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Salter-Harris type II proximal humerus injuries: state-of-the-art treatment
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Pediatric Supracondylar Humerus Fracture 2020 Review
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Proximal epiphyseal injuries of the humerus represent a very low percentage of traumatic growth pathologies, 5 % of all fractures during childhood. In the literature, there have been only a limited number of clinical studies investigating these injuries, basically from an epidemiological point of view, focusing on the incidence of the different types of fractures. We report our experience of 6 young patients with Salter-Harris type II proximal humerus epiphyseal injuries adopting a minimally invasive surgical technique consisting of closed reduction and percutaneous fixation with Kirschner wires. At 2 years of follow-up, the results consisting in constant; disabilities of the arm, shoulder, and hand; simple shoulder test; and Visual Analogue Scale scores obtained have been excellent and all the patients come back to a normal life with sports practice and normal daily activities. The range of motion was completely restored without any deficit in abduction-adduction, flection-extension, or intra-extra rotation. No differences in anthropometric parameters were found with no case of malangulation, vascular, or neurological complications. Our data support with evidence how the close reduction internal fixation with K-wires treatment can give to the surgeons and the patients a better security about the correct fracture healing. Furthermore, with this article, we will provide a detailed review of the literature in order to define the state-of-the-art treatment to better face such a challenging skeletal injury.
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Complications of posterior cruciate ligament surgery
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DoD - ACS - Interrater Reliability
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In addition to standard risks associated with all orthopedic surgical procedures, posterior cruciate ligament (PCL) reconstruction poses some relatively unique potential complications. These complications arise from a combination of several factors: the relative infrequency of PCL injuries, the lack of knowledge and experience in treating them, the proximity of neurovascular structures to the PCL, and the technically demanding nature of reconstructive procedures. This article discusses the anatomy, pathogenesis, and prevention of intraoperative and postoperative complications of PCL surgery including neurovascular injury, osteonecrosis, fracture, motion loss, and persistent laxity.
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Chemokine Expression in Neutrophils and Subcutaneous Adipose Tissue Cells Obtained during Abdominoplasty from Patients with Obesity and Normal Body Weight
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Panniculectomy & Abdominoplasty CPG
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The study was aimed at assessing the role of chemokines in inflammatory changes in tissue following abdominoplasty. The levels of neutrophil-coupled chemokines and their receptors in the serum and blood cells, as well as in cells isolated from the subcutaneous adipose tissue sampled during abdominoplasty were compared in patients with obesity and normal body weight. The levels of chemokines CCL3, CCL3, and CCL5 in blood serum and expression of chemokine receptor CXCR2 and CXCR6 on blood neutrophils were significantly higher (p<0.05) in obese patients in comparison with patients with normal body weight. Elevated expression of chemokines CCL2, CCL3, CCL4, CCL5, CCL18, and CCL20 (p<0.05) was detected in subcutaneous adipose tissue cells isolated obese patients in comparisons with persons with normal body weight. These findings attest to favorable conditions for enhanced neutrophil migration to the adipose tissue in patients with obesity, which can promote leukocyte infiltration of the suture site after abdominoplasty and serves as additional risk factor for the development of postoperative complications associated with activity of neutrophil-derived proteolytic enzymes.
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A fresh osteochondral allograft alternative
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AMP (Acute Meniscal Pathology)
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Fresh osteochondral allografts were used for post-traumatic knee defects >3 cm in diameter and 1 cm in depth. Harvesting of the grafts was carried out within 24 hours of the death of the donor, and implantation into the recipient was carried out within 72 hours. The grafts were unipolar, fixed by screws, and combined with realignment osteotomy if a deformity existed. Meniscal transplantation also was performed if indicated. The survivorship of all grafts (plateaus and condyles) at 7.5 years was 85%. The survivorship of femoral condyle grafts at 10 years was 85%. Viable hyaline cartilage has been confirmed at 17 years.
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Physeal separation and complete resorption of femoral head associated with chronic osteomyelitis of femoral diaphysis in a young child: rare case report
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Pediatric Diaphyseal Femur Fractures 2020 Review
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We report the case of a two and a half-year-old girl who presented with injury to the right thigh along with a discharging sinus in the midthigh region following a nonorthopaedic surgical procedure. Radiographs of the thigh indicated osteomyelitis of the femoral diaphysis with pathological fracture. During follow-up examination, shortening was observed in the affected limb, along with complete separation of the femoral epiphysis with partial resorption of the femoral head. A few cases of physeal separation of the femoral head following osteomyelitis of the femoral diaphysis have been reported in the published literature, but still it may go undiagnosed until late stages because of the lack of awareness among orthopaedicians about this entity. There was no history of any precipitating trauma to the hip. This case is of interest because of the difficulty in making differential diagnosis at the first evaluation; there was an orthopaedic misdiagnosis on the basis of the lack of complete preoperative imaging. Because of the devastating sequelae on immature skeleton including limb shortening, osteomyelitis, epiphyseal separation of proximal epiphysis and pathological fracture of shaft femur, the importance of early diagnosis, complete preoperative imaging and prompt treatment must be overemphasized.
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Global Perspectives on Arthroplasty of Hip and Knee Joints
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OAK 3 - Non-arthroplasty tx of OAK
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There is a broad variation of implantation rates, indications, and types of prostheses used for hip and knee joint replacement procedures among different countries. The establishment of national joint registers has improved knowledge and quality of data related to joint implantation. Comparing reports of different national registries is crucial to determine potential variations in practices among surgeons and arthroplasty centers and to identify topics for future analysis. In this report, data from these registries in addition to manufacturer reports were used to evaluate procedure volumes and implants utilization trends of primary and revision total hip and knee replacement around the world.
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Alendronate improves screw fixation in osteoporotic bone
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Management of Hip Fractures in the Elderly
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BACKGROUND: Animal studies have demonstrated the efficacy of the use of bisphosphonates to enhance screw fixation in bone. In this prospective, randomized study of pertrochanteric fractures treated with external fixation, we tested whether systemic administration of bisphosphonates would improve the fixation of hydroxyapatite-coated screws implanted in osteoporotic bone. METHODS: Sixteen consecutive patients with a pertrochanteric fracture were selected. Inclusion criteria were female gender, an age of at least sixty-five years, and a bone mineral density T-score of less than -2.5 standard deviations. Exclusion criteria included bisphosphonate treatment during the two-year period prior to the fracture. Fractures were fixed with a pertrochanteric fixator and four hydroxyapatite-coated pins. Two pins were implanted in the femoral head (pin positions 1 and 2), and two were placed in the femoral diaphysis (pin positions 3 and 4). The patients were randomized either to therapy with alendronate for a three-month postoperative period (Group A) or to no therapy (Group B). The Group-A patients received an oral dose of 70 mg of alendronate per week. The fixators were removed after three months. RESULTS: All of the fractures healed, and no loss of reduction, nonunion, or delayed union was observed. The combined mean extraction torque (and standard deviation) of the pins implanted at positions 1 and 2 (cancellous bone) was 2558 +/- 1103 N/mm in Group A and 1171 +/- 480 N/mm in Group B (p < 0.0005). The combined mean extraction torque of the pins implanted at positions 3 and 4 (cortical bone) was 4327 +/- 1720 N/mm in Group A and 4075 +/- 1022 N/mm in Group B. CONCLUSIONS: These data show that weekly systemic administration of alendronate improves pin fixation in cancellous bone in elderly female patients with osteoporosis. We observed a twofold increase in extraction torque with the pins implanted in cancellous bone. These results support the use of alendronate in the treatment of osteoporotic pertrochanteric fractures to improve screw fixation in the femoral head
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Relationship between osteoarthrosis and osteoporosis. An experimental and clinical study
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Management of Hip Fractures in the Elderly
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The authors conducted two studies to demonstrate the presence of a relationship between osteoporosis and arthrosis: the first study was experimental involving thirty femoral heads removed during hip arthroplasty, and the second was a clinical study conducted on forty patients with coxarthrosis. The results obtained confirm how the presence of one of the two pathologies may prevent or delay occurrence of the other, and on this basis the authors review the literature. Finally, also taking into account the interpretations of other authors, possible hypotheses on the inverse relationship that links the two pathologies are proposed
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Metabolic abnormality and the proinflammatory state following hip joint surgery
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AAHKS (2) Corticosteroids
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Hip surgery is one of the most commonly performed operations in adult orthopedics. A significant proportion of patients undergoing hip surgery are at considerable risk for postoperative complications secondary to age-related medical issues and the morbidity and mortality associated with hip fractures. Inflammation has been shown to play a pivotal role in the host response to total hip arthroplasty and hip fracture surgery. A newly evolved area of research aimed at investigating the complex biochemical roles of the immune system, cytokine cascades and adipose tissue in the systemic inflammatory response to hip surgery has already identified a few central players in this response, namely IL-6, leptin and cortisol. This new area of study has also begun to define the influence of the metabolic syndrome on creating an underlying, chronic state of low-grade systemic inflammation that may predispose patients to postoperative complications in the setting of hip surgery. The ultimate goal of researchers is to develop therapeutic strategies targeted at modulating and controlling postoperative inflammation. In doing so, it is believed that we can improve the biochemical environment in which hip surgery is performed, ameliorate patient outcomes in the realm of pain and function, and predict and reduce postoperative complications associated with aberrant immune and inflammatory responses. © 2011 Future Medicine Ltd.
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The free vascularized fibular epiphyseal transfer: Long-term results of wrist reconstruction in young patients
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DoD LSA (Limb Salvage vs Amputation)
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To date, the dominant blood supply to the head of the fibula and to the growth plate is known to be the anterior tibial artery. The peroneal artery had been used before, among other donor pedicles, for microvascular transfers of this epiphyseal region. This study presents the long-term results of this now obsolete pedicle and compares them to other reports in the literature. Follow-up was performed in 1996 and in 2003 with six patients who underwent wrist reconstruction in the 1980s. Procedures were performed following one resection of a malignant synovialoma, two traumatic hand amputations, and three radial aplasias. Evaluation was performed with functional and radiographic examinations. Three cases that were examined in 2003 are presented in detail. The study shows that if growth plates are closed at the time of procedure or the transplanted fibula is long enough to ensure anastomotic flow between metaphyseal and epiphyseal vessels, results are good. If any of these two conditions is not fulfilled, vascular supply to the epiphysis is insufficient. Long bone deviation or bone necrosis will result. These results confirm clinically current knowledge about the epiphyseal and metaphyseal blood supply to the fibula. Copyright © 2009 by Thieme Medical Publishers, Inc.
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(18) F-fluorodeoxyglucose positron emission tomography/computed tomography for the detection of recurrent bone and soft tissue sarcoma
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MSTS AUC - Based on ACR Lit Review
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BACKGROUND: The clinical utility of modern hybrid imaging modalities for detecting recurrent bone or soft tissue sarcoma remains to be determined. In this report, the authors present a clinical study on the diagnostic accuracy and incremental value of integrated (18) F-fluorodeoxyglucose positron emission tomography/computed tomography ((18) F-FDG PET/CT) in patients with a history of sarcoma who have clinically suspected disease recurrence. METHODS: Forty-three patients who had a history of bone or soft tissue sarcoma and had documented complete remission underwent (18) F-FDG PET/CT. Image analysis was performed independently for (18) F-FDG PET (n = 43) and for contrast-enhanced spiral CT (CE-CT) (n = 30) by 2 separate readers, whereas combined (18) F-FDG PET/CT (n = 43) images were analyzed in consensus by both readers. Imaging findings were rated on a 5-point scale and finally were reported as malignant, benign, or equivocal. Imaging findings were validated either by histopathology (n = 24) or by clinical follow-up (n = 19). RESULTS: (18) F-FDG PET/CT had greater sensitivity and specificity compared with CE-CT alone (94% and 92% vs 78% and 67%, respectively), resulting in significantly greater accuracy (93% vs 73%; P = .03). (18) F-FDG PET/CT was particularly superior regarding detection of local recurrence or soft tissue lesions (sensitivity and specificity: 83% and 100% vs 50% and 100%, respectively) or bone metastases (100% and 100% vs 85% and 88%, respectively). CONCLUSIONS: (18) F-FDG PET/CT had greater diagnostic accuracy in the detection of recurrent bone or soft tissue sarcoma compared with CE-CT alone. The detection of local recurrence was the most evident advantage of (18) F-FDG PET/CT over CE-CT. Cancer 2013. (c) 2012 American Cancer Society
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The posterolateral approach to the distal humerus for open reduction and internal fixation of fractures of the lateral condyle in children
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The Treatment of Pediatric Supracondylar Humerus Fractures AUC
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Our study describes a posterolateral approach to the distal humerus for open reduction and internal fixation of displaced fractures of the lateral condyle. A total of 20 patients had open reduction and internal fixation over a four-year period using this approach, and at a mean follow-up of 12 months had full union, range of movement and no complications, either clinical or radiological. This approach is well suited to the exact visualisation and accurate reduction of this difficult fracture with minimal dissection of tissues
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Long-term results of low contact stress mobile-bearing total knee replacements
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AMP (Acute Meniscal Pathology)
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Five hundred ninety-eight consecutive primary low contact stress total knee replacements were done in 502 patients between 1985 and 1990. Clinical review was available for 495 knees (406 patients), 228 knees with meniscal-bearing prostheses and 267 knees with rotating-platform prostheses. The average followup was 12 years (range, 10-15 years). The average postoperative knee and functional scores were 87 points and 75 points, respectively. The average postoperative range of motion was 110 degrees. Fifty-six knees (11%) required revision for excessive wear of the tibial insert (41), dislocation (10), patellar polyethylene breakage (one), component loosening (one patellar, one tibial), and infection (two). During revision, osteolysis (20 knees), patellar polyethylene failure (33), and femoral component fracture (one) were seen. The overall survivorship was 88.1% at 15 years using Kaplan-Meier analysis. The survival rate was 83% for the meniscal-bearing prostheses and 92.1% for the rotating-platform prostheses. The Low Contact Stress mobile-bearing knee prosthesis has no superiority over that of fixed-bearing knees, especially for the meniscal-bearing design in prevention of polyethylene failure or revision. Based on the results of this study, the use of the LCS meniscal-bearing prosthesis does not appear to be justified.
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The efficacy of periarticular multimodal drug infiltration in total hip arthroplasty
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AAHKS (4) Acetaminophen
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Background: Patient-controlled analgesia is a widely used and effective method of controlling pain after THA. This method is associated with substantial undesirable side effects. Local infiltration has been introduced in an attempt to reduce opioid requirements postoperatively, but its ability to reduce pain without complications is still questioned. Questions/Purposes: We evaluated patient-controlled analgesia use, pain and satisfaction scores, complication rates, and ropivacaine levels associated with the use of periarticular multimodal drug infiltration in THA. Patients and Methods: We randomized 64 patients undergoing THA to receive a periarticular intraoperative multimodal drug injection or to receive no injection. All patients received patient-controlled analgesia for 24 hours after surgery. The final assessment was at 6 weeks. Results: Patients receiving the periarticular injection used less patient-controlled analgesia 6 hours postoperatively. The 24-hour patient-controlled analgesia requirement postsurgery also was less. The visual analog scale score for pain on activity in the postanesthetic care unit was less for patients who received an injection. The visual analog scale satisfaction score was similar in the two groups throughout the followup period. Recorded unbound ropivacaine levels were 2.5 times lower than toxic levels. Conclusions: Periarticular intraoperative injection with multimodal drugs can reduce postoperative patient-controlled analgesia requirements and pain on activity in patients undergoing THA with no apparent increase in risk. Level of Evidence: Level I, therapeutic study. See the guidelines online for a complete description of level of evidence. © 2009 The Association of Bone and Joint Surgeons®.
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The older worker with osteoarthritis of the knee
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SR for PM on OA of All Extremities
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BACKGROUND: Changing demographics mean that many patients with large joint arthritis will work beyond traditional retirement age. This review considers the impact of knee osteoarthritis (OA) on work participation and the relation between work and total knee replacement (TKR). SOURCES: Two systematic searches in Embase and Medline, supplemented by three systematic reviews. AREAS OF AGREEMENT: Probably, although evidence is limited, knee OA considerably impairs participation in work (labour force participation, work attendance and work productivity). AREAS OF UNCERTAINTY/RESEARCH NEED: Little is known about effective interventions (treatments, work changes and policies) to improve vocational participation in patients with knee OA; or how type of work affects long-term clinical outcomes (e.g. pain, function and the need for revision surgery) in patients with TKRs. The need for such research is pressing and opportune, as increasing numbers of patients with knee OA or TKR expect to work on
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Temperature of the human knee - A review
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SR for PM on OA of All Extremities
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BACKGROUND: Temperature measurement of the knee joint has a long tradition in medical thermometry. However, neither a standard for recording knee temperature nor agreed values of knees in healthy subjects or in articular disease are available. AIM OF THE STUDY: To compute available data on knee temperature from the literature including the conditions of temperature recording, measurement sites and temperature values. METHOD: A literature search was performed in the databases Medline and Embase using the search terms "skin temperature" or "intra-articular temperature" and "knee". Only papers written in English or German related to humans were considered for inclusion. The following data were extracted from included papers: Surface (skin) temperature, intra-articular temperature, site of measurement for skin or intra-articular temperature, measurement device, number of investigated knees, diagnosis of investigated subjects, biographic data of investigated subjects, room temperature, time of acclimatisation. If possible, temperature values were pooled if they have been recorded under similar conditions. RESULTS: In total, the database included temperature measurements from 3463 knee joints, comprising data from 876 healthy subjects, 629 patients with osteoarthritis (OA), 512 patients with rheumatoid arthritis (RA), 67 patients with non rheumatoid and other non specified inflammatory arthritis have been investigated. 86 patients suffered from joint inflammation caused by trauma, and 96 patients had various injuries of ligaments and other fibro-cartilagenous tissues of the knee. 131 temperature measurements were performed during surgery and 285 after surgery. 33 patients suffered from algodystrophy, 200 patients were investigated during or after various methods of cryotherapy and 50 subjects during heat treatment. Only pattern description without temperature values was reported in 5700 other subjects with various knee disorders. Based on contact temperature measurements, the mean temperature of the anterior knee in healthy subjects was 30.5 (plus or minus) 1.1(degrees)C. Determined with radiometers, the corresponding mean temperature was 28.7 (plus or minus) 0.6(degrees)C (95% confidence interval: 27.9 to 29.5). In thermal images from healthy subjects, the mean temperature of the anterior knee was 29.5 (plus or minus) 1.6(degrees)C (95% confidence interval: 28.5 to 30.5((degrees))C) and 33,1 (plus or minus) 0.0 ((degrees))C of the posterior knee. The side difference of temperature was 0.2 (plus or minus)1(degrees)C for both the anterior and the posterior knee. Mean intra-articular temperature varied between measurements recorded during knee surgery (29.9 (plus or minus) 4.4 ((degrees))C; 95% confidence interval: 23.0 to 36.8), in patients with rheumatoid arthritis (35,1 (plus or minus) 0.7 ((degrees))C; 95% confidence interval: 34.2 to 36.0((degrees))C) or osteoarthritis (33,5 2,7(degrees)C; 95% confidence interval: 30.1 to 36.9) and healthy subjects (32.6 (plus or minus) 0.9((degrees))C; 95% confidence interval: 31.5 to 33.7). Measurements with contact thermometers revealed in patients with rheumatoid arthritis a mean temperature of 32.5 (plus or minus) 0.9((degrees))C (95% confidence interval: 31.4 to 33.9(degrees)C) for the anterior knee, while the corresponding temperature recorded with infrared thermal images was 30.5 (plus or minus) 0.8((degrees))C (95% confidence interval: 27.8 to 33.1 ((degrees))C). In osteoarthritis patients, contact thermometers obtained a mean anterior knee temperature of 31.3 (plus or minus) 1,3(degrees)C and temperature measurements from infrared thermograms revealed a mean temperature of 30.7 (plus or minus) 1.3((degrees))C (95% confidence interval: 29.4 to 32.0 ((degrees))C). CONCLUSION: Knee temperatures vary with respect to the method of temperature determination and between different health conditions of the knee joint. Moreover, mean knee temperature describes the condition of the knee incompletely and should be supplemented with a description of the temperature distribution
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Mesenchymal stem cells for subchondral bone marrow lesions: From bench to bedside
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Osteochondritis Dissecans 2020 Review
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Subchondral bone marrow lesions (BMLs) are areas of disease within subchondral bone that appear as T1 hypointense and T2 hyperintense ill-defined areas of bone marrow on magnetic resonance imaging. The most common bone marrow lesions include subchondral lesions related to osteoarthritis, osteochondral defects, and avascular necrosis. Emerging therapies include autologous biologic therapeutics, in particular mesenchymal stem cells (MSCs), to maintain and improve cartilage health; MSCs have become a potential treatment option for BMLs given the unmet need for disease modification. Active areas in the preclinical research of bone marrow lesions include the paracrine function of MSCs in pathways of angiogenesis and inflammation, and the use of bioactive scaffolds to optimize the environment for implanted MSCs by facilitating chondrogenesis and higher bone volumes. A review of the clinical data demonstrates improvements in pain and functional outcomes when patients with knee osteoarthritis were treated with MSCs, suggesting that BM-MSCs can be a safe and effective treatment for patients with painful knee osteoarthritis with or without bone marrow lesions. Preliminary data examining MSCs in osteochondral defects suggest they can be beneficial as a subchondral injection alone, or as a surgical augmentation. In patients with hip avascular necrosis, those with earlier stage disease have improved outcomes when core decompression is augmented with MSCs, whereas patients in later stages post-collapse have equivalent outcomes with or without MSC treatment. While the evidence for the use of MSCs in conditions with associated bone marrow lesions seems promising, there remains a need for continued investigation into this treatment as a viable treatment option.
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No difference in blood loss between posterior-cruciate-ligament-retaining and posterior-cruciate-ligament-stabilized total knee arthroplasties
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OAK 3 - Non-arthroplasty tx of OAK
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PURPOSE: Posterior-cruciate-ligament-retaining (PCR) and posterior-cruciate-ligament-stabilized (PS) arthroplasties are two major common practices in total knee arthroplasty (TKA). The hypothesis of the present study was that compared with the PCR technique, the PS technique is associated with a higher amount of postoperative blood loss and greater need for blood transfusion in cemented TKA.
METHODS: In this prospective, randomized study, 100 patients diagnosed with primary knee osteoarthritis were randomly assigned to either the PCR group (Group I) or the PS group (Group II). The exclusion criteria were rheumatological joint disease, previous knee surgery, anticoagulant therapy and hypertension. There were no significant differences in age, body mass index and gender, between the groups. The haemoglobin and haematocrit levels of each patient were recorded preoperatively and on postoperative days 1, 3 and 5. The postoperative suction drainage and blood transfusion volumes were also recorded.
RESULTS: There were no statistically significant differences in haemoglobin or haematocrit levels between the groups on postoperative days 1, 3 and 5. There were also no statistically significant differences in the total measured blood loss volume, postoperative drainage amounts or transfusion rates between the groups.
CONCLUSION: Use of the PS technique during cemented TKA does not appear to influence the amount of perioperative blood loss or the need for postoperative blood transfusion in general. The clinical relevance of this study is that the difference in blood loss between the PCR and PS techniques does not need to be considered by surgeons when performing TKA.
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Outcomes of Nonoperative Treatment of Salter-Harris II Distal Radius Fractures: A Systematic Review
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Distal Radius Fractures
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BACKGROUND: Despite the frequent occurrence of these injuries, we know little about the natural history of Salter-Harris II (SH II) distal radius fractures. We conducted a systematic review of studies examining the radiographic and clinical outcomes of nonoperatively managed SH II distal radius fractures.
METHODS: Systematic searches of the MEDLINE and Cochrane computerized literature databases and manual searches of bibliographies were performed. We reviewed both descriptive and quantitative data.
RESULTS: Seven studies including 434 SH II fractures were reviewed. Two studies reported clinical outcomes based on patient age, but neither study described a statistical correlation between patient age and outcome. Two studies discussed the effect of age on radiographic outcome and reported higher rates of anatomic remodeling in children 10 years or younger. Two studies with long-term (average follow-up greater than 8 years) clinical results reported complication rates of 5%. Long-term follow-up of radiographic outcomes appeared in 4 studies with variable results. Five studies reported the frequency of premature physeal arrest after SH II fractures, with results ranging from 0% to 4.3%.
CONCLUSIONS: Based on this review, no recommendations can be made as to what defines an acceptable reduction or which fractures would benefit from surgical intervention. Angular deformity seems to correct to an acceptable alignment in patients less than 10 years of age, but these younger patients seem to be at higher risk for symptomatic shortening if a growth arrest occurs. Redisplacement after reduction is fairly common, and other more severe complications such as pain, loss of motion, and nerve injury can occur.
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Effect of glenoid cementation on total shoulder arthroplasty for degenerative arthritis of the shoulder: a review of the New Zealand National Joint Registry
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Glenohumeral Joint OA
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BACKGROUND: Despite the lack of literature showing improved results compared with cemented designs, uncemented glenoid components are still commonly used in total shoulder arthroplasty (TSA). Most studies comparing cemented with uncemented glenoids involve small numbers or include patients with inflammatory arthritis.
METHODS: New Zealand National Joint Registry data was used to compare the outcomes of uncemented and cemented glenoids in TSA performed for degenerative arthritis. Measured variables were the revision rate and the Oxford Shoulder Score (OSS).
RESULTS: Data were retrieved on 1596 patients, with a mean follow-up 3.5 years (range 2-10.7 years), 1065 of whom had a cemented glenoid. There were no significant differences in any preoperative factors between the 2 groups. The revision rate for uncemented glenoids was 4.4 times higher than for cemented glenoids (1.92 vs. 0.44 revisions per 100 component-years, P < .001). Age <55 years was an independent risk factor for revision (P < .001). The most common reason for revision was rotator cuff wear (35.5%) in the uncemented glenoids and loosening (36.3%) in the cemented glenoids. The difference in the mean OSS between the 2 groups was less than 1 point at 6 months (P = .109) and at 5 years (P = .377).
CONCLUSION: Uncemented glenoids had a markedly higher revision rate. Patients aged <55 years have the highest revision rate regardless of glenoid fixation method. The higher revision rate in the uncemented glenoid group persisted when the effect of young age was corrected for. There was no clinically or statistically significant difference in the OSS results for clinical outcome between the two groups.
LEVEL OF EVIDENCE: Level III, retrospective cohort, treatment study.
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Vascular trauma and compartment syndromes
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DOD - Acute Comp Syndrome CPG
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Vascular injuries produce ischemia, and their repair produces reperfusion. Ischemia and reperfusion produce compartment syndrome. Although a local event, a compartment syndrome risks not only the affected extremity, but also the life of the patient. A high index of suspicion coupled with adequate knowledge of subtle clinical symptoms (and confirmed by intracompartmental pressure measurement) improve management of compartment syndrome, and this article discusses common pitfalls in its diagnosis and treatment. [References: 44]
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Clinician-led surgical site infection surveillance of orthopaedic procedures: a UK multi-centre pilot study
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Management of Hip Fractures in the Elderly
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The UK Department of Health established the Healthcare-associated Infection (HAI) Surveillance Steering Group in 2000 to develop a strategy for implementing a national programme for HAI surveillance in National Health Service trusts. A subgroup of this committee examined the surveillance of surgical site infections following orthopaedic surgery. This group oversaw a pilot scheme that was set up in 12 hospitals around the UK to explore the feasibility of implementing a system of surveillance that engaged clinical staff in its operation, provided a process for continuous data collection and could be maintained as part of routine hospital operation over time. A minimum data set was established by the subgroup, and Centers for Disease Control and Prevention (CDC) definitions of infection were used. By March 2003, the surveillance had been undertaken continuously in 11 sites for one to two years, depending on the date of implementation. Only one hospital had ceased data collection. The information was collected mainly by clinical staff, with support and co-ordination usually provided by infection control teams. Data on more than 5400 procedures were available for analysis for four core procedures: arthroplasty of the hip and knee; hemi-arthroplasty of the hip; and internal fixation of trochanteric fractures of the femur. The data set permitted the calculation of risk-adjusted rates, allowing comparisons between hospitals and within a hospital over time. The methodology enhanced clinical ownership of the surveillance process, re-inforced infection control as the responsibility of all staff, and provided timely feedback and local data analysis. The use of CDC definitions permitted international comparisons of the data
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Early experience about Anteversa(registered trademark) plate for lateral femur fractures
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HipFx Supplemental Cost Analysis
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Introduction. The hip fractures appear to be a real epidemic problem, especially in the western world, due primarily to higher average age. The social and economical impact is considerable with a continue social and health costs up-rising. The female-male ratio is approximately 8:1. Purpose. The purpose of this report is to present a system of osteosynthesis for fractures of the lateral femoral neck. This system is a plate developed by INTRAUMA O'nil(registered trademark), 3-hole plate with an 130(degrees) angle of valgus and 7(degrees) of anteversion. Materials and methods. At the I Orthopedic Department at the University of Pisa from January 2009 to February 2012 were treated 52 fractures of the femur neck side with this system. All patients undergone to a clinical and X-ray evaluation according to the AO classification: 14 31-A1, 7 31-A2, 4 31-A3. Results. The mean follow-up was 10 months, in all cases we did not have cut-outs with a TAD average of 23 mm. Conclusions. This system offers the possibility to perform surgery quickly with low risk of cut-out thanks to 7(degrees) of anteversion. Ensures optimal fixation to the femoral shaft and an equitable distribution of forces, eliminating the risk of breakage of the implant and loosening of the screws
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Face Validity and Content Validity of a Game for Distal Radius Fracture Rehabilitation
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Pediatric Supracondylar Humerus Fracture 2020 Review
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Background â??Patients recovering from a variety of wrist injuries are frequently advised to exercise to regain lost wrist and hand function. Treatment regimens to regain motion in the wrist are highly variable, and adherence to exercise protocols is known to be low. A serious game ReValidate! incorporating standardized exercise regimens was developed to motivate patients. In this study, the game is evaluated regarding its face validity and content validity. Methods â??In this cross-sectional study, a mixed group of "users" ( n â??=â??53) including patients currently recovering from wrist injury, and a mixed group of "experts" ( n â??=â??46) including professionals advising patients on therapy regimen after wrist injury played at least one complete level of the serious game. Players evaluated the game by means of a structured questionnaire regarding its content, clinical applicability, and user experience. Questions were answered on a Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree). Results â??All groups valued the game as being able to support wrist rehabilitation and being of use to patients recovering from a distal radius fracture (users: median 4, P25-P75 3-4 vs. experts: median 4, P25-P75 3.50-5; p â??=â??not significant). The types of exercises performed during the game were considered to be both realistic and complete compared with regular physiotherapy exercises (users: median 4, P25-P75 3-4 vs. experts: median 4, P25-P75 3-5, p â??=â??not significant). Conclusions â??The ReValidate! serious game can be regarded as a valid tool for patients to regain their wrist function after injury. Level of evidence â??This is a Level II study.
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Hand ischemia associated with elbow trauma in children
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DoD SSI (Surgical Site Infections)
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OBJECTIVES: Previous observational studies suggest that children with hand ischemia following elbow trauma can be safely observed if Doppler signals are present in the wrist arteries (pink pulseless hand, PPH). Nonoperative management of PPH is predicated on the assumption that PPH results from local arterial spasm, but the mechanism of arterial compromise has not been investigated. We hypothesized that PPH signifies a brachial artery injury that requires surgical repair.
METHODS: Retrospective review of operations performed on children with hand ischemia following elbow trauma at a level I trauma center pediatric hospital.
RESULTS: Between 2003 and 2010, 12 children (seven males, mean age 7.4 years) underwent brachial artery exploration for hand ischemia following elbow trauma (11 supracondylar fractures, one elbow dislocation) due to falls (n = 10) or motor vehicle crashes (n = 2). At presentation, three subjects had normal radial pulses, eight subjects had Doppler signals but no palpable pulses, and one had weak Doppler flow with advanced hand ischemia. Six of the nine subjects without palpable pulses also had neurosensory changes. All 12 subjects underwent brachial artery exploration either initially (n = 2) or following orthopedic fixation (n = 10) due to persistent pulselessness. At operation, eight of 12 patients (67%) had focal brachial artery thrombosis due to intimal flaps, and four had brachial artery and median nerve entrapment within the pinned fracture site. At discharge, all 12 subjects had palpable radial pulses, but three with entrapment had dense median nerve deficits. One of the three subjects with dense neurologic deficit had complete recovery of neurologic function at ten months. The other two subjects had residual median nerve deficits with partial recovery at 5 and 6 months follow-up, respectively. No patient developed Volkman's contracture.
CONCLUSIONS: Brachial artery injuries should be anticipated in children with hand ischemia associated with elbow trauma. Neurovascular entrapment at the fracture site is a possible complication of orthopedic fixation. Absence of palpable wrist pulses after orthopedic fixation should prompt immediate brachial artery exploration. PPH should not be considered a consequence of arterial spasm in these patients.
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0 |
Constrained Liners Implanted Simultaneously at the Time of Acetabular Shell Revision with a Highly Porous Implant: Surprisingly Good Fixation at 10 Years
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Hip Fx in the Elderly 2019
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BACKGROUND: Many surgeons are reluctant to use a constrained liner at the time of acetabular component revision because of concerns that doing so might result in early acetabular component loosening related to high bone-implant interface stresses transmitted from the constrained liner. We hypothesized that, with appropriate initial implant stabilization using highly porous acetabular components with robust supplemental screw fixation, constrained liners could be safely used at the time of acetabular revision.
METHODS: We retrospectively identified 148 revision total hip arthroplasties (THAs) in which a constrained liner of 1 design was cemented into a newly placed highly porous acetabular component fixed with supplemental screws (mean, 5 screws). The mean age at the time of revision THA was 69 years, and 68% of the patients were female. The most common indications for revision were 2-stage reimplantation (33%), recurrent dislocation (30%), and aseptic loosening of the acetabular component (22%) or both the acetabular and femoral components (9%). The mean duration of follow-up was 7 years.
RESULTS: There were no failures at the bone-implant interface. No cases of acetabular metal shell loosening were identified on radiographic analysis. The 10-year survival rates with acetabular revision and any reoperation as the end points were 75% and 67%, respectively. Overall, 33 hips (22%) required revision or reoperation because of infection or wound complications (n = 12), dislocation or mechanical failure of the constrained liner (n = 11), periprosthetic femoral fracture (n = 4), femoral loosening (n = 3), or other reasons (n = 3). The 10-year survival rate with re-revision for instability as the end point was 88% overall, which was similar to the 85% 10-year survival rate with re-revision for instability as the end point among hips that were specifically revised because of instability during index revision THA (p = 0.9).
CONCLUSIONS: Implanting a constrained liner at the time of acetabular revision in high-risk patients resulted in no cases of aseptic metal acetabular component loosening in this large series. This finding is likely related to the fact that a highly porous acetabular component was utilized with robust supplemental screw fixation in each case. Such information is valuable as these data favor a paradigm shift when compared with some traditionally held tenets.
LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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0 |
0414 Cumulative mercury exposure and peripheral nerve function in a sample of U.S. dental professionals
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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OBJECTIVES: To calculate individual cumulative mercury exposures from a convenience sample of dental professionals and measure the effect on peripheral nerve function. METHOD: Participants attended the American Dental Association's (ADA) conventions held from 1997-2006. Individual surveys were completed and measurements were taken of the median and ulnar sensory nerve amplitude and latency in the dominant hand. The ADA has measured the average urinary mercury concentration of participants since 1977, allowing a cumulative mercury exposure to be estimated for each individual dentist based on the number of years they practiced dentistry. Both fixed and mixed effects (accounting for repeated measures) linear regression models were used. RESULTS: 3923 observations from 2649 dentists were used to perform linear regression using multiple models. Models included individuals with or without imputed BMI, along with either repeated measures or initial observations only. Adjusted covariates included hand temperature, gender, age and BMI. Individuals with rheumatoid arthritis, diabetes, carpal tunnel syndrome (for median nerve models only), or hand temperatures interfering with the accuracy of the instrument were excluded. The main effect of cumulative exposure was found to be significant (p-value <0.05) in median nerve latency and amplitudes but insignificant in ulnar nerve measures. All models but ulnar nerve latency showed a highly significant interaction of cumulative exposure and age (p-value < 0.01). CONCLUSIONS: Using an estimated cumulative mercury exposure as the measure of effect shows a significant positive association with decreased peripheral nerve function. This study is the first of its kind to estimate dentists' cumulative mercury exposure and its effect on peripheral nerve function
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0 |
MR imaging of the knee in marathon runners before and after competition
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AMP (Acute Meniscal Pathology)
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OBJECTIVE: To evaluate the findings in MRI-studies of the knee in recreational long-distance runners after competition and to assess the reversibility of the findings.
DESIGN AND PATIENTS: Eight recreational long-distance runners underwent MRI studies of the knee before, immediately after and 6-8 weeks after taking part in the Vienna City Marathon. The studies were evaluated regarding alterations of pre-existing lesions and new pathological findings.
RESULTS: In six runners without major pre-existing alterations no negative effects were experienced. In one runner with pre-existing grade III alterations of the menisci, signs of progressive osteoarthritis were experienced 2 months after the competition. In all other cases increased meniscal signal alterations and minor signal changes in the bone marrow after the race were transitory.
CONCLUSION: In healthy individuals no negative long-term-effects were experienced. Pre-existing high-grade lesions of the menisci might be a predisposing risk for osteoarthritis, triggered by the stress of long-distance running.
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0 |
Orexigenic agents in geriatric clinical practice
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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The problem of involuntary weight loss (IWL) is more pronounced among elderly individuals with psychiatric ailments, with depression being the leading cause. The combination of precipitating factors such as multiple medical comorbidities, polypharmacy, depression and the cachexia of aging, which are unique to elderly patients, present difficulties for physicians treating these individuals. Although research has indicated that certain medications may help promote appetite and weight gain in elderly patients with IWL, as a general rule, drugs should not be considered as first-line treatment. Although the focus of this article has been limited to reviewing the evidence for current orexigenic agents that are used to treat elderly individuals who are experiencing IWL, maintaining a healthy weight is an essential element of well-being and decreased morbidity and mortality. This article will discuss the increased occurrence and risk of IWL in elderly patients and will review the various pharmacotherapeutic agents in the management of IWL. (copyright) 2013 Future Medicine Ltd
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0 |
Extracranial skeletal metastases from an intracranial meningeal chondrosarcoma: case report
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MSTS 2018 - Femur Mets and MM
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This report describes a meningeal chondrosarcoma over the convexity of the brain with extracranial metastases to the left femur and pelvis.
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1 |
Comparison of the efficacy of corticosteroid, dry needling, and PRP application in lateral epicondylitis
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PRPs for Lateral Epicondylitis/Elbow Tendinopathies
|
PURPOSE: The aim of this study was to compare the short-term efficacy of dry needling, corticosteroids, and platelet-rich plasma application (PRP) in the management of lateral epicondylitis.
METHODS: The study included 72 patients diagnosed with lateral epicondylitis divided into three groups of 24 individuals using the sealed envelope method. Group 1 underwent dry needling, Group 2 received 40 mg methylprednisolone acetate, and Group 3 received PRP treatment. Patients were assessed using the visual analog scale (VAS) and the Disabilities of the Shoulder, Arm, and Hand (DASH) score, and Jamar grip strength before treatment and 3rd week and 3rd month.
RESULTS: At the 3rd month, the mean VAS score was 1.16 +/- 0.56 in dry needling group and 0.75 +/- 0.60 in corticosteroids group, showing a statistically significant difference between dry needling and corticosteroids group, and between corticosteroids and PRP group (p = 0.015 and p = 0.000, respectively). At the 3rd week and 3rd month, VAS scores decreased in each treatment modality group, showing a statistically significant difference between the groups (p < 0.01). Jamar grip strength increased over time in all groups. There were no significant differences between the DASH scores of all groups at the 3rd week (p > 0.05). DASH scores decreased significantly from the 3rd week to the 3rd month in dry needling and corticosteroids group (p < 0.01), while it increased slightly in PRP group during the same period with a statistically insignificant change (p > 0.05). DASH scores decreased significantly at the 3rd month for all groups (p = 0.014).
CONCLUSION: Dry needling is an effective and safe application for the short-term treatment of lateral epicondylitis.
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0 |
Post-traumatic knee osteoarthritis in the young patient: therapeutic dilemmas and emerging technologies
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OAK 3 - Non-arthroplasty tx of OAK
|
Traumatic knee injury is common in young adults and strongly contributes to premature development of knee osteoarthritis (OA). Post-traumatic knee OA poses a therapeutic dilemma to the physician, since no known therapy has an acceptable safety profile, effectively relieves joint pain, and enjoys reasonable patient acceptance. Consequently, these young patients will ultimately be faced with the decision to either undergo surgical intervention, despite prosthesis durability concerns, or to continue with ineffective nonsurgical treatment. Emerging therapies, such as biologics, disease-modifying drugs, partial joint resurfacings, and minimally invasive joint-unloading implants are currently being studied to fill this therapeutic void in the young patient with post-traumatic knee OA.
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0 |
Bone and nerve injuries due to birth trauma
|
The Treatment of Pediatric Supracondylar Humerus Fractures AUC
|
An incidence of 3.02 per 1000 live births for fractures and nerve injuries was observed among 26,852 consecutive live born babies over the last decade. Fractures constituted 51.8 % and nerve injuries 48.2 % of total injuries studied. Amongst the fractures the bones involved were the clavicle (44.7 %), humerus (21.6 %), femur (16.9 %), skull bones (14.3 %), and epiphyseal injury (2.5 %). The nerve injuries included Erb's palsy (48.7 %), facial palsy (38.4 %), and other brachial plexus injury (12.9 %). Lack of antenatal care, primiparity, abnormal fetal position, operative delivery, and birth weight above 3500 g significantly increased the risk of bone and nerve injuries. Babies with birth trauma had low Apgar scores and needed longer hospitalisation. Ten babies with injuries and 1 in the control group expired. Therefore, proper antenatal care, identification of high risk mothers, and appropriate management will reduce the incidence of birth injuries
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0 |
Long-term results of arthroscopic partial meniscectomy
|
AMP (Acute Meniscal Pathology)
|
Detailed analysis of a series of 99 arthroscopic partial meniscectomies with a minimum follow-up time of 2.1 years (mean, 3 years; maximum, 4.5 years) showed that the spectacularly good early results were maintained in the longer term. Group I knees (67) had no previous surgery or ligamentous insufficiency, but those with chondromalacia were included. The remaining knees were designated Group II and analyzed separately. Group I showed 51.5% excellent and 39% good results, using criteria based on those of Tapper and Hoover. When only results in bucket handle tears were considered, 73% were excellent and 19% were good. Results in Group I also depended on the presence or absence of chondromalacia. Results in Group II were poorer than in Group I, but were still satisfactory in 67% of knees, although many had a torn anterior cruciate ligament of frank osteoarthritis. The arthroscopic technique should, where possible, become the standard method of treatment if patients require meniscectomy.
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1 |
Body contouring following significant weight loss
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Panniculectomy & Abdominoplasty CPG
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Patients who have undergone the surgical correction of morbid obesity present a challenge for body contouring after their weight loss. They most often request improvement of their arms, breasts, abdomen, thighs, and repair of hernias. This chapter will explore one approach to these challenges.
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0 |
Clinical findings in 2 techniques of spica casting in treatment of femoral shaft fractures in children
|
Pediatric Diaphyseal Femur Fractures 2020 Review
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Background: Femoral shaft fracture is the most prevalent major orthopedic injury in children. Usually, we use two methods for spica casting for femoral shaft fractures. This survey aimed two compare them. Methods: This singleâ?blind randomized clinical trial study was performed on the 35 2â? to 6â?yearsâ?old patients with isolated and nonâ?complicate femoral shaft fracture referred to Shahid Bahonar hospital, Kerman, Iran. All the patients were followed for 6 months. 17 patients were treated with type 1 method (90/90 casting) and 18 ones underwent type 2 method (45/45 casting). Patient was examined in regard of limb length, angular deformity, muscle power, neurovascular lesion, compartment syndrome, and dermal injury. After opening the cast, a researcherâ?made questionnaire about the child's activities was completed by parents. Findings: In all the patients in both groups, after maximum of 8 weeks, union was completed. The average difficulty in moving around independently was 5.77 ± 2.41 and 8.05 ± 1.43 in 45/45 and 90/90 groups, respectively, with a significant difference (P = 0.002). The average difficulty rate of leaving family residence or was 5.77 ± 2.94 and 8.00 ± 1.76 in 45/45 and 90/90 groups, respectively, which was statistically different (P = 0.011). Conclusion: Based on the results of the present study, it seems that the child is more comfortable with 45/45 spica cast.
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0 |
Closure of the femoral medullary canal after retrograde nailing using an in-situ osteochondral autograft-Technical trick and a case series
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Osteochondritis Dissecans 2020 Review
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Retrograde intramedullary nailing (RIMN) is the favored over antegrade intramedullary nailing in fractures of the distal femur. It provides a longer working length and allows for multiple distal screw insertion and therefore a more stable construct. Concerns remain regarding the violation of the knee cartilage and the effect this has on knee function. Many studies have shown high incidence of knee pain with reports varying from 20 to 86%. We describe a novel technical trick aiming at partially restoring the knee cartilage of the operated side and decreasing the hemorrhage stemming from the medullary canal. Our experience of the technique and the case series shows that closing the entrance point of the medullary canal after a RIMN procedure leads to better function and less knee pain in the postoperative period.
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0 |
Update of multimodal pain management strategies for total knee arthroplasty
|
AAHKS (8) Anesthetic Infiltration
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Total knee arthroplasty [TKA] has traditionally been one of the most painful orthopedic procedures. Postoperative pain control in the past depended on high doses of opioids, resulting in dizziness and nausea, delayed ambulation, and prolonged hospital stays. Over the last decade, multimodal pain control has been developed that provides excellent pain control and reduces opioid consumption. The key principle is the use of a variety of interventions that affect different sites in the pain pathway. Multimodal pain management for TKA includes preemptive analgesia, regional anesthesia, and local infiltrative anesthesia (periarticular injection) as well as various oral and intravenous pain medications such as NSAIDs, COX-2 inhibitors, and gabapentinoids. The goal ofthis review is to provide an update of current knowledge ofmultimodal pain management for TKA.
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0 |
Impact of postoperative venous thromboembolism on Medicare recipients undergoing total hip replacement or total knee replacement surgery
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Management of Hip Fractures in the Elderly
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PURPOSE: The impact of postoperative venous thromboembolism (VTE) during initial hospitalization for total hip replacement (THR) or total knee replacement (TKR) surgery was assessed. METHODS: Using Medicare Provider Analysis and Review files, patients who underwent THR, TKR, or hip fracture surgery from 2005 to 2007 were identified using appropriate procedure codes from the International Classification of Diseases, 9th Revision, Clinical Modification. Medicare managed care patients were excluded from the study. Eligible patients were classified as having had deep venous thrombosis (DVT), pulmonary embolism (PE), DVT and PE, or no VTE during their initial hospitalization. Risk adjustment was performed using propensity score matching. Medicare cost, cost to beneficiaries, and cost to primary payers were analyzed to determine risk-adjusted differences in outcome measures, including mortality, rehospitalization, bleeding, length of stay, and total health care expenditures related to VTE events. RESULTS: A total of 170,047 patients were identified. Postoperative VTE events occurred in 3,014 patients (1.77%) during their initial hospitalization. Risk-adjusted mortality rates were three to four times higher for patients with VTE compared with those without VTE. Patients with VTE were more likely to be rehospitalized and experience bleeding within 30 days. Risk-adjusted differences in annual mean cost, including Medicare cost and costs to beneficiaries and primary payers, were significantly greater for patients with VTE. CONCLUSION: Patients who developed VTE after THR or TKR had a higher likelihood of mortality, bleeding, and rehospitalization; were hospitalized longer; and incurred higher costs to Medicare, Medicare beneficiaries, and private payers compared with patients without VTE
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0 |
Cathepsin D non-proteolytically induces proliferation and migration in human omental microvascular endothelial cells via activation of the ERK1/2 and PI3K/AKT pathways
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MSTS 2018 - Femur Mets and MM
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Epithelial ovarian cancer (EOC) frequently metastasises to the omentum, a process that requires pro-angiogenic activation of human omental microvascular endothelial cells (HOMECs) by tumour-secreted factors. We have previously shown that ovarian cancer cells secrete a range of factors that induce pro-angiogenic responses e.g. migration, in HOMECs including the lysosomal protease cathepsin D (CathD). However, the cellular mechanism by which CathD induces these cellular responses is not understood. The aim of this study was to further examine the pro-angiogenic effects of CathD in HOMECs i.e. proliferation and migration, to investigate whether these effects are dependent on CathD catalytic activity and to delineate the intracellular signalling kinases activated by CathD. We report, for the first time, that CathD significantly increases HOMEC proliferation and migration via a non-proteolytic mechanism resulting in activation of ERK1/2 and AKT. These data suggest that EOC cancer secreted CathD acts as an extracellular ligand and may play an important pro-angiogenic, and thus pro-metastatic, role by activating the omental microvasculature during EOC metastasis to the omentum.
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0 |
Can pain intensity in osteoarthritis joint be indicator of the impairment of endothelial function?
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OAK 3 - Non-arthroplasty tx of OAK
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We propose that pathological remodeling in joint tissues of osteoarthritis (OA) patients persistently stimulates local secretion of pro-inflammatory mediators, which overflow into the blood, activating leukocytes that impair endothelial function and accelerate the atherosclerotic process. During periods of pain, endothelial dysfunction progresses more aggressively due to elevated secretion of these pro-inflammatory mediators, which are involved in both atherosclerosis and the sensation of pain. Concentrations of pro-inflammatory cytokines and their antagonists, activating and decoy receptors of the broad interleukin (IL)-1 and IL-17 families, IL-15, and monocyte chemotactic protein-1 should be measured in peripheral blood samples of OA patients and compared with (I) OA clinical severity; (II) subclinical parameters of atherosclerosis; (III) ischemic heart disease risk factors; (IV) soluble factors indicating endothelial dysfunction; (V) degree of bone destruction; and (VI) results of a six-minute walk test. Arthroscopy and joint replacement surgery provide an opportunity to estimate mRNA and protein expression of inflammatory mediators in specimens of synovial fluid, synovial membrane, cartilage, and/or subarticular bone. A range of methods, including questionnaires, X-ray, computed tomography, ultrasound, enzyme-linked immunosorbent assay, immunohistology, immunofluorescence, and reverse transcription and in situ polymerase chain reaction are available. Understanding the inflammatory and immune mechanisms underlying OA may allow the early identification of patients at high risk of cardiovascular disease, independently of classical coronary risk factors. Pain may constitute an extrinsic indicator of currently worsening endothelial function.
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1 |
Relative efficacy of hyaluronic acid in comparison with NSAIDs for knee osteoarthritis: a systematic review and meta-analysis
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OAK 3 - Non-arthroplasty tx of OAK
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OBJECTIVE: To assess the relative efficacy of intra-articular hyaluronic acid (IAHA) in comparison with non-steroidal anti-inflammatory drugs (NSAIDs) for knee osteoarthritis (OA).
METHODS: We searched Medline, EMBASE, Google Scholar, ISI Web of Science, and Cochrane Database from inception until February 2013. Randomized controlled trials comparing HA with NSAIDs for knee OA were included if they reported at least one pain outcome. Two reviewers abstracted data and determined quality. Outcomes included pain, function, and stiffness. Random-effects meta-analyses were performed.
RESULTS: Five trials (712 participants) contributed to the pain analysis. Both groups showed improvement from baseline. The analysis found an effect size (ES) of -0.07 (95% CI: -0.24 to 0.10) at trial end, favoring neither treatment. There were no statistically significant differences between the groups at 4 and 12 weeks in function [ES = -0.08 (95% CI: -0.39 to 0.23)] or stiffness [ES = 0.03 (95% CI: -0.27 to 0.34)] analyses based on two trials. Injection site pain was the most common adverse event reported in the HA group, and gastrointestinal adverse events were more common in the NSAIDs group.
CONCLUSION: This meta-analysis suggests that IAHA is not significantly different from continuous oral NSAIDs at 4 and 12 weeks. Our study detected no safety concerns; however, the included trials had only a short follow-up duration. Given the favorable safety profile of IAHA over NSAIDs, this result suggests that IAHA might be a viable alternative to NSAIDs for knee OA, especially for older patients at greater risk for systemic adverse events.
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0 |
Risk factors for the effect of anticoagulant and antiplatelet agents on perioperative blood loss following proximal femoral fractures
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Hip Fx in the Elderly 2019
|
To examine the effect of oral anticoagulant and antiplatelet agents on perioperative blood loss following proximal femoral fractures and to identify the risk factors associated with perioperative blood loss.Retrospective cross-sectional study. In a retrospective cross-sectional study, we treated 334 consecutive patients with proximal femoral fractures (100 who received anticoagulant or antiplatelet drugs and 234 who did not) and an overall mean age of 85.5 years (standard deviation 8.2 years). We performed retrospective multivariate analysis to determine the independent factors related to perioperative decreases in the hemoglobin (Hb) level, a proxy for blood loss.Multivariate analysis confirmed that anticoagulant or antiplatelet drugs significantly affected decreases in the Hb level (regression coefficient [RC], 0.61; 95% confidence interval [CI], 0.14-1.08; P = 0.01). In addition to anticoagulant or antiplatelet drugs, multivariate analysis confirmed that the fracture type (Orthopedic Trauma Association classification A2: RC, 1.19; 95% CI, 0.71-1.67; P < 0.01; A3: RC, 2.47; 95% CI, 1.41-3.53; P < 0.01), platelet count (RC, -0.08; 95% CI, -0.12 to -0.04; P < 0.01), and operative time (RC, 0.02; 95% CI, 0.004-0.03; P = 0.01) affected the decreases in Hb level. The use of anticoagulants and antiplatelet agents is an independent risk factor for perioperative blood loss following proximal femoral fractures. Fracture type, platelet count, and operative time also affect perioperative blood loss. The fracture type was the greatest contributing factor to perioperative blood loss.Level of evidence grade: Prognostic level III.
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1 |
Effect of Intravenous Acetaminophen on Postoperative Opioid Consumption in Adult Orthopedic Surgery Patients
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AAHKS (4) Acetaminophen
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<b>Background</b>: Postoperative pain is managed with opioids, which are associated with adverse effects. The efficacy of intravenous (IV) acetaminophen in reducing opioid consumption has been studied with inconsistent results. The primary outcome of this study was to assess the effect of IV acetaminophen on opioid consumption 24 hours postoperatively. Secondary outcomes included the opiate consumption at 48 hours after the operation, opioid-related side effects 72 hours after the operation, discharge disposition, and length of stay. <b>Methods:</b> This was an IRB-approved, retrospective cohort study including adult patients who underwent an elective total knee arthroplasty (TKA). Patients were stratified into IV and no IV acetaminophen groups; patients who had received at least one dose of IV acetaminophen were included in the IV acetaminophen group. Total opioids were collected, converted to morphine equivalents, and compared between groups. Patients were excluded for alcohol abuse, substance abuse treatment, non-elective TKA, or medication mischarting. <b>Results</b>: Of the 161 patients evaluated, 148 patients were included: 86 in the IV acetaminophen and 62 in the no IV acetaminophen group. There were no differences in mean morphine equivalents between groups postoperatively at 24 hours (54.2 +/- 35.9 mg vs 45.4 +/- 30.2 mg; p = .12) and 48 hours (99.2 +/- 68.7 mg vs 79.5 +/- 49.1 mg; p = .06). There were no differences in secondary outcomes (administration of bowel regimen medications, antiemetics, naloxone, discharge disposition, or length of stay) between the groups. <b>Conclusion</b>: The use of IV acetaminophen was not associated with a decrease in opiate use, opiate-related side effects, or any secondary outcomes in patients who underwent TKA.
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0 |
Somatostatin receptors in non-neuroendocrine malignancies: The potential role of somatostatin analogs in solid tumors
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MSTS 2018 - Femur Mets and MM
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Somatostatin receptors (sstrs) are G-protein-coupled receptors that mediate various physiological effects when activated by the neuropeptide somatostatin or its synthetic analogs. In addition to the well-documented antisecretory effects of sstr2-preferential somatostatin analogs octreotide and lanreotide, ligand binding to sstr initiates an inhibitory action on tumor growth. This effect may result from both indirect actions (suppression of growth factors and growth-promoting hormones [e.g., GH/IGF-1 axis] and inhibition of angiogenesis) and direct actions (activation of antigrowth activities [e.g., apoptosis]). As solid tumor cells express multiple sstrs, there is a rationale to evaluate the potential antitumor effects of pasireotide (SOM230), a multireceptor-targeted somatostatin analog with high binding affinity for sstr1-3 and sstr5. Pasireotide reduces systemic IGF-1 levels more potently than currently available somatostatin analogs and has been well tolerated in clinical trials. © 2011 Future Medicine Ltd.
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1 |
A Trial of Wound Irrigation in the Initial Management of Open Fracture Wounds
|
DoD SSI (Surgical Site Infections)
|
BACKGROUND: The management of open fractures requires wound irrigation and debridement to remove contaminants, but the effectiveness of various pressures and solutions for irrigation remains controversial. We investigated the effects of castile soap versus normal saline irrigation delivered by means of high, low, or very low irrigation pressure.
METHODS: In this study with a 2-by-3 factorial design, conducted at 41 clinical centers, we randomly assigned patients who had an open fracture of an extremity to undergo irrigation with one of three irrigation pressures (high pressure [>20 psi], low pressure [5 to 10 psi], or very low pressure [1 to 2 psi]) and one of two irrigation solutions (castile soap or normal saline). The primary end point was reoperation within 12 months after the index surgery for promotion of wound or bone healing or treatment of a wound infection.
RESULTS: A total of 2551 patients underwent randomization, of whom 2447 were deemed eligible and included in the final analyses. Reoperation occurred in 109 of 826 patients (13.2%) in the high-pressure group, 103 of 809 (12.7%) in the low-pressure group, and 111 of 812 (13.7%) in the very-low-pressure group. Hazard ratios for the three pairwise comparisons were as follows: for low versus high pressure, 0.92 (95% confidence interval [CI], 0.70 to 1.20; P=0.53), for high versus very low pressure, 1.02 (95% CI, 0.78 to 1.33; P=0.89), and for low versus very low pressure, 0.93 (95% CI, 0.71 to 1.23; P=0.62). Reoperation occurred in 182 of 1229 patients (14.8%) in the soap group and in 141 of 1218 (11.6%) in the saline group (hazard ratio, 1.32, 95% CI, 1.06 to 1.66; P=0.01).
CONCLUSIONS: The rates of reoperation were similar regardless of irrigation pressure, a finding that indicates that very low pressure is an acceptable, low-cost alternative for the irrigation of open fractures. The reoperation rate was higher in the soap group than in the saline group. (Funded by the Canadian Institutes of Health Research and others; FLOW ClinicalTrials.gov number, NCT00788398.).
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0 |
Microvasculature of the human medial meniscus: operative findings
|
AMP (Acute Meniscal Pathology)
|
The purpose of our study was to weigh the probability of a successful meniscus repair on the basis of the microvasculature of the human medial meniscus. In a series of 105 patients who underwent an anterior cruciate ligament reconstruction between January 1985 and December 1986, we chose the 40 patients who had a subtotal medial meniscectomy (38%) to study the microvasculature of the human medial meniscus adequately; the other patients had either an intact meniscus (23%), a meniscus repair (29%), or an already removed meniscus (10%). Forty medial menisci, from 40 male patients with an average age of 27 years, having an anterolateral and/or anteromedial chronic knee laxity and an associated meniscal pathology, were subdivided into two groups: (a) 20 tears restricted to the posterior horn, and (b) 20 bucket-handle tears observed under light microscopy. Meaningful capillary plexuses penetrating into the meniscal stroma were found in 18 of 40 menisci (45%). They were easier to identify in posterior horn tears (55%) than in bucket-handle tears (35%), and were found especially in younger patients (22 years on the average). Therefore, we encourage meniscus repairs even in chronic tears, particularly in younger patients and in posterior-horn tears.
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1 |
A randomized comparison of volar plate and external fixation for intra-articular distal radius fractures
|
Distal Radius Fractures
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PURPOSE: To compare surgical outcomes of volar locking plates (VP) and external fixation (EF) (with or without intra-focal fixation) for AO-type C2 and C3 fractures of the distal radius.
METHODS: From an initial group of 92 patients with AO-type C2 and C3 distal radius fractures who were enrolled in a prospective, randomized study comparing volar plate fixation with external fixation (with or without intra-focal fixation), 74 patients were studied. The researchers evaluated functional assessments (wrist range of motion, grip strength, and Michigan Hand Questionnaire) at each patient visit and measured radiographic assessment (radial inclination, volar tilt, ulnar variance, and articular congruity) at 12 months.
RESULTS: The grip strength of the VP group was significantly greater than that of the EF group at 3 and 6 months. The range of motion was significantly greater in the VP group than in the EF group at 3 months. There were no significant differences in the range of motion and grip strength between the 2 groups at 12 months. The Michigan Hand Questionnaire score was higher in the VP group than in the EF group at 3 months but was same at 12 months. There was no significant difference between groups with respect to volar tilt or radial inclination. The VP group showed superior radiologic outcomes in terms of the ulnar variance. One patient in the VP group and 3 in the EF group had an intra-articular stepoff deformity greater than 2 mm. This difference did not reach statistical significance.
CONCLUSIONS: These results for functional recovery after distal radius surgery offer insight into treatment decisions and interpretations of treatment outcomes for patients with comminuted intra-articular distal radius fractures.
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0 |
Maternal diet-induced obesity during suckling period programs offspring obese phenotype and hypothalamic leptin/insulin resistance
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Reduction Mammoplasty for Female Breast Hypertrophy
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During the early post-natal period, offspring are vulnerable to environmental insults, such as nutritional and hormonal changes, which increase risk to develop metabolic diseases later in life. Our aim was to understand whether maternal obesity during lactation programs offspring to metabolic syndrome and obese phenotype, in addition we aimed to assess the peripheral glucose metabolism and hypothalamic leptin/insulin signaling pathways. At delivery, female Wistar rats were randomly divided in two groups: Control group (CO), mothers fed a standard rodent chow (Nuvilab); and Diet-induced obesity group (DIO), mothers who had free access to a diet performed with 33% ground standard rodent chow, 33% sweetened condensed milk (Nestle), 7% sucrose and 27% water. Maternal treatment was performed throughout suckling period. All offspring received standard rodent chow from weaning until 91-day-old. DIO dams presented increased total body fat and insulin resistance. Consequently, the breast milk from obese dams had altered composition. At 91-day-old, DIO offspring had overweight, hyperphagia and higher adiposity. Furthermore, DIO animals had hyperinsulinemia and insulin resistance, they also showed pancreatic islet hypertrophy and increased pancreatic beta-cell proliferation. Finally, DIO offspring showed low ObRb, JAK2, STAT-3, IRbeta, PI3K and Akt levels, suggesting leptin and insulin hypothalamic resistance, associated with increased of hypothalamic NPY level and decreased of POMC. Maternal obesity during lactation malprograms rat offspring to develop obesity that is associated with impairment of melanocortin system. Indeed, rat offspring displayed glucose dyshomeostasis and both peripheral and central insulin resistance.
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Successful use of spinal anesthesia in a patient with severe Klippel-Trenaunay syndrome associated with upper airway abnormalities and chronic Kasabach-Merritt coagulopathy
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Surgical Management of Osteoarthritis of the Knee CPG
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Klippel-Trenaunay syndrome is a rare disorder characterized by the triad of capillary or cavernous hemangiomas, venous varicosities or malformations, and soft tissue or bone hypertrophy. Neuraxial anesthesia in patients with Klippel-Trenaunay syndrome has been infrequently described and has not been previously reported when accompanied by consumptive coagulopathy with thrombocytopenia (Kasabach-Merritt syndrome). The authors describe their clinical management of a 23 year-old woman with Klippel-Trenaunay syndrome who presented for elective total knee arthroplasty. Her past medical history was notable for chronic Kasabach-Merritt syndrome, hypersplenism with pancytopenia, and intermittent lower gastrointestinal bleeding resulting from colonic hemangiomas. The physical examination revealed several large cavernous hemangiomas located on her right face, neck, chest, arm, and leg. No hemangiomas were noted within the dermatomal levels innervated by the upper lumbar spine. The neck hemangioma was very large and filled with blood when the patient assumed a supine position, making it almost impossible for her to breathe. The oropharynx revealed markedly hypertrophied soft tissue, pharyngeal, and hypopharyngeal hemangiomas, and a Mallampati class IV airway. Spinal and epidural hemangiomas were excluded based on a magnetic resonance imaging study before surgery. Kasabach-Merritt coagulopathy was corrected preoperatively by administration of cryoprecipitate. These interventions allowed the authors to safely perform a spinal anesthetic for the operation. The current case illustrates that major conduction anesthesia may be safely performed in patients with Klippel-Trenaunay disease provided that preoperative imaging studies exclude neurovascular involvement and coexisting coagulopathy is appropriately corrected
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Infection in diabetic patients with ankle fractures
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DoD LSA (Limb Salvage vs Amputation)
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Between January 1992 to June 1993, 93 ankle fractures underwent surgical treatment, of which, 10 patients were diabetic and 83 were non-diabetic. Infection occurred in 5 patients and all belonged to the diabetic group. The average follow-up period of the infected cases was 16.2 months. Wound infection occurred in 4 patients treated with open reduction and internal fixation. An infected pressure sore developed in the other patient treated initially in a below-knee cast for which arthrodesis of the ankle was performed. Infection was resistant to treatment in 2 patients and they ended up with below-knee amputation. Infection resolved in 3 patients with treatment. Of these, 1 developed neuropathic ankle joint and the other 2 achieved fracture union.
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1 |
Well Leg Compartment Syndrome After Abdominal Surgery
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DOD - Acute Comp Syndrome CPG
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BACKGROUND: Well leg compartment syndrome (WLCS) is a complication to abdominal surgery. We aimed to identify risk factors for and outcome of WLCS in Denmark and literature.
METHODS: Prospectively collected claims to the Danish Patient Compensation Association (DPCA) concerning WLCS after abdominal operations 1996-2013 and cases in literature 1970-2013 were evaluated. Cases of fasciotomy within 2 weeks after abdominal surgery 1999-2008 were extracted from the Danish National Patient Register (DNPR).
RESULTS: There were 40 cases in DPCA and 124 in literature. In 68 % legs were supported under the knees during surgery. Symptoms of WLCS presented within 2 h after surgery in 56 % and in only 3 cases after 24 h. Obesity was not confirmed as risk factor for WLCS. The mean diagnostic delay was 10 h. One-third of fasciotomies were insufficient. The diagnostic delay increased with duration of the abdominal surgery (p = 0.04). Duration of the abdominal surgery was 4 times as important as the diagnostic delay for severity of the final outcome. DNPR recorded 4 new cases/year, and half were reported to DPCA.
CONCLUSION: The first 24 h following abdominal surgery of >4 h' duration with elevated legs observation for WLCS should be standard. Pain in the calf is indicative of WLCS, and elevated serum CK can support the diagnosis. Mannitol infusion and acute four-compartment fasciotomy of the lower leg is the treatment. The risk of severe outcome of WLCS increases with duration of the primary operation. A broad support and change of legs' position during surgery are suggested preventative initiatives.
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A Cost-efficiency Analysis of Primary Assessors for Patients With Knee Pain in Primary Care
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OAK 3 - Non-arthroplasty tx of OAK
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Problem statements: What is the difference in cost efficiency between a healthcare process with a physical therapist as primary assessor and a physician as primary assessor for patients with suspected KOA? Which effect does a clinical pathway with a physical therapist as primary assessor for patients with suspected knee osteoarthritis have on quality adjusted life years compared with a physician as primary assessor? What are the differences in costs between the two healthcare processes initiated by either a physiotherapist or a physician set against the differences in effects? Patient recruitment: Some data has already been collected for another clinical trial (ID: NCT03715764), which will be used in this study too. The patient recruitment is finished, while data collection regarding cost variables has not started yet. Patients were recruited from primary care centers and rehabilitation centers in southwestern Sweden. Screening procedure: Nurses and administration personnel at the recruitment units got information about the study and the screening protocol from the data collector and project leader. Each recruiting unit had a contact person that were responsible for the protocols and to contact the data collector when an eligible patient was found. It was regular contact between the project leader and the contact persons at the recruiting units. All screening protocols were sent to the data collector. All participants got orally and written information about the study from the data collector, and patients provided written informed consent. Randomization: A computerâ?generated list of random numbers was used, where participants were randomly assigned to being assessed, diagnosed and treated either by a physiotherapist or a physician first. The project coordinator managed the sequence generation, allocation concealment, enrolment and assignments of participants and kept the concealed randomization scheme and sequentially numbered, sealed envelopes in a locked cupboard (in the same building where the enrolment will be), only available for the project coordinator. The project coordinator revealed the allocation to the participant shortly after the baseline measurement and to the health care providers. Data collector, data analyst and statistician were blinded of allocation until completion of data collection for the primary outcome measures at the 12 months follow up for the last recruited patient. Group allocation was revealed when analysing data for the other clinical trial (ID: NCT03715764). The project coordinator was not involved in the screening procedure nor the data collection, and was included among the healthcare providers in the study. The blinded data collector and analyst, whom is a physical therapist, were not involved in assessing, diagnosing and treating patients with knee osteoarthritis while the first study (ID: NCT03715764) was conducted. Data collection: Demographic data and measurements of HrQoL has already been collected for another clinical trial (ID: NCT03715764). These data will also be used for the costâ?efficiency analysis. Demographic data were collected at baseline. Measurements of HrQoL were measured with EuroQol 5 dimensions 3 levels (EQ5Dâ?3L) and collected at baseline (before randomization), 3â? , 6â? and 12 months follow ups. New data collection will be made for cost variables. Data regarding costs for the healthcare processes will be extracted from patient journals. The costs for visits to physical therapist, physician or other healthcare provider will be collected from the healthcare organization. The drug prices will be collected from the Swedish Association of Local Authorities and Regions for the time period the drugs were prescribed. Production loss due to sickâ?leave and health care visits will be valued according to mean gross salary (including taxes and social fees). Calculating total costs (number of contacts per patient * costs ) for: â? Physiotherapy contacts in primary care â? Physician contacts in primary care â? Referral to xâ?ray â? Referrals to other health are givers â? Drug prescription â? Sickâ?leave days Data management: All data will be coded and managed according to the General Data Protection Regulation. All data will be confidential and only authorized will have access to the patient registry. No individual information can be identified since the results will be presented at group level. Data will be saved for at least 10 years to enable audit. Sample size: A sample size of 50 patients per group will be necessary to detect a minimal clinical improvement of 0.121(SD 0.2) on the EQ5Dâ?3Lâ?index, given an anticipated dropout rate of 14%. The sample size calculation was calculated with a twoâ?sided 5% significance level and a power of 80%. Statistical analysis plan: Data will be analyzed descriptively and presented as numbers and percent, mean and standard deviation or median and 25th to 75th percentiles. Statistical analysis will be made in SPSS Windows and the analysis will be applied with intentionâ?toâ?treat (ITT). The economic evaluation will be developed together with a health economist. The method will be a costâ?effectiveness analysis alongside the clinical trial comparing costs and effects for the two alternatives based on collected data from the trial. The EQ5Dâ?3L measurements will be used for analyzing quality adjusted life years. The result will be presented as an incremental costâ?effectiveness ratio (ICER) and a nonâ?parametric bootstrapping will be conducted to demonstrate the uncertainties surrounding the ICER.
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Intravenous dexamethasone fails to prolong psoas compartment block when assessed by objective pinprick sensory testing: a prospective, randomised, dose-dependent, placebo-controlled equivalency trial
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AAHKS (8) Anesthetic Infiltration
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BACKGROUND: Recent studies have concluded that i.v. dexamethasone can prolong the duration of peripheral nerve blockade. We hypothesized that a 4 mg dose would equally prolong the duration of psoas compartment blocks (PCBs) when compared with 8 mg, and that both doses would prolong the duration when compared with placebo.
METHODS: This was a prospective, randomized, placebo-controlled, dose-dependent, equivalency trial with 115 patients undergoing total hip arthroplasty. The patients received a PCB. Subsequently, 15 patients received i.v. normal saline (placebo), 50 patients received i.v. dexamethasone 4 mg, and 50 patients received i.v. dexamethasone 8 mg. The primary outcome was the duration in hours of PCB, determined by serial pinprick assessments. Secondary outcomes included pain scores, time to first analgesic, and opioid consumption. An intention-to-treat-analysis (ITA) and per-protocol analysis (PPA) were performed.
RESULTS: The ITA showed that block duration in the 4 and 8 mg groups was equivalent [mean (standard deviation), 18.5 h (8.0) vs 18.1 h (7.1)]. However, neither group differed from placebo [19.6 h (6.7), (4 mg vs placebo), P=0.97; (8 mg vs placebo), P=0.77)]. Postoperative pain scores and opioid consumption were not different between groups. Time to first analgesic was not different between the 4 and 8 mg groups, or the 4 mg and placebo groups. The 8 mg group, however, had a longer time to first analgesic (median of 533 vs 432 min, P=0.047) when compared with placebo, although the significance was not observed in the PPA (P=0.058).
CONCLUSIONS: I.V. dexamethasone did not prolong PCB when duration was objectively assessed, or decrease total opioid consumption. However, dexamethasone 8 mg prolonged the time to first analgesic.
Clinical trial registration: Nct 02464176.
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Ultrasound diagnosis for preventing knee injuries in cuban high-performance athletes
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AMP (Acute Meniscal Pathology)
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Introduction Diagnostic evaluation of the musculoskeletal system has traditionally been based on medical history, physical examination, and x-rays (techniques that provide limited information), and more recently on computerized axial tomography and magnetic resonance imaging (both very expensive). Ultrasound, a non-invasive and less expensive method, has become an indispensable tool for diagnosing overuse sports injuries. The Imaging Department at the Cuban Sports Medicine Institute (abbreviated in Spanish as IMD) developed a preventive ultrasound diagnostic imaging method and has applied it for the last 15 years as part of the IMD's medical management of high-performance athletes.
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Dupuytren's disease, carpal tunnel syndrome, trigger finger, and diabetes mellitus
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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A comparative prospective study of 120 adult diabetics (60 insulin dependent, 60 non-insulin dependent) and 120 non-diabetic adults as controls showed significantly higher incidence of Dupuytren's disease, limited joint motion, carpal tunnel syndrome, and flexor tenosynovitis in the diabetic population. Of the diabetic patients one third had a mild non-progressive form of Dupuytren's disease, which commonly involved the long and ring rays. Limited joint motion was noted in a third of diabetics, and carpal tunnel syndrome was observed in 15-25%, and flexor tenosynovitis in about a fifth. Limited joint motion co-existed with Dupuytren's disease in 57% of insulin-dependent diabetics. Diabetic polyneuropathy was found in two thirds of insulin-dependent diabetics and in one third of non-insulin dependent diabetics. All these hand changes were more marked in insulin-dependent diabetics and they showed a positive correlation with increasing age of the patient, duration of the diabetes, and the presence of a microangiopathy
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Compress periprosthetic fractures: interface stability and ease of revision
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DoD LSA (Limb Salvage vs Amputation)
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UNLABELLED: Periprosthetic fractures after massive endoprosthetic reconstructions pose a reconstructive challenge and jeopardize limb preservation. Compressive osseointegration technology offers the promise of relative ease of prosthetic revision, since fixation is achieved by means of a short intramedullary device. We retrospectively reviewed the charts of 221 patients who had Compress((R)) devices implanted in two centers between December, 1996 and December, 2008. The mean followup was 50 months (range, 1-123 months). Six patients (2.7%) sustained periprosthetic fractures and eight (3.6%) had nonperiprosthetic ipsilateral limb fractures occurring from 4 to 79 months postoperatively. All periprosthetic fractures occurred in patients with distal femoral implants (6/154, 3.9%). Surgery was performed in all six patients with periprosthetic femur fractures and for one with a nonperiprosthetic patellar fracture. The osseointegrated interface was radiographically stable in all 14 cases. All six patients with periprosthetic fracture underwent limb salvage procedures. Five patients had prosthetic revision; one patient who had internal fixation of the fracture ultimately underwent amputation for persistent infection. Periprosthetic fractures involving Compress((R)) fixation occur infrequently and most can be treated successfully with further surgery. When implant revision is needed, the bone preserved by virtue of using a shorter intramedullary Compress((R)) device as compared to conventional stems, allows for less complex surgery, making limb preservation more likely. LEVEL OF EVIDENCE: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
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0 |
Protease resistance and binding of Ig light chains in myeloma-associated tubulopathies
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MSTS 2018 - Femur Mets and MM
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Kidney tubule dysfunction and lesions are frequent complications of myeloma, related to unknown properties of the monoclonal light chain. We have analyzed protease sensitivity and binding properties of urinary light chains from four patients with Fanconi's syndrome, 12 with cast nephropathy, and four control patients without myeloma-associated tubulopathy. All light chains were normal-sized, monomeric and/or dimeric, and none was N-glycosylated. Kinetic studies of light chain digestion by pepsin and the lysosomal enzyme cathepsin B showed the generation of a protease-resistant 12 kDa fragment, corresponding to the V domain of the kappa chain in the four Fanconi's syndrome patients; in two out of four the V domain was also completely resistant to trypsin. Western and dot blots revealed similar patterns of reactivity of light chains from patients with the Fanconi's syndrome towards other light chains. Properties of cast-nephropathy light chains were more heterogeneous but clearly differed from those of Fanconi's syndrome: (i) 9 out of 12 were of the lambda-type; (ii) only four yielded a transient 12 kDa fragment after cathepsin B digestion, but all showed some resistance to proteolysis of the entire molecule or a fragment thereof to at least one protease, at variance with control light chains; (iii) they displayed various patterns of reactivity with other light chains; (iv) 7 out of 12 reacted specifically with Tamm-Horsfall protein (THP) by ELISA, in contrast with those of Fanconi's syndrome. In one patient who presented with cast nephropathy and the Fanconi's syndrome, the light chain exhibited both partial resistance of the V kappa domain to cathepsin B and the highest reactivity with THP.(ABSTRACT TRUNCATED AT 250 WORDS)
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Strategies for the study of long-term sequelae of oral and facial injuries
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DoD PRF (Psychosocial RF)
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Measurement of morbidity after orofacial trauma is necessary to monitor progress and to enable decisions to be made concerning surgical intervention, compensation awards, and psychological support. Although some measurements are routinely made in the assessment of recovery after trauma, many are still in a developmental phase or have only been used in research work. There is a need for a rational, comprehensive, quantitative means of assessing morbidity after orofacial trauma. Such assessments need to include measures of social and psychological distress, as well as physical abnormalities. This article reviews available methods of measuring morbidity and identifies areas in which new methods and developments are necessary. This quantitative approach to the assessment of trauma patients is consistent with developments in traumatology and psychology, which include injury severity scoring and the use of psychomatic tests. A scoring system for assessing orofacial deformity and disability and the attendant psychosocial distress appears to be an attainable objective. [References: 67]
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The efficacy, tolerability, and safety of 1200 mg/d of oxaprozin and 1500 mg/d of nabumetone in the treatment of patients with osteoarthritis of the knee
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OAK 3 - Non-arthroplasty tx of OAK
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This 6â?week, multicenter, doubleâ?masked, placeboâ?controlled study compared the efficacy, tolerability, and safety of the recommended starting dose of oxaprozin (1200 mg/d) and a 1500â?mg/d dose of nabumetone in the treatment of patients with moderateâ?toâ?severe osteoarthritis (OA) of the knee. A total of 347 patients with a mean age of 61.1 years were randomized to receive oxaprozin (116 patients), nabumetone (115 patients), or placebo (116 patients). Adults of either sex who were older than 18 years of age were eligible for entry into the study, if they had had OA of the knee for at least 6 months. Efficacy variables included knee pain on weight bearing, knee pain on motion, patients' and physicians' global assessments of OA, pain intensity as measured on a visual analog scale, and time to walk 50 feet as quickly as possible. Efficacy variables were assessed at baseline and at weeks 1, 2, 4, and 6. Betweenâ?group differences in efficacy variables were evident by week 1. Mean improvements were significantly greater with oxaprozin than with placebo for all efficacy variables at all time periods, except knee pain on motion at weeks 2 and 4 and time to walk 50 feet at weeks 1, 2, and 4. Mean improvements were significantly greater with nabumetone than with placebo for all efficacy variables at all time periods, except the following: knee pain on weight bearing at weeks 2, 4 and 6; knee pain on motion at weeks 2 and 4; patients' global assessment at week 4; and pain intensity as measured on a visual analog scale at weeks 2 and 4. There were, however, no significant differences between oxaprozin and nabumetone in any of these efficacy variables. Adverse events were reported by 83 (71.6%) patients who took oxaprozin, by 80 (69.6%) patients who took nabumetone, and by 57 (49.1%) patients who took placebo. Adverse events were reported for significantly more patients taking oxaprozin or nabumetone than placebo. However, adverse events tended to be mild or moderate and rarely resulted in patients withdrawing from the study. Combined with the results of an earlier study, the results of this study showed that a 1500â?mg/d dose of nabumetone, which is higher than the recommended starting dose of 1000 mg/d, is required for efficacy equivalent to that of the recommended starting dose of oxaprozin, 1200 mg/d, in relieving the symptoms of OA. Thus nabumetone may require dosage titration from the recommended starting dose. Oxaprozin and nabumetone were found to have similar tolerability profiles, as shown by adverseâ?event monitoring and withdrawal rates, as well as clinically similar safety profiles, as demonstrated by physical examinations, hematologic and biochemical laboratory testing, hemoccult testing, and adverseâ?event monitoring and symptom assessment.
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Excimer laser-assisted femoral angioplasty: early results
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DoD LSA (Limb Salvage vs Amputation)
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The ability to ablate atheroma without generating heat makes the excimer laser wavelength a promising intraluminal technique for the treatment of arterial occlusive disease. This series reviews a preliminary experience treating patients with superficial femoral arterial disease admitted with limb-threatening ischemia or claudication. Twenty-six diseased superficial femoral arteries (5 stenotic and 21 occluded) were treated in 23 consecutive patients. Patients with claudication (18) reluctant to undergo bypass or with limb-threatening ischemia (8) at extremely high risk for surgery were included. There were 10 men and 13 women with a mean age of 67 years. A 308 nm excimer laser with an over-the-wire catheter (19) or balloon-centered end-on catheter (7) was used followed by balloon angioplasty. Twenty-four procedures were performed percutaneously, and two were performed with the vessel open in the operating room. Technical success, defined as disobliteration confirmed by angiography and greater than 0.15 increase of the ankle/brachial index, was achieved in 15 of 26. Eleven of 21 occlusions (52%) and four of five stenoses (80%) were opened. Only two of 11 lesions longer than 10 cm were successfully treated. Unsuccessful attempts (technical failure) occurred in 11 of 26 patients and resulted in four elective and one emergency femoral-popliteal bypass. Five patients were discharged with their claudication unchanged, and one had an elective amputation. Six arterial perforations with three arteriovenous fistulas occurred, all resolved without operation. No unanticipated limb loss occurred. In the 15 successful cases, the mean ankle/brachial index increase was 0.34. Seven (47%) of these 15 remain patent with a mean follow-up of 9.5 months (1.5 to 14 months).(ABSTRACT TRUNCATED AT 250 WORDS)
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Stem cell transplantation for the treatment of osteochondral defects of the knee: operative technique for a single-stage transplantation procedure using bone marrow-derived mesenchymal stem cells
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Osteochondritis Dissecans 2020 Review
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Background: Autologous chondrocyte implantation (ACI) is a NICE-approved technique to regenerate hyaline cartilage in chondral and osteochondral defects (OCDs). The drawbacks of ACI include that it requires a two-stage approach, involves a lengthy rehabilitation process and is expensive. Bone marrow harvest with mesenchymal stem cell transplantation using a single-stage procedure and an accelerated rehabilitation programme has been developed to overcome this. The aim of this paper is to describe the surgical technique for stem cell transplantation of the knee for OCDs with reference to case examples. Methods: The surgical technique for stem cell transplantation of the knee for OCDs is described, with reference to three cases. Magnetic resonance imaging was performed at six months postoperatively. Results: The surgical technique is described in this paper. The three patient cases described all improved clinically with reduced pain and improved function at a minimum of six months follow-up. Conclusions: Stem cell transplantation has the potential to produce favourable outcomes for patients with osteochondral defects of the knee. This single-stage approach and accelerated rehabilitation is associated with reduced financial costs. A long-term prospective study of this technique is currently underway at our institution and randomised controlled trials are planned to demonstrate the effectiveness over other techniques.
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The scent of COVID-19: viral (semi-)volatiles as fast diagnostic biomarkers?
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Coronavirus Disease 2019 (COVID-19)
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The COVID-19 pandemic pressurizes the healthcare system. Protective measures against SARS-CoV-2 infection, like social distancing or isolation, are being taken too late and COVID-19 symptoms are non-specific and can resemble those from rhinoviral infection or influenza, causing a rush of anxious patients with (mild) symptoms to the hospitals. Furthermore, COVID-19 diagnosis is made by taking swabs from the upper of lower respiratory tract, which is not only an unpleasant experience for the patient, but is also time-consuming. Therefore, a fast differential diagnosis between SARS-COV-2, influenza or rhinovirus infection would allow to optimize the hospital management and hospitalize those patients with proven COVID-19 disease, where other patients can easily recover at home. Breath analysis could therefore be explored investigating both volatile organic compounds (VOC) and exhaled breath condensate (EBC) and aerosols (EBA) in a non-invasive manner, without discomforting the patient. However, breath research is highly affected since human-mediated transmission of viral particles through breath is of high concern. Nevertheless, breathomics can provide fast results and the sampling materials can be cleaned and autoclaved thoroughly, minimizing the risk for cross-contamination. Breath analysis also allows the breath sample to be taken by the patient himself, hence, considering the social distancing measures and protecting health care workers. In this article, we summarize 3 pathways in which SARS-CoV-2 could generate specific VOCs. In that way, breath analysis could allow a fast differential diagnosis as first line screening, optimizing COVID-19 management.
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Quantitative ultrasound measurements and vitamin D status in the assessment of hip fracture risk in a nationally representative population sample
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Management of Hip Fractures in the Elderly
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Adjusted for age, gender, height and weight, calcaneal quantitative ultrasound (QUS) and serum 25-hydroxyvitamin D (S-25(OH)D) proved to be significant predictors of hip fracture among subjects aged >/=50 years. Even if their contribution to the predictive power was modest, they may be useful in the assessment of hip fracture risk in the elderly. INTRODUCTION: This study assessed calcaneal QUS measurements, S-25(OH)D and several other factors for the prediction of hip fracture risk in a nationally representative population sample. METHODS: The study population consisted of 3,305 subjects (1,872 women), aged 50 years or over, who had participated in a comprehensive health survey. QUS measurements were made by means of the Hologic Sahara device. S-25(OH)D was measured by radioimmunoassay. Emerging cases of hip fracture were identified from the National Hospital Discharge Register. RESULTS: During a mean follow-up of 8.4 years, 95 subjects sustained a hip fracture. After adjusting for age, gender, height, weight and each other, a 1 standard deviation increment in the quantitative ultrasound index (QUI) (21.7) and in S-25(OH)D (17.5 nmol/L) reduced the risk of hip fracture by 40 % (hazard ratio [HR] = 0.60, 95 % confidence interval [CI] = 0.42-0.86) and by 31 % (HR = 0.69, 95 % CI = 0.55-0.87), respectively. The predictive power of a model including age, gender, height and weight was improved by about 8 % after the addition of QUI and S-25(OH)D. Among subjects aged 75 years or over, the corresponding improvement was about 130 %. CONCLUSIONS: QUI and S-25(OH)D were significant and independent predictors of hip fracture. However, their ability to increase the predictive power of a statistical model including readily available simple variables such as age, gender, height and weight was rather modest. Still, our findings suggest that QUI and S-25(OH)D may be of clinical use in the assessment of hip fracture risk particularly in the elderly
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The independent, unfavorable prognostic factors endothelin A receptor and chemokine receptor 4 have a close relationship in promoting the motility of nasopharyngeal carcinoma cells via the activation of AKT and MAPK pathways
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MSTS 2018 - Femur Mets and MM
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BACKGROUND: Recent studies have indicated that the expression of endothelin A receptor (ETAR) and chemokine receptor 4 (CXCR4) could be used as an indicator of the metastatic potential of nasopharyngeal carcinoma (NPC). The aim of this study was to determine the prognostic value of ETAR and CXCR4 in NPC patients and to reveal the interplay of the endothelin-1 (ET-1)/ETAR and stromal-derived factor-1(SDF-1)/CXCR4 pathways in promoting NPC cell motility.
METHODS: Survival analysis was used to analyze the prognostic value of ETAR and CXCR4 expression in 153 cases of NPC. Chemotaxis assays were used to evaluate alterations in the migration ability of non-metastatic 6-10B and metastatic 5-8F NPC cells. Real-time PCR, immunoblotting, and flow cytometric analyses were used to evaluate changes in the expression levels of CXCR4 mRNA and protein induced by ET-1.
RESULTS: The expression levels of ETAR and CXCR4 were closely related to each other and both correlated with a poor prognosis. A multivariate analysis showed that the expression levels of both ETAR and CXCR4 were independent prognostic factors for overall survival (OS), progression-free survival (PFS), and distant metastasis-free survival (DMFS). The migration of 6-10B and 5-8F cells was elevated by ET-1 in combination with SDF-1alpha. The knockdown of ETAR protein expression by siRNA reduced CXCR4 protein expression in addition to ETAR protein expression, leading to a decrease in the metastatic potential of the 5-8F cells. ET-1 induced CXCR4 mRNA and protein expression in the 6-10B NPC cells in a time- and concentration-dependent fashion and was inhibited by an ETAR antagonist and PI3K/AKT/mTOR and MAPK/ERK1/2 pathway inhibitors.
CONCLUSIONS: ETAR and CXCR4 expression levels are potential prognostic biomarkers in NPC patients. ETAR activation partially promoted NPC cell migration via a mechanism that enhanced functional CXCR4 expression.
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1 |
A comparison between medial meniscus repair, partial meniscectomy, and normal meniscus in anterior cruciate ligament reconstructed knees
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Anterior Cruciate Ligament Injuries CPG
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A clinical, radiographic, and scintigraphic comparative study was performed on 57 consecutive successful patellar tendon anterior cruciate ligament reconstructions for chronic laxity. Patients were divided into 3 matched groups according to the medial meniscal treatment. Group A included 18 patients with medial meniscal repairs; Group B, 19 patients with partial medial meniscectomies; and Group C, 20 patients with normal menisci (controls). The average followup was 55 months. At clinical examination, patients in Group B had more activity-related pain than those in Group C (p = 0.04). The anteroposterior weight-bearing views in extension showed more degenerative changes in the medial compartment in Group B than in the other 2 groups (Group A versus B, p = 0.01; Group C versus B, p < 0.001). Scintigraphy showed an increased uptake in the operated knee as compared with the normal side (11%), but no differences among the 3 study groups. The patients with partial meniscectomies had more pain and degenerative radiographically evident changes than the control group. Medial meniscal repair offers a better chance than partial meniscectomy to preserve the articular cartilage of the medial compartment. Bone homeostasis, as detected by bone scanning, remains slightly altered in successful reconstructions as compared with the opposite normal side
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1 |
The Effect of Hering's Law on Different Ptosis Repair Methods
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Upper Eyelid and Brow Surgery
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BACKGROUND: The Hering's law effect has significant importance in surgical planning and outcomes of eyelid surgery. OBJECTIVES: The current study examined the preoperative and intraoperative effect of Hering's law in Mullerectomy and levator aponeurosis advancement. METHODS: A retrospective analysis was conducted of 52 patients with unilateral ptosis who underwent surgical repair from January 2011 through June 2013. Patients underwent levator aponeurosis advancement or Mullerectomy with or without tarsectomy. Preoperative and postoperative clinical documentation and photographs were evaluated. Preoperative Hering's dependency and postoperative changes in positioning of the non-operated eyelid were measured. The decision to operate on the ptotic eye alone or on both eyelids was based on preoperative Hering's dependence and intraoperative changes in the contralateral eyelid. RESULTS: Fifty-two patients with unilateral ptosis were included. Average age was 63.3 +/- 20.1 years (range, 22-88 years; median, 61 years); 34 (65.4%) were female. The 14 cases that were not aponeurotic (either congenital, secondary to trauma, or due to postoperative ptosis) did not need contralateral repair (p = .000). In 4 (19%) cases of Mullerectomy and in 9 (52.9%) cases of levator advancement, both eyelids required surgery (p = .029). Hering's law effect was significantly more apparent in the levator advancement approach than in Mullerectomy. CONCLUSIONS: Levator surgery resulted in a higher incidence of combined intraoperative and postoperative Hering's law effect than did Mullerectomy. Cases with poor levator function or congenital ptosis can be repaired unilaterally with no need for contralateral surgery. The fibrotic levator palpebrae muscle and its special innervations probably explain this phenomenon. This should be considered in surgical planning.
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The role of imaging in osteoarthritis
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AMP (Acute Meniscal Pathology)
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Osteoarthritis (OA) is the most prevalent joint disorder with no approved disease-modifying treatment available. The importance of imaging in assessing all joint structures involved in the disease process, including articular cartilage, meniscus, subarticular bone marrow, and synovium for diagnosis, prognostication, and follow-up, has been well recognized. In daily clinical practice, conventional radiography is still the most commonly used imaging technique for the evaluation of a patient with known or suspected OA and radiographic outcome measures are still the only approved end point by regulatory authorities in clinical trials. The ability of magnetic resonance imaging (MRI) to visualize all joint structures in three-dimensional fashion including tissue ultrastructure has markedly deepened our understanding of the natural history of the disease. This article describes the roles and limitations of different imaging modalities for clinical practice and research in OA, with a focus on radiography and MRI and an emphasis on the knee joint.
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Isokinetic evaluation of the wrist flexors and extensors in women with postmenopausal osteoporosis
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Distal Radius Fractures
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BACKGROUND: Distal radius fractures are the third most common fracture observed in osteoporotic patients. In addition, wrist muscle weakness may be a risk factor for such fractures because of the protective role these muscles play during falls. OBJECTIVE: The main objective was to explore isokinetic wrist muscle strength in osteoporotic and matched non-osteoporotic postmenopausal women. MATERIALS AND METHODS: Twenty osteoporotic postmenopausal women (patient group) and 15 healthy non-osteoporotic postmenopausal women with a normal DXA score (control group) were recruited. Bone mineral density was measured using a DXA device. Vertebral (L1-L4), femoral neck, and femoral total measurements were recorded. Wrist muscle strength was evaluated isokinetically. RESULTS: Peak moment values of the wrist flexors at 60 and 180°/s were significantly lower in the patient group than in the control group. Extensor muscle strength did not differ significantly between the 2 groups. CONCLUSION: Wrist flexors strength is lower in osteoporotic postmenopausal women than their non-osteoporotic counterparts. As this variation might be a risk factor for distal radius fractures in osteoporotic postmenopausal women, strengthening this muscle group should be seriously explored.
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0 |
The effect of clindamycin gel insert in periodontal pockets, as observed on smears and cultures
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Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures
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This study is aimed at the evaluation of a 1% clindamycin hydrochloride containing gel on the microbial flora of periodontal pockets deeper than 5 mm. In order to achieve that purpose. 20 patients with pocketing in the premolar-molar regions were selected. Active and placebo gel were inserted once during the first 2 weeks of this experimental study. Microbial samplings were performed 1, 2, 4 and 12 weeks after the experiment started. The samples were submitted to microscopic examination and also to culture. Changes in the microbial content of the periodontal pockets treated by subgingival scaling and clindamycin 1% gel were significant, compared with those obtained with subgingival scaling and placebo gel, particularly with respect to anaerobic black-pigmented bacteria and the motile gram-negative flora. However, after 3 months, most of the treated cases were recolonized by the same initial species, though never at pre-clindamycin levels. In the light of this study, it will be concluded that the use of a small amount of clindamycin hydrochlolide inserted into a periodontal pocket, once a week for 2 weeks as a complement to periodontal subgingival scaling, is beneficial in the treatment of adult periodontitis, by eliminating more effectively the microbial pocket colonization
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0 |
Tibial plateau fractures treated with plate fixation: To lock or not to lock
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DoD SSI (Surgical Site Infections)
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Background: This retrospective study with follow-up was undertaken to compare postoperative results and functional outcomes of tibial plateau fractures treated with non-locking and locking plate fixation. Methods: Over a 5-year period, 60 tibial plateau fractures were treated with plate fixation. Fracture classifications, complications and tibial alignment were compared, and the Knee Society Knee Score and EuroQol questionnaire were used to evaluate functional outcomes. Results: The mean length of follow-up was 19 months. Although the locking plate cohort had a higher proportion of older patients and severe fractures, less bone grafts were used and less complications were observed. Eighteen percent of cases were malaligned on the coronal plane. Conclusion: The locking plate cohort had some operative advantages and showed less ongoing subsidence for malaligned cases. There was no significant difference in functional outcomes. However a larger study with age, fracture-classification and health status matched cohorts may identify improved functional outcomes in the locking plate cohort. © 2008 Springer-Verlag.
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Use of orbicularis oculi muscle flap for undercorrected blepharoptosis with previous frontalis suspension
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Upper Eyelid and Brow Surgery
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The frontalis muscle and its fascia are connected with the orbicularis oculi muscle at the level of the eyebrow. Therefore, the superiorly based orbicularis oculi muscle flap, when advanced and attached to the tarsal plate, can dynamically elevate the upper lid and correct blepharoptosis with previous frontalis sling. Six patients with undercorrected blepharoptosis after frontalis sling suspension were included in this study. The superiorly based orbicularis oculi muscle flap was advanced to the tarsal plate in these patients and the redundant portion of the distal flap was resected. Postoperative results were satisfactory after 1-year follow-up. (C) 2000 The British Association of Plastic Surgeons.
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1 |
Effects of geriatric interdisciplinary home rehabilitation on complications and readmissions after hip fracture: a randomized controlled trial
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Hip Fx in the Elderly 2019
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OBJECTIVE:: This pre-planned secondary analysis of geriatric interdisciplinary home rehabilitation, which was initially found to shorten the postoperative length of stay in hospital for older individuals following hip fracture, investigated whether such rehabilitation reduced the numbers of complications, readmissions, and total days spent in hospital after discharge during a 12-month follow-up period compared with conventional geriatric care and rehabilitation.
DESIGN:: Randomized controlled trial.
SETTING:: Geriatric department, participants' residential care facilities, and ordinary housing.
SUBJECTS:: Individuals aged 70 years with acute hip fracture ( n = 205) were included.
INTERVENTION:: Geriatric interdisciplinary home rehabilitation was individually designed and aimed at early discharge with the intention to prevent, detect, and treat complications after discharge.
MAIN MEASURES:: Complications, readmissions, and days spent in hospital were registered from patients' digital records and interviews conducted during hospitalization and at 3- and 12-month follow-up visits.
RESULTS:: No significant difference in outcomes was observed. Between discharge and the 12-month follow-up, among participants in the geriatric interdisciplinary home rehabilitation group ( n = 106) and control group ( n = 93), 57 (53.8%) and 44 (47.3%) had complications ( P = 0.443), 46 (43.4%) and 38 (40.9%) fell ( P = 0.828), and 38 (35.8%) and 27 (29.0%) were readmitted to hospital ( P = 0.383); the median total days spent in hospital were 11.5 and 11.0 ( P = 0.353), respectively.
CONCLUSION:: Geriatric interdisciplinary home rehabilitation for older individuals following hip fracture resulted in similar proportions of complications, readmissions, and total days spent in hospital after discharge compared with conventional geriatric care and rehabilitation.
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0 |
Use of flexible intramedullary rods for fixation of femoral fractures in eight dogs
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DoD LSA (Limb Salvage vs Amputation)
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High-density, polysulfone rods were used to repair 4 comminuted and 4 short-oblique, mid-diaphyseal femoral fractures in 8 dogs. Bony union was achieved in 2 dogs at 10 and 12 weeks after surgery. In one dog, the femoral fracture was healing when amputation of the limb became necessary because of sciatic nerve damage secondary to an ipsilateral pelvic fracture. In a fourth dog, fracture repair resulted in nonunion, despite normal clinical function at 18 months after surgery. In the remaining 4 dogs (50%), the rods failed at 3.5, 4, 6, and 22 weeks after surgery. These fractures were then stabilized by use of other methods. Although several factors may have contributed to failure of the rods, multiple autoclaving of the thermoplastic implants may have caused embrittlement and subsequent breakage.
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0 |
Anterior quadratus lumborum block analgesia for total hip arthroplasty: a randomized, controlled study
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AAHKS (8) Anesthetic Infiltration
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BACKGROUND AND OBJECTIVES: Quadratus lumborum (QL) block is a new regional analgesic technique for upper and lower abdominal surgeries as part of a multimodal analgesic regime. It has also been reported to relieve pain after total hip arthroplasty (THA). In this prospective, randomized, double-blind study, we compared QL block with control (no block) in patients undergoing primary THA.
METHODS: Eighty patients undergoing primary THA surgery under spinal anesthesia were randomized into two groups, one with and one without QL block. The patients in both groups were randomized after sedation, positioning and ultrasound scanning. Both the patient and the researcher collecting data were blinded to the patient's group assignment. Opioid consumption and visual analog scores (VAS) pain scores were measured at 12, 24, and 48 hours after surgery. Also, the ambulation distance, patient satisfaction, and length of stay were recorded.
RESULTS: The study analysis included 36 patients in the QL group and 35 patients in the control group. Both VAS pain score at 24 hours (difference -1.76, 95% CI -2.87 to -0.64) and cumulative opioid consumption were significantly lower in the QL group at 12, 12-24, 24, 24-48, and 48 hours after surgery as compared with the control group (difference at 48 hours -36.13, 95% CI -62.89 to -9.37) (p<0.05). However, there was no difference in pain score at 12 and 48 hours, nor in the ambulation distance and duration of hospital stay between the two groups. The patient satisfaction score was significantly higher in the QL group.
CONCLUSIONS: Our preliminary data show that the QL block provided effective analgesia and decreased opioid requirements up to 48 hours after primary THA.
Trial registration number: Nct03408483.
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0 |
Effect of Hypovitaminosis D on Postoperative Pain Outcomes and Short-Term Health-Related Quality of Life After Knee Arthroplasty: A Cohort Study
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OAK 3 - Non-arthroplasty tx of OAK
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Vitamin D may have an important role in pain perception. Inadequate vitamin D levels are associated with suboptimal recovery after surgery. However, the effects of hypovitaminosis D on postoperative pain-related outcomes and its impact on health-related quality of life after surgery are not well understood. The objective of this study was to determine the effects of hypovitaminosis D on postoperative pain-related outcomes and health-related quality of life at 3 months after knee arthroplasty.This was a longitudinal cohort study of 191 consecutive Hong Kong Chinese patients who were given patient-controlled morphine analgesia for up to 72 hours after 214 knee arthroplasties. Serum total 25-hydroxyvitamin D (25-OHD) concentration was assessed by liquid chromatography-tandem mass spectrometry. The primary outcomes were postoperative pain intensity at rest scores (0-72 h), Western Ontario and McMaster Universities (WOMAC) osteoarthritis index (pain, stiffness and function), and moderate-to-severe persistent pain (transformed WOMAC pain score of 0-75 at 3 months after knee arthroplasty; 0, extreme pain; 100, no pain). Group differences were analyzed using generalized estimating equation models and a logistic regression model.The prevalence of preoperative hypovitaminosis D (25-OHD <50 nmol/L) was 44% (95% confidence interval [CI]: 37%-51%). There were transient higher pain intensity scores in the moderate-to-severe hypovitaminosis D (25-OHD <30 nmol/L) group compared with the sufficient vitamin D group. Vitamin D status had no effect on total WOMAC index (P = 0.22). The incidence of moderate-to-severe persistent pain was 9% (95% CI: 6%-14%). Hypovitaminosis D increased the risk of moderate-to-severe persistent pain (adjusted odds ratio 2.64, 95% CI: 1.03-6.77).Preoperative hypovitaminosis D had subtle effects on pain intensity scores in the early postoperative period and is a risk factor for moderate-to-severe persistent pain after knee arthroplasty. Hypovitaminosis D was not associated with worse health-related quality of life at 3 months after knee arthroplasty.
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0 |
A Randomised Trial of Endovascular and Open Surgery for Ruptured Abdominal Aortic Aneurysm - Results of a Pilot Study and Lessons Learned for Future Studies
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DOD - Acute Comp Syndrome CPG
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Introduction: EVAR has the potential to improve outcome after ruptured abdominal aortic aneurysm (AAA). Published series have been based upon selected populations. Methods: An interim analysis of a single centre prospective randomised controlled trial comparing endovascular aneurysm repair (EVAR) with open aneurysm repair (OAR) in patients with ruptured AAA was performed. Patients who had a ruptured AAA and who were considered fit for open repair were randomised to EVAR or OAR after consent had been obtained. Those in the EVAR group had pre-operative spiral computed tomographic angiography (CTA). The primary endpoint was operative (30-day) mortality and secondary endpoints were moderate or severe operative complications, hospital stay and time between diagnosis and operation. A power study calculation required 100 patients to be recruited. Results: Between September 2002 and December 2004, 103 patients were admitted with suspected ruptured AAA. Only 32 patients were recruited to the study. Of these, four patients died before receiving surgical treatment. On an intention to treat basis the 30-day mortality rate was 53% in the EVAR group and 53% in the OAR group. Moderate or severe operative complications occurred in 77% in the EVAR group and in 80% in the OAR group. Median total hospital stay in the EVAR group was 10 days (inter-quartile range 6-28) and 12 days (4-52) in the OAR group. Median time between diagnosis and operation was 75 minutes (64-126) in the EVAR group and 100 minutes (48-138) in the OAR group. Conclusions: Despite the relative high operative mortality in the EVAR group, these preliminary results show that it is possible to recruit patients to a randomised trial of OAR and EVAR in patients with ruptured AAA. CT scanning does not delay treatment. © 2006 Elsevier Ltd. All rights reserved.
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Management of prosthetic joint infection treated with two-stage exchange: the impact of antimicrobial therapy duration
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PJI DX Updated Search
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Background: The optimal duration of parenteral antimicrobial therapy in patients with prosthetic joint infection treated with a two-stage exchange is unknown. Methods: This analysis compares the outcomes between patients treated with 4 weeks and those treated with 6 weeks of parenteral antimicrobial therapy after a two-stage exchange for prosthetic joint infection. The medical records of all patients with total knee arthroplasty or total hip arthroplasty infections treated with a two-stage exchange between 1995 and 1999 at our institution were reviewed. Cox regression models were used to compare treatment failure rates between patients who were treated for 4 weeks and those who were treated for 6 weeks with antimicrobial therapy after adjusting for the propensity to be treated for 6 weeks. Results: Two hundred and eight prosthetic joint infections occurred in 201 patients. Thirty-nine percent and 61% of prosthetic joint infections were treated with 4 weeks or 6 weeks of parenteral antimicrobials, respectively. The 5-year success rate was 84% and 73% in the 4-week and 6-week groups, respectively. After adjusting for the propensity to be treated for 6 weeks, there was no significant differences in the treatment failure rates between those treated with 6 weeks of parenteral antimicrobials and those treated with 4 weeks [hazard ratio (HR)=1.4, 95% confidence interval (CI), 0.7-2.7; P=0.31]. Conclusions: Six weeks of parenteral antimicrobials between stages did not decrease the treatment failure rate in patients with prosthetic joint infections compared with 4 weeks of treatment. é 2011 Wolters Kluwer Health | Lippincott Williams and Wilkins
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0 |
Mechanical calf compression and aspirin prophylaxis for total knee arthroplasty
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AAHKS (9/10) Regional Nerve Blocks
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UNLABELLED: We used aspirin and mechanical calf pneumatic compression for thromboembolism prophylaxis in 856 consecutive primary and revision total knee arthroplasties. Regional anesthesia was used in 97% of the procedures. Duplex ultrasonography was performed before discharge. We advised patients with calf thrombi to continue aspirin and have repeat duplex scans in 7 to 10 days. Patients with popliteal or femoral thrombi were given low-molecular-weight heparin and warfarin for 6 weeks. Using this protocol, the 90-day mortality rate was 0.14%. There was one fatal myocardial infarction. Three patients developed symptomatic nonfatal pulmonary embolisms, two occurring early and one late. Deep vein thrombosis occurred in 56 patients (9.3%). Only nine patients (1.5%) had symptomatic thrombosis, with four ipsilateral calf and five ipsilateral proximal thrombi. The data confirm the efficacy of a multimodal protocol with calf mechanical prophylaxis for almost all patients undergoing primary or revision total knee arthroplasty.
LEVEL OF EVIDENCE: Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.
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0 |
Independent predictors of all osteoporosis-related fractures in healthy postmenopausal women: the OFELY study
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Management of Hip Fractures in the Elderly
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Several epidemiological studies have identified clinical factors that predict the risk of hip fractures in elderly women independently of the level of bone mineral density (BMD), such as low body weight, history of fractures, and clinical risk factors for falls. Their relevance in predicting all fragility fractures in all postmenopausal women, including younger ones, is unknown. The objective of this study was to identify independent predictors of all osteoporosis-related fractures in healthy postmenopausal women. We prospectively followed for 5.3 +/- 1.1 years a cohort of 672 healthy postmenopausal women (mean age 59.1 +/- 9.8 years). Information on social and professional conditions, demographic data, current and past medical history, fracture history, medication use, alcohol consumption, caffeine consumption, daily calcium intake, cigarette smoking, family history of fracture, and past and recent physical activity was obtained. Anthropometric and total hip bone mineral density measurements were made. Incident falls and fractures were ascertained every year. We observed 81 osteoporotic fractures (annual incidence, 21 per 1000 women/year). The final model consisted of seven independent predictors of incident osteoporotic fractures: age > or = 65 years, odds ratio estimate (OR), 1.90 [95% confidence interval (CI) 1.04-3.46], past falls, OR, 1.76 (CI 1.00-3.09), total hip bone mineral density (BMD) < or = 0.736 g/cm(2), OR, 3.15 (CI 1.75-5.66), left grip strength < or = 0.60 bar, OR, 2.05 (CI 1.15-3.64), maternal history of fracture, OR, 1.77 (CI 1.01-3.09), low physical activity, OR, 2.08 (CI 1.17-3.69), and personal history of fragility fracture, OR, 3.33 (CI 1.75-5.66). In contrast, body weight, weight loss, height loss, smoking, neuromuscular coordination assessed by three tests, and hormone replacement therapy were not independent predictors of all fragility fractures after adjustment for all variables. We found that some--but not all--previously reported clinical risk factors for skeletal fragility predicted all fragility fractures independently of BMD in healthy postmenopausal women, although they differed somewhat from those predicting specifically hip fractures in elderly women. These risk factors appear to reflect quality of bone structure (previous fragility fracture), lifestyle habits (physical activity), muscle function and health status (grip strength), heredity (maternal history of fracture), falls, and aging. Measurements of these variables should be included in the clinical assessment of the risk of osteoporotic fractures in postmenopausal women
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0 |
Total hip replacement by the Brunswik prosthesis. A preliminary report of 189 operations
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Management of Hip Fractures in the Elderly
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The results of 189 Brunswik total hip replacements, performed at the Orthopaedic Hospital of the Invalid Foundation, Helsinki, Finland, and followed up for 2-3 years, are presented. According to the modified system of Merle D'Aubigne & Postel excellent results were achieved in 11.1 per cent (21/189), good in 56.6 per cent (107/189) and fair in 27.5 per cent (52/189). The failure rate was 4.8 per cent (9/189) and consisted of four deep infections, four cases of aseptic loosening and one case of allergic loosening. Local complications occurred after primary operations in 7.5 per cent (12/159) and after revision operations in 26.7 per cent (8/30) and the difference was statistically significant (P less than 0.01). Among the complications, deep infections were encountered in 2.6 per cent (5/189), aseptic loosenings in 2.1 per cent (4/189). Other local complications were: ectopic ossification in 1.6 per cent (3/189), nerve injuries in 1.6 per cent (3/189), dislocations in 1.1 per cent (2/189), and peroperative fractures in 1.1 per cent (2/189). General complications were observed in 8.9 per cent (17/189). Thromboembolic complications were only seen in 2.6 per cent (5/189). A possible explanation for this low figure was the early ambulation of the patients on the first postoperative day. No deaths related to the operation occurred
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0 |
Pulmonary circulatory changes after bilateral total knee arthroplasty during regional anesthesia
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Surgical Management of Osteoarthritis of the Knee CPG
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STUDY OBJECTIVE: To monitor the pulmonary hemodynamics of patients undergoing bilateral total knee arthroplasty (BTKA) intraoperatively and up to 24 hours following surgery. DESIGN: Prospective observational study. SETTING: University-affiliated teaching hospital. PATIENTS: 30 ASA physical status 2 and 3 patients scheduled for single-stage, cemented BTKA during epidural anesthesia. INTERVENTIONS: Pulmonary artery catheters were in all patients. MEASUREMENTS: Systemic vascular resistance (SVR), pulmonary vascular resistance (PVR), the ratio of PVR to SVR at baseline, at the beginning of surgery, and after each knee implantation were recorded and compared with measurements taken one day postoperatively (POD 1). MAIN RESULTS: On POD 1, PVR/SVR was increased by 30% compared with baseline (P < 0.0001) and by 20% versus the end of surgery (P < 0.0001). Systemic vascular resistance decreased during surgery and was significantly lower than baseline at 24 hours after surgery (P < 0.0001). No significant change in PVR was noted during surgery. CONCLUSION: The PVR/SVR ratio on the day following BTKA was increased. This change may represent the different effects of inflammatory perioperative stresses on the pulmonary and systemic vasculature
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0 |
The role of meniscal repair for prevention of early onset of osteoarthritis
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AMP (Acute Meniscal Pathology)
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BACKGROUND: The meniscus plays an important role in the integrity of the knee joint. Therefore, meniscus tissue preserving techniques for the therapy of meniscus injuries seem to be reasonable. One of the important questions is whether meniscal repair can prevent the knee joint from early onset of osteoarthritis.
METHODS: According to the review of the current literature, the principles of a successful meniscal repair are explained and the functional outcome and its impact on the prevention of osteoarthritis are analyzed in this article.
RESULTS: Current data show a positive impact of a successful meniscus repair on the functional outcome in long-term. By this a protective effect on the development of osteoarthritis via the repair of meniscus lesions to restore the meniscus integrity can be confirmed. However, higher rates of re-operations in context to meniscus suturing have to be considered.
CONCLUSION: Due to the improved functional outcomes as well as preventive effect on the development of osteoarthritis within the knee joint in long-term, it is of importance to preserve as much meniscus tissue as possible in meniscus therapy. Patients previously have to be informed about the higher revision rate in context to meniscus suturing.
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Elderly patients with intertrochanteric fractures after intramedullary fixation : Analysis of risk factors for calf muscular vein thrombosis
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Hip Fx in the Elderly 2019
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OBJECTIVE: Calf muscular vein thrombosis (CMVT) has been known for approximately 40 years and many research studies for CMVT have been conducted but many opinions about the incidence and risk factors are still controversial. The objective of this retrospective study was to investigate the incidence and analyze the risk factors for CMVT in elderly patients with isolated intertrochanteric fractures that were managed surgically.
MATERIAL AND METHODS: The medical documents of patients suffering from intertrochanteric fractures who were treated in the traumatic orthopaedics department of our hospital from January 2009 to August 2017 were reviewed. The patients were allocated to the CMVT group and non-CMVT group basing on color Doppler flow imaging examination, according to the inclusion and exclusion criteria. The clinical data such as age, gender, body mass index (BMI) and the Working Group on Osteosynthesis Questions/American Orthopaedic Trauma Association (AO/OTA) classification of fractures were collected. Logistic regression analysis was used to determine the independent risk factors for CMVT.
RESULTS: In total, 312 patients were included in this study of which 31 patients were diagnosed with CMVT and allocated to the CMVT group and 281 patients were excluded from suffering from CMVT and included in the non-CMVT group. The incidence of CMVT was 9.94% in our study. The multivariate logistic regression showed that a fracture classification of A3, diabetes, time between injury and operation greater than 48h are independent risk factors for CMVT in elderly patients with intertrochanteric fractures after intramedullary fixation.
CONCLUSION: Complicated fractures, diabetes and prolonged time from injury to surgery are risk factors for CMVT in elderly patients with intertrochanteric fractures treated with intramedullary fixation.
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0 |
The treatment of pilon fractures
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DoD LSA (Limb Salvage vs Amputation)
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Soft tissue complications, skin slough, and superficial infection lead to deeper infection and amputation. By avoiding these complications, it is expected that better results can be obtained. Two techniques are available to do this. The first is to limit incisions and use external fixation to obtain stability. Even in these cases, care must be taken with the soft tissues. The second is a staged reconstruction, whereby stage one allows soft tissue stabilization. To this end, the fibula is plated, and transarticular external fixation is performed; this maintains anatomic length, preventing soft tissue contraction and permitting edema resolution. The second stage, formal tibial open reduction and internal fixation, is performed with plates and screws when operative intervention is safe. These methods appear to be equally effective in reducing major soft tissue complications. Surgeons should treat these complex fractures with the method with which they are most comfortable. Surgeons who feel comfortable with techniques of internal fixation are best qualified to perform open reductions. Surgeons who have experience with percutaneous fixation and hybrid external fixator application should use this method. Surgeons with limited or minimal experience with pilon fractures should consider fibula fixation and transarticular external fixation followed by transfer to an orthopedic trauma surgeon for definitive management.
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0 |
Rupture of the extensor pollicis longus tendon after wrist trauma
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Distal Radius Fractures
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In the period of 1976 to 1997 our clinic treated 33 patients after Colles fracture with ruptured extensor pollicis longus tendon. The occurrence of functional loss was observed after the trauma in 3 to 9 weeks. In 30 cases the surgical treatment of extensor indicis proprius tendon, in 2 cases a direct suture of the ruptured tendon was performed as a primary repair and in one patient a palmaris longus interposition was utilised.
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0 |
Distal Radius Fracture Fixation With the Specialized Threaded Pin Device
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Distal Radius Fractures
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This study investigated the outcomes of extra-articular distal radius fractures and simple intra-articular radial styloid fractures stabilized with a novel threaded cannulated device. This was a retrospective study of 24 distal radius fractures treated with the T-Pin device (Union Surgical LLC, Philadelphia, Pennsylvania), with a minimum of 1 year of postoperative follow-up. Outcome data included wrist range of motion, grip strength, and pinch strength. Radiographs were analyzed to determine volar tilt and radial height. At final follow-up, patients completed the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire. At an average of 2 years after surgery (range, 1-4 years), flexion was 89%, extension was 96%, supination was 99%, and pronation was 100% of contralateral wrist motion. Grip strength was 93% (range, 40%-137%) and lateral pinch strength was 99% (range, 48%-130%) of the contralateral upper extremity. The average final DASH score was 4.4 (range, 0-35). One patient lost 6 mm of radial height from the initial postoperative radiograph to the final follow-up radiograph. One patient elected to have the quiescent threaded pins removed, and 1 patient had tenderness with wrist range of motion that resolved after pin removal. After hardware removal, neither patient had further symptoms. No postoperative soft tissue complications occurred, and this was an expected benefit of the minimally invasive approach and intramedullary placement of the device. The stability of fixation allows patients to begin active range of motion early in the postoperative course. The threaded pin offers reliable fracture fixation for the treatment of extra-articular and simple articular distal radius fractures.
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0 |
The outcome of infected total knee arthroplasty: culture-positive versus culture-negative
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PJI DX Updated Search
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PURPOSE: We studied the outcome in culture-positive and culture-negative infected total knee arthroplasty (TKA). METHODS: We retrospectively reviewed 140 patients with culture-positive and 102 patients with culture-negative infected TKAs. We determined the infection control rate and clinical outcome after repeated debridement, and repeated 2-stage TKA in the culture-positive and culture-negative groups. The mean follow-up was 9.3 years (range 5-14 years) in the culture-positive group and 10.6 years (5-22) in the culture-negative group. RESULTS: The overall infection control rate was 56 % in both groups after the first treatment. The overall infection control rate was 90 % in the culture-positive group and 95 % in the culture-negative group. A functional knee was obtained in 90 % in the culture-positive group and 95 % in the culture-negative group. CONCLUSIONS: The data suggest that treatment according to the types of infection in both culture-positive and culture-negative groups after TKA controlled infection and maintained functional TKA with a firm level of fixation for most patients. Repeated debridement and repeated two-stage exchange TKA further improved infection control rates after the initial treatment and increased the likelihood of maintaining a functional TKA
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0 |
Ptosis Repair in Ocular Myasthenia Gravis
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Upper Eyelid and Brow Surgery
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Ptosis repair was performed in patients with ocular myasthenia gravis by a posterior approach (Fasanella-Servat, 12 eyelids of nine patients) or levator advancement (eight eyelids of five patients) techniques. There were eight males and five females. Median age was 73 years and range 30-86 years. The median duration of myasthenia was 10 years and range 2 to 28 years. Pyridostigmine and prednisone were widely used prior to surgical referral, but ineffective or intolerable in all. The mean preoperative upper margin-reflex distance (MRD) was 0.55 mm (range -1 to 2 mm). The levator excursion range was 10 to 16 mm and mean 12.4 mm. Mean follow-up was 9.1 months. Postoperatively, the MRD ranged from 0.5 to 4 mm, with a mean of 2.3 mm. Two patients had lagophthalmos postoperatively (one posterior approach, one levator advancement) that did not require correction. Three of five patients who underwent levator advancement required repeat ptosis repair.
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1 |
F-18 FDG uptake of bone marrow on PET/CT scan: It's correlation with CD38/CD138 expressing myeloma cells in bone marrow of patients with multiple myeloma
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MSTS 2018 - Femur Mets and MM
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The percentage of myeloma cells in bone marrow is subsequently an important index of disease in patients with multiple myeloma (MM). Bone marrow myeloma cells can be detected by strong CD38/CD138 positivity and light scatter characteristics using flow cytometry. The aim of the study was to evaluate the relationship between the degree of F-18 fluorodeoxyglucose (F-18 FDG) uptake and the percentage of CD38/CD138 expressing myeloma cells in the bone marrow of patients with MM. A total of 31 patients with MM (14 females and 17 males, mean age 59.5±1.9 years, range 29-80 years) were included in the study. All patients underwent FDG-positron emission tomography/computed tomography (PET/CT) scan within 2 weeks after the completion of the usual staging workup for MM, consisting of X-ray skeletal survey and hematological/biochemical parameters including complete blood count, liver and kidney function test, erythrocyte sedimentation rate, serum immunoglobulins, urine light chain excretion, C-reactive protein, β2-microglobulin, and bone marrow plasma cell infiltration. In all patients, flow cytometry was performed for assessing the percentage of CD38/CD138 expressing myeloma cells in the bone marrow samples. The extent of bone marrow FDG uptake on PET/CT scans was visually graduated using a qualitative scoring system as extension score (E-score) and also a semiquantitative scoring system defined as mean standardized uptake value (mSUV) of both femora. There was a statistically significant positive correlation between the percentage of CD38/CD138 expressing plasma cells in bone marrow and both mean qualitative (r=0.616) and semiquantitative (r=0.755) results of F-18 FDG uptakes. mSUV and E-score of bone marrow FDG uptake values were also correlated with serum beta-2-microglobulin levels (r=0.523 and r=479, respectively). mSUV of bone marrow FDG uptake values were also negatively correlated with serum albumin levels (r=-0.424), whereas there was no correlation between E-score and albumin levels. In conclusion, our results indicate that increased F-18 FDG uptake of bone marrow is related to the percentage of plasma cell infiltration of bone marrow in patients with MM. Therefore, F-18 FDG-PET/CT study may be a useful tool for predicting the levels of myeloma cells in bone marrow, and an additional analysis of FDG uptake of bone marrow on FDG-PET/CT scans should be performed in patients undergoing PET studies during the initial staging, evaluating the therapy response, and monitoring patients with MM. © 2010 Springer-Verlag.
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Systemic administration of local anesthetic agents to relieve neuropathic pain
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SR for PM on OA of All Extremities
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Background: Lidocaine, mexiletine, tocainide, and flecainide are local anesthetics which give an analgesic effect when administered orally or parenterally. Early reports described the use of intravenous lidocaine or procaine to relieve cancer and postoperative pain. Interest reappeared decades later when patient series and clinical trials reported that parenteral lidocaine and its oral analogs tocainide, mexiletine, and flecainide relieved neuropathic pain in some patients. With the recent publication of clinical trials with high quality standards, we have reviewed the use of systemic lidocaine and its oral analogs in neuropathic pain to update our knowledge, to measure their benefit and harm, and to better define their role in therapy.Objectives: To evaluate pain relief and adverse effect rates between systemic local anesthetic-type drugs and other control interventions.Search methods: We searched MEDLINE (1966 through 15 May 2004), EMBASE (January 1980 to December 2002), Cancer Lit (through 15 December 2002), Cochrane Central Register of Controlled Trials (2nd Quarter, 2004), System for Information on Grey Literature in Europe (SIGLE), and LILACS, from January 1966 through March 2001. We also hand searched conference proceedings, textbooks, original articles and reviews.Selection criteria: We included trials with random allocation, that were double blinded, with a parallel or crossover design. The control intervention was a placebo or an analgesic drug for neuropathic pain from any cause.Data collection and analysis: We collected efficacy and safety data from all published and unpublished trials. We calculated combined effect sizes using continuous and binary data for pain relief and adverse effects as primary and secondary outcome measurements, respectively.Main results: Thirty-two controlled clinical trials met the selection criteria; two were duplicate articles. The treatment drugs were intravenous lidocaine (16 trials), mexiletine (12 trials), lidocaine plus mexiletine sequentially (one trial), and tocainide (one trial). Twenty-one trials were crossover studies, and nine were parallel. Lidocaine and mexiletine were superior to placebo [weighted mean difference (WMD) = -11; 95% CI: -15 to -7; P < 0.00001], and limited data showed no difference in efficacy (WMD = -0.6; 95% CI: -7 to 6), or adverse effects versus carbamazepine, amantadine, gabapentin or morphine. In these trials, systemic local anesthetics were safe, with no deaths or life-threatening toxicities. Sensitivity analysis identified data distribution in three trials as a probable source of heterogeneity. There was no publication bias.Authors' conclusions: Lidocaine and oral analogs were safe drugs in controlled clinical trials for neuropathic pain, were better than placebo, and were as effective as other analgesics. Future trials should enroll specific diseases and test novel lidocaine analogs with better toxicity profiles. More emphasis is necessary on outcomes measuring patient satisfaction to assess if statistically significant pain relief is clinically meaningful
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Abdominal compartment syndrome and acute pancreatitis
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DOD - Acute Comp Syndrome CPG
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Significant visceral edema associated with massive fluid resuscitation, paralytic ileus and formation of pancreatic ascites in patients with severe acute pancreatitis (SAP) can lead to abdominal compartment syndrome (ACS) that can contribute to the early development of multiple organ dysfunction syndrome (MODS), especially in the early stages of the disease. The prevalence of intra-abdominal hypertension (IAH) in SAP is about 40% and a manifest ACS occurs in about 10% of the patients warranting close monitoring of intra-abdominal pressure (IAP) in all patients with the severe form of the disease. Although nonsurgical management utilizing percutaneous drainage of ascites or continuous hemodiafiltration may decrease IAP, most patients require decompressive laparostomy and temporary abdominal closure. The primary aim in managing the ensuing open abdomen is delayed fascial closure during initial hospitalization. On many occasions a planned hernia approach, either with early skin grafting over the exposed bowel or managing the ASC primarily with a subcutaneous linea alba fasciotomy, is the only available option. The development of ACS in patients with SAP seems to be associated with increased mortality.
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Spine radiographs to improve the identification of women at high risk for fractures
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Management of Hip Fractures in the Elderly
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In women older than 60 years with clinical risk factors for osteoporosis but without osteoporosis based on bone mineral density (T-score(element of)(greater-than or equal to)(element of)- 2.5), a systematic survey with X-rays of the spine identified previously unknown vertebral deformities in 21% of women. Introduction: This study determines the prevalence of vertebral deformities in elderly women with clinical risk factors for osteoporosis but with BMD values above the threshold for osteoporosis (T-score(element of)(greater-than or equal to)(element of)-2.5). Methods: Bisphosphonate naive women older than 60 years attending 35 general practices in the Netherlands with (greater-than or equal to)2 clinical risk factors for osteoporosis were invited for BMD measurement (DXA). In women with T-score(element of)(greater-than or equal to)(element of)-2.5 at both spine and the hips, lateral radiographs of the thoracic and lumbar spine were performed. Results: Of 631 women with a DXA measurement, 187 (30%) had osteoporosis (T- score(element of)<(element of)-2.5 at the spine or the hip). Of the remaining 444 women with T-score(element of)(greater-than or equal to)(element of)-2.5 at both spine and hip, 387 had additional spine radiographs, of whom 80 (21%) had at least one vertebral deformity. Conclusion: In elderly women with clinical risk factors for osteoporosis but BMD T-score(element of)(greater-than or equal to)(element of)-2.5, addition of spine radiographs identified vertebral deformities in 21% (95% CI: 17-25). Since these women are at risk of future fractures, antiosteoporotic treatment should be considered. (copyright) 2008 International Osteoporosis Foundation and National Osteoporosis Foundation
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Forearm and distal radius fractures in children
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Distal Radius Fractures
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Pediatric forearm and distal radius fractures are common injuries. Resultant deformities are usually a product of indirect trauma involving angular loading combined with rotational displacement. Fractures are classified by location, completeness, angular and rotational deformity, and fragment displacement. Successful outcomes are based on restoration of adequate pronation and supination and, to a lesser degree, acceptable cosmesis. When several important concepts are kept in mind, these goals are usually met with conservative treatment by reduction and immobilization. Greenstick fractures are reduced by rotating the forearm such that the palm is directed toward the fracture apex. Complete fractures are manipulated and reduced with traction and rotation; extremities are then immobilized in well-molded plaster casts until healing, which usually takes about 6 weeks. Radiographs should be obtained between 1 and 2 weeks after initial reduction to detect early angulation. In fractures in any level in children less than 9 years of age, complete displacement, 15 degrees of angulation, and 45 degrees of malrotation are acceptable. In children 9 years of age or older, 30 degrees of malrotation is acceptable, with 10 degrees of angulation for proximal fractures and 15 degrees for more distal fractures. Complete bayonet apposition is acceptable, especially for distal radius fractures, as long as angulation does not exceed 20 degrees and 2 years of growth remains. Operative intervention is used when the fracture is open and when acceptable alignment cannot be achieved or maintained. Single-bone intramedullary fixation has proven useful.
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Biomechanical investigations on chondromalacia of the knee after meniscal flap lesion and partial meniscal resection: an experimental model
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AMP (Acute Meniscal Pathology)
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Meniscal tears and resections may cause chondral lesions of the knee. To eliminate muscular control during investigation of this problem, we designed a biomechanical setup based on a knee-joint simulator, ensuring physiological, free-motion mobility of the joint. Fresh human knee specimens with intact cartilage were exposed to loads to 2,000 N at a frequency of 0.85 Hz during 48 hours of gait. After a preliminary test series, 18 specimens were divided into three groups: group I was tested with unchanged meniscal status, group II with arthroscopically induced mobile flap tears at the posterior horns of the menisci, and group III after partial resection of the posterior horns. Motion patterns between the groups changed after as little as a few hours due to increased translation in group III. Macroscopic and histological examination and scanning electron microscopy revealed severe chondromalacic changes after meniscal resection. We conclude that meniscal resection-however partial-may have considerable joint-damaging potential if muscle control is lacking whereas mobile flap tears maintain stability. Our findings might explain the differences in clinical reports on cartilage status after partial meniscal resection. This study underlines the importance of muscle training when active stabilisation of the knee is reduced after partial meniscal resection.
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Liposomal Bupivacaine Does Not Reduce Inpatient Opioid Prescription or Related Complications after Knee Arthroplasty: A Database Analysis
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AAHKS (9/10) Regional Nerve Blocks
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WHAT WE ALREADY KNOW ABOUT THIS TOPIC: WHAT THIS MANUSCRIPT TELLS US THAT IS NEW: BACKGROUND:: Although some trials suggest benefits of liposomal bupivacaine, data on real-world use and effectiveness is lacking. This study analyzed the impact of liposomal bupivacaine use (regardless of administration route) on inpatient opioid prescription, resource utilization, and opioid-related complications among patients undergoing total knee arthroplasties with a peripheral nerve block. It was hypothesized that liposomal bupivacaine has limited clinical influence on the studied outcomes.
METHODS: The study included data on 88,830 total knee arthroplasties performed with a peripheral nerve block (Premier Healthcare Database 2013 to 2016). Multilevel multivariable regressions measured associations between use of liposomal bupivacaine and (1) inpatient opioid prescription (extracted from billing) and (2) length of stay, cost of hospitalization, as well as opioid-related complications. To reflect the difference between statistical and clinical significance, a relative change of -15% in outcomes was assumed to be clinically important.
RESULTS: Overall, liposomal bupivacaine was used in 21.2% (n = 18,817) of patients that underwent a total knee arthroplasty with a peripheral nerve block. Liposomal bupivacaine use was not associated with a clinically meaningful reduction in inpatient opioid prescription (group median, 253 mg of oral morphine equivalents, adjusted effect -9.3% CI -11.1%, -7.5%; P < 0.0001) and length of stay (group median, 3 days, adjusted effect -8.8% CI -10.1%, -7.5%; P < 0.0001) with no effect on cost of hospitalization. Most importantly, liposomal bupivacaine use was not associated with decreased odds for opioid-related complications.
CONCLUSIONS: Liposomal bupivacaine was not associated with a clinically relevant improvement in inpatient opioid prescription, resource utilization, or opioid-related complications in patients who received modern pain management including a peripheral nerve block.
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Factors affecting the incidence of surgical site infection after geriatric hip fracture surgery: a retrospective multicenter study
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DoD SSI (Surgical Site Infections)
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BACKGROUND: Geriatric hip fracture is a common type of osteoporotic fracture with high mortality and disability; surgical site infection (SSI) can be a devastating complication of this injury. By far, only a few studies identified easily remediable factors to reduce infection rates following hip fracture and less researches have focused on geriatric patients. The objective of this study was to identify potentially modifiable factors associated with SSI following geriatric hip fracture surgery.
METHODS: This retrospective, multicenter study involves three level I hospitals. A total of 1240 patients (60 years or older) underwent hip surgery with complete data were recruited between January 2016 and June 2018. Demographics information, medications and additional comorbidities, operation-related variables, and laboratory indexes were extracted and analyzed. Receiver operating characteristic (ROC) analysis was performed to detect the optimum cut-off value for quantitative data. Univariate and multivariate logistic analysis model were performed respectively to identify the independent predictors.
RESULTS: Ninety-four (7.58%) patients developed SSI in this study, and 76 (6.13%) had superficial infection, while 18 (1.45%) were diagnosed with deep infection. Results of univariate and multivariate analysis showed age > 79 years (OR, 2.60; p < 0.001), BMI > 26.6 kg/m<sup>2</sup> (OR, 2.97; p < 0.001), operating time > 107 min (OR, 2.18; p = 0.001), and ALB < 41.6 g/L (OR, 2.01; p = 0.005) were associated with an increased incidence of SSI; drainage use (OR, 0.57; p = 0.007) could reduce the incidence of wound infection for patients after geriatric hip fracture.
CONCLUSION: Accurate modifiable variables, operating time > 107 min, serum albumin < 41.6 g/L, BMI > 26.6 kg/m<sup>2</sup>, and age > 79 years could be applied to distinguish geriatric patients with high-risk of postoperative surgical site infection.
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Soft tissue reconstruction and salvage of infected fixation hardware in lower extremity trauma
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DoD LSA (Limb Salvage vs Amputation)
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BACKGROUND: Tibial fracture management may be complicated by infection of internal fixation hardware (iIFH) resulting in increased morbidity and amputation rate. When iIFH removal is not possible, salvage of the lower extremity is attempted through debridement, antibiotics, and vascularized soft tissue coverage. This study investigates lower extremity salvage with retention of iIFH. METHODS: Demographics, outcomes, and bacterial speciation in patients with tibial fractures at a level 1 trauma center from 2007 to 2014 were reviewed. The primary outcome was infection suppression, while secondary outcomes included limb salvage, amputation, and osseous union. RESULTS: Twenty-five patients underwent soft tissue reconstruction for salvage of iIFH. Average age was 41, 19 (76%) were male, average BMI 30.1 kg/m(2) , 10 (40%) patients smoked. Tibial fractures were closed in 8 (32%), Gustilo-Anderson grade I in 1 (4%), II in 8 (32%), IIIb in 5 (20%), and IIIc in 1 (4%). Staphylococcus was most commonly cultured with 11 (44%) demonstrating methicillin-resistance. Soft tissue reconstruction was performed by local flap in 15 (60%) and free flap in 10 (40%). At an average of 16.1 months, 19 (76%) hardware salvage patients demonstrated clinical suppression of infection, 11 of 19 (57.9%) patients had bony union, and 24 (96%) maintained a salvaged limb. One patient was amputated for recurrent infection. CONCLUSIONS: Following complex, infected tibial fractures, salvage of the lower extremity may be attempted even when iIFH cannot be removed. Thorough debridement, antibiotics, and vascularized soft tissue may suppress infection long enough to facilitate osseous union and subsequent removal of iIFH.
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Use of provincial health insurance plan billing data to estimate carpal tunnel syndrome morbidity and surgery rates
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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Following a work refusal at a plant manufacturing ice cream novelties in Ontario, we were asked to document cases of cumulative trauma disorders (CTDs) and carpal tunnel syndrome (CTS) in this workplace. There were 17 employees with possible hand and wrist problems identified from Workers Compensation Board (WCB) Forms, and from a list prepared at the time of the refusal. After obtaining consents, confirmations of the diagnoses of CTDs, CTS, and of surgical procedures for CTS were obtained from the physicians involved. The relative risk for these disorders among plant employees was estimated in two ways: 1) the rate of CTS operations between 1979 and 1990 was compared to that in the general population using Ontario Health Insurance Plan (OHIP) data on physicians' billings for these operations; and 2) the frequency of WCB first payment claims for tendinitis and CTS during 1987 to 1989 at the plant was compared to that among the entire labor force of Ontario. CTDs had been diagnosed in all 17 workers: 9 had had operations for CTS, but one had had this operation prior to working at the plant. Compared to the remaining 8 workers who had CTS operations, an estimated 0.08 CTS operations would be expected among the 150 employees on the plant's seniority lists between 1979 and 1990, if the estimated rates in the general population were present at the plant, giving a Standardized Morbidity Ratio of 10.0 (95% confidence interval [CI] 4.3-19.7; one-sided p = 2.1 x 10(-6)). There were 6 WCB claims for tendinitis and CTS among plant employees during 1987 through 1989. This frequency was about 68 times that in the entire Ontario labor force (95% CI 24.7-150). This investigation has shown that CTDs, and particularly CTS, documented by medical records, have occurred at least 10 times more frequently than expected at this plant. Use of health insurance billing data to estimate CTS operation rates represents a simple method for estimating the burden of illness at the individual plant level due to CTS (at least for that portion proceeding to surgery), using an objective outcome that can be confirmed from medical records
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Microbiology of odontogenic bacteremia: beyond endocarditis
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Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures
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SUMMARY: The human gingival niche is a unique microbial habitat. In this habitat, biofilm organisms exist in harmony, attached to either enamel or cemental surfaces of the tooth as well as to the crevicular epithelium, subjacent to a rich vascular plexus underneath. Due to this extraordinary anatomical juxtaposition, plaque biofilm bacteria have a ready portal of ingress into the systemic circulation in both health and disease. Yet the frequency, magnitude, and etiology of bacteremias due to oral origin and the consequent end organ infections are not clear and have not recently been evaluated. In this comprehensive review, we address the available literature on triggering events, incidence, and diversity of odontogenic bacteremias. The nature of the infective agents and end organ infections (other than endocarditis) is also described, with an emphasis on the challenge of establishing the link between odontogenic infections and related systemic, focal infections
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