND: To date, details of the surgical and clinical outcomes of one-stage bilateral total hip arthroplasty using the direct anterior approach have not been widely available. The purpose of this study was to report the perioperative blood management and investigate the perioperative complication rate of one-stage bilateral total hip arthroplasty using the direct anterior approach.
METHODS: We retrospectively assessed 325 consecutive patients (650 hips) who underwent one-stage bilateral total hip arthroplasty through the direct anterior approach.
RESULTS: The mean intraoperative blood loss and operating time were 412 g and 87.2 min, respectively. One patient (0.3%) required postoperative transfusions of allogeneic blood. Post-operative local major complications occurred in 6 hips (0.9%) in 6 patients, including 2 (0.3%) dislocations, 2 (0.3%) early cup migrations, and 2 (0.3%) peri-prosthetic femoral fractures. No systemic major complication was detected.
CONCLUSION: We conclude that the low rate of systemic complications in this study was due to supine positioning and the minimally invasive aspect of the direct anterior approach, and that the approach is therefore a reasonable choice for one-stage bilateral THA.
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Skp2 protein expression in soft tissue sarcomas
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MSTS 2022 - Metastatic Disease of the Humerus
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Background: p45 S phase kinase-assotiated protein-2 (p45skp2), a member of the F-box family of proteins, is an important component of the Skp 1-Cullin-F-box protein (SCF) ubiquitin-ligase complex (SCFskp2). The latter has been implicated in the ubiquitination and degradation of p27 kip1 (p27) and G1-S cell cycle progression. The expression and prognostic role of Skp2 in a large series of soft tissue sarcomas has not been previously investigated. Methods: Clinicopathologic features and immunohistochemical expression of Skp2, p27, and Ki-67 proteins were studied in 182 cases of soft tissue sarcomas (American Joint Committee on Cancer stages II and III). Survival analyses were performed using the Kaplan-Meier method and the Cox regression model. Results: The male to female ratio was 1.2:1, and the median age at the diagnosis was 53 years. The tumors were predominantly located in the lower extremities (n = 163; 90%) and had a median size of 9 cm. High Skp2 expression (= 10% of the cells) was identified in 68 tumors (37%), and was correlated with high grade histology (P = .002) and Ki-67 proliferative index (r = 0.44; P < .0001), but not with p27 expression (r = -0.02; P = .80). By univariate analysis, high Skp2 expression was associated with decreased metastasis-free, disease-free, and overall survival. In a multivariate model, high Skp2 expression was an independent predictor for decreased local recurrence-free, disease-free, and overall survival. Conclusion: These results indicate that Skp2 expression is associated with cell proliferation and a worse prognosis in soft tissue sarcomas. The lack of an inverse correlation between Skp2 and p27 suggests that additional molecular events associated with either Skp2 expression or p27 proteolysis may be operating in these tumors. © 2003 by American Society of Clinical Oncology.
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Cementless femoral revision arthroplasty. 2- to 5-year results with a modular titanium alloy stem
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Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures
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Seventy-five consecutive cementless femoral revision arthroplasties were performed, using a modular titanium alloy stem (S-ROM, Joint Medical Products, Stamford, CT). Sixty-six hips were available for complete follow-up evaluation at 2 to 5 years (average, 3.4 years). Independent clinical analysis compared pre- with postoperative modified Harris hip scores and examined patient satisfaction. Independent radiographic analysis was also undertaken. There were two rerevisions, both for hematogenous sepsis. Of the rest, clinical scores improved from a preoperative value of 44 to a postoperative value of 83. Eighty-nine percent of patients were satisfied or very satisfied with the results of surgery. Fifty-two stems had solid bony ingrowth, seven were stabilized by fibrous tissue, and five were radiographically loose. Five-year survival, with rerevision as endpoint, was 96.4%
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Limb Salvage After Failed Initial Operative Management of Bimalleolar Ankle Fractures in Diabetic Neuropathy
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DoD LSA (Limb Salvage vs Amputation)
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BACKGROUND: Ankle fractures in patients with diabetes mellitus (DM) can be difficult to manage, especially in the presence of peripheral neuropathy. In patients who fail initial operative management, attempts at limb salvage can be challenging, and no clear treatment algorithm exists. This study examined outcomes of different procedures performed for limb salvage in this population. METHODS: This study retrospectively reviewed 17 patients with DM complicated by peripheral neuropathy who sustained a bimalleolar ankle fracture and failed initial operative management. Patients were treated with revision open reduction internal fixation (ORIF) (3/17), closed reduction external fixation (CREF) (8/17), or primary ankle joint fusion (3/17 tibiotalocalcaneal fusion with hindfoot nail [TTCN] and 3/17 with tibiotalar arthrodesis using plates and screws [TTA]). Median follow-up was 20 months. RESULTS: The overall rate of limb salvage was 82.3% (14/17). All patients who went on to amputation presented with infection and were treated initially with CREF (3/3). All patients who achieved successful limb salvage ended up with a clinically fused ankle joint (14/14); 9 underwent a primary or delayed formal fusion and 5 had a clinically fused ankle joint at study conclusion after undergoing revision ORIF or CREF with adjunctive procedures. CONCLUSION: This small study suggests that in this complicated group of patients it is difficult to achieve limb salvage with an end result of a functional ankle joint. CREF can be a viable option in cases where underlying infection or poor bone quality is present. Treatment with revision ORIF frequently requires supplementary external fixator or tibiotalar Steinman pin placement for additional stability. All patients who underwent revision ORIF ended up with clinically fused ankle joints at the end of the study period. Primary fusion procedures (TTA, TTCN) were associated with a high rate of limb salvage and a decreased number of operations. LEVEL OF EVIDENCE: Level III, retrospective case series.
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