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Does local recurrence impact survival in low-grade chondrosarcoma of the long bones?
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MSTS 2022 - Metastatic Disease of the Humerus
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We hypothesized local recurrence of Grade 1 chondrosarcoma in the long bones of the extremity negatively influences survival. To explore that notion, we retrospectively reviewed 164 patients treated surgically for Grade 1 chondrosarcoma of the long bones. Local recurrence occurred in 21 (13%) patients. Four patients had progression of tumor grade on recurrence, and six patients had more than one local recurrence. Seven of the 21 patients with local recurrences had metastasis. Six of the 21 patients with local recurrences died secondary to chondrosarcoma. Local recurrence, progression of grade at recurrence, and distant metastases all were associated with a decrease in overall survival. The difference in survival was not apparent until after 5 years and was more pronounced after 10 years. Recurrence may be regarded as a declaration of an aggressive phenotype and should be treated as such.
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0 |
Musculoskeletal Hydatid Cysts Resembling Tumors: A Report of Five Cases
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DoD SSI (Surgical Site Infections)
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Although challenges in treatment of musculoskeletal hydatid cysts (HC) lesions have been documented, data regarding the musculoskeletal HC lesions resembling tumor is scarce. This paper presented 5 patients (3 males, 2 females) with a mean age of 41.6 years with tumor-like lesions of HC. Three of them had left ilium and acetabulum involvement, one involved left femur, and one involved left thigh muscle compartments. Pain was the main symptom and was seen in all patients. Clinical examination, radiologic evaluation, and histologic analysis were performed for diagnosis. Patients were treated through different surgical options, including simple debridement, bone cement filling with or without internal fixation, hip arthrodesis, reconstruction using hemipelvic replantation with femoral prosthesis and distal femur endoprosthetic replacement. After surgery, the operation region was washed by 20% hypertonic saline, and debridement was performed carefully without contamination. All patients received albendazole treatment. Cases were followed up 1 to 9 years for the recurrence. Walking difficulty and pain were the main symptoms during the follow-up. One patient was symptom-free. A reoccurrence in the perioperative soft tissue was detected in only one patient and control visits with antihelmintic treatment were recommended. We would like to emphasize that HC should be kept in mind for the differential diagnosis of the cystic or tumoral lesions of the musculoskeletal system, particularly in the endemic regions. Prompt diagnosis is of paramount importance for preventing destruction and complications.
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1 |
Predictors of short-term mortality in critically ill patients with solid malignancies
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MSTS 2022 - Metastatic Disease of the Humerus
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UNLABELLED: Admission of cancer patients with serious medical complications to the ICU remains controversial primarily because of the high short-term mortality rates in these patients. However, the cancer patient population is heterogeneous regarding age, underlying conditions, and curability of their disease, suggesting that large variations may occur in the effectiveness of intensive care within this subgroup of critically ill patients.
OBJECTIVES: To identify factors predicting 30-day mortality in patients with solid tumors admitted to a medical ICU.
PATIENTS AND METHODS: We conducted a retrospective study in 120 consecutive cancer patients (excluding patients with hematological malignancies) admitted to the medical ICU of a 650-bed university hospital between January 1990 and July 1997. Medical history, physical and laboratory test findings at admission, and therapeutic interventions within the first 24 h in the ICU were recorded. The study endpoint was vital status 30 days after ICU admission. Stepwise logistic regression was used to identify independent prognostic factors.
RESULTS: The observed 30-day mortality rate was 58.7 % (n = 68), with most deaths (92 %) occurring in the ICU. Univariate predictors of 30-day mortality were either protective [prior surgery for the cancer (p = 0.01) and complete remission (p = 0.01)] or associated with higher mortality [Knaus scale C or D (p = 0.02), shock (p = 0.04), need for vasopressors (p = 0.0006) or for mechanical ventilation (p = 0.0001), SAPS II score greater than 36 (p = 0.0001), LOD score greater than 6 (p = 0.0001), and ODIN score > 2 (p = 0.0001)]. Three variables were independent predictors: previous surgery for the cancer (OR 0.20, 95 % CI 0.07-0.58), LOD score > 6 (OR 1.26, 95 % CI 1.09-1.44), and need for mechanical ventilation (OR 3.55, 95 % CI; 1.26-6.7). Variables previously thought to be indicative of a poor prognosis (i. e., advanced age, metastatic or progressive disease, neutropenia or bone marrow transplantation) were not predictive of outcome.
CONCLUSION: When transfer to an ICU is considered an option by patients and physicians, 30-day mortality is better estimated by an evaluation of acute organ dysfunction than by the characteristics of the underlying malignancy.
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The impact of patient-specific instrumentation on unicompartmental knee arthroplasty: a prospective randomised controlled study
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AMP (Acute Meniscal Pathology)
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PURPOSE: Patient-specific instrumentation (PSI) has been proposed as a means of improving surgical accuracy and ease of implantation during technically challenging procedures such as unicompartmental knee arthroplasty (UKA). The purpose of this prospective randomised controlled trial was to compare the accuracy of implantation and functional outcome of mobile-bearing medial UKAs implanted with and without PSI by experienced UKA surgeons.
METHODS: Mobile-bearing medial UKAs were implanted in 43 patients using either PSI guides or conventional instrumentation. Intra-operative measurements, meniscal bearing size implanted, and post-operative radiographic analyses were performed to assess component positioning. Functional outcome was determined using the Oxford Knee Score (OKS).
RESULTS: PSI guides could not be used in three cases due to concerns regarding accuracy and registration onto native anatomy, particularly on the tibial side. In general, similar component alignment and positioning was achieved using the two systems (n.s. for coronal/sagittal alignment and tibial coverage). The PSI group had greater tibial slope (p = 0.029). The control group had a higher number of optimum size meniscal bearing inserted (95 vs 52%; p = 0.001). There were no differences in OKS improvements (n.s).
CONCLUSION: Component positioning for the two groups was similar for the femur but less accurate on the tibial side using PSI, often with some unnecessarily deep resections of the tibial plateau. Although PSI was comparable to conventional instrumentation based on OKS improvements at 12 months, we continue to use conventional instrumentation for UKA at our institution until further improvements to the PSI guides can be demonstrated.
LEVEL OF EVIDENCE: Therapeutic, Level I.
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0 |
Avoidance of vertebral fractures in men with idiopathic osteoporosis by a three year therapy with calcium and low-dose intermittent monofluorophosphate
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Management of Hip Fractures in the Elderly
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There are currently no trial-based recommendations for the treatment of idiopathic osteoporosis in men. A prospective, controlled, randomized 3-year study was conducted to evaluate the effects of intermittent, low-dose fluoride combined with continuous calcium supplementation on bone mass and future fracture events in men with this disease. Sixty-four men with idiopathic osteoporosis (mean age 53 years; mean T-score at L2-4, -2.75) and no previous vertebral fractures were randomly assigned to two treatment groups. Group A received intermittent (3 months on, 1 month off) treatment with monofluorophosphate 114 mg/day (i.e. 15 mg fluoride ions) plus continuous calcium supplementation (950-1000 mg/day). Group B received continuous calcium (1000 mg/day) alone. Bone mineral density was measured at the lumbar spine, hip and radius at 6-months intervals; thoracic and lumbar spine radiographs were obtained every 12 months. In group A bone density increased at all sites (by between +1.2% and +8.8%), while group B showed moderate decreases (by between -1.4% and -5.2%). After 36 months, bone densities at all sites in group A were significantly higher than those of group B. Three patients (10%) in group A suffered a total of 4 vertebral fractures versus 12 patients (40%) with 17 fractures in group B (p = 0.008). Non-vertebral fractures occurred in 3 patients in group A versus 11 in group B, though this difference was not significant. Back pain was significantly reduced in group A and unchanged in group B (after 3 years p = 0.0003). All side-effects were mild and transient. Early treatment of idiopathic osteoporosis in the male using the fluoride-calcium regimen we tested can improve cancellous and cortical bone density, reduce the incidence of vertebral fractures and attenuate back pain
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0 |
Repair of the posterior root of the medial meniscus
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AMP (Acute Meniscal Pathology)
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Tears of the posterior root of the medial meniscus are becoming increasingly recognized. Early identification and treatment of these tears help halt the progression of cartilage degeneration and osteoarthritis of the knee. Repair of these tears is essential for recreating the hoop stress of the medial meniscus. In this note, we describe a successful arthroscopic technique to repair this lesion. A posteromedial portal is established by which two 2-0 PDS sutures are placed through the meniscus root and pulled down through a trans-tibial tunnel and fixed using an EndoButton distally along the anterolateral cortex of the tibia. This has been performed successfully in five patients with no complications.
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0 |
Infrapatellar fat pad-derived mesenchymal stromal cells from osteoarthritis patients: In vitro genetic stability and replicative senescence
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OAK 3 - Non-arthroplasty tx of OAK
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Different sources of mesenchymal stromal cells can be considered for regenerative medicine applications. Here we analyzed human adipose-derived stromal cells from infrapatellar fat pad (IFPSC) of osteoarthritis patients, representing a very interesting candidate for cartilage regeneration. No data are available concerning IFPSC stability after in vitro expansion. Indeed, replicative potential and multipotency progressively decrease during culture passages while DNA damage and cell senescence increase, thus possibly affecting clinical applications. To investigate whether in vitro expansion influences the genetic stability and replicative senescence of IFPSC, we performed long-term cultures and comparatively analyzed cells at different culture passages. Stromal vascular fraction was harvested from infrapatellar fat pad of 11 osteoarthritis patients undergoing knee replacement surgery. Cell recovery, growth kinetics, surface marker profile, and differentiation ability in inductive culture conditions were recorded. Genetic integrity maintenance was estimated by microsatellite instability analysis and mismatch repair gene expression, whereas telomere length and telomerase activity were assessed to evaluate replicative senescence. Anchorage-dependent growth was tested by soft agar culture. IFPSC displayed a phenotype similar to mesenchymal stromal cells from subcutaneous fat and showed differentiation ability. No microsatellite instability was documented even at advanced culture times in accordance to a sustained expression of mismatch repair genes, thus highlighting stability of short repeated sequences in the genome. No significant telomere attrition nor telomerase activity were documented during culture and cells did not lose anchorage-dependent growth ability. The presented data support the suitability and safety of in vitro expanded IFPSC from osteoarthritis patients for applications in regenerative medicine approaches. © 2016 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:1029-1037, 2017.
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0 |
Utilization of Orthobiologics by Sports Medicine Physicians: A Survey-based Study
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PRP (Platelet-Rich Plasma)
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INTRODUCTION: Investigations are rapidly increasing into products referred to as orthobiologics and their utility in the nonsurgical and surgical treatment of diverse orthopaedic pathology.
METHODS: Members (599) of the American Orthopaedic Society for Sports Medicine were sent a survey that assessed their usage, motivation for use, and perceived efficacy of the following orthobiologics: leukocyte-rich platelet-rich plasma, leukocyte-poor platelet-rich plasma (PRP-LP), bone marrow aspirate concentrate, amniotic membrane products, adipose-derived mesenchymal stromal cells, and umbilical cord-derived cells. Application of these orthobiologics for the following pathologies was assessed: osteoarthritis, muscle injuries, tendon injuries, ligament injuries, labral injuries, and focal articular cartilage tears.
RESULTS: The survey was completed by 165 respondents (27.5%), of which 66.1% reported using at least one orthobiologic in their practice. Orthobiologic users reported the following: 71.6% are increasing their use, and 23.9% advertise their use. PRP-LP is the most commonly used orthobiologic for 76.1%, with 30% of PRP-LP users reporting use due to competitor utilization. The pathology most commonly treated with orthobiologics is osteoarthritis, for 71.6% of users, who primarily use PRP-LP in the knee joint. Leukocyte-rich platelet-rich plasma is the most popular orthobiologic in muscle, ligament, tendon, and labral injuries, whereas bone marrow aspirate concentrate is most popular for focal articular cartilage injuries. Primary orthobiologic-eligible groups were adults and recreational noncompetitive athletes. More than half (>50%) of orthobiologic users perceived all but umbilical cord-derived cells to be efficacious.
CONCLUSION: Orthobiologics are used by a significant number of sports medicine physicians and are likely increasing in popularity. Among orthobiologics, platelet-rich plasmas are the most popular, and osteoarthritis is the pathology most likely to be treated. Orthobiologics are sometimes used for reasons other than clinical efficacy, especially competitor utilization, and physicians are disparate in their application of these products.
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Risk factors and complications of diabetes: Highlights from the Annual Professional Conference of Diabetes UK, held March 5-7, 2008, in Glasgow, U.K
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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Diabetes UK held its annual professional conference on March 5-7, 2008, in Glasgow, U.K. The meeting was devoted to developments in different areas of diabetes, including basic and clinical science, treatment options, risk factors, complications and healthcare delivery and improvement. Copyright 2008 Prous Science, S.A.U. or its licensors. All rights reserved
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0 |
Trends in the Use of Regional Anesthesia: Neuraxial and Peripheral Nerve Blocks
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AAHKS (8) Anesthetic Infiltration
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BACKGROUND: A growing body of evidence indicates that the use of regional anesthesia offers advantages over general anesthesia, not only in terms of reducing complications but also regarding resource utilization and patient satisfaction. Because of the paucity of data on the nationwide adoption of regional anesthesia techniques, we aimed to elucidate trends in the use of neuraxial anesthesia (NA) and peripheral nerve blocks (PNBs) in orthopedic surgeries.
METHODS: We extracted data from N = 959,257 (Premier Perspective database; 2006-2013) total hip and knee arthroplasties (THA, TKA) and assessed NA/PNB use by a 2-year period, stratified by demographics and hospital factors. Cochran-Armitage trend tests assessed significance of trends.
RESULTS: Comparing 2006-2007 with 2012-2013, NA utilization decreased slightly from 21.7% to 19.7% for THA patients; this was 24.7% to 21.3% for TKA patients (with the main drop between 2012 and 2013). Conversely, PNB utilization increased from 6.5% to 8.7% for THA patients and 10.3% to 20.4% for TKA patients (all P < 0.001). These general trends did not change when stratified by patient demographics, whereas stratification by hospital factors did show differences: the highest NA utilization was seen in rural, nonteaching, and small hospitals, whereas the highest PNB utilization was seen in large and teaching hospitals.
CONCLUSIONS: Our findings provide important insight into the dynamics of the adoption of regional anesthetic techniques. Whereas PNB utilization is significantly increasing, overall, NA and PNBs are performed in the minority of cases. With accumulating evidence in favor of regional anesthesia, promoting the use of NA and a further increase in PNB utilization could have far-reaching medical and economic implications.
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1 |
Fascia iliaca compartment block as a preoperative analgesic in elderly patients with hip fractures - effects on cognition
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Hip Fx in the Elderly 2019
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BACKGROUND: Impaired cognition is a major risk factor for perioperative delirium. It is essential to provide good pain control in patients with hip fractures and especially important in patients with severely impaired cognitive status, as they receive less pain medication, have poorer mobility, poorer quality of life and higher mortality than patients with intact cognition. The purpose of this study was to examine the association between preoperative pain management with nerve blocks and cognitive status in patients with hip fractures during the perioperative period.
METHODS: One hundred and twenty-seven patients with hip fractures participating in a double-blind, randomised, controlled trial were included in this study. At hospital admission, a low-dose fascia iliaca compartment block (FICB) was administered as a supplement to regular analgesia. Cognitive status was registered on arrival at hospital before FICB and on the first postoperative day using the Short Portable Mental Status Questionnaire.
RESULTS: Changes in cognitive status from arrival at hospital to the first postoperative day showed a positive, albeit not significant, trend in favour of the intervention group. The results also showed that patients with no or a moderate cognitive impairment received 50% more prehospital pain medication than patients with a severe cognitive impairment. FICB was well tolerated in patients with hip fractures.
CONCLUSION: Fascia iliaca compartment block given to patients with hip fractures did not affect cognitive status in this study. Patients with a cognitive impairment may receive inadequate pain relief after hip fracture and this discrimination needs to be addressed in further studies.
TRIAL REGISTRATION: EudraCT number 2008-004303-59 date of registration: 2008-10-24.
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0 |
Endoscopic techniques in aesthetic plastic surgery
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Panniculectomy & Abdominoplasty CPG
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There has been an explosive interest in endoscopic techniques by plastic surgeons over the past two years. Procedures such as facial rejuvenation, breast augmentation and abdominoplasty are being performed with endoscopic assistance. Endoscopic operations require a complex setup with components such as video camera, light sources, cables and hard instruments. The Hopkins Rod Lens system consists of optical fibers for illumination, an objective lens, an image retrieval system, a series of rods and lenses, and an eyepiece for image collection. Good illumination of the body cavity is essential for endoscopic procedures. Placement of the video camera on the eyepiece of the endoscope gives a clear, brightly illuminated large image on the monitor. The video monitor provides the surgical team with the endoscopic image. It is important to become familiar with the equipment before actually doing cases. Several options exist for staff education. In the operating room the endoscopic cart needs to be positioned to allow a clear unrestricted view of the video monitor by the surgeon and the operating team. Fogging of the endoscope may be prevented during induction by using FREDD (a fog reduction/elimination device) or a warm bath. The camera needs to be white balanced. During the procedure, the nurse monitors the level of dissection and assesses for clogging of the suction.
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0 |
Overuse injuries in classical ballet
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DOD - Acute Comp Syndrome CPG
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Successful management of classical ballet dancers with overuse injuries requires an understanding of the art form, precise knowledge of anatomy and awareness of certain conditions. Turnout is the single most fundamental physical attribute in classical ballet and 'forcing turnout' frequently contributes to overuse injuries Common presenting conditions arising from the foot and ankle include problems at the first metatarsophalangeal joint, second metatarsal stress fractures, flexor hallucis longus tendinitis and anterior and posterior ankle impingement syndromes. Persistent shin pain in dancers is often due to chronic compartment syndrome, stress fracture of the posteromedial or anterior tibia. Knee pain can arise from patellofemoral syndrome, patellar tendon insertional pathologies, or a comination of both. Hip and back problems are also prevalent in dancers. To speed injury recovery of dancers, it is important for the sports medicine team to cooperate fully. This permits the dancer to benefit from accurate diagnosis, technique correction where necessary, the full range of manual therapies to joint and soft tissue, appropriate strengthening programmes and maintenance of dance fitness during any time out of class with Pilates-based exercises and multri tion advice. Most overuse ballet conditions respond well to a combination of conservative therapies. Those dancers that do require surgical management still depend heavily on ballet-specific rehabilitation for a complete recovery.
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0 |
Total elbow arthroplasty for distal humerus fractures
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The Treatment of Pediatric Supracondylar Humerus Fractures AUC
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Total elbow arthroplasty has become increasingly popular for the treatment of distal humerus fractures in elderly patients with poor bone quality, comminution, and/or pre-existent elbow abnormalities. The procedure is performed without violating the extensor mechanism; the fractured fragments are exposed and resected on both sides of the triceps, and the components can be implanted through the same exposure. Early outcomes are satisfactory in most elbows and compare favorably with internal fixation in this same group of elderly patients. Advances in elbow arthroplasty for fractures will likely combine refinement of the indications and development of implants with lower rates of failure
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0 |
Peripheral tears of the triangular fibrocartilage complex cause distal radioulnar joint instability after distal radial fractures
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Distal Radius Fractures
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The aim of this prospective study was to determine whether peripheral tears of the triangular fibrocartilage complex (TFCC) in patients younger than the osteoporotic age (males,<60 years; females, <50 years) were related to chronic distal radioulnar joint (DRUJ) instability. Fifty-one patients (27 women) with displaced distal radial fractures were included in the study. The median age was 41 years (range, 20-57 years). Arthroscopy at the time of fracture showed complete or partial TFCC tears in 43 patients (24 had only peripheral tears, 10 had only central perforations, and 9 had combined tears). The 1-year (range, 11-27 months) follow-up period included an interview, physical examination, and radiographic evaluation. Ten of the 11 patients with complete peripheral TFCC tears had DRUJ instability at the follow-up examination compared with 7 of the 32 patients with only partial or no peripheral tears. Patients with instability of the DRUJ had a worse Gartland and Werley wrist score. Instability was not associated with any radiographic finding either at the time of fracture or at the follow-up examination. Initial fracture or nonunion of the styloid was even slightly more common in stable patients.
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0 |
Inside-out meniscus repair
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AMP (Acute Meniscal Pathology)
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Meniscus repair over resection, when feasible, should be strongly considered in an effort to preserve meniscus integrity and function, especially in younger patients. Currently, a number of techniques and implants may be used to achieve a successful result. Although all-inside meniscus repair devices have evolved significantly since their introduction and have become the repair technique of choice for many surgeons, the classic inside-out repair technique is still very useful to have in one's armamentarium. Though less popular because of the ease of current-generation fixators, the inside-out technique can still offer advantages for those surgeons who are proficient. With the versatility to address most tear patterns, the ability to deliver sutures with smaller needle diameters, and proven long-term results, it has been considered the gold standard in meniscus repair. We review the inside-out repair technique for both a medial and lateral meniscus tear with some helpful tips when performing the technique, and we present a video demonstration of the lateral meniscus repair technique.
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0 |
Can introduction of an uncemented, hydroxyapatite coated hemiarthroplasty for displaced femoral neck fractures be recommended?
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Management of Hip Fractures in the Elderly
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The role of uncemented fully hydroxyapatite coated hemiarthroplasties for the treatment of displaced femoral neck fractures remains unclear. We investigated if complications, reoperations and mortality differed from that of cemented hemiarthroplasties. The study groups consisted of 78 cemented and 97 uncemented, hydroxyapatite coated hemiarthroplasties with minimum 1 year follow-up. The dislocation rate was 3% in both groups (p=0.84). Proximal femoral fracturing occurred in 1% in the cemented group and in 4% in the uncemented group (p=0.26). Reoperations were performed following 4% of procedures in the cemented group and following 2% of procedures in the uncemented group (p=0.48). Mortality rates did not differ statistically significant between groups. Outcomes were comparable. Introduction of an uncemented hydroxyapatite coated hemiarthroplasty for treatment of displaced femoral neck fractures can be recommended
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0 |
Diagnosing amyloidosis: Sensitive tools and alert physicians
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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Plasma cell clones can give rise to disorders related to tumor burden, such as multiple myeloma and Waldenstrom macroglobulinemia, as well as to other more subtle and deceptive diseases, such as AL amyloidosis. In this disorder the clone is usually small in size and produces a monoclonal light chain that causes multiorgan damage (1). Here we report two cases of AL amyloidosis in which the diagnosis required advanced laboratory techniques. A 68 year old man was admitted to the local cardiology unit due to the onset of heart failure. During the previous year he had developed xerostomia and bilateral carpal tunnel syndrome. The electrocardiogram showed no signs of ischemia. Troponin I (cTnI) was constantly elevated (0.07 ng/mL). Echocardiography showed left ventricular hypertrophy. A minor salivary gland biopsy, performed to rule out Sjogren syndrome, showed amyloid deposits. No monoclonal components were detected by serum and urine immunofixation electrophoresis (IFE). A 99m Tc-DPD scintigraphy showed moderate tracer localization in the heart. These findings suggested transthyretin (TTR) amyloidosis (familial or senile) and the patient was referred to our center. By high-resolution IFE no monoclonal protein was detected in serum and a small band formed by k light chains was identified in urine. Circulating (kappa) free light chain were 169 mg/L ((kappa)/(lambda) ratio 21.9), a bone marrow aspirate showed a 6% plasma cell infiltrate, N-terminal pro-natriuretic peptide type-B (NT-proBNP) was 6931 ng/L, cTnI 0.06 ng/mL, there were no signs of renal and liver involvement. The abdominal fat aspirate showed amyloid deposits which reacted with anti-(kappa) light chain antibodies and did not react with anti-(lambda) and anti-TTR antibodies at immuno electron microscopy. No mutations were found in the TTR gene. A 53 year old woman had complained of dyspepsia and abdominal discomfort with weight loss (6 Kg) for 3 years before being admitted to the local hospital, where massive hepatomegaly was detected. A liver biopsy was performed that showed amyloid deposits. No monoclonal components were found by serum and urine IFE, and the bone marrow plasma cell infiltrate was 3% . The patient was referred to our center for further testing. By high-resolution IFE a faint (kappa) band was detected in the urine. Circulating (kappa) free light chain concentration was 612 mg/L ((kappa)/(lambda) ratio 77.3), albuminuria was 2.2 g/24h, alkaline phosphatase was 533 U/L (upper reference limit 150 U/L). There was no sign of heart involvement. The abdominal fat aspirate showed amyloid deposits which reacted with anti-(kappa) light chain antibodies and did not react with anti-(lambda) and anti-ApoAI antibodies at immuno electron microscopy. In both cases a diagnosis of AL amyloidosis was made and chemotherapy was initiated. In these patients, only the combination of advanced laboratory techniques could identify the amyloidogenic monoclonal light chain and demonstrate its etiologic role. The increasing availability of the FLC measurement will facilitate the diagnosis, but difficult cases should be promptly referred to specialized centers for amyloid typing
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1 |
Effect of single injection of platelet-rich plasma in comparison with corticosteroid on knee osteoarthritis: a double-blind randomized clinical trial
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PRP (Platelet-Rich Plasma)
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BACKGROUND: Evidence on the effect of platelet-rich plasma (PRP) in treating osteoarthritis (OA) is insufficient. Therefore, the present study compares the effects of a one-time injection of PRP and corticosteroid (CS).
METHODS: In the present randomized double blind clinical trial, the participants who suffered from knee osteoarthritis (Grades II/III), were randomly divided into two groups: intra articular injection of PRP and CS. Knee injury and osteoarthritis outcome score (KOOS), the 20-Meter-Walk Test (20MW), active and passive ranges of motions (ROM), flexion contracture, and pain intensity based on Visual Analog Scale (VAS) were assessed before, 2-months, and 6-months after interventions.
RESULTS: Forty-one participants (48 knees) were involved in the research (66.7% women; average age of 61.1+/-7.0 years old). Compared to the group treated with corticosteroid, pain relief (df: 6, 35; F=11.0; P=0.007), symptom free (df:6, 35; F=23.0; P<0.001), activities of daily living (ADL) (df:6, 35; F=10.7; P=0.005) and quality of life (df:6, 35; F=5.2; P=0.02) in the RPR group were significantly higher, but sporting ability was not different between the two groups (df: 6, 35; F=0.6; P=0.55). PRP was significantly more helpful for relieving patients' pain (VAS) compared to corticosteroids (df: 6, 35; F=32.0; P=0.001). It is also notable that using PRP was more helpful in improving the 20MW test than corticosteroid treatment (df: 6, 35; F=7.4; P=0.04) but none of the treatments had any impact on active flexion ROM, passive flexion ROM and flexion contracture (P>0.05).
CONCLUSIONS: Our study demonstrated that one shot of PRP injection, decreased joint pain more and longer-term, alleviated the symptoms, and enhanced the activity of daily living and quality of life in short-term duration in comparison with CS.
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0 |
Identification of N-Glycoproteins of Knee Cartilage from Adult Osteoarthritis and Kashin-Beck Disease Based on Quantitative Glycoproteomics, Compared with Normal Control Cartilage
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AMP (Acute Meniscal Pathology)
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Glycoproteins are involved in the development of many diseases, while the type and content of N-glycoproteins in the cartilage of osteoarthritis (OA) and Kashin–Beck disease (KBD) are still unclear. This research aims to identify N-glycoproteins in knee cartilage patients with OA and KBD compared with normal control (N) adults. The cartilage samples were collected from gender- and age-matched OA (n = 9), KBD (n = 9) patients, and N (n = 9) adults. Glycoproteomics and label-free liquid chromatography-tandem mass spectrometry (LC-MS/MS) obtained N-glycoproteins of KBD and OA. A total of 594 N-glycoproteins and 1146 N-glycosylation peptides were identified. The identified data were further compared and analyzed with Gene Ontology (GO), Kyoto Encyclopedia of Genes and Genomes (KEGG), and Protein–Protein Interactions (PPI). Pairwise comparison of the glycoproteins detected in the three groups showed that integrin beta-1 (ITGB1), collagen alpha-1 (II) chain (COL2A1), collagen alpha-1 (VII) chain (COL7A1), carbohydrate sulfotransferase 3 (CHST-3), carbohydrate sulfotransferase 4 (CHST-4), thrombospondin 2 (THBS2), bone morphogenetic protein 8A (BMP8A), tenascin-C (TNC), lysosome-associated membrane protein (LAMP2), and beta-glucuronidase (GUSB) were significantly differentially expressed. GO results suggested N-glycoproteins mainly belonged to protein metabolic process, single-multicellular and multicellular organism process, cell adhesion, biological adhesion, and multicellular organism development. KEGG and PPI results revealed that key N-glycoproteins were closely related to pathways for OA and KBD, such as phagosome, ECM-receptor interaction, lysosome, focal adhesion, protein digestion, and absorption. These results reflected glycoprotein expression for OA and KBD in the process of ECM degradation, material transport, cell–cell or cell–ECM interaction, and information transduction. These key significantly differentially expressed N-glycoproteins and pathways lead to the degeneration and degradation of the cartilage of OA and KBD mainly by disrupting the synthesis and catabolism of basic components of ECM and chondrocytes and interfering with the transfer of material or information. The key N-glycoproteins or pathways in this research are potential targets for pathological mechanisms and therapies of OA and KBD.
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0 |
The risks and external effects of diabetic foot ulcer on diabetic patients: A hospital-based survey in Wuhan area, China
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DoD SSI (Surgical Site Infections)
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Diabetic foot ulcer (DFU) is a common complication observed in diabetic patients and affects diabetic patients in multiple ways. Severe DFU even leads to amputation in many cases. Early detection and intervention of DFU in diabetic patients can significantly relieve the pain caused by the ulcer and also keep patients from losing limbs in severe cases. In this study, the risks of diabetic patients getting DFU were estimated through a hospital-based survey. This survey collected information from hospitalized diabetic patients in Wuhan City, Hubei Province, China, using a questionnaire. This investigation includes studies from two stages with 502 diabetic patients from 20 hospitals in Wuhan City. The results suggested that patients with a long history of diabetes are often associated with a high risk of DFU (?2 = 11.428, p = 0.0007), smoking (?2 = 8.386, p = 0.0007), diabetic complications (?2 = 13.484, p < 0.0001), and especially patients with diabetic foot complications (?2 = 57.6621, p < 0.0001). Foot lesions appeared to be important attributors to DFU since our data demonstrated close correlations between DFU and patients with calluses/corns (?2 = 4.584, p = 0.0323), tinea pedis (?2 = 4.030, p = 0.0447), and cracked skin (?2 = 8.712, p = 0.0032). Only a small number of patients seek for the assistance from specialists, such as trimming toenails (3.4%), removing corn or calluses (1.4%) or treating wounds (11.78%), when they are suffering from foot problems. The findings of this study can potentially be utilized to develop an early DFU diagnostic method in diabetic patients and can provide objective evidence for suggesting that patients who are suffering from foot problems should seek professional help.
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0 |
Revision Meniscal Allograft Transplantation in the Lateral Compartment: Disparate MRI and Clinical Outcomes During the Early Postoperative Period
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AMP (Acute Meniscal Pathology)
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BACKGROUND: Little is known about clinical outcomes after revision meniscal allograft transplantation (RMAT), and there are no studies on magnetic resonance imaging (MRI) evaluations during the early remodeling period.
HYPOTHESIS: The objective imaging results, as determined by MRI evaluation, would be inferior to those of published data on primary meniscal allograft transplantations (MATs), although short-term clinical improvement would be achieved after RMAT.
STUDY DESIGN: Case series; Level of evidence, 4.
METHODS: We retrospectively reviewed 9 consecutive patients (6 male and 3 female) who underwent RMAT from 2010 to 2014. The mean patient age was 33 years (range, 28-45 years). All patients had prior failed MATs in the lateral compartment. None of the patients had malalignment or ligament instability, and 7 patients had grade 3 or higher chondral degeneration. We assessed the RMAT with routine MRI evaluations during the remodeling period of the first postoperative year to determine graft healing and the mode of refailures, if any. We also investigated the problems specific for revision operations, as well as clinical outcomes.
RESULTS: Four of the 9 RMAT patients had significant intra-articular fibrosis with or without motion limitations at the time of RMAT. MRI evaluations demonstrated that the overall early refailure rate was 33.3% (3/9) during the first year; bucket-handle displacement with no meniscocapsular healing was the mode of all failures. Insufficient meniscal healing was also found in 2 other RMATs without premature failure. After a mean follow-up of 29.2 months (range, 21-45 months) in the 6 patients with preserved RMATs, Lysholm and International Knee Documentation Committee subjective scores showed significant improvements over preoperative scores (from 53.3 +/- 6.0 to 87.7 +/- 2.9 [P = .028] and from 53.4 +/- 9.0 to 69.9 +/- 4.8 [P = .043], respectively; Wilcoxon signed rank test).
CONCLUSION: The MRI findings showed that poor or insufficient meniscal healing to the host joint capsule was the major drawback of RMAT. Although more than half of our patients experienced clinical improvement after RMAT, the short-term graft survival was inferior to that of primary MATs in the literature. Our findings suggest that this challenging revision procedure requires great caution, especially with regard to the effects of poor host tissue quality on meniscal healing. Although RMAT can be an effective treatment, close observation with routine MRI evaluation is necessary during the early remodeling period to assess the status of the revised meniscal allograft.
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0 |
Phase-contrast enhanced synchrotron micro-tomography of human meniscus tissue
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AMP (Acute Meniscal Pathology)
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OBJECTIVE: To investigate the feasibility of synchrotron radiation-based phase contrast enhanced micro-computed tomography (SR-PhC-muCT) for imaging of human meniscus. Quantitative parameters related to fiber orientation and crimping were evaluated as potential markers of tissue degeneration.
DESIGN: Human meniscus specimens from 10 deceased donors were prepared using different preparation schemes: fresh frozen and thawed before imaging or fixed and paraffin-embedded. The samples were imaged using SR-PhC-muCT with an isotropic voxel size of 1.625 mum. Image quality was evaluated by visual inspection and spatial resolution. Fiber voxels were defined using a grey level threshold and a structure tensor analysis was applied to estimate collagen fiber orientation. The area at half maximum (FAHM) was calculated from angle histograms to quantify orientation distribution. Crimping period was calculated from the power spectrum of image profiles of crimped fibers. Parameters were compared to degenerative stage as evaluated by Pauli histopathological scoring.
RESULTS: Image quality was similar between frozen and embedded samples and spatial resolutions ranged from 5.1 to 5.8 mum. Fiber structure, including crimping, was clearly visible in the images. Fibers appeared to be less organized closer to the tip of the meniscus. Fiber density might decrease slightly with degeneration. FAHM and crimping period did not show any clear association with histopathological scoring.
CONCLUSION: SR-PhC-muCT is a feasible technique for high-resolution 3D imaging of fresh frozen meniscus tissue. Further work is needed to establish quantitative parameters that relate to tissue degeneration, but this imaging technique is promising for future studies of meniscus structure and biomechanical response.
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0 |
Median and ulnar nerve transections treated with microsurgical interfascicular cable grafting with autogenous sural nerve
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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Interfascicular nerve grafting was used in 37 median and 26 ulnar nerves, all completely transected. In a follow-up period of 2.5 5 years, useful motor recovery (M3 or higher) was ahieved in 84% of median nerve lesions; in ulnar lesions, useful motor recovery (M2+ or higher) was achieved in 73%. Sensory recovery with some retrun of two-point discrimination sense was found in 63% of low median and 50% of low ulnar nerve lesions. In the medain nerve group, results for patients younger 20 years of age were significantly better than in older patients. Neurophysiological investigations gave evidence for nerve regrowth through the grafts in all but one patient, although the loss of axons was probably considerable if the amplitudes of sensory potentials were used as a parameter. Grafts of 2.5 to 5 cm in length gave better results than longer grafts, and results for the distal median nerve lesions were superior to those for the distal ulnar nerve lesions. Use of interfascicular nerve grafting techniques for nerve gaps greater than 2.5 cm is recommended
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1 |
Polytrauma and High-energy Injury Mechanisms Are Associated with Worse Patient-reported Outcomes After Distal Radius Fractures
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Distal Radius Fractures
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BACKGROUND: Patient-reported outcomes (PROs) are increasingly relevant when evaluating the treatment of orthopaedic injuries. Little is known about how PROs may vary in the setting of polytrauma or secondary to high-energy injury mechanisms, even for common injuries such as distal radius fractures.
QUESTIONS/PURPOSES: (1) Are polytrauma and high-energy injury mechanisms associated with poorer long-term PROs (EuroQol Five Dimension Three Levels [EQ-5D-3L] and QuickDASH scores) after distal radius fractures? (2) What are the median EQ-5D-3L, EQ-VAS [EuroQol VAS], and QuickDASH scores for distal radius fractures in patients with polytrauma, high-energy monotrauma and low-energy monotrauma METHODS: This was a retrospective study with followup by questionnaire. Patients treated both surgically and conservatively for distal radius fractures at a single Level 1 trauma center between 2008 and 2015 were approached to complete questionnaires on health-related quality of life (HRQoL) (the EQ-5D-3L and the EQ-VAS) and wrist function (the QuickDASH). Patients were grouped according to those with polytrauma (Injury Severity Score [ISS] >= 16), high-energy trauma (ISS < 16), and low-energy trauma based on the ISS score and injury mechanism. Initially, 409 patients were identified, of whom 345 met the inclusion criteria for followup. Two hundred sixty-five patients responded (response rate, 77% for all patients; 75% for polytrauma patients; 76% for high-energy monotrauma; 78% for low-energy monotrauma (p = 0.799 for difference between the groups). There were no major differences in baseline characteristics between respondents and nonrespondents. The association between polytrauma and high-energy injury mechanisms and PROs was assessed using forward stepwise regression modeling after performing simple bivariate linear regression analyses to identify associations between individual factors and PROs. Median outcome scores were calculated and presented.
RESULTS: Polytrauma (intraarticular: beta -0.11; 95% confidence interval [CI], -0.21 to -0.02]; p = 0.015) was associated with lower HRQoL and poorer wrist function (extraarticular: beta 11.9; 95% CI, 0.4-23.4; p = 0.043; intraarticular: beta 8.2; 95% CI, 2.1-14.3; p = 0.009). High-energy was associated with worse QuickDASH scores as well (extraarticular: beta 9.5; 95% CI, 0.8-18.3; p = 0.033; intraarticular: beta 11.8; 95% CI, 5.7-17.8; p < 0.001). For polytrauma, high-energy trauma, and low-energy trauma, the respective median EQ-5D-3L outcome scores were 0.84 (range, -0.33 to 1.00), 0.85 (range, 0.17-1.00), and 1.00 (range, 0.174-1.00). The VAS scores were 79 (range, 30-100), 80 (range, 50-100), and 80 (range, 40-100), and the QuickDASH scores were 7 (range, 0- 82), 11 (range, 0-73), and 5 (range, 0-66), respectively.
CONCLUSIONS: High-energy injury mechanisms and worse HRQoL scores were independently associated with slightly inferior wrist function after wrist fractures. Along with relatively well-known demographic and injury characteristics (gender and articular involvement), factors related to injury context (polytrauma, high-energy trauma) may account for differences in patient-reported wrist function after distal radius fractures. This information may be used to counsel patients who suffer a wrist fracture from polytrauma or high-energy trauma and to put their outcomes in context. Future research should prospectively explore whether our findings can be used to help providers to set better expectations on expected recovery.
LEVEL OF EVIDENCE: Level III, therapeutic study.
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0 |
Comparison of mental health between individuals with spinal cord injury and able-bodied controls in Neiva, Colombia
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DoD PRF (Psychosocial RF)
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Although research has investigated the mental health of individuals with spinal cord injury (SCI), an overwhelming majority of this research has been conducted in the United States, Western Europe, and other developed countries. The purpose of this study was to compare the mental health of individuals with SCI with able-bodied controls in Neiva, Colombia, South America. Subjects included 40 Colombians with SCI and 42 age- and sex-matched controls (N = 82). The groups did not differ based on age, sex, years of education, or socioeconomic status. However, controls were twice as likely to be married. Four measures assessed mental health, including satisfaction with life (Satisfaction with Life Scale), depressive symptoms (Patient Health Questionnaire-9), self-esteem (Rosenberg Self-Esteem Scale), and anxiety (State-Trait Anxiety Inventory). In comparison with able-bodied controls, individuals with SCI reported significantly lower mental health on both depressive symptoms and satisfaction with life. These effect sizes were medium and large, respectively. The groups did not differ significantly on measures of self-esteem or anxiety. Mental health of individuals with SCI should be considered a central part of SCI rehabilitation interventions, particularly in Latin America.
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0 |
Gait analysis in patients with a preformed articulated knee spacer
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PJI DX Updated Search
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Two-stage revision is one of the most widely accepted procedures to eradicate infection and restore function in infected knee prosthesis; while the use of an articulated spacers is advocated by many as a means to preserve function between stages, no data are available regarding gait parameters after spacer implant. The aim of present study was to assess and compare the gait parameters of patients with articulated knee spacers with a normal reference population and with the sound limb. Computerised gait analysis, was performed 8 to 14 weeks after the infected knee prosthesis had been removed and a preformed, articulated, knee spacer had been implanted, in 10 consecutive patients. Kinematic data show a mean gait velocity reduction of 70% and a decrease of the range of motion of the operated knee of 59%, compared with controls. While ground reaction forces were only slightly reduced, frontal and sagittal moments and calculated powers around the affected knees were near zero or zero. Our findings point out the ability of a preformed articulated spacer to preserve, although reduced, the normal gait parameters and joint range of motion and the capacity of the human body to provide useful postural modifications, even in the absence of the proprioceptive input from a normal knee or from a traditional total knee replacement
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0 |
Ipsilateral supracondylar humerus fracture and Monteggia lesion: A case report
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Distal Radius Fractures
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Two to 13% of supracondylar humerus fractures in children are associated with an ipsilateral forearm fracture, most of which are distal radius fractures. We present an unusual case of a 2-year-old girl with an ipsilateral supracondylar humerus fracture and a Monteggia lesion. Our management consisted of percutaneous K-wire fixation of the supracondylar humerus fracture and percutaneous insertion of an intramedullary K-wire for stabilization of the ulna fracture. Our patient had an excellent result, and we would recommend this method of fixation for similar injuries. Ipsilateral injury to the elbow and forearm is a rare entity in the pediatric population. Some have reported small series of patients with this so-called floating elbow injury. The majority of children sustain a supracondylar humerus fracture and a distal radius fracture (3,10,13,14, 15,17). After careful review of the English literature, we can find only three reported cases of an ipsilateral supracondylar humerus fracture and a Monteggia lesion (1,8,16). We present one such case.
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0 |
The results of the titanium-coated RM acetabular component at 20 years: A long-term follow-up of an uncemented primary total hip replacement
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Management of Hip Fractures in the Elderly
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In a prospective study, 93 unselected consecutive uncemented hip arthroplasties were performed in 80 patients using the titanium-coated RM acetabular component and the CLS femoral component. The mean age of the patients at operation was 52 years (28 to 81). None were lost to follow-up. In the 23 patients who had died (26 hips) only one acetabular component had been revised. In the 57 living patients (67 hips), 13 such revisions had been performed. Of the 14 revisions, seven were for osteolysis, five for loosening and two for infection. Survival analysis of this implant showed a total probability of survival of 83% (95% confidence interval 73 to 90), with all revisions as the endpoint, and a probability of 94% (95% confidence interval 87 to 98) with revision for aseptic loosening as the endpoint, indicating reliable long-term fixation of the titanium-coated RM acetabular component. (copyright)2008 British Editorial Society of Bone and Joint Surgery
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0 |
Are postoperative complications more common with single-stage bilateral (SBTKR) than with unilateral knee arthroplasty: guidelines for patients scheduled for SBTKR
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Surgical Management of Osteoarthritis of the Knee CPG
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A significant number of patients with degenerative arthritis of the knee require bilateral knee arthroplasty. Single-stage bilateral total knee arthroplasty (SBTKR) has been associated with increased patient morbidity and mortality. At our institution, the following steps have been taken to minimize the risks to patients undergoing this procedure: regional anesthesia and analgesia, invasive monitoring, postoperative observation in an intensive care unit setting, and aggressive management of hemodynamic aberrations. We reviewed the medical records of 462 sequential total knee arthroplasty patients, consisting of 169 SBTKR and 293 unilateral total knee arthroplasty (UTKR) cases. A total of 122 patients from each group were matched for age, weight, and a history of ischemic heart disease and hypertension. Patients for SBTKR exhibited a significantly higher incidence of fat embolism syndrome and cardiac arrhythmias than UTKR patients. There were no deaths in either group and the incidence of other serious postoperative complications was low and similar between the two groups. Elderly patients (approximately 75 years old) had more postoperative complications. With aggressive clinical management SBTKR can be safely performed in selected patients. Guidelines for the selection of these patients are presented
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1 |
Sensory-motor index is useful parameter in electroneurographical diagnosis of carpal tunnel syndrome
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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It was performed electroneurographic (ENG) studies with surface electrodes and examined nervus medianus (NM) in 60 patients (38 females), average age of 50,28 years (X+/-SD=50,28+/-11), with clinical diagnosis of carpal tunnel syndrome (CTS) and at least one border or discrete abnormal value of conventional electrophysiological tests. It was also examined 57 healthy individuals (33 females) as control group, average age of 45,65 years (X+/-SD=45,65+/-9,68). The sensitivity and specificity of sensory-motor index (SMI), terminal latency index (TLI) and residual latency (RL) were calculated and compared. SMI is determinate by using following formula: distal distance (DD) (in cm)/distal motor latency (DML) (in ms) + sensory conduction velocity (SCV) (in m/s)/motor conduction velocity (MCV) (in m/s) of NM. SCV of NM was measured by antidromic technique in segment wrist-index finger and MCV of NM in forearm segment above wrist. SMI mean value of control group was 3,45 (X+/-SD=3,45+/-0,45) with lower limit of normal value 2,82 and in patients with CTS 2,13 (X+/-SD=2,13 +/-0,37). The sensitivity of SMI in patients with CTS was 98,51%. SMI is useful parameter in electroneurographical diagnosis of CTS and it's determination is easy and fast and specially important in cases with border or discrete abnormal values of other NM electrophysiological parameters, when SMI values can indicate incipient phase of CTS evolution. In rare cases (about 1%) of CTS with selective NM motor axons affection, SMI may have normal value (false negative result), but DML is always prolonged in this cases. SMI is not dependent on age and DD values in patients with CTS and control subjects
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0 |
Comparison of volumetric bone mineral density in the operated and contralateral knee after anterior cruciate ligament and reconstruction: A 1-year follow-up study using peripheral quantitative computed tomography
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OAK 3 - Non-arthroplasty tx of OAK
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The purpose of this study was to quantify changes in volumetric bone mineral density (vBMD) in the tibial plateau of the operated and contralateral leg measured using peripheral quantitative computed tomography (pQCT) before and 3, 6, and 12 months after anterior cruciate ligament (ACL) reconstruction. The ACL was reconstructed with a hamstring tendon autograft using press-fit fixation. pQCT measurements of the proximal tibia were obtained in 61 patients after ACL reconstruction, and total, cortical, and trabecular vBMD were calculated. vBMD in the operated leg decreased from baseline to 3 months (-12% [total], -11% [cortical], and -12.6% [trabecular]; p<0.001) and remained below baseline for 12 months after surgery (6 months: -9.5%, -9.4%, and -9.6%, p<0.001; 12 months: -8%, -5%, and -11%, p<0.001). vBMD in the contralateral leg was slightly reduced only 6 months after surgery. Including age and sex as covariates into the analysis did not affect the results. ACL reconstruction contributed to loss in bone mineral density within the first year after surgery. The role of factors such as time of weight-bearing, joint mechanics, post-traumatic inflammatory reactions, or genetic predisposition in modulating the development of posttraumatic knee osteoarthritis after ACL injury should be further elucidated.
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0 |
Hemiosteoporosis after severe stroke, independent of changes in body composition and weight
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Management of Hip Fractures in the Elderly
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BACKGROUND AND PURPOSE: Fractures are a serious complication after stroke, and the risk of hip fractures among stroke patients is increased 2 to 4 times versus a reference population. Fractures after stroke are probably caused by the development of hemiosteoporosis and the high incidence of accidental falls. The aim of this study was to investigate the development of hemiosteoporosis in relation to other changes in body composition during the first year after severe stroke. METHODS: The study included 24 patients with extensive paresis after stroke. Bone mineral content (BMC) and fat and lean mass were assessed 1, 4, 7, and 12 months after stroke onset by a dual-energy x-ray absorptiometer. RESULTS: The loss of total body BMC was significant during the first year after stroke (-1.6%; P<0.05), but there were no significant changes in total lean or fat mass. At inclusion, there were no significant differences between sides in lean or fat mass or BMC, but during follow-up, BMC of the affected side decreased significantly compared with the same side at inclusion (-7.5%; P<0.01). Side differences in fat mass became significant between legs (9.3%; P<0.001) and whole sides (4. 8%; P<0.01). There were only minor side changes in lean mass. Loss of BMC was independent of weight changes. CONCLUSIONS: During the first year after severe stroke, patients developed pronounced hemiosteoporosis. This was not associated with general changes in lean or fat mass. The development of hemiosteoporosis was independent of weight changes after stroke
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0 |
Male-female differences in the association between incident hip fracture and proximal femoral strength: A finite element analysis study
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Management of Hip Fractures in the Elderly
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Hip fracture risk is usually evaluated using dual energy X-ray absorptiometry (DXA) or quantitative computed tomography (QCT) which provide surrogate measures for proximal femoral strength. However, proximal femoral strength can best be estimated explicitly by combining QCT with finite element (FE) analysis. To evaluate this technique for predicting hip fracture in older men and women, we performed a nested age- and sex-matched case-control study in the Age Gene/Environment Susceptibility (AGES) Reykjavik cohort. Baseline (pre-fracture) QCT scans of 5500 subjects were obtained. During 4-7years follow-up, 51 men and 77 women sustained hip fractures. Ninety-seven men and 152 women were randomly selected as age- and sex-matched controls. FE-strength of the left hip of each subject for stance (F(Stance)) and posterolateral fall (F(Fall)) loading, and total femur areal bone mineral density (aBMD) were computed from the QCT data. F(Stance) and F(Fall) in incident hip fracture subjects were 13%-25% less than in control subjects (p(less-than or equal to)0.006) after controlling for demographic parameters. The difference between FE strengths of fracture and control subjects was disproportionately greater in men (stance, 22%; fall, 25%) than in women (stance, 13%; fall, 18%) (p(less-than or equal to)0.033), considering that F(Stance) and F(Fall) in fracture subjects were greater in men than in women (p<0.001). For men, F(Stance) was associated with hip fracture after accounting for aBMD (p=0.013). These data indicate that F(Stance) provides information about fracture risk that is beyond that provided by aBMD (p=0.013). These findings support further exploration of possible sex differences in the predictors of hip fracture and of sex-specific strategies for using FE analysis to manage osteoporosis. (copyright) 2011 Elsevier Inc
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0 |
Preliminary findings on biomarker levels from extracerebral sources in patients undergoing trauma surgery: Potential implications for TBI outcome studies
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Hip Fx in the Elderly 2019
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Background: Despite several experimental studies on the role of S100B and NSE in fractures, no studies on the influence of surgery on the biomarker serum levels have been performed yet. Methods: The serum levels of S100B and NSE were analysed in patients with fractures that were located in the spine (group 1, n = 35) or in the lower extremity (group 2, n = 32) pre- and post-operatively. Results: The mean S100B serum level showed a significant increase (p = 0.04) post-surgery in the patients of group 1. In patients undergoing acute surgery (< 24 hours) the mean S100B serum level was 0.23 ± 0.22 μg Lâ??1 pre-operatively and 1.24 ± 1.38 μg Lâ??1 post-operatively. Likewise, the mean S100B serum level significantly increased in group 2 after surgery (p < 0.0001). In this group patients undergoing acute surgery showed a mean S100B serum level of 0.23 ± 0.14 μg Lâ??1 and 1.11 ± 0.73 μg Lâ??1 pre- and post-operatively. Conclusion: This study demonstrates significant alterations of the biomarker S100B serum levels in patients undergoing surgery. Higher S100B serum levels were found within 24 hours and might be related to the acute fracture. The NSE serum levels were unchanged and this biomarker may offer the probability to serve as a future outcome predictor in studies with patients with traumatic brain injury and additional extracerebral injuries.
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0 |
Epidemiology of fractures in England and Wales
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Management of Hip Fractures in the Elderly
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Records from the General Practice Research Database were used to derive age- and gender-specific fracture incidence rates for England and Wales during the period 1988-1998. In total, 103,052 men and 119,317 women in the sample of 5 million adults sustained a fracture over 10.4 million and 11.2 million person-years (py) of follow-up. Among women, the most frequent fracture sites were the radius/ulna (30.2 cases per 10,000 py) and femur/hip (17.0 per 10,000 py). In men, the most common fracture was that of the carpal bones (26.2 per 10,000 py); the incidence of femur/hip fracture was 5.3 per 10,000 py. Varying patterns of fracture incidence were observed with increasing age; whereas some fractures became more common in later life (vertebral, distal forearm, hip, proximal humerus, rib, clavicle, pelvis), others were more frequent in childhood and young adulthood (tibia, fibula, carpus, foot, ankle). The lifetime risk of any fracture was 53.2% at age 50 years among women, and 20.7% at the same age among men. Whereas fractures of the proximal femur and vertebral body were associated with excess mortality over a 5 year period following fracture diagnosis among both men and women, fractures of the distal forearm were associated with only slight excess mortality in men. This study provides robust estimates of fracture incidence that will assist health-care planning and delivery
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0 |
Results of the Latarjet coracoid bone block procedure performed by mini invasive approach
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Glenohumeral Joint OA
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Introduction: The coracoid block technique described by Latarjet was modified by Patte and Walch in order to increase the glenoid surface. Saragaglia further modified this technique and described a minimally invasive approach which allows faster post-operative recovery. The aim of this study was to evaluate the medium-term functional and radiological results of this technique. Methods: This is a single surgeon cohort of 40 shoulders in 38 patients (32 men, 6 women) with an average age of 34.5Â years operated on between January and December 2014. The skin incision was 3 to 6Â cm long allowing the bony block to be passed under the subscapularis tendon without sectioning it and to be placed in lying position. The bone block was fixed with a 6.5 cancellous screw or a 7.0 cannulated screw. Results: At an average follow-up of 48Â months, there were no recurrent dislocations. The average WOSI score was 42, the average Constant score was 95 corrected to 97% and the average SSV was 97. Visual analogue scores were 0 at rest and 0.6 with activity. The bone block healed in 92.5% of cases. It was flush with the edge of the glenoid in 84% of cases, lateralised in 10% and medialised in 6% of cases. Mean internal rotation power was 12Â kg in the operated shoulder compared with 9Â kg in the non-operated shoulder. Conclusion: The treatment of recurrent anterior shoulder instability by mini invasive Latarjet gives excellent medium-term functional results. The rate of recurrent dislocation in this series was zero and internal rotation power was well preserved. This is an excellent alternative to arthroscopic procedures which are yet to demonstrate their superiority over open surgery.
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0 |
The essential features of microorganisms and the rationale for antimicrobial therapy
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Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures
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Antimicrobial agents have had a major impact on the control of most bacterial diseases; however, viral, fungal, protozoal and helminthic diseases have generally been less amenable to drug therapy. The reason for this lies in the different structural and physiological features that each group of microorganisms have. This article will outline the basic features of the various types of microorganisms, and relate these to the mode of action of commonly used antimicrobial agents
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0 |
Women's experiences of postnatal distress: a qualitative study
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DoD PRF (Psychosocial RF)
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BACKGROUND: Women can experience a range of psychological problems after birth, including anxiety, depression and adjustment disorders. However, research has predominantly focused on depression. Qualitative work on women's experiences of postnatal mental health problems has sampled women within particular diagnostic categories so not looked at the range of potential psychological problems. The aims of this study were to explore how women experienced and made sense of the range of emotional distress states in the first postnatal year.
METHODS: A qualitative study of 17 women who experienced psychological problems in the first year after having a baby. Semi-structured interviews took place in person (n =15) or on the telephone (n =2). Topics included women's experiences of becoming distressed and their recovery. Data were analysed using Interpretative Phenomenological Analysis (IPA). Themes were developed within each interview before identifying similar themes for multiple participants across interviews, in order to retain an idiographic approach.
RESULTS: Psychological processes such as guilt, avoidance and adjustment difficulties were experienced across different types of distress. Women placed these in the context of defining moments of becoming a mother; giving birth and breastfeeding. Four superordinate themes were identified. Two concerned women's unwanted negative emotions and difficulties adjusting to their new role. "Living with an unwelcome beginning" describes the way mothers' new lives with their babies started out with unwelcome emotions, often in the context of birth and breastfeeding difficulties. All women spoke about the importance of their postnatal healthcare experiences in "Relationships in the healthcare system". "The shock of the new" describes women's difficulties adjusting to the demands of motherhood and women emphasised the importance of social support in "Meeting new support needs".
CONCLUSIONS: These findings emphasise the need for exploration of psychological processes such as distancing, guilt and self-blame across different types of emotional difficulties, as these may be viable targets for therapeutic intervention. Breastfeeding and birth trauma were key areas with which women felt they needed support with but which was not easily available.
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0 |
In vivo measurement of localized tibiofemoral cartilage strains in response to dynamic activity
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AMP (Acute Meniscal Pathology)
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BACKGROUND: Altered local mechanical loading may disrupt normal cartilage homeostasis and play a role in the progression of osteoarthritis. Currently, there are limited data quantifying local cartilage strains in response to dynamic activity in normal or injured knees.
PURPOSE/HYPOTHESIS: To directly measure local tibiofemoral cartilage strains in response to a dynamic hopping activity in normal healthy knees. We hypothesized that local regions of cartilage will exhibit significant compressive strains in response to hopping, while overall compartmental averages may not.
STUDY DESIGN: Controlled laboratory study.
METHODS: Both knees of 8 healthy subjects underwent magnetic resonance imaging before and immediately after a dynamic hopping activity. Images were segmented and then used to create 3-dimensional surface models of bone and cartilage. These pre- and postactivity models were then registered using an iterative closest point technique to enable site-specific measurements of cartilage strain (defined as the normalized change in cartilage thickness before and after activity) on the femur and tibia.
RESULTS: Significant strains were observed in both the medial and lateral tibial cartilage, with each compartment averaging a decrease of 5%. However, these strains varied with location within each compartment, reaching a maximum compressive strain of 8% on the medial plateau and 7% on the lateral plateau. No significant averaged compartmental strains were observed in the medial or lateral femoral cartilage. However, local regions of the medial and lateral femoral cartilage experienced significant compressive strains, reaching maximums of 6% and 3%, respectively.
CONCLUSION: Local regions of both the femur and tibia experienced significant cartilage strains as a result of dynamic activity. An understanding of changes in cartilage strain distributions may help to elucidate the biomechanical factors contributing to cartilage degeneration after joint injury.
CLINICAL RELEVANCE: Site-specific measurements of in vivo cartilage strains are important because altered loading is believed to be a factor contributing to the development and progression of osteoarthritis. Specifically, this methodology and data could be used to evaluate the effects of soft tissue injuries (such as ligament or meniscus tears) on cartilage strains in response to dynamic activities of daily living.
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0 |
Practice considerations for proton beam radiotherapy of uveal melanoma during the COVID-19 pandemic: PTCOG Ocular experience
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Coronavirus Disease 2019 (COVID-19)
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Uveal melanoma (UM) is a rare but life-threatening cancer of the eye. In light of the COVID-19 pandemic, hospitals and proton eye therapy facilities must analyze several factors to ensure appropriate treatment protocols for patients and provider teams. Practice considerations to limit COVID-19 transmission in the proton ocular treatment setting for UM are necessary. The Particle Therapy Co-Operative Group (PTCOG) is the largest international community of particle/proton therapy providers. Participating experts are/were affiliated with the member institutions of the PTCOG Ocular subcommittee with long-standing high-volume proton ocular programs. The practices reviewed in this document must be taken in conjunction with local hospital procedures, multidisciplinary recommendations, and regional/national guidelines, as each community may have its unique needs, supplies, and protocols. Importantly, as the pandemic evolves, so will the strategies and recommendations. Given the unique circumstances for UM patients, along with indications of potential ophthalmologic transmission as a result of healthcare providers working in close proximity to patients and intrinsic infectious risk from eyelashes, tears and hair, practice strategies may be adapted to reduce the risk of viral transmission. Certainly, providers and health care systems will continue to examine and provide as safe and effective care as possible for patients in the current environment.
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0 |
Reduction of post-traumatic swelling and compartment pressure by impulse compression of the foot
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DOD - Acute Comp Syndrome CPG
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Following the discovery of a powerful venous pump in the foot that is activated by weight-bearing independently of muscular action, a pneumatic impulse device was developed to actuate this pump artificially. In a multicentre international trial the device was shown to reduce post-traumatic and postoperative swelling; pain also was alleviated. Evidence is also presented that dangerously high compartment pressures may be reduced to acceptable levels and fasciotomy avoided. We present an explanation of the clinical effects of activation of the venous footpump, based on recent improved understanding of the physiology of the microcirculation. The hyperaemic response that follows the liberation of endothelial-derived relaxing factor (EDRF) by sudden changes of pressure after weight-bearing or impulse compression is particularly important.
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0 |
Osteoarthritis of the knee
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OAK 3 - Non-arthroplasty tx of OAK
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As of mid-2016, there is still no evidence that hyaluronic acid is more effective than placebo in osteoarthritis of the knee. It does however have adverse effects.
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0 |
Malignant Spinal Cord Compression: Adapting Conventional Rehabilitation Approaches
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MSTS 2018 - Femur Mets and MM
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Spinal tumors are classically grouped into 3 categories: extradural, intradural extramedullary, and intradural intramedullary. Spinal tumors may cause spinal cord compression and vascular compromise resulting in pain or neurologic compromise. They may also alter the architecture of the spinal column, resulting in spinal instability. Oncologic management of spinal tumors varies according to the stability of the spine, neurologic status, and presence of pain. Treatment options include surgical intervention, radiation therapy, chemotherapy, and hormonal manipulation. When combined with this management, rehabilitation can serve to relieve symptoms, improve quality of life, enhance functional independence, and prevent further complications in patients.
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0 |
Aseptic meningitis associated with cephalosporins in an infant with trisomy 21
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Patrick’s pharmacoepidemiology project
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The authors report a case of aseptic meningitis associated with cephalosporins in an infant. A 1-year-old boy with trisomy 21 received several antimicrobials including cefotaxime and ceftriaxone for bacterial meningitis caused by Haemophilus influenzae b. High fever continued for more than a month, and discontinuation of cefotaxime broke the fever and improved the findings of cerebrospinal fluid. Because third-generation cephalosporins are the first choice against bacterial meningitis for infants, recognition and diagnosis of this rare occurrence of drug-induced aseptic meningitis is important. It is treatable by withdrawal of the drug, and recurrence can be prevented
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0 |
Emerging anti-cancer molecular mechanisms of aminobisphosphonates
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MSTS 2018 - Femur Mets and MM
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Bone metastases are common in patients with many types of cancer, especially breast and prostate cancer - in which the incidence is approximately 70% among patients with advanced metastatic disease. Aminobisphosphonates (NBPs) have entered clinical practice in the treatment of bone metastases from several neoplasms, including breast and prostate adenocarcinoma, as a result of their anti-resorption properties. However, evidence has accumulated on the direct anti-tumour effects of NBPs. This review describes the metabolic pathways that are putative molecular targets of NBPs and that are involved in the prenylation processes of several intracellular small GTP-binding proteins (ras family related proteins). The latter regulate the intracellular survival and proliferative pathways of tumour cells and could be the intracellular molecular targets of the NBPs responsible for the direct anti-cancer effects, even if definitive conclusions cannot be drawn at present. Different mechanisms have been reported to account for the anti-neoplastic action of NBPs, including: the induction of apoptosis; cell cycle perturbations; and anti-invasive, anti-migration and anti-angiogenic effects. Moreover, this review describes the most important clinical studies that demonstrate the activity of NBPs in preventing skeletal-related events induced by bone metastases. The main pharmacokinetic pitfalls of NBPs are described, and methods of overcoming these pitfalls through the use of liposome vehicles are proposed. Finally, the principal pre-clinical studies on the interaction between NBPs and other biological agents are also described; these studies may enable reductions in the in vivo NBP concentrations required to achieve anti-tumour activity. To date, however, the real molecular targets of NBPs are not completely known and new technological platforms are required in order to detect them and to develop new anti-cancer strategies based on the use of NBPs. © 2006 Society for Endocrinology.
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0 |
Fixed bearing lateral unicompartmental knee arthroplasty--short to midterm survivorship and knee scores for 101 prostheses
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Surgical Management of Osteoarthritis of the Knee CPG
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BACKGROUND: Isolated unicompartmental knee arthritis is less common laterally than medially. Lateral unicompartmental knee arthroplasty (UKA) constitutes only 1% of all knee arthroplasty performed. Use of medial UKA is supported by several published series showing good long-term survivorship and patient satisfaction, in large patient cohorts. Results of lateral UKA however have been mixed. We present the short and mid-term survivorship and 5-year clinical outcome of 101 lateral UKAs using a single prosthesis. METHODS: Over a 9 year period, 100 patients who satisfied inclusion criteria underwent a lateral fixed-bearing unicompartmental arthroplasty. American Knee Society (AKSS), Oxford Knee (OKS) and modified Western Ontario McMaster Universities Arthritis Index (WOMAC) scores were completed preoperatively and at 1, 2 and 5 years postoperatively. Kaplan-Meier survival analysis was used to determine the 2-year and 5-year survivorship, using revision for any cause as end point. RESULTS: Survivorship was 98.7% and 95.5% at 2 and 5 years respectively. 1 knee was revised for subsidence of the tibial component and 1 knee for progression of medial compartment osteoarthritis. Of a possible 35 knees in situ at 5 year follow-up, 33 knees were fully scored. Median AKSS, OKS and modified WOMAC scores were 182, 41, and 16 respectively. CONCLUSIONS: The mid-term survivorship and outcome scores at 5-years suggest that lateral unicompartmental knee arthroplasty provides a valuable alternative to total joint replacement in selected patients with isolated lateral tibio-femoral arthritis at mid-term follow-up. Level II evidence
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0 |
Longitudinal Change in Knee Cartilage Thickness and Function in Subjects with and without MRI-Diagnosed Cartilage Damage
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AMP (Acute Meniscal Pathology)
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Objective: Cartilage damage diagnosed by magnetic resonance imaging (MRI) is highly prevalent in the population. In this article, we explore whether such cartilage damage is associated with greater longitudinal change in 3D cartilage thickness and knee function in subjects without (risk factors of) knee osteoarthritis. Design: Eighty-two knees of Osteoarthritis Initiative healthy reference cohort participants had baseline and 4-year follow-up MRI and knee function data. Baseline presence of semiquantitatively assessed MRI-based cartilage damage (MOAKS [MRI Osteoarthritis Knee Score] = grade 1.0) was recorded by an experienced radiologist. Longitudinal femorotibial cartilage thickness change was determined after segmentation, using location-independent methodology. Knee function was evaluated by patient-reported outcomes and functional performance measures. Statistical comparisons included analysis of covariance adjusting for age, sex, and body mass index. Results: Forty-five percent of the participants had cartilage damage in at least one femorotibial subregion; the cartilage thickness change score was 15% greater in participants with than in those without damage (1216 ± 434 vs. 1058 ± 277 µm). This difference reached borderline statistical significance with and without adjustment for age, sex, and body mass index (P = 0.05). No significant differences in the change of patient-reported outcomes of knee function (PASE [physical activity score of the elderly] and WOMAC [Western Ontario McMaster Osteoarthritis Index]) or chair stand test results were detected. Of those without femorotibial damage, 58% had cartilage damage in at least one femoropatellar subregion; these had a 9% greater femorotibial cartilage change score than those without femoropatellar or femorotibial damage (difference not statistically significant). Conclusions: In the absence of osteoarthritis risk factors, semiquantitatively assessed MRI-based cartilage damage appears to be associated with greater longitudinal location-independent femorotibial cartilage thickness changes, but not with greater functional deteriorations.
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1 |
Popliteal artery repair in massively transfused military trauma casualties: a pursuit to save life and limb
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DoD SSI (Surgical Site Infections)
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BACKGROUND: Popliteal artery war wounds can bleed severely and historically have high rates of amputation associated with ligation (72%) and repair (32%). More than before, casualties are now surviving the initial medical evacuation and presenting with severely injured limbs that prompt immediate limb salvage decisions in the midst of life-saving maneuvers. A modern analysis of current results may show important changes because previous limb salvage strategies were limited by the resuscitation and surgical techniques of their eras. Because exact comparisons between wars are difficult, the objective of this study was to calculate a worst-case (a pulseless, fractured limb with massive hemorrhage from popliteal artery injury) amputation-free survival rate for the most severely wounded soldiers undergoing immediate reconstruction to save both life and limb.
METHODS: We performed a retrospective study of trauma casualties admitted to the combat support hospital at Ibn Sina Hospital in Baghdad, Iraq, between 2003 and 2007. US military casualties requiring a massive transfusion (> or = 10 blood units transfused within 24 hours of injury) were identified. We extracted data on the subset of casualties with a penetrating supra or infrageniculate popliteal arterial vascular injury. Demographics, injury mechanism, Injury Severity Score, tourniquet use, physiologic parameters, damage control adjuncts, surgical repair techniques, operative time, and outcomes (all-cause 30-day mortality, amputation rates, limb salvage failure, and graft patency) were investigated.
RESULTS: Forty-six massively transfused male casualties, median age 24 years (range, 19-54 years; mean Injury Severity Score, 19 +/- 8.0), underwent immediate orthopedic stabilization and vascular reconstruction. There was one early death. The median operative time for the vascular repairs was 217 minutes (range, 94-630 minutes) and included all damage control procedures. Combined arterial and venous injuries occurred in 17 (37%). Ligation was performed for no arterial and 9 venous injuries. Amputations (transtibial or transfemoral) were considered limb salvage failures (14 of 48, 29.2%) and were grouped as immediate (< or = 48 hours, 5), early (>48 hours and < or = 30 days, 6), or late (>30 days, 3). Limb losses were from graft thrombosis, infection, or chronic pain. Combined arterial and venous injuries occurred in 17 (37%). Ligation was performed for no arterial and nine venous injuries. For a median follow-up (excluding death) of 48 months (range, 23-75 months), the amputation-free survival rate was 67%.
CONCLUSIONS: This study, a worst-case study, showed comparable results to historical controls regarding limb salvage rates (71% for Iraq vs. 56-69% for the Vietnam War). Thirty-day survival (98%), 4-year amputation-free survival (67%), and complication-free rates (35%) fill knowledge gaps. Guidelines for managing popliteal artery injuries show promising results because current resuscitation practices and surgical care yielded similar amputation rates to prior conflicts despite more severe injuries. Significant transfusion requirements and injury severity may not indicate a life-over-limb strategy for popliteal arterial repairs. Future studies of limb salvage failures may help improve casualty care by reducing the complications that directly impact amputation-free survival.
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0 |
Variations in treatment of postmenopausal osteoporosis
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Management of Hip Fractures in the Elderly
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The purpose of this study was to determine trends and differences between various medical specialties with regard to the treatment of postmenopausal osteoporosis. The method used was a cross-sectional survey, and the authors' sample was composed of 116 physicians. There was an overall lack of consensus on choice of treatment for postmenopausal osteoporosis. Treatment varies with the individual physician without any strict adherence to a formal therapeutic protocol. Calcium was the treatment modality most widely used by all the specialties. Gynecologists and endocrinologists show the greatest usage of estrogens, while orthopedic surgeons show the least. Fluoride was used significantly less than calcium, vitamin D, estrogen, diet, and exercise by all the specialties surveyed. One in three postmenopausal women in the United States has osteoporosis, and one in five will sustain a hip or vertebral fracture. Twelve to twenty percent of elderly patients die within six months of sustaining a hip fracture. There is an obvious need for carefully constructed clinical programs evaluating multiple agents and diagnostic techniques
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0 |
Late follow-up of femoral head avascular necrosis managed by intertrochanteric osteotomy & bone grafting
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AAHKS (2) Corticosteroids
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A prospective study was carried out on fifty hips in forty-eight patients with Ficat stage III (Steinberg stage IV) avascular necrosis (head deformity evident on plain x-ray) involving the supero-ventral segment. Mean age was 33 +/- 8 years (mean and standard deviation). There were thirty-six male and twelve female patients. Followup was 3-14 years (mean 8 years). This study precluded patients who were more than 45 years old, had an underlying condition requiring continued chemotherapy or cortisone, who had extensive dorsal (posterior) head segment involvement or those who were poorly motivated. Avascular necrosis was associated with alcohol in 35% of hips, trauma in 26% and 39% were idiopathic. One pregnancy related case was included in the latter subgroup. Curettage of the avascular segment and impaction of the bone graft was performed via subcapital fenestration of the anterior femoral neck. Pain was the presenting symptom in all cases. The mean pre-operative Harris hip score was 36 points and the mean score at last assessment was 87 points. Seven hips (14%) failed, failure implied conversion to a hip replacement or a Harris hip score of less than 70 points. Failures were seen within the first 3 years after osteotomy. Kaplan Meyer Survivorship analysis demonstrated an overall survivorship probability of 86% at 14 years. One patient died 10 years post surgery, the head was retrieved for histological study. Statistical study (Mann-Whitney U test) was carried out to determine factors related to failure. Of significance were age of the patient at time of osteotomy, contralateral hip involvement and size of the lesion. X ray studies of the femoral head included measurement of the necrotic angle, evaluation of restoration and maintenance of head contour and graft incorporation or stabilisation. Subsequent CAT scan studies enabled accurate quantification and siting of the avascular segment. Secondary x ray degenerative changes of the joint tended to manifest with time but these changes had little bearing on the clinical outcome. Osteotomy does have a measure of unpredictability, but in the appropriate case a high incidence of satisfactory results would be anticipated.
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0 |
Modular prosthesis reconstruction after tumour resection, evaluation of failures and survival
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MSTS 2022 - Metastatic Disease of the Humerus
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OBJECTIVE: To analyze a series of patients with bone tumours reconstructed with modular prostheses and to evaluate: 1) Survival of the implant. 2) Causes of failure. 3) Complication rates. 4) Limb salvage overall survival. 5) Functional results and full weight bearing.
MATERIALS AND METHODS: A retrospective study from longitudinally maintained oncology databases was undertaken. All patients with bone tumours reconstructed with endoprosthesis were analysed. A toal of 106patients matched the inclusion criteria. They were divided into groups: group 1, primary bone tumours; group 2, bone metastasis; group 3, osteoarticular allograft reconstruction revisions. The type of failures were classified according to Henderson et al. (2014) and functional results assessed by the Musculoskeletal Tumor Society (MSTS). Demographic analysis, survival and the differences between groups were recorded.
RESULT: The mean follow-up of the patients was 68 months. Mean age was 43 years. Overall implant survival was 86.4% at 2 years (95% CI: 79-94) and 73% at 5 years (95% CI: 60-80). Nineteen patients (18%) developed a prosthetic failure. The limb salvage overall survival was 96% at 5 years (95% CI: 91-99). The mean functional results according to the MSTS was 24 and mean time to full weight bearing was 2.3 weeks.
CONCLUSIONS: Limb conservation surgery and endosprosthetic reconstruction is a valid option for patients with bone tumours with failure rates similar to other reconstruction methods.
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0 |
Effects of ultrasound guidance on the minimum effective anaesthetic volume required to block the femoral nerve
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Surgical Management of Osteoarthritis of the Knee CPG
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BACKGROUND: We tested the hypothesis that ultrasound guidance may reduce the minimum effective anaesthetic volume (MEAV50) of ropivacaine 0.5% required to block the femoral nerve compared with nerve stimulation guidance. METHODS: After standard premedication and sciatic nerve block were given, 60 patients undergoing knee arthroscopy were randomly allocated to receive a femoral nerve block with ropivacaine 0.5% using either nerve stimulation (group NS, n = 30) or ultrasound (group US, n = 30) guidance. The volume of the injected solution was varied for consecutive patients based on an up-and-down staircase method according to the response of the previous patient. The initial volume was 12 ml. A double-blinded observer evaluated the occurrence of complete loss of pinprick sensation in the femoral nerve distribution, with concomitant block of the quadriceps muscle: positive or negative responses within 30 min after the injection determined a 3 ml decrease or increase for the next patient, respectively. RESULTS: The mean (sd) MEAV50 for femoral nerve block was 15 (4) ml (95% CI, 7-23 ml) in group US and 26 (4) ml (95% CI, 19-33 ml) in group NS (P = 0.002). The effective dose in 95% of cases (ED95) calculated with probit transformation and logistic regression analysis was 22 ml (95% CI, 13-36 ml) in group US, and 41 ml (95% CI, fs 24-66 ml) in group NS. CONCLUSIONS: Ultrasound guidance provided a 42% reduction in the MEAV of ropivacaine 0.5% required to block the femoral nerve as compared with the nerve stimulation guidance
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0 |
Platelet-derived growth factor-coated decellularized meniscus scaffold for integrative healing of meniscus tears
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OAK 3 - Non-arthroplasty tx of OAK
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The aim of this study was to examine the potential of platelet-derived growth factor (PDGF)-coated decellularized meniscus scaffold in mediating integrative healing of meniscus tears by inducing endogenous cell migration. Fresh bovine meniscus was chemically decellularized and covalently conjugated with heparin and PDGF-BB. In vitro PDGF release kinetics was measured. The scaffold was transplanted into experimental tears in avascular bovine meniscus explants and cultured for 2 and 4weeks. The number migrating and proliferating cells at the borderline between the scaffold and injured explant and PDGF receptor-beta (PDGFRbeta) expressing cells were counted. The alignment of the newly produced ECM and collagen was analyzed by Safranin-O, picrosirius red staining, and differential interference contrast (DIC). Tensile testing of the explants was performed after culture for 2 and 4weeks. Heparin conjugated scaffold showed immobilization of high levels of PDGF-BB, with sustained release over 2weeks. Insertion of the PDGF-BB treated scaffold in defects in avascular meniscus led to increased PDGFRbeta expression, cell migration and proliferation into the defect zone. Safranin-O, picrosirius red staining and DIC showed tissue integration between the scaffold and injured explants. Tensile properties of injured explants treated with PDGF-BB coated scaffold were significantly higher than in the scaffold without PDGF. In conclusion, PDGF-BB-coated scaffold increased PDGFRbeta expression and promoted migration of endogenous meniscus cells to the defect area. New matrix was formed that bridged the space between the native meniscus and the scaffold and this was associated with improved biomechanical properties. The PDGF-BB-coated scaffold will be promising for clinical translation to healing of meniscus tears.
STATEMENT OF SIGNIFICANCE: Meniscus tears are the most common injury of the knee joint. The most prevalent forms that occur in the inner third typically do not spontaneously heal and represent a major risk factor for the development of knee osteoarthritis. The goal of this project was to develop an approach that is readily applicable for clinical use. We selected a natural and readily available decellularized meniscus scaffold and conjugated it with PDGF, which we had previously found to have strong chemotactic activity for chondrocytes and progenitor cells. The present results show that insertion of the PDGF-conjugated scaffold in defects in avascular meniscus led to endogenous cell migration and proliferation into the defect zone with tissue integration between the scaffold and injured explants and improved tensile properties. This PDGF-conjugated scaffold will be promising for a translational approach to healing of meniscus tears.
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0 |
A Unique Failure Mechanism of a Constrained Total Hip Arthroplasty. A Brief Review of the Literature
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Management of Hip Fractures in the Elderly
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Constrained acetabular systems are successful in achieving stability in patients with recurrent dislocations, abductor deficiency, or where a source of instability cannot be determined. We report on one patient with 2 dissociations of a tripolar constrained acetabular liner caused by impingement when the patient exceeded the allowed range of motion. The inner liner dissociated from the outer liner, whereas the reinforcing ring remained intact and in place. Despite an extensive literature search, we were unable to find any other published reports concerning this specific mode of failure for this constrained liner. Surgeons should be aware that constrained liners are not infallible and have limitations to range of motion. Maximizing the size of the femoral head may reduce the risk of this mode of failure. (copyright) 2008 Elsevier Inc. All rights reserved
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Low-frequency sonication may alter surface topography of endoprosthetic components and damage articular cartilage without eradicating biofilms completely
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PJI DX Updated Search
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Two-stage exchange arthroplasty is the current standard of care for arthroplasty-related infections. Reinfection rates up to 30% are reported, and there is significant morbidity for the patient. In cases of failure, arthrodesis or amputation may result. Ultrasonic treatment has the potential to eradicate biofilms and avoid two-stage exchange arthroplasty. Data in the specific context of arthroplasty infections is scant, and there is debate regarding optimal frequency and intensity of treatment. Surface topography alterations of the endoprosthetic components and damage to adjacent bone and cartilage have not been investigated. We found incomplete biofilm eradication and significant increase in surface roughness (maximum peak-to-valley height) of cobalt-chrome unicondylar knee components as well as reduction in articular cartilage thickness area from 10 retrieved femoral heads after low-frequency sonication treatment according to manufacturer-specified recommendations. Our data collectively suggest that sonication treatment for biofilm eradication in arthroplasty infections may not be effective and surface topography alterations may potentially reduce implant longevity
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0 |
Hydrogels for precision meniscus tissue engineering: a comprehensive review
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AMP (Acute Meniscal Pathology)
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The meniscus plays a pivotal role to preserve the knee joint homeostasis. Lesions to the meniscus are frequent, have a reduced ability to heal, and may induce tibiofemoral osteoarthritis. Current reconstructive therapeutic options mainly focus on the treatment of lesions in the peripheral vascularized region. In contrast, few approaches are capable of stimulating repair of damaged meniscal tissue in the central, avascular portion. Tissue engineering approaches are of high interest to repair or replace damaged meniscus tissue in this area. Hydrogel-based biomaterials are of special interest for meniscus repair as its inner part contains relatively high proportions of proteoglycans which are responsible for the viscoelastic compressive properties and hydration grade. Hydrogels exhibiting high water content and providing a specific three-dimensional (3D) microenvironment may be engineered to precisely resemble this topographical composition of the meniscal tissue. Different polymers of both natural and synthetic origins have been manipulated to produce hydrogels hosting relevant cell populations for meniscus regeneration and provide platforms for meniscus tissue replacement. So far, these compounds have been employed to design controlled delivery systems of bioactive molecules involved in meniscal reparative processes or to host genetically modified cells as a means to enhance meniscus repair. This review describes the most recent advances on the use of hydrogels as platforms for precision meniscus tissue engineering.
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0 |
Allograft reconstruction of segmental defects of the humeral head associated with posterior dislocations of the shoulder
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Glenohumeral Joint OA
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Six men underwent operative management of defects of the humeral head involving at least 40% of the articular surface, following posterior dislocation of the humeral head. The cause of dislocation was a grand mal seizure in three and a fall in three cases. In five cases the dislocation was reduced under general anaesthesia, and in all the posterior dislocation recurred early. Time between dislocation and surgery ranged from 7 to 8 weeks. The defect in the head, revealed by CT, was filled with an allogeneic segment of humeral head contoured to restore the spherical shape. All the patients returned to their occupation 4 months later. The mean duration of follow-up was 62.6 (60-68) months. At discharge, four of the men had no complaints of pain, instability, clicking or catching; two had pain, clicking, catching and stiffness. Radiographs and CT revealed no failures of fixation or of incorporation of the allograft. In four cases the contour and volume of the graft were maintained, but in the two with a bad clinical result, flattening and collapse of the graft and osteoarthrosis were observed. If the procedure fails, prosthetic reconstruction should be simple because the skeletal anatomy has not been distorted.
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0 |
Distal humeral fractures: impact of lateral approach and fracture-specific plating on radial nerve palsies
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Distal Radius Fractures
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We retrospectively reviewed supracondylar distal humeral fractures that had been treated with fracture-specific plating and definitive fixation through a lateral approach with a medial triceps mobilization technique. We determined the incidences of preoperative and postoperative radial nerve palsies (RNP) to evaluate the impact of the plating and fixation technique on RNP. Seventy-three patients treated at our institution from 2006 through 2009 were included in the study. The patients were assigned to 2 groups: 57 to the blunt injury group (motor vehicle collisions, falls, struck pedestrians, throwing) and 16 to the gunshot wound group. The incidence of known preoperative RNP in the blunt injury group was 27% (13 of 48 nonintubated patients); the incidence of known preoperative RNP in the gunshot wound group was 20% (2 of 10 nonintubated patients). The incidence of postoperative RNP for the combined groups of nonintubated patients who had intact radial nerve function preoperatively was 12% (5 of 43 patients). We found a high frequency of preoperative RNP, and we found postoperative RNP rates similar to those reported in the literature despite the use of the lateral approach medial triceps mobilization technique with a fracture-specific plate.
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0 |
CXCL12 genetic variants as prognostic markers in nasopharyngeal carcinoma
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MSTS 2018 - Femur Mets and MM
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The chemokine receptor 4/chemokine ligand 12 (CXCR4/CXCL12) axis plays an important role in tumorigenesis, metastasis, and recurrence of tumors. Its single nucleotide polymorphisms (SNPs) are associated with patient survival in several types of cancer. However, the prognostic value of SNPs in nasopharyngeal carcinoma (NPC) has not been fully investigated. This retrospective study assessed the relationships between CXCR4 rs2228014 and CXCL12 rs1801157 polymorphisms and patient outcome in 222 patients newly diagnosed with NPC. The analysis found no significant correlation between the presence of both SNPs and clinicopathological factors. However, univariate analysis showed that N classification, clinical stage, and the CXCL12 rs1801157 polymorphism were significantly associated with distant metastasis-free survival (P=0.018, 0.028, and 0.013, respectively) and progression-free survival (P=0.007, 0.046, and 0.021, respectively). After adjusting clinicopathological factors, multivariate analysis identified CXCL12 rs1801157 as an independent prognostic factor for distant metastasis-free survival and progression-free survival (hazard ratio: 3.332; 95% confidence interval: 1.597-6.949; P=0.001 and hazard ratio: 2.665 95% confidence interval: 1.387-5.119; P=0.003, respectively). Our results suggest that CXCL12 rs1801157 AA genotype might serve as a potential prognostic factor in patients with NPC.
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0 |
Preventing osteoporosis in every day life
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Management of Hip Fractures in the Elderly
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Osteoporosis is a condition characterized by low bone mineral density, microarchitectural deterioration of bone tissue, and a consequent increase in fracture risk. The public health impact of osteoporosis stems from its association with fractures of the hip, spine and forearm. Between 10 and 20 percent of hip fracture patients die within a year of the event, and among those who survive, almost two-thirds remain disabled. The medical costs of osteoporosis and its attendant fractures have been placed at 5.2 billion dollars each year in the US and 615 million pound sterling each year in the UK. In Asia, osteoporosis is rapidly becoming a major public health problem with an increasing incidence of hip fracture and a rapidly aging population. By the year 2050, more than half of the hip fracture around the world would occur in Asia, with the total number approaching 3.2 million. Osteoporosis can be attributed to both genetic factors and environmental factors. While it is difficult to modify genes, much can be done to prevent osteoporosis in our every day life. These are discussed below
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0 |
Monoclonal gammopathy of undetermined significance: why identification of these patients and assessment of their skeletons is important
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MSTS 2018 - Femur Mets and MM
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Monoclonal gammopathy of undetermined significance (MGUS) is a plasma cell disorder characterized by the presence of a serum monoclonal immunoglobulin (M-protein) at <or= 3 g/dL. It is an asymptomatic premalignant disorder that can progress to multiple myeloma and related B-cell disorders. Recent studies have suggested the association of MGUS with enhanced bone loss and debilitating skeletal complications, particularly vertebral compression fractures (VCFs) often leading to back pain. Early identification of MGUS and evaluation of bone status will facilitate prophylactic treatment with bisphosphonates to increase bone density and likely reduce the risk of fractures as well as identify patients with VCFs who might benefit from early surgical intervention. With proper diagnostic and treatment strategies, these patients will experience improved outcomes and quality of life.
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0 |
Does a Triple-Wedge, Broach-Only Stem Design Reduce Early Postoperative Fracture in Anterior Total Hip Arthroplasty?
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Hip Fx in the Elderly 2019
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INTRODUCTION: The direct anterior (DA) approach for total hip arthroplasty (THA) is gaining popularity; however, this approach still poses a higher risk for femoral complications, including fracture. The design of cementless stems can also impact the risk of fracture. The purpose of this study is to evaluate the early postoperative femoral complications with a short, triple-wedge broach-only tapered stem used in primary THA via a DA approach. MATERIALS AND METHODS: A retrospective review of our institution's arthroplasty registry from 2015 through 2018 was performed to identify all patients who underwent a primary total hip arthroplasty via a direct anterior approach with the Klassic® Blade Stem (Total Joint Orthopedics, Inc., Salt Lake City, Utah). Patients were excluded if the stem was used for a revision surgery, within 90 days of surgery, or if research consent was refused. Two-hundred forty-five patients (289 hips) met inclusion criteria. Clinical and operative notes were reviewed, along with postoperative radiographs. RESULTS: Average follow up was 0.6 years (range, 0.25 to 3.6 years). Mean patient age was 62.9 years and mean body mass index (BMI) was 29.4 kg/m2. Gender was male in 130 patients (53%) and female in 115 patients (47%). No patients sustained an early postoperative periprosthetic femur fracture. No femoral revisions have been performed at most recent follow up. All 150 patients with >90-day postoperative radiographs demonstrated bony ingrowth of the stem. Early outcomes scores showed a mean postoperative Harris Hip Scores (HHS) of 80.1 (range, 10 to 100) and a pain score of 35.9 (range, 0 to 44). CONCLUSION: This triple-wedge broach-only implant demonstrated low rates of early perioperative femoral complications in primary THA via a direct anterior approach. The authors will continue to monitor the longer-term survival and patient outcomes with this implant.
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1 |
A preliminary evaluation of the motivational model of pain self-management in persons with spinal cord injury-related pain
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DoD PRF (Psychosocial RF)
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UNLABELLED: Chronic pain commonly accompanies long-term disabilities such as spinal cord injury (SCI). Research suggests that patient motivation to engage in adaptive pain coping strategies, such as exercise/stretching and task persistence, is an important factor in determining the impact that this pain will have on quality of life. One recently proposed model (the Motivational Model of Pain Self-Management) suggests that motivation to manage pain is influenced by 2 primary variables: Beliefs about the importance of engaging in pain self-management (ie, perceived importance) and beliefs about one's own ability to engage in these behaviors (ie, self-efficacy). The purpose of this study was to provide a preliminary test of this model in a sample of 130 adults with SCI who completed a return by mail survey. Measures included a numerical rating scale of pain intensity and the revised version of the Multidimensional Pain Readiness to Change Questionnaire. Mediation analyses were performed using multiple regression. Results suggested that the effects of perceived importance and self-efficacy on exercise behavior were mediated by readiness to engage in exercise, consistent with the proposed model. However, the model could not be established for the outcome of task persistence.
PERSPECTIVE: This study tests a model describing motivation to engage in pain management behaviors (ie, "readiness to change") in adults with SCI. This model could potentially aid clinicians in their conceptualization of the factors that affect patient motivation to manage pain.
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0 |
Aging and sequelae of poliomyelitis
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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Objective: We estimate that there are about 50,000 persons who survived poliomyelitis in their childhood in France (mean age estimated between 50 and 65 years). After a few decades of stability, 30 to 65% of individuals who had been infected and recovered from polio begin to experience new signs and symptoms. Method: Review of the literature on Pubmed with the following keywords "Poliomyelitis" and "Post-Polio Syndrome (PPS)". Results: These new signs and symptoms are characterized by muscular atrophy (decreased muscle mass), muscle weakness and fatigue, muscle and/or joint pain. All these symptoms lead to significant changes in mobility with falls and inability to carry on with daily life activities. There are several intricate causes. The normal aging process and weight gain are regularly blamed. Respiratory disorders and sleep disorders must be looked for: respiratory insufficiency, sleep-related breathing disorders such as sleep apnea, restless legs syndrome. Orthopedics complications are quite common: soft-tissue pathologies of the upper limbs, degenerative pathologies of the large joints or spinal cord, fall-related fractures. Finally, the onset of an authentic PPS is possible. Conclusion: The therapeutic care of this late functional deterioration requires regular monitoring check-ups in order to implement preventive measures and appropriate treatment. This therapeutic care must be multidisciplinary as physical rehabilitation; orthotics and technical aids are all essential. (copyright) 2009 Elsevier Masson SAS. All rights reserved
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1 |
A meta-analysis of etidronate for the treatment of postmenopausal osteoporosis
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Management of Hip Fractures in the Elderly
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The aim of the study was to review the effect of etidronate on bone density and fractures in postmenopausal women. We searched MEDLINE from 1966 to 1998, examined citations of relevant articles, and the proceedings of international osteoporosis meetings. We contacted osteoporosis investigators to identify additional studies, primary authors, and pharmaceutical industry sources for unpublished data. We included 13 trials that randomized women to etidronate or an alternative (placebo or calcium and/or vitamin D) and measured bone density for at least 1 year. For each trial, three independent reviewers assessed the methodologic quality and abstracted data. The data suggested a reduction in vertebral fractures with a pooled relative risk of 0.63 (95% CI 0.44 to 0.92). There was no effect on nonvertebral fractures (relative risk 0.99, (95% CI 0.69 to 1.42). Etidronate, relative to control, increased bone density after 1-3 years of treatment in the lumbar spine by 4.06% (95% CI 3.12 to 5.00), in the femoral neck by 2.35% (95% CI 1.66 to 3.04) and in the total body by 0.97% (95% CI 0.39 to 1.55). Effects were larger at 4 years, though the number of patients followed much smaller. Etidronate increases bone density in the lumbar spine and femoral neck for up to 4 years. The pooled estimates of fracture reduction with etidronate suggest a reduction in vertebral fractures, but no effect on nonvertebral fractures
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0 |
Risk factors for hip fractures occurring in the hospital
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Management of Hip Fractures in the Elderly
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Risk factors for in-hospital hip fractures among patients aged > or = 65 years were evaluated in a population-based case-control study conducted in the Canadian province of Saskatchewan from 1983 through 1985. There were 129 cases with confirmed in-hospital hip fractures and 234 controls, who were those controls from a previous study in this setting hospitalized on their assigned index date. Study variables were abstracted from the hospital chart. Six factors were independently associated with a significantly increased risk of in-hospital hip fracture: impaired vision (odds ratio = 1.97, 95% confidence interval (CI) 1.18-3.30), assisted ambulation (odds ratio = 2.12, 95% CI 1.25-3.59), confusion (odds ratio = 2.48, 95% CI 1.37-4.48), psychotropic drug use (odds ratio = 2.02, 95% CI 1.22-3.33), lowest weight tertile (odds ratio = 2.86, 95% CI 1.38-5.92), and prior in-hospital fall (odds ratio = 2.71, 95% CI 1.52-4.82). The risk increased substantially with the number of factors present, from an odds ratio of 4.08 (95% CI 1.56-10.67) for one factor (reference group, no factors) to 82.84 (95% CI 18.6-368.7) for four or more factors (p < 0.001, test for trend). These data underscore the multifactorial etiology of in-hospital hip fracture and suggest that prevention programs need to target multiple risk factors
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Type D personality is independently associated with major psychosocial stressors and increased health care utilization in the general population
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DoD PRF (Psychosocial RF)
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BACKGROUND: Type D is considered as a non pathological personality trait and propensity for mental distress. Its relationship with mental distress has been mainly studied in cardiovascular patients and with respect to depression. The knowledge about the relationship of Type D with mental disorders, psychosocial stressors and health care utilization in the general population is insufficient. Therefore the present study sought to determine the associations of Type D with mental distress, major psychosocial stressors, health status, and health care utilization in the general population.
METHODS: Cross-sectional analysis in a representative population based sample of n = 2495 subjects (mean age 49 years, range 14-92 years) of whom 33.1% had Type D personality.
RESULTS: Individuals with Type D had an increased risk for clinically significant depression, panic disorder, somatization and alcohol abuse. After adjustment for these mental disorders Type D was still robustly associated with all major psychosocial stressors. The strongest associations emerged for feelings of social isolation and for traumatic events. After comprehensive adjustment Type D still remained associated with increased help seeking behavior and utilization of health care, especially of mental health care.
LIMITATIONS: The main limitation is the reliance on self-report measures and the lack of information about the medical history and clinical diagnosis of the participants.
CONCLUSION: Type D identifies persons with severely increased risk for mental distress, major psychosocial stressors and increased health care utilization. As a frequent disposition, Type D is assumed to be of high relevance for health care.
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Quantitative measurement of cartilage volume with automatic cartilage segmentation in knee osteoarthritis
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AMP (Acute Meniscal Pathology)
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Purpose: To determine the reproducibility of the automatic cartilage segmentation method using a prototype KneeCaP software (version 1.3; Siemens Healthcare, Erlangen, Germany) and to compare the difference in cartilage volume (CV) between the normal knee joint and knee osteoarthritis (KOA) of different degrees by using the above software. Materials and methods: The study included 62 subjects with knee OA and 29 healthy control subjects. The cartilage lesion patients were divided into a mild-to-moderate OA group (n = 29) and severe OA group (n = 33). Automatic cartilage segmentation was performed on all the subjects, and among them, 19 knee cases were randomly selected to also do the manual cartilage segmentation. Statistical significance was determined with one-way analysis of variance (ANOVA), intraclass correlation coefficient (ICC), and Pearson correlation coefficient. Automatic segmentation was compared with the manual one. The relative cartilage volume percentages of the femur, tibia, and patella in the normal control/mild-to-moderate/severe OA groups were assessed. Results: Comparing the cartilage volumes derived by manual and automatic segmentation, the ICC value for the knee joint, patella, femur, or tibia was 0.784, 0.815, 0.740, and 0.797. The relative cartilage volume percentages of the femur, tibia, and patella in the normal control/mild-to-moderate/severe OA groups were 57.28%/59.30%/62.45% (femur), 25.35%/23.46%/21.84% (tibia), and 17.37%/17.24%/15.71% (patella), respectively. Compared with the normal control group, the relative tibia cartilage volume percentage was lower in the mild-to-moderate OA group and the severe OA group. Corresponding index showed a similar difference between the mild-to-moderate OA group and the severe OA group (p < 0.001). Conclusion: This study demonstrated that the relative cartilage volume percentage is correlated with the semi-quantitative systems and may be a preferred outcome measure in clinical studies of OA. Automatic cartilage segmentation using KneeCaP delivered reliable results on high-spatial-resolution 3 T MR images for the healthy, mild-moderate OA patients.Key Points• The cartilage automatic segmentation has excellent reproducibility and was not affected by inter-observer variation.• The relative cartilage volume percentage is correlated with the semi-quantitative systems and may be a preferred outcome measure in clinical studies of OA.
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"Long-term stability of stimulating spiral nerve cuff electrodes on human peripheral nerves"
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DoD LSA (Limb Salvage vs Amputation)
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BACKGROUND: Electrical stimulation of the peripheral nerves has been shown to be effective in restoring sensory and motor functions in the lower and upper extremities. This neural stimulation can be applied via non-penetrating spiral nerve cuff electrodes, though minimal information has been published regarding their long-term performance for multiple years after implantation. METHODS: Since 2005, 14 human volunteers with cervical or thoracic spinal cord injuries, or upper limb amputation, were chronically implanted with a total of 50 spiral nerve cuff electrodes on 10 different nerves (mean time post-implant 6.7 +/- 3.1 years). The primary outcome measures utilized in this study were muscle recruitment curves, charge thresholds, and percent overlap of recruited motor unit populations. RESULTS: In the eight recipients still actively involved in research studies, 44/45 of the spiral contacts were still functional. In four participants regularly studied over the course of 1 month to 10.4 years, the charge thresholds of the majority of individual contacts remained stable over time. The four participants with spiral cuffs on their femoral nerves were all able to generate sufficient moment to keep the knees locked during standing after 2-4.5 years. The dorsiflexion moment produced by all four fibular nerve cuffs in the active participants exceeded the value required to prevent foot drop, but no tibial nerve cuffs were able to meet the plantarflexion moment that occurs during push-off at a normal walking speed. The selectivity of two multi-contact spiral cuffs was examined and both were still highly selective for different motor unit populations for up to 6.3 years after implantation. CONCLUSIONS: The spiral nerve cuffs examined remain functional in motor and sensory neuroprostheses for 2-11 years after implantation. They exhibit stable charge thresholds, clinically relevant recruitment properties, and functional muscle selectivity. Non-penetrating spiral nerve cuff electrodes appear to be a suitable option for long-term clinical use on human peripheral nerves in implanted neuroprostheses.
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Experience and technical refinements in the "donut" mastopexy with augmentation mammaplasty
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Reduction Mammoplasty for Female Breast Hypertrophy
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Minor ptosis and pseudoptosis of the breast may be corrected by a "donut" mastopexy. This technique offers the opportunity to reach a good aesthetic result with minimal scarring. A prosthesis is inserted at the time of the mastopexy and the skin is reduced in an elliptical way to achieve a good balance between the breast volume and the skin envelope.
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Has orthopaedic intervention for rheumatoid arthritis changed in line with combination and anti-TNF therapies? an evaluation of joint surgery rates and prognostic factors in two UK inception cohorts (1986-2011)
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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Background: Orthopaedic surgery in RA is considered a surrogate marker for joint destruction. It has been postulated that the need for orthopaedic surgery would be reduced with greater use of more intense therapies for RA. We were able to examine this proposal in two UK multicentre inception cohorts conducted between 1986 & 2011. Methods: The Early RA Study (ERAS) recruited from 1986-1999 (n=1465), the Early RA Network (ERAN) from 2002 (n=1236). Symptom onset to baseline was median 6 months in both and time to 1st DMARD was median 2 & 1 month respectively. Standardized clinical, laboratory and x-ray measures were performed yearly in both cohorts. Disease-modifying, steroid and biologic therapies reflected conventional practice and guidelines of the time frames examined. Source data of all orthopaedic interventions included clinical datasets (patient report and medical records from 1986), which were validated with Hospital Episode Statistics (HES from 1997) and the National Joint Registry (NJR from 2002). Length of follow up was based on the National Death Registry. Results: In
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The effect of bone quality on the outcome of ingrowth total knee arthroplasty
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Surgical Management of Osteoarthritis of the Knee CPG
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Bone quality generally is felt to be an important consideration when planning total knee arthroplasty (TKA). This prospective study was conducted to see if bone quality, as assessed intraoperatively in 346 knees, affects the outcome of ingrowth TKA. Group A consisted of 272 knees with good or excellent bone quality in all areas and Group B consisted of 74 knees with fair or poor bone in at least one area. The average follow-up was 48 months, with 301 knees (87%) available for follow-up. Group A knees had more males, were heavier, had fewer patients with rheumatoid arthritis, and exhibited more varus. Preoperatively, Groups A and B had modified Hospital for Special Surgery (HSS) knee scores that averaged 55 and 48, respectively. At 4 years post-surgery, Groups A and B had HSS scores of 92 and 90, respectively. Fluoroscopic radiographs of the bone-prosthesis interfaces showed 13% incomplete radiolucencies in Group A and 7% in Group B. A complete radiolucency was seen in one patient in Group A. Based on these results, it can be concluded that bone quality as determined by gross intraoperative inspection had little effect on the 4-year outcome of this ingrowth TKA
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Decisions on drug therapies by numbers needed to treat: a randomized trial
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Management of Hip Fractures in the Elderly
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BACKGROUND: The number needed to treat (NNT) has been promoted as the preferred effect measure when patients and physicians share decision making. Our aim was to explore the impact of the NNT on laypeople's decisions about preventive drug therapies. METHODS: Two thousand subjects were selected for the survey; 1201 (60%) responded for a representative sample of the Norwegian population. Respondents were allocated to scenarios with random combinations of a disease to be prevented, drug treatment costs, and effect size in terms of NNT. They were interviewed about their hypothetical consent to the therapy, then randomized to different interpretations of NNT and asked to reconsider their initial responses. RESULTS: The proportions consenting varied from 76% when the NNT was 50 to 67% when the NNT was 1600 (P for trend = .06). When faced with the prospect of avoiding lethal disease, stroke, myocardial infarction, or hip fracture, the proportions consenting were 84%, 76%, 68%, and 53%, respectively (P<.01). Across different treatment costs ($37, $68, $162, and $589) the proportions consenting varied from 78% to 61% (P for trend <.01). Twenty-four percent of the respondents changed their decision when informed about how to interpret the NNT, and 93% of those switched from positive to negative decisions, regardless of the magnitude of NNT. CONCLUSIONS: Respondents' decisions were influenced by the type of disease to be prevented and the cost of the intervention, but not by the effect size in terms of NNT. This suggests that NNT is difficult to understand and that other effect formats should be considered for shared decision making
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Small-dose intrathecal clonidine and isobaric bupivacaine for orthopedic surgery: a dose-response study
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AAHKS (8) Anesthetic Infiltration
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We examined the dose-response relationship of intrathecal clonidine at small doses (<or=150 microg) with respect to prolonging bupivacaine spinal anesthesia. We aimed for establishing doses of intrathecal clonidine that would produce clinically relevant prolongation of spinal anesthesia and pain relief without significant side effects. Eighty orthopedic patients were randomly assigned to intrathecally receive isobaric 0.5% bupivacaine, 18 mg, plus saline (Group 1), clonidine 37.5 microg (Group 2), clonidine 75 microg (Group 3), and clonidine 150 microg (Group 4). Duration of the sensory block (regression below level L1) was increased in patients receiving intrathecal clonidine: 288 +/- 62 min (Group 1, control), 311 +/- 101 min in Group 2 (+8%), 325 +/- 69 min in Group 3 (+13%), and 337 +/- 78 min in Group 4 (+17%) (estimated parameter for dose 0.23 [95% confidence interval -0.05-0.50]). Duration of pain relief from intrathecal clonidine administration until the first request for supplemental analgesia was significantly prolonged: 295 +/- 80 min (Group 1, control), 343 +/- 75 min in Group 2 (+16%), 381 +/- 117 min in Group 3 (+29%), and 445 +/- 136 min in Group 4 (+51%) (estimated parameter for dose 1.02 [95% confidence interval 0.59-1.45]). Relative hemodynamic stability was maintained and there were no between-group differences in the sedation score. We conclude that small doses of intrathecal clonidine (<or=150 microg) significantly prolong the anesthetic and analgesic effects of bupivacaine in a dose-dependent manner and that 150 microg of clonidine seems to be the preferred dose, in terms of effect versus unwarranted side effects, when prolongation of spinal anesthesia is desired.
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Osteoporosis and shoulder osteoarthritis: incidence, risk factors, and surgical implications
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Glenohumeral Joint OA
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BACKGROUND: Patients with osteoarthritis undergoing shoulder arthroplasty may suffer from osteoporosis. The purpose of this study was to determine whether computed tomography (CT)-derived Hounsfield unit (HU) measurements correlate with bone mineral density (BMD) and whether these data could predict implant size and fixation choice.
MATERIALS AND METHODS: The study analyzed preoperative dual energy x-ray absorptiometry and shoulder CT scans for 230 patients who underwent total shoulder arthroplasty. Hip BMD and T scores and HU attenuation in the humerus were correlated. HU cutoff values were developed to aid in differentiating patients whose BMD values were within normal reference ranges from patients with osteopenia or osteoporosis. Risk factors associated with low BMD were correlated, and the effect of BMD on humeral stem size, and fixation method was investigated.
RESULTS: Significant correlations between HU and hip BMD and T score were identified (P < .001). HU value ranges were identified that may alert the surgeon of metabolic bone disease. Significant correlation (P < 0.05) was found between low BMD and certain osteoporosis risk factors. Age at time of surgery was a predictor of cemented stem fixation (P = .024). Patients with a lower BMD were statistically more likely to receive a larger-diameter humeral stem (P = .016).
CONCLUSIONS: Orthopedic surgeons may be able to use data obtained from shoulder CT scans to predict the need for larger stem size or cement fixation during shoulder arthroplasty. In combination with the risk factor profile, these data may be useful in predicting the need for an osteoporosis workup and treatment.
LEVEL OF EVIDENCE: Level III, Study of Nonconsecutive Patients, Diagnostic Study.
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Parental stress and burden following traumatic brain injury amongst children and adolescents
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DoD PRF (Psychosocial RF)
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PRIMARY OBJECTIVES: To assess parental stress following paediatric traumatic brain injury (TBI), and examine the relationship between self-reported problems, parental stress and general health.
RESEARCH DESIGN: Parents of 97 children admitted with a TBI (49 mild, 19 moderate, 29 severe) to North Staffordshire National Health Service Trust, and parents of 31 uninjured children were interviewed and assessed.
METHODS AND PROCEDURES: Structured interviews were carried out with families, and parents assessed on the Parenting Stress Index (PSI/SF) and General Health Questionnaire (GHQ-12) at recruitment, and repeated 12 months later.
MAIN OUTCOMES AND RESULTS: Forty parents (41.2%) of children with TBI exhibited clinically significant stress. Regardless of injury severity, parents of injured children suffered greater stress than control parents as measured by the PSI/SF (p = 0.001). There was a highly significant relationship between number of problems reported and level of parental stress (p = 0.001). Financial burden was related to severity of TBI. At follow-up, one third of parents of children with severe TBI scored > or =18 on the GHQ-12, signifying poor psychological health.
CONCLUSIONS: The parents of a child with serious TBI should be screened for abnormal levels of stress. Parental stress and family burden may be alleviated by improved information, follow-up and support.
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Gait and clinical improvements with a novel knee brace for knee OA
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OAK 3 - Non-arthroplasty tx of OAK
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INTRODUCTION: Knee osteoarthritis causes debilitating pain, and results in characteristic gait changes. Some authors believe that a system of neuromuscular retraining may improve these parameters. We therefore evaluated a novel brace that combines pneumatic joint unloading and active swing-assist to assess: (1) differences in pain levels or medication usage; (2) reductions in additional interventions; (3) changes in quadriceps muscle strength; and (4) improvements in specific gait measurements after 3 months.
PATIENTS AND METHODS: A prospective pilot series of 10 knee osteoarthritis patients who had exhausted other nonoperative treatment measures were enrolled. These patients were compared with the previous 15 knee osteoarthritis patients who met similar criteria, but were not braced. Quadriceps muscle strength was measured, as were pain levels, and additional interventions such as injections or total knee arthroplasty procedures. Gait parameters measured included: walking speed, total range-of-motion, knee flexion at foot-strike, and knee adduction moment.
RESULTS: All but one of the compliant patients reported a decrease of at least two pain points after 3 months of use. There was one additional intervention in the brace cohort versus a statistical increase of 10 in the nonbrace cohort. All patients who were compliant with the brace showed an increase in thigh girth measurements, compared with none in the nonbrace cohort. Braced patients experienced retained improvements in at least one gait parameter including improved walking speed, total range of motion, and improved knee-angle at heel strike. The mean improvement in knee adduction moment was a decrease of 0.2255 Nm/kg (range, 0.56 to 0.564 Nm/kg), showing a mean improvement of 48% (range, 16 to 76% of original peak moment).
CONCLUSIONS: The use of a brace that has features including a combination of unloader characteristics along with active swing-assist, provided neuromuscular retraining benefits for patients who have knee osteoarthritis. In summary, although quite encouraging, future larger scale and prospective randomized studies need to assess the potential benefits of this brace for treating knee osteoarthritis.
LEVEL OF EVIDENCE: Level II.
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Pediatric trauma beyond the brain
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DOD - Acute Comp Syndrome CPG
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In pediatric trauma care, many long-held tenets of management have been revised. This article reviews the latest advances in pediatric trauma care, particularly in the areas of resuscitation and management of thoracic and abdominal injuries. The final topic is a discussion of what the intensivist and surgeon must know when caring for the pediatric victim of terrorist attacks.
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A review of transfusion risks and optimal management of perioperative bleeding with cardiac surgery
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Coronavirus Disease 2019 (COVID-19)
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Although the incidence and pathophysiology of many transfusion-related complications are well documented, unresolved questions persist. Transfusion medicine initiatives are being implemented to reduce complications (e.g., chemical inactivation of pathogens, WBC depletion); however, the literature is describing an increased incidence of other potential transfusion-related problems (e.g., TRALI, immune-modulation, MOSF), in addition to identifying new potential pathogens (e.g., variant CJD, SARS, avian influenza viruses). Furthermore, blood shortages may limit our ability to adequately manage our anemic and bleeding patients. Excessive bleeding after cardiac surgery can result in increased morbidity and mortality due to transfusion- and hypoperfusion-related complications, as well as injury to critical organ systems. Use of POC tests of hemostatic function can facilitate the optimal management of excessive bleeding and reduce transfusion. Accordingly, POC tests that assess PLT function may also identify patients at risk for acquired, PLT-related bleeding that may be attenuated with pharmacologic agents. In addition, rapid acquisition of coagulation data can also allow physicians to better differentiate between microvascular bleeding and surgical bleeding. An ideal algorithm would encompass test systems that evaluate heparin activity, fibrinolysis, coagulation factor levels, and qualitative and quantitative PLT abnormalities. rFVIIa has the potential to reduce transfusions and transfusion-related sequelae and may be life-saving in certain circumstances. Randomized, controlled trials are warranted, however, to assess both the efficacy and, more importantly, the safety of this intervention in cardiac surgical patients before its use as a first-line therapy for bleeding or for bleeding prophylaxis. We must continue to carefully investigate the role of new interventions, because the ability to reduce use of blood products to decrease operative time and/or reexploration rates has important implications for disease prevention, overall patient safety, blood inventory, and associated costs, as well as overall health care costs.
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Skeletal disorders in children with renal failure
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Diagnosis and Treatment of Osteochondritis Dissecans AUC
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There are relatively few reports concerning management of the musculoskeletal problems of children with renal failure. From a population group of 124 children with renal failure treated at The Children's Hospital, Camperdown, 16 were referred for management of skeletal problems. These problems included genu valgum, slipped capital femoral epiphysis, ankle valgus, procurvatum of the tibia, osteonecrosis, osteochondritis dissecans, "brown tumors," gout, and pathological fracture. The methods of management of these problems are discussed
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Body mass index as a predictor of fracture risk: a meta-analysis
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Management of Hip Fractures in the Elderly
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Low body mass index (BMI) is a well-documented risk factor for future fracture. The aim of this study was to quantify this effect and to explore the association of BMI with fracture risk in relation to age, gender and bone mineral density (BMD) from an international perspective using worldwide data. We studied individual participant data from almost 60,000 men and women from 12 prospective population-based cohorts comprising Rotterdam, EVOS/EPOS, CaMos, Rochester, Sheffield, Dubbo, EPIDOS, OFELY, Kuopio, Hiroshima, and two cohorts from Gothenburg, with a total follow-up of over 250,000 person years. The effects of BMI, BMD, age and gender on the risk of any fracture, any osteoporotic fracture, and hip fracture alone was examined using a Poisson regression model in each cohort separately. The results of the different studies were then merged. Without information on BMD, the age-adjusted risk for any type of fracture increased significantly with lower BMI. Overall, the risk ratio (RR) per unit higher BMI was 0.98 (95% confidence interval [CI], 0.97-0.99) for any fracture, 0.97 (95% CI, 0.96-0.98) for osteoporotic fracture and 0.93 (95% CI, 0.91-0.94) for hip fracture (all p <0.001). The RR per unit change in BMI was very similar in men and women ( p >0.30). After adjusting for BMD, these RR became 1 for any fracture or osteoporotic fracture and 0.98 for hip fracture (significant in women). The gradient of fracture risk without adjustment for BMD was not linearly distributed across values for BMI. Instead, the contribution to fracture risk was much more marked at low values of BMI than at values above the median. This nonlinear relation of risk with BMI was most evident for hip fracture risk. When compared with a BMI of 25 kg/m(2), a BMI of 20 kg/m(2) was associated with a nearly twofold increase in risk ratio (RR=1.95; 95% CI, 1.71-2.22) for hip fracture. In contrast, a BMI of 30 kg/m(2), when compared with a BMI of 25 kg/m(2), was associated with only a 17% reduction in hip fracture risk (RR=0.83; 95% CI, 0.69-0.99). We conclude that low BMI confers a risk of substantial importance for all fractures that is largely independent of age and sex, but dependent on BMD. The significance of BMI as a risk factor varies according to the level of BMI. Its validation on an international basis permits the use of this risk factor in case-finding strategies
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Bilateral carpal tunnel syndrome in an adolescent
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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A 13-year-old boy with nocturnal paresthesias of the hands was shown to have bilateral carpal tunnel syndrome by electrodiagnosis. Surgical findings included thickening of the transverse carpal ligament and local anomalies of tendon and muscle. Surgical correction produced prompt relief
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Influence of age and body weight on spine and femur bone mineral density in U.S. white men
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Management of Hip Fractures in the Elderly
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Bone mineral density (BMD) was measured in normal white males using 153 Gd dual-photon absorptiometry. Measurements were made on the lumbar spine (n = 315) and on the proximal femur (n = 282) utilizing three regions of interest. There was a small but significant age-related decrease in spinal BMD (r = -0.11; -0.001 g/cm2 per year) and trochanteric BMD (r = 0.27; -0.002 g/cm2 per year). The BMD of the other femoral sites decreased more rapidly; the femoral neck (r = -0.58; -0.005 g/cm2 per year) and Ward's triangle (r = -0.69; -0.007 g/cm2 per year) declined by about 21 and 34%, respectively, from age 20 to age 70. These femoral BMD decreases were three to four times greater than those usually seen in the peripheral skeleton in males but less than the decreases of 25-30 and 40% in the femoral neck and Ward's triangle of white females. This pattern of aging bone loss may partially explain the paucity of spine fractures and the lower incidence of hip fractures in males versus females
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Biomechanical Osteoarthritis Outcomes in Meniscectomy Patients
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OAK 3 - Non-arthroplasty tx of OAK
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The key aim of this study is to examine biomechanical measures associated with osteoarthritis (OA) progression in patients who have lateral and medial menisci injuries during various tasks. The likelihood is that individuals who have a meniscal injury often develop knee osteoarthritis. Therefore understanding biomechanical changes from the injury, specifically undertaking both functional and sporting activities, may provide a conservative approach to delaying or minimising the development of OA. Threeâ?dimensional kinetic and kinematic measures will be assessed during seven tasks (walking, running, side cuts, single leg landing, small knee bend squat and isokinetic leg strength), prior to and following treatment. In addition, Strength and balance will be assessed to indicate if there is more work in the rehabilitation program that is needed for functional movement.
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The operative management of osteoporotic fractures of the knee: to fix or replace?
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Surgical Management of Osteoarthritis of the Knee CPG
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This review considers the surgical treatment of displaced fractures involving the knee in elderly, osteoporotic patients. The goals of treatment include pain control, early mobilisation, avoidance of complications and minimising the need for further surgery. Open reduction and internal fixation (ORIF) frequently results in loss of reduction, which can result in post-traumatic arthritis and the occasional conversion to total knee replacement (TKR). TKR after failed internal fixation is challenging, with modest functional outcomes and high complication rates. TKR undertaken as treatment of the initial fracture has better results to late TKR, but does not match the outcome of primary TKR without complications. Given the relatively infrequent need for late TKR following failed fixation, ORIF is the preferred management for most cases. Early TKR can be considered for those patients with pre-existing arthritis, bicondylar femoral fractures, those who would be unable to comply with weight-bearing restrictions, or where a single definitive procedure is required
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The National Register of Joint Replacements of the Czech Republic
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PJI DX Updated Search
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The National Register of Joint Replacements of the Czech Republic was established as part of the National Health Information System in 2002. The register's administrator is the Institute of Health Information and Statistics of the Czech Republic, the Czech Society for Orthopaedics and Traumatology acts as its guarantor of scientific quality. The register is financed from governmental sources. It was launched into full operation in 2003 and it currently focuses on hip joint replacements. Register of knee and shoulder joint replacements is in the process of preparation. The register provides aggregate epidemiological data and other statistics, including the Revision Rate (RR) and curves of cumulative survival probability (Kaplan-Meier) for the main monitored groups of patients and implants used. In years 2003-2012 there were 101,734 primary implantations and 13,459 revision surgeries registered. In terms of gender distribution there is a predominance of females amounting to 59.4% in primary implantations and to 63.49% in revision surgeries. The age structure covers the entire range of adult population; however, more than 50% of the replacements are being implanted between 60-74 years of age. Most frequent indications for primary implantation are primary coxarthrosis (69.85%), post-fracture conditions (13.41%) and post-dysplasia arthritis (8.73%). The most frequent indications for revision surgery are aseptic loosening of acetabular component (38.15%), aseptic loosening of femoral component (22.01%) and recurrent dislocation (6.5%). 45,450 (44.68%) of primary implantations were cemented, 36,477 (35.86%) uncemented, 16,559 (16.28%) hybrid with cemented femur and 656 (0.64%) hybrid with cemented acetabulum. There were also records of 2,592 cervicocapital prostheses (2.55%). Most commonly used is the classic anterolateral approach 75.86% in primary implantations and 50.06% in revision surgeries. Mini-invasive approaches in primary implantations did not exceed 3.2% of all cases. Bone grafts were used in 23.89% of primary implantations and 39.55% of revisions. Most widely used implants in primary implantations were cemented PE cup type Muller (Aesculap) 14,000 pcs, original Czech cemented steel Stem with conical neck 12/14 AK (Beznoska) 13,433 pcs, from uncemented models Plasmacup SC (Aesculap) 9,762 pcs and Stem SL "Zweymuller Alloclassic" (Zimmer) 4,337 pcs. Generally most widely used implants in revision surgeries are uncemented Czech Oval cup MO (Medin) with titanium & hydroxyapatite porous coat 956 pcs and uncemented Stem SL WAGNER, lateralised, cone 12/14 (Zimmer) 712 pcs. The Revision Rate for primary implants due to infection for period 2003-2012 represented 0.06% at the end of the followup as of June 30, 2013. Cumulative survival probability (Kaplan-Meier) in year 11 of the follow-up is 95.69% in cemented implants, 94.55% in uncemented, 92.90% in hybrids with cemented femur and 84.11% in hybrids with cemented cup
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The most important frequently asked questions of patients with hip or knee osteoarthritis: a best-worst scaling exercise
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OAK 3 - Non-arthroplasty tx of OAK
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OBJECTIVE: The aim of this study was to collect and prioritize which questions (FAQs) patients with hip or knee osteoarthritis and healthcare professionals consider to be the most important to be answered, in order to identify informational needs that go beyond guideline recommendations.
METHODS: The following steps were taken: 1) FAQs were collected among healthcare professionals and from the arthritis-helpline of the Dutch Arthritis Foundation. 2) After deleting overlapping FAQs, remaining FAQs were prioritized by patients and healthcare professionals using a Maximum Difference Scaling method. Hierarchical Bayesian method was used to calculate relative importance scores (RIs). Differences between healthcare professionals and patients were analyzed using independent t-tests (significance level of p <= 0.05).
RESULTS: 28 healthcare professionals and the arthritis-helpline provided 192 FAQs. After deleting overlapping FAQs, 60 FAQs were prioritized by 94 patients (57 (60.6%) women, mean age 67.3 years) and 122 healthcare professionals (67 (54.9%) women, mean age 45.7 years). The FAQ "What can I do myself to decrease symptoms and to prevent the OA from getting worse?" was prioritized as most important by both patients and professionals. FAQs that were highly prioritized by patients and significantly different from professionals were more directed towards treatment options offered by different healthcare professionals, whereas highly prioritized FAQs of professionals were more often focused on treatment options involving self-management.
CONCLUSION: Healthcare professionals' perspective on informational needs differ from that of OA-patients. These differences are important to address in order to achieve more active involvement of patients in their own treatment process. This article is protected by copyright. All rights reserved.
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Noncemented Total Hip Arthroplasty in Sickle-Cell Disease: Long-Term Results
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DoD SSI (Surgical Site Infections)
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Background: Avascular necrosis of the femoral head is a well-known sequela of sickle-cell disease (SCD) requiring a surgical intervention that comes with technical challenges. Methods: Uncemented hip arthroplasty for avascular necrosis of the femoral head due to SCD was carried out for 101 patients (133 hips) between 2000 and 2012. The duration of follow-up ranged from 5 to 17 years (mean, 14.59 years). All patients received a noncemented femoral stem and a noncemented acetabular shell. Results: After surgery, all patients showed improvement in their hip scores for pain, range of motion, and function. The 10-year survivorship was 98%. There were 6 intraoperative fractures of the proximal femur (4.5%), 4 superficial and 5 deep infections (6.77%), 1 aseptic shell failure (0.75%), and 1 aseptic femoral stem failure (0.75%). Brooker grade IV heterotopic ossification developed in 5 hips (3.76%). Conclusion: Hip arthroplasty in SCD is now a safe and effective procedure when the high rate of complications associated with this disease is given full consideration. With careful preoperative and postoperative planning, a highly successful outcome can be achieved. Noncemented shells and noncemented stems have shown durable long-term results.
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Outcome of allogeneic hematopoietic cell transplantation from HLA-identical siblings for severe aplastic anemia in patients over 40 years of age
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Reconstruction After Skin Cancer
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Patients with severe aplastic anemia (SAA) over 40 years of age are often not offered treatment with hematopoietic cell transplantation (HCT) because of concerns about treatment-related morbidity or mortality. To evaluate this risk, we analyzed outcomes after allogeneic HCT from HLA-identical sibling donors for all older patients with SAA at our center since 1988. The 23 consecutive patients ranged in age from 40 to 68 years. The conditioning regimen was cyclophosphamide (200 mg/kg) and horse antithymocyte globulin. Methotrexate and cyclosporine were given for postgrafting immunosuppression. The cumulative incidences of grades II, III, and IV acute graft-versus-host-disease were 30%, 4%, and 0%, respectively; that for chronic GVHD was 26%. With a median follow-up of 9.1 years, overall survival was 65%. Documented infections within 1 month before HCT were significantly associated with risk of early treatment-related mortality (P < .001). The median time to discontinuation of posttransplant immunosuppression was 6.2 (range: 5.9-92.0) months. Three patients developed superficial basal cell carcinoma between 5.5 and 15 years after HCT. Our data favor a practice of extending HLA-identical sibling HCT for treatment of SAA in patients older than 40 years of age who are without significant medical comorbidities. © 2010 American Society for Blood and Marrow Transplantation.
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Low incidence of calcium pyrophosphate dihydrate crystal deposition in rheumatoid arthritis, with modification of radiographic features in coexistent disease
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AMP (Acute Meniscal Pathology)
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A negative correlation between rheumatoid arthritis (RA) and calcium pyrophosphate dihydrate (CPPD) crystal deposition was demonstrated in separate controlled radiographic and synovial fluid surveys of RA patients aged 55-75 years. Knee chondrocalcinosis was detected in 14% of 135 normal controls and 28% of 87 post-meniscectomy ("joint damage") controls (P less than 0.05), but only 3% of 100 RA and 75 osteoarthritis patients revealed CPPD crystals in 1% and 23%, respectively (P less than 0.01). Ten subjects with coexistent RA and CPPD deposition were also studied; 7 showed radiographic features atypical of RA, including patchy, asymmetric disease, retained bone density, prominent osteophytosis, well-corticated cysts, and paucity of progressive erosive disease. It is suggested that rheumatoid joint damage, unlike that in osteoarthritis, is not conducive to CPPD crystal formation. When RA and CPPD coexist, atypical radiographic features reflecting a hypertrophic reparative response may occur.
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Effect of hypoxia/reoxygenation on the cytokine-induced production of nitric oxide and superoxide anion in cultured osteoarthritic synoviocytes
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OAK 3 - Non-arthroplasty tx of OAK
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OBJECTIVE: Hypoxia/reoxygenation (H/R) is an important feature in the osteoarthritis (OA) physiopathology. Nitric oxide (NO) is a significant proinflammatory mediator in the inflamed synovium. The purpose of this study was to investigate the effects of H/R on inducible NO synthase (iNOS) activity and expression in OA synoviocytes. In addition we studied the relationship between nitrosative stress and NADPH oxidase (NOX) in such conditions.
METHODS: Human cultured synoviocytes from OA patients were treated for 24 h with interleukin 1-beta (IL-1beta), tumour necrosis factor alpha (TNF-alpha) or neither; for the last 6 h, they were submitted to either normoxia or three periods of 1-h of hypoxia followed by 1-h of reoxygenation. .NO metabolism (iNOS expression, nitrite and peroxynitrite measurements) was investigated. Furthermore, superoxide anion O2(.-) production, NOX subunit expression and nitrosylation were also assessed.
RESULTS: iNOS expression and nitrite (but not peroxynitrite) production were ~0.20 to ~0.12 nmol min(-1) mg proteins(-1) (P < 0.05), while NOXs' subunit expression and p47-phox phosphorylation were increased. NOXs and p47-phox were dramatically nitrosylated under H/R conditions (P < 0.05 vs normoxia). Using NOS inhibitors under H/R conditions, p47-phox nitrosylation was prevented and O2(.-) production was restored at normoxic levels (0.21 nmol min(-1) mg of proteins(-1)).
CONCLUSIONS: Our results provide evidence for an up-regulation of iNOS activity in OA synoviocytes under H/R conditions, associated to a down-regulation of NOX activity through nitrosylation. These findings highlight the importance of radical production to OA pathogenesis, and appraise the metabolic modifications of synovial cells under hypoxia.
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Future directions in regional treatment strategies for melanoma and sarcoma
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Reconstruction After Skin Cancer
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Hyperthermic isolated limb perfusion (HILP) with melphalan and more recently isolated limb infusion (ILI) with melphalan +/- dactinomycin are common treatment modalities for both in-transit melanoma of the extremity and advanced extremity sarcoma. In order to further optimize treatment, future research should focus on selection of appropriate patients, verification of a technique that produces consistent results while maintaining acceptable toxicity, and development of novel strategies and agents. Development of these novel agents and strategies has potential to not only improve the efficacy of regional chemotherapy but may also help guide future strategies for systemic treatment.
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Should Kirschner wires for fixation of lateral humeral condyle fractures in children be buried or left exposed? A systematic review
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DoD SSI (Surgical Site Infections)
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BACKGROUND: Displaced lateral humeral condyle fractures in children are usually treated with open reduction and internal fixation. When treated operatively with Kirschner wires, the bent cut near side wire ends are either buried in the subcutaneous tissue or are left exposed. It is believed that burying the wires allows them to remain in longer and hence facilitate better union. Leaving them exposed seems to necessitate earlier removal, especially to reduce the risk of wire tract infection. There is not a clear consensus in published literature whether subcutaneous wire burial is better or not.
PATIENTS AND METHODS: A systematic review of literature was performed using online database EMBASE, Pubmed, Medline, CINAHL and Cochrane database. The inclusion criteria comprised only those studies that compared lateral humeral condyle fracture fixation in children with wires buried subcutaneously versus those left exposed to skin.
RESULTS: Of the four studies identified, three reported that it was safe to leave the wires exposed and that there was no statistically significant advantage of burying the wires with regards to risk of infection. However, our meta-analysis of the four studies demonstrated on forest plot charts that there is an increased risk of infection when the wires are left exposed (odds ratio 0.538 CI 0.437-0.639), but the overall complication rate was less in the group treated with exposed wires. Treatment with exposed wires was also cost effective when compared to treatment with buried wires.
DISCUSSION: Our review concluded that despite a higher risk of superficial infections, exposed wires are safe and an economical option when fixing lateral humeral condyle fractures in children.
LEVEL OF EVIDENCE: II, systematic review.
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0 |
Evaluating Anterior Knee Pain
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Osteochondritis Dissecans 2020 Review
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Musculoskeletal complaints account for about 20% to 30% of all primary care office visits; of these visits, discomfort in the knee, shoulder, and back are the most prevalent musculoskeletal symptoms. Having pain or dysfunction in the front part of the knee is a common presentation and reason for a patient to see a health care provider. There are a number of pathophysiological etiologies to anterior knee pain. This article describes some of the common and less common causes, and includes sections on diagnosis and treatment for each condition as well as key points. © 2014 Elsevier Inc.
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1 |
Noncontiguous and open fractures of the lower extremity: Epidemiology, complications, and unplanned procedures
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DoD SSI (Surgical Site Infections)
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INTRODUCTION: Isolated fractures of the lower extremity are relatively common injuries while multifocal injuries resulting from high-energy trauma are less frequently encountered. Our objectives are to characterise patients who sustained multiple noncontiguous fractures and open fractures of the lower extremity, report the incidence of major complications, and identify factors that may contribute to complications and unplanned re-operations.
PATIENTS AND METHODS: A retrospective review of patients was performed at a Level 1 trauma centre from 2000 to 2013. Patients who sustained two or more noncontiguous operative fractures in an ipsilateral lower extremity, with at least one open fracture were included. Noncontiguous was defined as fractures in the same lower limb that were not in continuity on preoperative radiographs or intra-operatively. Demographic, injury characteristics, and hospitalisation data were collected. Primary outcomes included non-union, deep infection, and the need for unplanned surgeries.
RESULTS: 257 patients sustained a total of 876 lower extremity fractures with an average of 1.7 open and 2.7 operative fractures in the qualifying limb. Ninety-nine patients (38.5%) sustained bilateral lower extremity injuries. Following their initial stay, 22.6% of patients had planned procedures (definitive fixation, skin, or planned bone grafting). Nearly half (45.9%) required one or more unplanned re-operation. Complications included deep infections (19.5%), non-unions (19.5%), and mal-unions (2.7%). 17.5% of the patients had at least one procedure for removal of painful implants. A deep infection was predictive of having a non-union (odds ratio, OR 7.5). The presence of a Gustilo-type IIIB/IIIC (OR 24.6/16.0) fracture was predictive of having a deep infection. After excluding painful implant removal, a type IIIB fracture was associated with an unplanned procedure (OR 13.8).
CONCLUSIONS: Patients with multiple non-contiguous lower extremity injuries associated with open fractures can expect complications including non-unions, deep infections, and painful implants. Nearly half of the patients will need further operative treatment.
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0 |
Prospective study on harvesting autologous bone grafts from the anterior iliac crest using a new specialized reamer
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DoD SSI (Surgical Site Infections)
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The iliac crest remains the most frequent donor site for bone harvesting. Despite the surgical access to the iliac crest being relatively simple and the operation being carried out regularly, there are frequent complications. Therefore, a new, manual iliac crest reamer (R group) was compared to the classical harvesting of a corticocancellous bone graft by means of an oscillating saw (Con group) in a prospective study on 80 consecutive patients having hand surgery. Follow-up time was 3 months. Operation time and incidence of hematomas, seromas, and paresthesias in the R group were significantly shorter and less, respectively, than in the Con group. Pain at harvest site measured with the visual analogue scale (VAS) at 5 days, 6 weeks, and 12 weeks postoperatively was significantly less in group R as well. The utilization of the iliac crest reamer allows bone graft harvest in a relatively quick and simple operation with relatively few complications but with the limitation in that the maximum diameter of a bone cylinder that it can harvest is 20 mm.
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0 |
Changing incidence of orthopedic surgery in rheumatic disease: Contributing factors topical collection on surgery and perioperative care
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AMP (Acute Meniscal Pathology)
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Rheumatic diseases are multisystem conditions that predominantly affect the musculoskeletal system, leading to soft tissue and articular damage. Historically, medical therapy was able to slow, but not prevent, erosion and joint destruction, resulting in the frequent need for orthopedic procedures to maintain function and minimize pain. However, the widespread use of disease-modifying anti-rheumatic drugs (DMARDs) and biologic therapy over the last twenty years has resulted in a dramatic decrease in the incidence of musculoskeletal damage and impairment among these patients. This review will discuss changing patterns of orthopedic surgery among patients with rheumatic diseases, focusing on rheumatoid arthritis and systemic lupus erythematosus. © 2013 Springer Science+Business Media New York.
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0 |
Induction of prolactin expression and release in human preadipocytes by cAMP activating ligands
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Reduction Mammoplasty for Female Breast Hypertrophy
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In addition to the pituitary, prolactin (PRL) in humans is produced at non-pituitary sites where it acts as a cytokine. We previously reported that PRL is expressed and released from breast adipose explants, raising the question as to the dynamics of its production and its regulation. Preadipocytes were isolated from breast adipose tissue obtained during breast reduction. PRL expression was transiently increased during early preadipocyte differentiation. Both isoproterenol, a beta-adrenergic receptor agonist, and PACAP, pituitary adenylate cyclase activating peptide, increased PRL expression, and release from preadipocytes. This stimulation was suppressed by several protein kinase inhibitors, suggesting involvement of multiple signaling pathways. Transfection of preadipocytes with a superdistal PRL promoter/luciferase reporter revealed two stimulatory domains and an inhibitory domain. These data establish the transcriptional regulation of adipocyte PRL by the superdistal PRL promoter, its transient expression during adipogenesis, and the stimulatory effect of catecholamines and PACAP.
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0 |
Distribution of Porphyromonas gingivalis fimA genotypes in cardiovascular specimens from Japanese patients
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Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures
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INTRODUCTION: Porphyromonas gingivalis, a major periodontal pathogen, is gaining increasing attention for its possible association with cardiovascular diseases. Its fimbriae are classified into six genotypes (types I-V and Ib) based on the diversity of the fimA genes encoding the fimbrial subunits. In this study, fimA genotypic distribution was analyzed in P. gingivalis-infected cardiovascular specimens. METHODS: A total of 112 heart valves and 80 atheromatous plaque specimens were collected from patients undergoing cardiovascular surgery, as well as 56 dental plaque specimens. Bacterial DNA was extracted from each, and polymerase chain reaction analysis was carried out with a P. gingivalis-specific set of primers. P. gingivalis-positive specimens were further analyzed to discriminate the fimA genotype using polymerase chain reaction with fimA type-specific primer sets. RESULTS: P. gingivalis was detected in 10.4% of the cardiovascular specimens and 50.0% of the dental plaque samples. In the latter, type II was most frequently detected (35.7%), followed by types I (28.6%) and IV (21.4%), while types IV and II were detected with considerable frequencies of 45.0% and 30.0%, respectively, in the cardiovascular specimens. In contrast, the occurrence of type I was limited (5.0%) in the cardiovascular specimens. CONCLUSION: These results suggest that specific fimA genotypic clones, which are reportedly associated with periodontitis, are also frequently harbored in cardiovascular specimens, indicating the possible involvement of type II and IV clones in the initiation and progression of cardiovascular diseases
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