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The use of autologous platelet-rich plasma (platelet gel) and autologous platelet-poor plasma (fibrin glue) in cosmetic surgery
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Reduction Mammoplasty for Female Breast Hypertrophy
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The purpose of this study was to evaluate a new technique of harvesting and preparing autologous platelet gel and autologous fibrin glue (body glue) and to evaluate their effectiveness in stopping capillary bleeding in the surgical flaps of patients undergoing cosmetic surgery. A convenience sample of 20 patients ranging from 25 to 76 years of age undergoing cosmetic surgery involving the creation of a surgical flap were included in the study. The types of surgical procedures included face lifts, breast augmentations, breast reductions, and neck lifts. Platelet-poor and platelet-rich plasma were prepared during the procedure from autologous blood using a compact, tabletop, automated autologous platelet concentrate system (SmartPReP, Harvest Autologous Hemobiologics, Norwell, Mass.). The platelet-poor and platelet-rich plasma were combined with a thrombin-calcium chloride solution to produce autologous fibrin glue and autologous platelet gel, respectively. Capillary bed bleeding was present in all cases and effectively sealed within 3 minutes following the application of platelet gel and fibrin glue. The technique for making the solution and for evaluating its effectiveness in achieving and maintaining hemostasis during cosmetic surgical procedures is described. Autologous platelet gel and fibrin glue prepared by the automated concentrate system are compared with autotransfusor-prepared platelet gel and Tisseel (Baxter Healthcare Corp.), a commercially prepared fibrin sealant preparation.
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Development and validation of a SEER-based prognostic nomogram for patients with bone metastatic prostate cancer
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MSTS 2022 - Metastatic Disease of the Humerus
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Controversies exist between the previous two prognostic nomograms for patients with bone metastatic prostate cancer (PCa), and a nomogram applied to western patients has yet to be established. Thus, we aimed to build a reliable and generic nomogram to individualize prognosis. The independent prognostic factors were identified in a retrospective study of 1556 patients with bone metastatic PCa registered in the Surveillance, Epidemiology and End Results (SEER) database. Besides, the prognostic nomogram was developed using R software according to the result of multivariable Cox regression analysis. Then, the discriminative ability of the nomogram was assessed by analyses of receiver operating characteristic curves (ROC curves). We also performed 1-, 2-, and 3-year calibrations of the nomogram by comparing the predicted survival to the observed survival. Furthermore, the model was externally validated using the data of 711 patients diagnosed at different times enrolled in the SEER database.Age >=70 years, Gleason score >=8, PSA value of 201 to 900 ng/ml, stage T4, stage N1, with liver metastases, and Asian/Pacific ethnicity were identified as independent prognostic factors. In the primary cohort, 1-, 2-, and 3-year area under the ROC curve (AUC) of the nomogram for predicting cancer-specific survival (CSS) were 0.71, 0.70, and 0.70, respectively. Besides 1-, 2-, and 3-year AUC were 0.70, 0.68, and 0.69, respectively, in the external validation cohort. Moreover, calibration curves presented perfect agreements between the nomogram-predicted and actual 1-, 2-, and 3-year CSS rate in both the primary and external validation cohorts. In other words, our nomogram has great predictive accuracy and reliability in predicting 1-, 2-, and 3-year CSS for patients with bone metastatic prostate cancer. This study established and validated a prognostic nomogram applied to not only Asian patients but western patients with bone metastatic PCa, which will be useful for patients' counseling and clinical trial designing.
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0 |
Sudden appearance and spontaneous regression of diffuse large B cell lymphoma in a man with a broken arm
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MSTS 2022 - Metastatic Disease of the Humerus
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An elderly, demented man with stable kappa bi-clonal gammopathy of unknown significance suffered a severe displaced right humeral fracture in a fall. One week later a rapidly enlarging head, neck and axillary adenopathy first appeared, including a 2 cm tonsillar node that partially obstructed the oropharynx. A left cervical node biopsy demonstrated diffuse large B cell lymphoma with CD20+, bcl-2+, kappa+, CD3-, Epstein-Barr virus negative malignant cells. During the next month lymphadenopathy regressed more than 90% in the absence of treatment with chemotherapeutic agents, radiation or glucocorticoids. Following 2 months of clinical improvement, he died of pneumonia 95 days after the injury. An autopsy demonstrated residual right hilar and mediastinal malignant lymphadenopathy. These unusual events may be related to immunosuppressive and other systemic effects of acute injury on tumour behaviour.
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Does parallel item content on WOMAC's pain and function subscales limit its ability to detect change in functional status?
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Surgical Management of Osteoarthritis of the Knee CPG
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BACKGROUND: Although the Western Ontario and McMaster University Osteoarthritis Index (WOMAC) is considered the leading outcome measure for patients with osteoarthritis of the lower extremity, recent work has challenged its factorial validity and the physical function subscale's ability to detect valid change when pain and function display different profiles of change. This study examined the etiology of the WOMAC's physical function subscale's limited ability to detect change in the presence of discordant changes for pain and function. We hypothesized that the duplication of some items on the WOMAC's pain and function subscales contributed to this shortcoming. METHODS: Two eight-item physical function scales were abstracted from the WOMAC's 17-item physical function subscale: one contained activities and themes that were duplicated on the pain subscale (SIMILAR-8); the other version avoided overlapping activities (DISSIMILAR-8). Factorial validity of the shortened measures was assessed on 310 patients awaiting hip or knee arthroplasty. The shortened measures' abilities to detect change were examined on a sample of 104 patients following primary hip or knee arthroplasty. The WOMAC and three performance measures that included activity specific pain assessments--40 m walk test, stair test, and timed-up-and-go test--were administered preoperatively, within 16 days of hip or knee arthroplasty, and at an interval of greater than 20 days following the first post-surgical assessment. Standardized response means were used to quantify change. RESULTS: The SIMILAR-8 did not demonstrate factorial validity; however, the factorial structure of the DISSIMILAR-8 was supported. The time to complete the performance measures more than doubled between the preoperative and first postoperative assessments supporting the theory that lower extremity functional status diminished over this interval. The DISSIMILAR-8 detected this deterioration in functional status; however, no significant change was noted for the SIMILAR-8. The WOMAC pain scale demonstrated a slight reduction in pain and the performance specific pain measures did not reflect a change in pain. All measures showed substantial improvement over the second assessment interval. CONCLUSIONS: These findings support the hypothesis that activity overlap on the pain and function subscales plays a causal role in limiting the WOMAC physical function subscale's ability to detect change
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The Role of Bisphosphonates in the Management of Patients That Have Cancer
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MSTS 2018 - Femur Mets and MM
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Bisphosphonates are pharmacologic agents widely used in people for managing pathologic bone resorptive conditions. Based on their physicochemical properties, bisphosphonates concentrate within areas of active bone remodeling and induce osteoclast apoptosis. Appropriate use of bisphosphonates for treating companion animals requires a thorough understanding of how bisphosphonates exert their biologic effects. This review article highlights general properties of bisphosphonates, including their pharmacology, mechanisms of action, adverse side effects, anticancer mechanisms, surrogate markers for assessing response, and potential clinical utility for treating dogs and cats diagnosed with malignant skeletal tumors. © 2007 Elsevier Inc. All rights reserved.
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An idiopathic gigantomastia
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Reduction Mammoplasty for Female Breast Hypertrophy
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Gigantomastia is a rare condition characterized by excessive breast growth. It has been reported that the majority of gigantomastia cases occur during either pregnancy or puberty. We were presented with a rare case of gigantomastia associated with neither pregnancy nor puberty, and successfully treated it with reduction mammaplasty and free nipple graft. This idiopathic gigantomastia is the very first case in Korea, and adds to the worldwide total of 9 reported cases.
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1 |
Adverse effect profile comparison of pain regimens with and without intravenous acetaminophen in total hip and knee arthroplasty patients
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AAHKS (4) Acetaminophen
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BACKGROUND: The use of adjunct, non-opioid agents is integral for pain control following total hip and knee arthroplasty. Literature comparing safety profiles of intravenous acetaminophen versus opioids is lacking.
OBJECTIVE: To determine whether there is a difference in frequency and type of adverse effects between intravenous acetaminophen-treated and non-intravenous acetaminophen-treated patients. Primary safety endpoints included any adverse effect noted in the electronic medical record post-surgically. Secondary endpoints included changes in laboratory values, vital signs, and pain scores.
METHODS: This is a retrospective, matched, cohort study with data collected from electronic medical records. Adverse effects were collected from progress notes, nursing notes, and post-operative notes. Mean pain score was measured by the 11-point visual analog scale over a 72-h period.
RESULTS: A total of 609 patients who underwent a total hip or knee replacement were included. In all, 406 patients were treated with intravenous acetaminophen, and 203 patients received medication management without intravenous acetaminophen. More patients treated with intravenous acetaminophen experienced an adverse effect compared to patients who did not receive intravenous acetaminophen (91.63% versus 84.73%; p=0.012). Mean cumulative acetaminophen exposure was similar in the intravenous acetaminophen group (7704.89+/-2558.6 versus 7260.1+/-3016.09mg; p=0.07). Mean opioid use was similar in the intravenous acetaminophen group as compared to the non-intravenous acetaminophen group (209.61+/-555.09 versus 163.89+/-232.44mg; p=0.152). Significantly higher mean pain scores were found in the intravenous acetaminophen group during the 72-h post-surgery period as compared with non-intravenous acetaminophen-treated patients.
CONCLUSION: The increased utilization of intravenous acetaminophen in multimodal pain management did not result in an improved safety or tolerability profile or reduced opioid utilization in orthopedic patients.
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Autogenous onlay graft with compression plate for treatment of persistent humeral shaft aseptic non-union with failed previous surgery
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MSTS 2022 - Metastatic Disease of the Humerus
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BACKGROUND: The humeral shaft fractures have a good rate of union, despite this fact, still there is a significant rate of nonunion after nonoperative treatment and more often after operative treatment. AIM: The aim of the study is to evaluate the autogenous onlay graft with compression plate for treatment of persistent humeral shaft non-union with failed previous surgery both radiological and functional outcome. MATERIALS AND METHODS: A prospective study on twenty patients having persistent aseptic non-union age between 20 and 60 years old, after failed surgical treatment of fractures humeral shaft in Al-Zahra teaching and Al-Kindy teaching hospitals, while infected nonunion, diabetes mellitus, secondary metastasis, smoking, alcoholism, and patients on long medication with corticosteroid were excluded from the study. All our patients were treated with corticocancellous onlay bone grafting harvesting from the ipsilateral upper tibia and compression plating (graft parallel to plate) and follow-up for at least 18 months post-operative to evaluate both radiology and functional using Mayo elbow performance index. RESULTS: All the patients ended with a solid union without hardware failure, and no one patient needs further surgery, even with significant resorption of the graft, there is a good chance of graft re-calcification and solid union with good to excellent functional outcome. CONCLUSION: Very successful solid union results achieve in those patients with established aseptic nonunion and pseudoarthrosis of the humerus.
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Patient beliefs and perceptions play a crucial role in the decision-making process when managing a meniscal tear. A qualitative systematic review of the literature
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AMP (Acute Meniscal Pathology)
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INTRODUCTION: There has been an increase in research on the effectiveness of treatment options for the management of meniscal tears. However, there is very little evidence about the patient experiences of meniscal tears.
AIM: To summarise the available qualitative evidence on patients' experiences and expectations of meniscal tears.
METHOD: A search of EMBASE, Medline, Sociofile and Web of Science up to November 2020 was performed to identify studies reporting patient experiences of meniscal tears. Studies were critically appraised using the CASP (Critical Appraisal Skills Program) checklist, and a meta-synthesis was performed to generate third-order constructs (new themes).
RESULTS: Two studies reporting semi-structured interviews from 34 participants (24 male; 10 female) were included. The mean interview length ranged from 16 to 45 min. Five themes were generated: (1) the imaging (MRI) results are a key driver in the decision-making process, (2) surgery is perceived to be the definitive and quicker approach, (3) physiotherapy and exercise is a slower approach which brought success over time, (4) patient perceptions and preferences are important in the clinical decision-making process and, (5) the impact on patient lives is a huge driver in seeking care and treatment decisions.
CONCLUSION: This is the first study to summarise the qualitative evidence on patient experiences with meniscal tears. The themes generated demonstrate the importance of patient perceptions of MRI findings and timing of treatment success as important factors in the decision-making process. This study demonstrates the need to strengthen our understanding of patients' experiences of meniscal tears.
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Osimertinib for Previously Treated Patients With Advanced EGFR T790M Mutation-Positive NSCLC: Tolerability and Diagnostic Methods From an Expanded Access Program
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MSTS 2018 - Femur Mets and MM
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Introduction: The osimertinib (AZD9291) US Expanded Access Program (EAP) provided compassionate access to osimertinib prior to US Food and Drug Administration (FDA) approval for patients with advanced/metastatic epidermal growth factor receptor (EGFR) T790M-positive non-small cell lung cancer (NSCLC) following progression on tyrosine kinase inhibitors (TKIs) targeting EGFR. Here, we report the patient demographics, safety and tolerability, and diagnostic methods used for T790M testing in the EAP. Methods: Adult patients with EGFR T790M-positive NSCLC following progression on prior EGFR-TKI therapy (irrespective of line of therapy) were enrolled in the EAP and treated with 80Â mg osimertinib once daily until dose reduction, discontinuation, or completion of the EAP following FDA approval (November 2015). Various testing methods were allowed for the required T790M testing. Results: In total, 248 patients from 25 centers throughout the USA were enrolled in the EAP. The starting dose of 80Â mg osimertinib once daily was maintained for 96% (n = 238) of patients over the duration of the EAP (median duration of exposure 84Â days). Most patients (overall 83% [n = 205/238]; patients aged â?¥ 75Â years 83% [n = 48/58]) completed the EAP and transitioned to commercially available osimertinib following FDA approval. Serious adverse events considered to be treatment related by investigators were reported in five patients (2%), all aged â?¥ 65Â years, and were dyspnea, deep vein thrombosis, femur fracture, alanine aminotransferase increase, and pneumonitis, respectively. A variety of biospecimen types were collected: solid tumor tissue (73%), blood (20%), cytology (6%), and urine (2%). PCR-based methods were most commonly used for determining EGFR mutation status (47%) followed by next-generation sequencing (33%). Conclusion: In a real-world setting, osimertinib was well tolerated, and most patients, including patients aged â?¥ 75Â years, transitioned to commercially available osimertinib following FDA approval. The EAP suggests there has been an uptake of minimally invasive T790M testing methods at some centers. Funding: AstraZeneca (Wilmington, DE, USA).
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Stress fracture of the hip. An unusual complication of total knee arthroplasty
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Management of Hip Fractures in the Elderly
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Stress fracture of the hip is a rare complication of total knee arthroplasty (TKA). Only eight cases seem to have been reported in the literature. A ninth case is reported in the present study. A 76-year-old obese woman was treated by right TKA for osteoarthrosis with cementing of the tibial component because of insufficient primary fixation. One year after TKA, she complained of tenderness above the right adductor tendons. There was no history of trauma. One month later, bone scintigrams and roentgenograms demonstrated a stress fracture of the femoral neck. Conservative management was successful. Etiologic factors such as rheumatoid arthritis, osteoporosis, steroid medication, or changes in static or dynamic forces of the hip secondary to knee arthroplasty could not be demonstrated in this patient. The increase in activity after TKA may be a factor in the incidence of these stress fractures of the hip. Radionuclear-type bone scan is helpful in diagnosis. The foci of increased isotope uptake are not always seen at the site of the stress fracture and only later visualized by roentgenograms
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Functional status and well-being in patients with glaucoma as measured by the Medical Outcomes Study Short Form-36 questionnaire
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Upper Eyelid and Brow Surgery
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PURPOSE: This study aimed to determine whether patients with glaucoma have different functional status and well-being than patients without glaucoma. DESIGN: Prospective case-control study. PARTICIPANTS: The study population was recruited from 2 university-based glaucoma clinical practices and a university-based general ophthalmology clinic and consisted of 121 patients with open-angle glaucoma, 42 with diagnosis of glaucoma suspect, and 135 with no chronic ocular conditions except cataract. INTERVENTION: Administration of Medical Outcomes Study 36-item short-form survey (SF-36) was performed. Demographic information, medical history, and responses to the SF-36 questionnaire were elicited by an interviewer. Medical record review was performed to obtain clinical examination data and to substantiate the medical and demographic data obtained by the interviewer. MAIN OUTCOME MEASURES: The SF-36 scores by diagnostic group, demographic characteristics, and medical history were examined. Secondary outcome measures were SF-36 scores in patients with glaucoma by visual field impairment and glaucoma medication use. RESULTS: Patients with glaucoma consistently had lower scores, control subjects had higher scores, and glaucoma suspects had scores intermediate between the two groups. After adjusting for the possible influence of all the other covariate factors, glaucoma was found to be a strong predictor of lower SF-36 scores. CONCLUSION: Patients with glaucoma have lower scores, indicating less-functional status, than patients without glaucoma as tested by the SF-36 survey questionnaire.
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Preoperative Pain and Function Profiles Reflect Consistent TKA Patient Selection Among US Surgeons
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Surgical Management of Osteoarthritis of the Knee CPG
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BACKGROUND: As the number of primary total knee arthroplasties (TKAs) performed in the United States increases, policymakers have questioned whether the indications and timing of TKA have evolved so that surgery is offered earlier. QUESTIONS/PURPOSES: We analyzed data from a US national TKA cohort to evaluate variation in surgeon selection criteria for elective unilateral TKA based on preoperative patient-reported pain and function scores. METHODS: Preoperative SF-36 (Physical Component Summary [PCS]/physical function) scores and Knee Injury and Osteoarthritis Outcome Score (KOOS) (pain, activities of daily living/function) of 4900 patients undergoing elective unilateral TKA enrolled in this national database of prospectively followed patients from 22 states were evaluated. The 25th, 50th, and 75th percentile pain and function scores for patients cared for in 24 orthopaedic offices with 20 or more patients in the database were compared to assess whether consistent preoperative criteria are used in selecting patients undergoing TKA across settings. RESULTS: The preoperative global function (PCS median, 32.6; national norm, 50; SD, 10) and knee-specific function (KOOS median, 51.5; maximum score, 100; SD, 17) percentile scores represented substantial patient disability, because both values approached 2 SDs below ideal. Consistency in patients across 24 surgeon offices, and more than 100 surgeons, was noted because site-specific medians varied from the national median by less than the minimum clinically important change. CONCLUSIONS: These data suggest that despite the rapidly growing use of TKA, surgeons in the participating sites use consistent patient criteria in scheduling TKA. Today's patients report significant pain and disability, supporting the need for TKA
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External fixation as a bridge to intramedullary nailing for patients with multiple injuries and with femur fractures: Damage control orthopedics
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DoD LSA (Limb Salvage vs Amputation)
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Background: The advantages of early fracture fixation in patients with multiple injuries have been challenged recently, particularly in patients with head injury. External fixation (EF) has been used to stabilize pelvic fractures after multiple injury. It potentially offers similar benefits to intramedullary nail (IMN) in long-bone fractures and may obviate some of the risks. We report on the use of EF as a temporary fracture fixation in a group of patients with multiple injuries and with femoral shaft fractures. Methods: Retrospective review of charts and registry data of patients admitted to our Level 1 trauma center July of 1995 to June of 1998. Forty-three patients initially treated with EF of the femur were compared to 284 patients treated with primary IMN of the femur. Results: Patients treated with EF had more severe injuries with significantly higher Injury Severity Scores (26.8 vs. 16.8) and required significantly more fluid (11.9 vs. 6.2 liters) and blood (1.5 vs. 1.0 liters) in the initial 24 hours. Glasgow Coma Scale score was lower (p < 0.01) in those treated with EF (11 vs. 14.2). Twelve patients (28%) had head injuries severe enough to require intracranial pressure monitoring. All 12 required therapy for intracranial pressure control with mannitol (100%), barbiturates (75%), and/or hyperventilation (75%). Most patients had more than one contraindication to IMN, including head injury in 46% of cases, hemodynamic instability in 65%, thoracoabdominal injuries in 51%, and/or other serious injuries in 46%, most often multiple orthopedic injuries. Median operating room time for EF was 35 minutes with estimated blood loss of 90 mL. IMN was performed in 35 of 43 patients at a mean of 4.8 days after EF. Median operating room time for IMN was 135 minutes with an estimated blood loss of 400 mL. One patient died before IMN. One other patient with a mangled extremity was treated with amputation after EF. There was one complication of EF, i.e., bleeding around a pin site, which was self-limited. Four patients in the EF group died, three from head injuries and one from acute organ failure. No death was secondary to the fracture treatment selected. One patient who had EF followed by IMN had bone infection and another had acute hardware failure. Conclusion: EF is a viable alternative to attain temporary rigid stabilization in patients with multiple injuries. It is rapid, causes negligible blood loss, and can be followed by IMN when the patient is stabilized. There were minimal orthopedic complications. Copyright © 2000 by Lippincott Williams & Wilkins, Inc.
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Application of Advanced Magnetic Resonance Imaging Techniques in Evaluation of the Lower Extremity
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AMP (Acute Meniscal Pathology)
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This article reviews current magnetic resonance imaging (MR imaging) techniques for imaging the lower extremity, focusing on imaging of the knee, ankle, and hip joints. Recent advancements in MR imaging include imaging at 7 T, using multiple receiver channels, T2* imaging, and metal suppression techniques, allowing more detailed visualization of complex anatomy, evaluation of morphologic changes within articular cartilage, and imaging around orthopedic hardware. © 2013 Elsevier Inc.
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Age does not influence the clinical outcome after high tibial osteotomy
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OAK 3 - Non-arthroplasty tx of OAK
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PURPOSE: Valgus high tibial osteotomy (HTO) is an established procedure for the medial gonarthrosis. In several studies, many negative influencing factors were evaluated. However, until now, the factor "age" was examined only insufficiently. The aim of our study was to evaluate the factor age in predicting the functional outcome after HTO, and we hypothesized that valgus HTO leads to equal results in the treatment of varus osteoarthritis independent of the patient's age.
METHODS: We could generate 13 pairs of patients with a median age at operation of 57 (55-63) years (group A) versus patients 15 years younger with a median age of 42 (39-47) years (group B). The patients were matched according to the following criteria: age, gender, operation/osteosynthesis method, body mass index, same additional operations, and follow-up time. Evaluation of the patients was done by use of the Tegner and Lysholm score and visual analogue scale (VAS) as well as by subjective satisfaction of the patients.
RESULTS: The Lysholm score showed a significant improvement in group A from 41 (SD +/- 12.3) to 65 (SD +/- 23.8) points (p = 0.01) and in group B from 33 (SD +/- 16.7) to 70 (SD +/- 31.8) points (p = 0.007). Moreover, the VAS decreased significantly in group A from 77 (SD +/- 15.3) to 36 (SD +/- 21.3) points (p = 0.003) and in group B from 73 (SD +/- 22.7) to 41 (SD +/- 33.7) points (p = 0.02). However, there was no significant difference for both groups regarding the activity of the patients evaluated by the Tegner score (group A: preop.: 5 (1-9), follow-up: 3.5 (1-6); group B: preop.: 6 (3-9), follow-up: 4 (2-7)). Furthermore, there was no significant difference between both groups in view of the Lysholm, Tegner and VAS.
CONCLUSION: Valgus high tibial osteotomy is an effective procedure for the treatment of medial gonarthrosis independent of the patient's age. As a consequence, the age of the patient does not have to be taken into consideration for the indication of high tibial osteotomy.
Level of evidence: Iii.
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Cryotherapy following total knee replacement
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OAK 3 - Non-arthroplasty tx of OAK
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Total knee replacement (TKR) is a common intervention for patients with end-stage osteoarthritis of the knee. Post-surgical management may include cryotherapy. However, the effectiveness of cryotherapy is unclear. To evaluate the acute (within 48 hours) application of cryotherapy following TKR on pain, blood loss and function. We searched the Cochrane Database of Systematic Reviews, CENTRAL, DARE, HTA Database, MEDLINE, EMBASE, CINAHL, PEDro and Web of Science on 15th March 2012. Randomised controlled trials or controlled clinical trials in which the experimental group received any form of cryotherapy, and was compared to any control group following TKR indicated for osteoarthritis. Two reviewers independently selected trials for inclusion. Disagreements were discussed and resolved involving a third reviewer if required. Data were then extracted and the risk of bias of trials assessed. Main outcomes were blood loss, visual analogue score (VAS) pain, adverse events, knee range of motion, transfusion rate and knee function. Secondary outcomes were analgesia use, knee swelling, length of hospital stay, quality of life and activity level. Effects of interventions were estimated as mean differences (MD), standardised mean differences (SMD) or given as risk ratios (RR), with 95% confidence intervals (CI). Meta-analyses were performed using the inverse variance method and pooled using random effects. Eleven randomised trials and one controlled clinical trial involving 809 participants met the inclusion criteria. There is very low quality evidence from 10 trials (666 participants) that cryotherapy has a small benefit on blood loss (SMD -0.46, 95% CI, -0.84 to -0.08), equivalent to 225mL less blood loss in cryotherapy group (95% CI, 39 to 410mL). This benefit may not be clinically significant. There was very low quality evidence from four trials (322 participants) that cryotherapy improved visual analogue score pain at 48 hours (MD = -1.32 points on a 10 point scale, 95% CI, -2.37 to -0.27), but not at 24 or 72 hours. This benefit may not be clinically significant. There was no difference between groups in adverse events (RR = 0.98, 95% CI, 0.28 to 3.47). There is low quality evidence from two trials (107 participants) for improved range of motion at discharge (MD 11.39 degrees of additional flexion, 95% CI 4.13 to 18.66), but this benefit may not be clinically significant. There was no difference between groups in transfusion rate (RR 2.13, 95% CI 0.04 to 109.63), and knee function was not measured in any trial. No significant benefit were found for analgesia use, swelling or length of stay. Outcomes measuring quality of life or activity level were not reported. Potential benefits of cryotherapy on blood loss, postoperative pain, and range of motion may be too small to justify its use, and the quality of the evidence was very low or low for all main outcomes. This needs to be balanced against potential inconveniences and expenses of using cryotherapy. Well designed randomised trials are required to improve the quality of the evidence.
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Prevention and management of hip fracture in older patients
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Management of Hip Fractures in the Elderly
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The average age at hip fracture is 83 for women and 84 for men, with about 80% of cases in women. The 30% mortality and 20% new institutionalisation rates at 12 months reflect the high prevalence of comorbidity and to some extent suboptimal management at the time of the fracture. With timely intervention and better clinical management many fractures can be prevented and when they do occur their human and economic costs can be greatly reduced. Fragility fractures occur in those with demonstrable osteoporosis or osteopaenia and/or risk factors. The goal of prevention is to identify and treat those at risk UK clinicians lack a single universally endorsed, decision support resource. The prudent strategy is to become familiar with all three available risk measures, introduce fracture risk assessment into routine practice, and allow clinical judgement to prevail in cases of doubt (perhaps, especially in very elderly people, more often in the direction of intervention). The classical signs after a fall by an older person, of severe pain, shortening and external rotation of the affected limb, and loss of mobility, should result in immediate and rapid transfer to hospital. It is not rare in the case of intracapsular fractures for mobility to be deceptively maintained on a moderately or minimally painful hip
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0 |
Chronic compartment syndrome. An unusual cause for claudication
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DOD - Acute Comp Syndrome CPG
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Chronic Compartment Syndrome (CCS) is usually caused by overuse injury in well-conditioned athletes (particularly runners). Less common causes of CCS include blunt trauma, venous insufficiency, and tumor. CCS is clinically manifested as claudication, tightness, and occasional paresthesia. Unlike other forms of overuse injury (tendonitis, stress fracture), CCS does not respond to rest, anti-inflammatory medications, or physical therapy. The diagnosis of this condition is confirmed by elevated compartment pressures (normal less than 15 mmHg; CCS greater than 20 mmHg). The only effective treatment is surgical compartment release. Two hundred nine patients have been surgically treated for CCS, 100 by subcutaneous fasciotomy (group I) and 109 by open fasciectomy (group II). These procedures were usually performed in ambulatory surgery using local anesthesia. Patients treated by open faciectomy instead of subcutaneous fasciotomy had fewer early postoperative wound complications (6% vs. 11%) and fewer late recurrences (2% vs. 11%).
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0 |
Patterns of survival in patients with recurrent follicular lymphoma: a 20-year study from a single center
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MSTS 2022 - Metastatic Disease of the Humerus
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PURPOSE: To examine outcome of treatment for patients with recurrent follicular lymphoma.
PATIENTS AND METHODS: Two hundred twelve newly diagnosed follicular lymphoma patients were studied. One hundred seventy-nine were initially treated successfully. Recurrent or progressive lymphoma developed in 116. Treatment was given according to disease stage and current protocols, mostly with single alkylating agents. A policy of repeated lymph node and bone marrow biopsy was pursued.
RESULTS: The overall median survival duration was 9 years, with a median follow-up duration of 12 years. Following recurrence, the median survival duration was 4 1/2 years. Only eight of 116 patients with recurrent disease died of causes unrelated to lymphoma. The overall response rate to first re-treatment was 78% and showed slight decline with successive recurrences, reaching 48% after the fourth treatment. The median duration of second remission was 13 months, (v 31 months for first remission), with the only significant predictive factor being quality of remission. Multivariate analysis showed only age at recurrence and number of prior treatments to correlate with survival after first recurrence. Survival after second remission was only correlated with age and quality of response: Kaplan-Meier estimates gave 53% of patients reaching second complete remission alive 10 years later, compared with 28% in partial remission.
CONCLUSION: Age and previous and continuing responsiveness of follicular lymphoma to therapy are the principal determinants of survival following recurrence. Improvement in survival with new treatments will be demonstrated most readily in older patients, while more intensive approaches should be tested in younger patients in whom remission is achieved with difficulty.
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0 |
Lateral collateral ligament instability of the elbow
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The Treatment of Pediatric Supracondylar Humerus Fractures AUC
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Lateral elbow support is provided by a combination of bony anatomy and the ligaments and tendons that originate at the lateral epicondyle. Instability is typically posttraumatic in nature. In the acute setting of elbow fracture-dislocation, restoration of lateral soft tissue support can be typically accomplished by a direct repair of the lateral ligament and extensor tendon origins to the humeral epicondyle. In chronic settings, a reconstruction is most commonly necessary using a free tendon graft. Indications and surgical techniques are discussed
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Traditional distance â??tip-apexâ?쳌 vs. new calcar referenced â??tip-apexâ?쳌 - which one is the best peritrochanteric osteosynthesis failure predictor?
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Hip Fx in the Elderly 2019
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Introduction: In the treatment of trochanteric fractures, the distance between the tip of the screw and the apex of the femoral head or tip-to-apex distance (TAD) was popularized by Baumgaertner about 20 years ago as an important predictor of failure. Recently, a new reference point for determining the apex has been advocated. In this new calcar tip-to-apex (calTAD) the femoral head apex is referenced to the femoral calcar and not the center of the neck. The aim of this study is to evaluate which of these two indexes is better in predicting failure of pertrochanteric fracture fixation. Materials and Methods: We conducted a retrospective study focusing on pertrochanteric fractures operated in our institution between 2010â??2013. Radiographic measurement of both indexes was performed. Demographic information, as well as several variables with recognized influence on the rate of failure, were collected. Finally, logistic regression analysis was used to identify variables independently associated with fixation failure. Results: A total of 463 pertrochanteric fractures were operated during this time period. One hundred and seventy cases were excluded because of early loss of follow-up (n = 143) or inadequate fluroscopic imaging (n = 27) control precluding accurate measurements. Two hundred and ninety-three fractures were included. Traditional TAD and calTAD were significantly different in the failure group: 24.9 vs. 18.0 mm (p < 0.001) and 29.2 vs. 22.6 mm (p < 0.001) respectively. No other registered variable was significantly different. Multivariate analysis confirms traditional TAD (p = 0.003; OR = 1.10) and calTAD (p = 0.002; OR = 1.12) as independent risk factors for failure. Discussion/Conclusion: Both the traditional TAD and the new calTAD have shown to be relevant indexes and independently predictive of the likelihood of failure of pertrochanteric fracture fixation. Interestingly, we found the optimal threshold for the traditional TAD to be lower (<20 mm) than the traditional cutoff (<25 mm). Our study did not confirm calTAD to be superior to the traditional TAD. From the surgical practice point of view, the authors argue that the ideal position of the screw is the central region of the femoral head (minimal traditional TAD). In case of deviation, it must be infero-central in order to maintain a low calTAD thus minimizing the risk of fixation failure.
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The use of two nutritional indicators in identifying long bone fracture patients who do and do not develop infections
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DoD SSI (Surgical Site Infections)
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One hundred consecutive orthopedic long bone fracture patients requiring surgical fixation were nutritionally assessed using both the nutritional index of Rainey-MacDonald et al. and total lymphocyte count. The ability of these two parameters to identify correctly those patients who do and do not develop postoperative complications was assessed using several error rate measures, which included sensitivity, specificity, positive predictive value, negative predictive value, and accuracy. Fourteen of our patients developed postoperative complications. All complications observed were infections. The accuracy of the nutritional index and total lymphocyte count in predicting patient outcome was 78 and 51%, respectively. The positive and negative predictive values calculated for the nutritional index were 36 and 94%, respectively. Total lymphocyte count analysis resulted in positive and negative predictive values of 15 and 87%, respectively. In our sample of patients, the nutritional index was a better predictor of patient outcome than total lymphocyte count, as indicated by the higher accuracy rate calculated for the nutritional index. Based upon positive predictive value results, neither of these indicators was most accurate in identifying patients who did develop infections. Not unexpectedly, both indicators were best in identifying those patients who did not develop postoperative infections.
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Fishtail deformity following fracture of the distal humerus in children: historical review, case presentations, discussion of etiology, and thoughts on treatment
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The Treatment of Pediatric Supracondylar Humerus Fractures AUC
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Fishtail deformity is an uncommon complication of distal humeral fractures in children. This article reports four cases accompanied by premature closure of a portion of the distal humeral physis with resultant deformity, length retardation, decreased elbow motion, and functional impairment. The ages of the patients at time of injury ranged from 4 years 2 months to 6 years 1 month (average 5 years 4 months). The average length of follow-up was 9 years 9 months (range, 3 years 5 months to 18 years 10 months). The cause of the arrest is multifactorial and may be due to a gap in reduction of an intracondylar fracture, avascular necrosis of the epiphysis, or central premature physeal arrest (bar formation) without a fracture gap or avascular necrosis. If identified in a young child, surgical closure of the medial and lateral portion of the physis may prevent the deformity from progressing and would not cause significant additional humeral length discrepancy
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Long-term results of hybrid alumina-on-alumina total hip arthroplasty: 10-14-Year results
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PJI DX Updated Search
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Between 2000 and 2004, 89 hybrid alumina-on-alumina hip replacements were performed by a single surgeon. There were 46 men and 43 women with an average age of 51 years. All patients were followed up for a minimum of 10 years. Prior to surgery, the mean Harris hip score (HHS) was 44 points (35-55). Following surgery, the HHS improved to an average of 94 points (87-100). There was no significant decline in pain and function even into the second decade following hip replacement. At final follow-up, the average
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The consequences of complacency: Managing the effects of unrecognized Charcot feet
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DoD LSA (Limb Salvage vs Amputation)
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Aims Several authors have discussed an early prodromal state of neuroarthropathy (stage 0 Charcot) prior to the development of frank radiographic changes. However, very few reports are available that detail the outcomes of these patients. The purpose of this study was to report on the outcomes of patients with undetected early Charcot neuroarthropathy of the foot.Methods Twenty patients, from two health science centres, were diagnosed retrospectively with stage 0 Charcot neuroarthropathy and were managed after referral from outside facilities. We evaluated any complications, including ulcer formation, infection, progression into active Charcot neuroarthropathy and the need for surgical reconstruction. Patients who did not progress to an active Charcot neuroarthropathy (Group I) were compared with those (Group II) who did progress to the destructive phase.Results The diagnosis of Charcot neuroarthropathy was missed in 19 of 20 patients prior to referral. The average delay in treatment in Group I was 4.1 ± 0.7 weeks compared with 8.7 ± 6.8 weeks in Group II (Mann-Whitney U-test = 24.5, n1 = 15, n2 = 7, P < 0.05 two-tailed). Sixteen of 22 feet (72%) developed a complication during their treatment course. Group II experienced more complications than Group I (66.7% compared with 14.3%). Overall, eleven of 22 feet (50%) required surgical treatment; however, no patient required an amputation during the follow-up course.Conclusions This study reveals that outcomes of stage 0 Charcot neuroarthropathy feet depend on proper recognition and early management. To reduce the rate of future complications for Charcot foot should be the goal of all treatment. © 2011 The Authors. Diabetic Medicine © 2011 Diabetes UK.
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The effectiveness of supplementing a standard rehabilitation program with superimposed neuromuscular electrical stimulation after anterior cruciate ligament reconstruction: a prospective, randomized, single-blind study
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Anterior Cruciate Ligament Injuries CPG
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BACKGROUND: Rehabilitation after anterior cruciate ligament reconstruction is a key determinant affecting patient return to usual activity levels. Neuromuscular electrical stimulation is a treatment that can counteract strength loss and serve as an adjunct to conventional therapy. PURPOSE: To compare the effect of adding traditional neuromuscular electrical stimulation (Polystim) or a novel garment-integrated neuromuscular electrical stimulation (Kneehab) to a standard postoperative rehabilitation program (control). STUDY DESIGN: Randomized controlled trial; level of evidence, 1. METHODS: Ninety-six patients, of a total enrolled cohort of 131 patients randomized to 1 of 3 intervention groups, completed a standard rehabilitation program. In addition, the 2 neuromuscular electrical stimulation groups underwent 20-minute sessions of neuromuscular electrical stimulation 3 times a day, 5 days a week, for 12 weeks, in which stimulation was superimposed on isometric volitional contractions. Outcome measures including isokinetic strength of the knee extensors of the injured and uninjured leg at 90 and 180 deg/s, along with functional tests of proprioception, were assessed at baseline and at 6 weeks, 12 weeks, and 6 months postoperatively. RESULTS: The Kneehab group achieved significantly better results at each time point compared with the Polystim and control groups (p < 0.001). Extensor strength of the Kneehab group at speeds of 90 and 180 deg/s increased by 30.2% and 27.8%, respectively, between the preoperative measurements and the 6-month follow-up point in the injured leg. The corresponding changes for Polystim were 5.1% and 5%, whereas for the control group they were 6.6% and 6.7%, respectively. The mean single-legged hop test hop score of the Kneehab group improved by 50% between the 6-week and 6-mo nth follow-up, whereas the corresponding changes for the Polystim and control groups were 26.3% and 26.2%, respectively. Although there was no significant difference between the groups with respect to the Tegner score and the International Knee Documentation Committee 2000 knee examination score, the Kneehab group showed a significant difference in mean improvement for the baseline corrected Lysholm score compared with the control group (p = 0.01; 95% confidence interval 1.12 to 8.59) and with the Polystim group (p < 0.001; 95% confidence interval 1.34 to 9.09) with no significant difference evident between Polystim and control groups (p = 0.97; 95% confidence interval -4.23 to 3.51). CONCLUSION: Intensive garment-integrated stimulation combined with standard rehabilitation is effective at accelerating recovery after knee surgery
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Molecular diagnosis of periprosthetic joint infection by quantitative RT-PCR of bacterial 16S ribosomal RNA
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PJI DX Updated Search
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The diagnosis of periprosthetic joint infection is sometimes straightforward with purulent discharge from the fistula tract communicating to the joint prosthesis. However it is often difficult to differentiate septic from aseptic loosening of prosthesis because of the high culture-negative rates in conventional microbiologic culture. This study used quantitative reverse transcription polymerase chain reaction (RT-qPCR) to amplify bacterial 16S ribosomal RNA in vitro and in 11 clinical samples. The in vitro analysis demonstrated that the RT-qPCR method was highly sensitive with the detection limit of bacterial 16S rRNA being 0.148 pg/ mu l. Clinical specimens were analyzed using the same protocol. The RT-qPCR was positive for bacterial detection in 8 culture-positive cases (including aerobic, anaerobic, and mycobacteria) and 2 culture-negative cases. It was negative in one case that the final diagnosis was confirmed without infection. The molecular diagnosis of bacterial infection using RT-qPCR to detect bacterial 16S rRNA around a prosthesis correlated well with the clinical findings. Based on the promising clinical results, we were attempting to differentiate bacterial species or drug-resistant strains by using species-specific primers and to detect the persistence of bacteria during the interim period before the second stage reimplantation in a larger scale of clinical subjects
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Modulation of Synovial Fluid-Derived Mesenchymal Stem Cells by Intra-Articular and Intraosseous Platelet Rich Plasma Administration
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PRP (Platelet-Rich Plasma)
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The aim of this study was to evaluate the effect of intra-articular (IA) or a combination of intra-articular and intraosseous (IO) infiltration of Platelet Rich Plasma (PRP) on the cellular content of synovial fluid (SF) of osteoarthritic patients. Thirty-one patients received a single infiltration of PRP either in the IA space (n = 14) or in the IA space together with two IO infiltrations, one in the medial femoral condyle and one in the tibial plateau (n = 17). SF was collected before and after one week of the infiltration. The presence in the SF of mesenchymal stem cells (MSCs), monocytes, and lymphocytes was determined and quantified by flow cytometry. The number and identity of the MSCs were further confirmed by colony-forming and differentiation assays. PRP infiltration into the subchondral bone (SB) and the IA space induced a reduction in the population of MSCs in the SF. This reduction in MSCs was further confirmed by colony-forming (CFU-F) assay. On the contrary, IA infiltration alone did not cause variations in any of the cellular populations by flow cytometry or CFU-F assay. The SF of osteoarthritic patients contains a population of MSCs that can be modulated by PRP infiltration of the SB compartment.
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Essentials of anterior cruciate ligament rupture management
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Surgical Management of Osteoarthritis of the Knee CPG
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Anterior cruciate ligament (ACL) rupture is a common knee injury and an understanding of current medical knowledge regarding its management is essential. Accurate and prompt diagnosis requires an awareness of injury mechanisms and risk factors, common symptoms and physical/radiologic findings. Early mobilization and physical therapy improves outcomes regardless of treatment modality. Many older patients regain sufficient stability and function after non-operative rehabilitation. Early ACL reconstruction is appropriate for younger patients and those who engage in activities requiring frequent pivoting and rapid direction changes. ACL surgery involves reconstruction of the torn ligament tissue with various replacement graft options, each with advantages and disadvantages. The guidance of a knowledgeable and experienced therapist is required throughout an intensive and prolonged rehabilitation course. Generally excellent outcomes and low complication rates are expected, but treatment does not prevent late osteoarthritis
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The transplantation of particulated juvenile allograft cartilage and synovium for the repair of meniscal defect in a lapine model
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AMP (Acute Meniscal Pathology)
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Background: Synovium has been confirmed to be the primary contributor to meniscal repair. Particulated Juvenile Allograft Cartilage (PJAC) has demonstrated promising clinical effect on repairing cartilage. The synergistic effect of synovium and PJAC transplant on meniscal fibrocartilaginous repair is unclear. We hypothesize that the transplantation of synovium and PJAC synergistically facilitates meniscal regeneration and the donor cells within graft tissues still survive in the regenerated tissue at the last follow up (16 weeks postoperatively).
Methods: The study included 24 mature female rabbits, which were randomly divided into experimental and control groups. A cylindrical full-thickness defect measuring 2.0 mm was prepared in the avascular portion of the anterior horn of medial meniscus in both knees. The synovium and PJAC transplant were harvested from juvenile male rabbits (2 months after birth). The experimental group received synovium and PJAC transplant encapsulated with fibrin gel. The control groups received synovium transplant encapsulated with fibrin gel, pure fibrin gel and nothing. The macroscopic, imageological and histological evaluations of repaired tissue were performed at 8 weeks and 16 weeks postoperatively. The in situ hybridization (ISH) of male-specific sex-determining region Y-linked (SRY) gene was performed to detect the transplanted cells.
Results: The regenerated tissue in experimental group showed superior structural integrity, superficial smoothness, and marginal integration compared to control groups at 8 weeks or 16 weeks postoperatively. More meniscus-like fibrochondrocytes filled the repaired tissue in the experimental group, and the matrix surrounding these cell clusters demonstrated strongly positive safranin O and type 2 collagen immunohistochemistry staining. By SRY gene ISH, the positive SRY signal of experimental group could be detected at 8 weeks (75.72%, median) and 16 weeks (48.69%, median). The expression of SOX9 in experimental group was the most robust, with median positive rates of 65.52% at 8 weeks and 67.55% at 16 weeks.
Conclusion: The transplantation of synovium and PJAC synergistically facilitates meniscal regeneration. The donor cells survive for at least 16 weeks in the recipient.
The translational potential of this article: This study highlighted the positive effect of PJAC and synovium transplant on meniscal repair. We also clarified the potential repair mechanisms reflected by the survival of donor cells and upregulated expression of meniscal fibrochondrocytes related genes. Thus, based on our study, further clinical experiments are needed to investigate synovium and PJAC transplant as a possible treatment to meniscal defects.
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Association between the +104T/C polymorphism in the 5'UTR of GDF5 and susceptibility to knee osteoarthritis: a meta-analysis
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OAK 3 - Non-arthroplasty tx of OAK
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Although the +104T/C polymorphism in the 5' untranslated region (UTR) of growth differentiation factor 5 (GDF5) plays a role in the pathogenesis of knee osteoarthritis, the results have been inconsistent. In this study, we performed a meta-analysis to assess the association of +104T/C polymorphism with knee osteoarthritis. Published literature from PubMed, Google Scholar and China National Knowledge Infrastructure data was retrieved. Pooled odds ratios (ORs) with 95% confidence intervals (CIs) were calculated using fixed- or random-effects models. A total of 6 case-control studies containing 2,744 patients and 4,518 controls were enrolled in this meta-analysis. Overall, a statistically significant association was found between the +104T/C polymorphism and risk of knee osteoarthritis (TT vs. CC: OR 1.68, 95% CI=1.41-2.01; TT vs. TC: OR 1.18, 95% CI=1.01-1.38; dominant model: OR 0.72, 95% CI=0.61-0.86). Taking into account the effect of ethnicity, further stratified analyses were performed. In the subgroup analysis, the same association was identified in Caucasian (TT vs. CC: OR 1.45, 95% CI=1.13-1.85) and Asian (TT vs. CC: OR 1.99, 95% CI=1.53-2.60; TT vs. TC: OR 1.33, 95% CI=1.16-1.52; dominant model: OR 0.64, 95% CI=0.56-0.72; recessive model: OR 1.77, 95% CI=1.37-2.29) populations. The meta-analysis results demonstrated that the +104T/C polymorphism in the 5'-UTR of GDF5 is associated with risk of knee osteoarthritis.
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Social work and the management of severe head injury
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DoD PRF (Psychosocial RF)
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This article examines the role of the health social worker in the management of the psychosocial sequelae of head injury from the membership perspective. Data relative to the incidence and medical dimensions of head injury and its psychosocial sequelae are briefly reviewed. The social work definition of head injury as a social process, rather than a medical event, is explored. Social work interventions designed to help those affected by head injury to manage home and community life are examined.
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Retrospective analysis of extra-articular distal humerus shaft fractures treated with the use of pre-contoured lateral column metaphyseal LCP by triceps-sparing posterolateral approach
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Distal Radius Fractures
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Management of extra-articular distal humerus fractures presents a challenge to the treating surgeon due to the complex anatomy of the distal part of the humerus and complicated fracture morphology. Although surgical treatment has shown to provide a more stable reduction and alignment and predictable return to function, it has been associated with complications like iatrogenic radial nerve palsy, infection, non-union and Implant failure. We in the present series retrospectively analysed 20 patients with extra-articular distal humerus shaft fractures surgically treated using the extra-articular distal humeral locking plate approached by the triceps-sparing posterolateral approach. The outcome was assessed using the DASH score, range of motion at the elbow and the time to union. The mean time to radiographic fracture union was 12 weeks.
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Phase 1, Dose Escalation Study Evaluating the Safety, Tolerability, Pharmacokinetics and Pharmacodynamics of SM04690 in Moderate to Severe Knee Osteoarthritis (OA)
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TO: WNT2 Pathway Modulator
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The purpose of this study is to find the optimal dose of SM04690 that can be safely given by intraâ?articular injection into the target knee joint of subjects with moderate to severe osteoarthritis.
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Infrequent attendance in general practice after a major disaster: a problem? A longitudinal study using medical records and self-reported distress and functioning
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DoD PRF (Psychosocial RF)
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OBJECTIVE: To assess the characteristics and implications for care of infrequent attendance in general practice in the aftermath of disaster.
METHODS: A study of the content of electronic medical records (EMRs) in pre- and post-disaster periods linked to an enquiry using self-reported questionnaires administered 3 weeks and 18 months post-disaster. The disaster (explosion of a firework depot in Enschede, The Netherlands) caused 23 deaths, about 1000 people injured and 1200 people who had to relocate. Sample included survivors (N = 922) who participated in two surveys and whose data could be linked to EMRs of GPs. A comparison of reported morbidity in 'infrequent' (a maximum of three times in men and four times in women in the first two post-disaster years) and 'more frequent attenders' (frequency determined post-disaster) in general practice examined in relation to health status (measured by diagnoses in EMRs, symptom checklist and quality of life instrument) was the
Main outcome measure:
RESULTS: Infrequent attenders reported approximately three times as few contacts as more frequent attenders in the pre-disaster year (P < 0.001). Multivariate logistic regression analyses revealed that infrequent attenders were likely to be younger, less depressed, have better subjective health and physical functioning and exhibited more hostile behaviour (measured by questionnaire). Infrequent attenders were less often personally bereaved by the disaster, but more often relocated, and had a lower prevalence of psychological problems pre- and post-disaster although this increased stronger (by 10-fold).
CONCLUSIONS: Both groups showed the same type of psychological problems post-disaster, but differed in the frequency of contacting the GP.
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Stem Cells for Treatment of Musculoskeletal Conditions - Orthopaedic/Sports Medicine Applications
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OAK 3 - Non-arthroplasty tx of OAK
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A myriad of musculoskeletal conditions afflicts a vast number of the world's population from birth to death. Countless pathological diseases and traumatic injuries (acute and chronic) contribute to different human disabilities, causing a tremendous financial toll on the economy of healthcare. The medical field is continually searching for novel ways to combat orthopedically related conditions. The immediate goal is the restoration of anatomy then ultimately return of function in hopes of enhancing quality if not the quantity of life. Traditional methods involve surgical correction/reconstruction of skeletal deformities from fractures/soft tissue damage/ruptures or replacement/resection of degenerated joints. Modern research is currently concentrating on innovative procedures to replenish/restore the human body close to its original/natural state [1, 2].
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Internal fixation and comparisons of different fixation methods for treating distal radial fractures in adults
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Management of Hip Fractures in the Elderly
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This is the protocol for a review and there is no abstract. The objectives are as follows:To evaluate the effectiveness of internal fixation for fractures of the distal radius in skeletally mature people. Additionally, to evaluate the relative effectiveness of different surgical methods of treating these fractures.More specifically, we will compare the effectiveness of:. internal fixation versus conservative treatment;. different methods of internal fixation, including different techniques associated with inserting implants, different implants, and different types and durations of immobilisation after internal fixation;. different fixation methods (percutaneous pinning, external fixation, internal fixation); and different combinations of surgical methods;. different techniques (e.g. use of arthroscopy) and approaches (e.g. surgical repair of the triangular fibrocartilagenous complex (fibrous tissue which binds together the distal ends of the radius and ulnar)) not already covered.We will consider these outcomes primarily in terms of patient-assessed functional outcome and satisfaction, and other measures of function and impairment, pain and discomfort, the incidence of complications, anatomical deformity and use of resources.If data allow it, we intend to study the outcomes in different age groups and for different types of fractures, especially whether they are extra-articular or intra-articular
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Total knee arthroplasty
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Surgical Management of Osteoarthritis of the Knee CPG
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Eighty-six nonhinged total knee arthroplasties performed between 1971 and 1981 have been reviewed. Fifty-one were of the geometric type and 35 of the anametric type. The use of both units resulted in a statistically and clinically significant improvement in preoperative pain and an increase in functional activities. Three of 51 geometric units developed loose components that required revision. None of the 35 anametric units has required revision for loosening. Partial radiolucent lines at the tibial bone-cement interface were noted in 43% of the group. Data analysis of age, weight, and sex demonstrated no statistically significant characteristic of this group when compared with the group without radiolucent lines. However, radiolucent lines were more common in those patients with osteoarthritis than in the group with rheumatoid arthritis. In addition, radiolucent lines were noted in 90% of knees in which a metal-backed tibial tray with a central post was used, compared with 36% of knees without metal-backed tibial components. Relief of pain and correction of instability and deformity can be achieved for most patients following nonhinged total knee arthroplasty
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TKR patients with prior ipsilateral menisectomy are younger and have significant pain and disability
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Surgical Management of Osteoarthritis of the Knee CPG
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Purpose: Total knee replacement (TKR) use is projected to increase by 673% by the year 2020 as the US population ages. Moreover, TKR demand in adults under 65 years of age is projected to significantly increase in the next decade. The surge in older and younger osteoarthritis (OA) patients will overlap in the next decade and contribute to rising disability and economic burden. With this background, we evaluated patient attributes and clinical risk factors, including prior knee procedures, in a national sample of TKR patients of varying age. Methods: Demographic and surgical data on 7715 primary, unilateral TKR patients in a registry of patients from 135 orthopedic practices who underwent TKR between 2000 and 2005 (Zimmer, Inc.) were analyzed retrospectively. Exploratory analyses compared the distribution of gender, pre-surgical body mass index (BMI), pain and function (SF12 pain and PCS), emotional health (SF12 MCS), prior ipsilateral meniscal repair (Arthoscopic Partial Menisectomy [APM] or open menisectomy), and knee malalignment (varus or valgus) in TKR patients younger and older than 60 years of age. Descriptive statistics (t-test, (chi)(2)) were performed u s in g S TATA . Results: 20% of all TKR patients reported a prior ipsilateral knee procedure and 60% of these procedures were APM or open. The TKR gender composition differed significantly between those with prior meniscal procedure v. the no prior procedure group: 44% male, 56% female in the prior ipsilateral meniscal procedure group as compared to 30% male, 67% female in the no prior procedure group. Significantly, more patients with a prior meniscal procedure were under 60 years of age (40% v. 18%) and were on average, 7 years younger than patients without a prior procedure. Comparing the prior meniscal procedure group v. the non- procedure group, no significant differences were observed in self-reported function (SF12 PCS = 31 v. 30); BMI (32 v. 32) or emotional health (SF12 MCS =51 v. 52). Patients experiencing pain levels in both the severe and moderate categories (PCS <30; 30-44) were significantly higher in the prior procedure group v. the non-prior procedure group (31% v. 26% and 25% v. 18%). In addition, significantly more patients had normal alignment in the prior procedure group than non-prior procedure group (56% v. 50%). Conclusions: The prevalence, incidence and burden of knee OA in those with prior ipsilateral meniscal injuries are not known. These analyses found a significant percentage (20) of TKR patients with a prior ipsilateral meniscal procedure (APM or open). When compared to TKR patients with no prior procedure, patients with prior meniscal procedures are younger at surgery but experience levels of pain, functional limitation, and emotional health comparable to the older TKR patients with no prior procedure. In fact, the proportion of patients with severe disability (PCS <30) was higher in the prior-procedure group than in the non- procedure group (31% v. 26%). Additional research is needed to clarify specific relationships between types of prior meniscal injuries and types of repair procedures and estimates of the incidence of OA in these younger patients. Taken together, current data suggest the possibility of growing a public health problem in which younger OA patients are more significantly impaired perhaps due to soft tissue knee injuries from more active lifestyles earlier in life. Since TKR is not an immediate option in all cases, chondroprotective pharmacologic research such as disease-modifying osteoarthritis drug (DMOADs) development is desirable to meet these needs
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Incidence and Characteristics of Meniscal Injuries in Cadets at a Military School, 2013-2015
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AMP (Acute Meniscal Pathology)
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CONTEXT: Meniscal injury is common among military service members.
OBJECTIVE: To examine the incidence and characteristics of meniscal injuries in cadets at a single military institution between 2013 and 2015.
DESIGN: Cohort study.
SETTING: Meniscal-injury data were collected at the Center of Rehabilitation Training, the People's Liberation Army University of Science and Technology.
PATIENTS OR OTHER PARTICIPANTS: A total of 2479 cadets participating in physical activities between 2013 and 2015.
MAIN OUTCOME MEASURE(S): Injury rates, injury proportions by body mass index, risk ratios (RRs), and injury proportion ratios were reported with 95% confidence intervals (CIs).
RESULTS: The overall incidence rate was 10.08 (95% CI = 6.84, 14.84) per 1000 person-years. A multiple-comparisons test revealed differences in the relative injury rate in overweight or obese cadets versus normal-weight cadets and underweight cadets (chi<sup>2</sup> = 8.98, P = .01). No differences were found between injured normal-weight cadets and underweight cadets (P = .66, RR = 1.39, 95% CI = 0.32, 6.06) or between injured overweight or obese cadets and injured underweight cadets (P = .24, RR = 0.42, 95% CI = 0.09, 1.91). The absolute injury rate was higher for overweight and obese cadets compared with normal-weight cadets (P < .01, RR = 0.30, 95% CI = 0.13, 0.69). The overall proportional distribution for patterns of injury was 2:1 (medial to lateral) for meniscal injuries. Grade 2 injuries were the most common.
CONCLUSIONS: The high frequency and level of severity of meniscal injuries may negatively affect the readiness and health of cadets. High body mass index was a risk factor for meniscal injury.
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The Effects of Collateral Meridian Therapy for Knee Osteoarthritis Pain Management
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AAHKS (2) Corticosteroids
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Knee OA patients aged 60 years or older were recruited from the orthopedic clinic of Taichung Armed Force General Hospital, Taichung, Taiwan. All the patients had been clinically and radiologically diagnosed with knee OA according to the criteria of the American College of Rheumatology and Lawrence radiographic changes in the tibiofemoral joint by using a visual analogue scale (VAS) pain score higher than 30 mm on a 100â?mm scale over the medial side of the knee while walking. Individuals who had undergone total knee arthroplasty, exhibited uncontrolled hypertension, had a history of cardiovascular disease, or suffered from neurological disorders that affected lower extremity functions were excluded from the study. Patients who received conflicting or ongoing interventions such as acupuncture, hyaluronan injections, intraâ?articular corticosteroid, and transcutaneous electrical nerve stimulation and thermotherapy were also excluded. Patients under drug treatment were included if no changes in medication had occurred, and the dosages had been administered for one month or longer. Oral paracetamol or nonâ?steroidal antiâ?inflammatory drugs (NSAIDs) were permitted as rescue pain medications for the duration of the study. Rescue pain medications or any change in medicines and dosages were recorded. This study was approved by the IRB of Triâ?Service General Hospital, Taipei, Taiwan and written informed consents were obtained from the enrolled participants. According to the sealed envelop method, the enrolled patients were randomly allocated to the control group or CMT group. Treatment CMT group The CMT group patients received, according to the CMT protocol described previously, CMT at the selected points with the CMT Electrotherapy Stimulator ("GEMORE" Multiâ?Function Electrotherapy Stimulator; GM390TE, GEMORE Co Ltd, Taiwan) to treat the affected OA knee. In brief, knee OA mostly induced knee pain at the medial side, the corresponding disease meridian of OA is AxI/3, the first yin meridian (AxI) over knee region ("3") on the medial aspect of the lower extremity (the spleen meridian in TCA). A reduction technique, to remove the obstructed overflowed Qi, was performed by treating the point "3" on the ipsilateral third yang meridian (TyIII) over the dorsal aspect of the upper extremity (TyIII/3:3), which corresponded to Tze Cheng (SI7) on the small intestine meridian in TCA; the aspect shares the same control Câ?point (the first "3" ) and Fâ?point (the second "3") to divert the obstructed Qi from obstructed diseased meridian to the healthy one; the Câ?point is used to link the diseased meridian to the treatment healthy meridian; manipulating the Fâ?point is for the treatment/removal of the disease/pain symptom. An enhancement technique was performed by treating contralateral meridian "Ax II/2:(3)," which represents treating "2" as the Câ?point and "3" as the Fâ?point, and a number in parentheses signifies usage of enhancement technique on the contralateral second yin meridian of the medial aspect of the lower extremity (corresponding to San Yin Jiao (SP6) and Lou Ku (SP7), respectively, on the liver meridian in TCA). The 6â?minute treatment (electrotherapy was set at 40 Hz biphasic and 30 mA) comprises reduction and enhancement procedures on the specific points (figures 1 and 2). Each patient received CMT twice per week for three weeks during the study. Control (CT) group The patients in the CT group received electronic leadâ?patches applied on the treatment points, which was identical to what the CMT group received, also for 6 minutes, though no electric stimulation was applied. Evaluation of outcomes Primary outcome measures were: (1) pain intensity at activity, quantified with a 100 mm VAS and (2) pain disability measured with the Western Ontario and McMasters Universities Osteoarthritis Index (WOMAC, 0â?96 points). The WOMAC is a diseaseâ?specific measure of pain, stiffness, and physical function for individuals with knee OA. The WOMAC comprises 5 items related to pain, 2 items related to stiffness, a d 17 items related to physical function. Each item is scored on a 5â?point Likert scale (0â?4). The reliability and validity of WOMAC scores have been established. The VAS and WOMAC scores were measured immediately by independent staff before the first treatment, and subsequently at one, two, three weeks, and three months after the first treatment. Statistical analysis Patients were excluded from analysis if they were not present for the followâ?up, or the outcomes were not assessed. The Mannâ?Whitney test was employed to analyze differences between the VAS and WOMAC scores of the two groups. SPSS software for Windows was used for statistical analysis. All the data are presented as means (±SD). The data with P values less than 0.05 are considered statistically significant.
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Transient bacteremia associated with diagnostic and therapeutic procedures
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Dental Implant Infection
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In general, all individuals known to have valvular heart disease should be considered candidates for prophylaxis. With dental and urinary tract procedures, the frequency of bacteremia seems sufficiently high to warrant antimicrobial prophylaxis. The value of prophylaxis is uncertain in procedures less commonly associated with bacteremia such as sigmoidoscopy, colonoscopy, barium enema, liver biopsy, and suction abortion, where available evidence does not prove the necessity of prophylaxis. With prosthetic valves, however, where aerobic gram-negative rods and other organisms can cause infection and where endocarditis is so often devastating, these same procedures may deserve antibiotic prophylaxis. On the other hand, intrauterine device insertion and removal, cervical biopsy, uncomplicated vaginal delivery, percutaneous angiography, and fiberoptic bronchoscopy have such a low incidence of bacteremia that prophylaxis does not seem warranted. Selection of appropriate prophylactic antibiotics requires knowledge both of the organisms most likely to invade the bloodstream during procedures producing transient bacteremia and of those most often responsible for infection of cardiac valves. For dental manipulations likely to cause bleeding, as well as surgery or instrumentation of the upper respiratory tract, prophylaxis is directed against Strep. viridans, and the following regimens are recommended. Aqueous crystalline penicillin 1 million units mixed with procaine penicillin G 600,000 units IM (or penicillin V 2.0 gm orally) 30 to 60 minutes before the procedure followed by penicillin V 500 mg orally every six hours for eight doses. For patients allergic to penicillin: erythromycin 1.0 gm orally (or vancomycin 1 gm IV over 30 minutes) one hour before the procedure followed by erythromycin 500 mg orally every six hours for eight doses. For patients with prosthetic heart valves: Aqueous crystalline penicillin 1 million units mixed with procaine penicillin G 600.000 units IM plus streptomycin 1 gm IM 30 to 60 minutes before the procedure followed by penicillin V 500 mg orally every six hours for eight doses. For procedures that cause significant trauma to the genitourinary or gastrointestinal tracts, prophylaxis is directed against enterococci, and the following regimens are recommended: Ampicillin 1.0 gm IV or IM plus gentamicin 1.5 mg/kg IM or IV 30 to 60 minutes before the procedure and every eight hours for two additional doses. For patients allergic to penicillin: Vancomycin 1.0 gm IV plus streptomycin 1.0 gm IM one hour before the procedure and repeated once 12 hours later.
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Evaluation of socket healing in patients undergoing bisphosphonate therapy: Experience of a single Institution
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MSTS 2018 - Femur Mets and MM
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Objective: To assess the clinical features of exodontias performed in cancer patients who have been receiving intravenous bisphosphonates (BPs). Study Design: This is a retrospective cohort study using a sample of 20 patients receiving BPs who had 62 teeth extracted. An univariate analysis was applied to calculate socket healing time (HT), comparing among exodontias performed according to cause, such as periodontal disease or caries, type of BP, and use of corticosteroid. In order to analyze the influence of each variable on HT, multiple statistical analyses were performed through logistic multiple regression. Results: From the 62 tooth extractions performed, 5 exodontias had evolved to 4 sites of bisphosphonate-related osteonecrosis of the jaws (BOJ). Of another 57 exodontias without development of BOJ, HT was significantly better for tooth extraction performed in patients receiving corticosteroid (p =.01), for tooth extracted due to caries (p =.04), and for extractions under pamidronate (p =.03). Sockets after exodontias due to periodontal diseases had OR= 5.22 (95% CI 1.73-133.66, p=0.01) for delayed HT, exodontias performed under corticosteroid use had OR=0.04 (95% CI 0.01-0.40, p<0.001), and exodontias performed under zoledronate had OR=0.31 (95% CI 0.08-1.25, p=0.10). Conclusions: Exodontias performed in patients under BP therapy had a low rate of BOJ occurrence. Zoledronate and periodontal diseases influence delayed socket healing. Adjuvant antibiotics could be relevant procedures aimed at reducing the risk of BOJ development. © Medicina Oral S. L. C.I.F.
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0 |
Quality of Relationships With Caregivers, Depression, and Life Satisfaction After Dysvascular Lower Extremity Amputation
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DoD LSA (Limb Salvage vs Amputation)
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OBJECTIVE: To describe the relationship between caregiver-specific support and conflict, and psychosocial outcomes among individuals experiencing their first dysvascular lower extremity amputation (LEA). DESIGN: Cross-sectional cohort study using self-report surveys. SETTING: Department of Veterans Affairs, academic medical center, and level I trauma center. PARTICIPANTS: Individuals undergoing their first major LEA because of complications of peripheral arterial disease (PAD) or diabetes who have a caregiver and completed measures of caregiver support and conflict (N=137; 94.9% men). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: The Patient Health Questionnaire-9 to assess depression and the Satisfaction With Life Scale to assess life satisfaction. RESULTS: In multiple regression analyses, controlling for global levels of perceived support, self-rated health, age, and mobility, caregiver-specific support was found to be associated with higher levels of life satisfaction and caregiver-specific conflict was found to be associated with lower levels of life satisfaction and higher levels of depressive symptoms. CONCLUSIONS: The specific relationship between individuals with limb loss and their caregivers may be an important determinant of well-being. Conflict with caregivers, which has received little attention thus far in the limb loss literature, appears to play a particularly important role. Individuals with limb loss may benefit from interventions with their caregivers that both enhance support and reduce conflict.
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Computer-telephone interactive tasks: Predictors of musculoskeletal disorders according to work analysis and workers' perception
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DoD PRF (Psychosocial RF)
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Sixty-two workers engaged in computer-telephone interactive tasks in an active telemarketing center and a telephone call center of an international bank subsidiary in São Paulo, Brazil, were assessed by means of a work analysis and a self-administered questionnaire aiming to determine the statistical relationship of ergonomic, organizational and psychosocial characteristics of their jobs with the report of symptoms in neck-shoulder and hand-wrist for more than 7 consecutive days and any time away from work during the current job due to musculoskeletal disorders (MSD). According to chi-square univariate tests and multiple logistic regression models, active telemarketing operations, duration in the job and the low level of satisfaction with the physical arrangement of the workstation emerged as the factors most related to neck-shoulder and hand-wrist MSD and MSD-induced time away from work. This study emphasizes the role of psychosocial factors and duration in the job in MSD occurrence and induced absenteeism among workers engaged in computer-telephone interactive tasks. © 2002 Published by Elsevier Science Ltd.
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Patient controlled epidural analgesia for bilateral versus unilateral total knee arthroplasty: A retrospective study of pain control
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AAHKS (8) Anesthetic Infiltration
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Background: Patient controlled epidural analgesia (PCEA) has been used commonly for postoperative pain management following total knee arthroplasty (TKA). The purpose of this study was to compare a single standardized PCEA protocol in patients who received unilateral TKA with patients who received simultaneous bilateral TKA. Methods: From October 2003 to October 2008, 912 patients were enrolled. Patient-machine interaction data were retrieved from PCA machines and stratified into 12 hour intervals. The data were analyzed according to the side of surgery, gender and methods of anesthesia. Patient demographic data, pain scores and side effect scores were compared to evaluate clinical efficacy. Results: There was no significant difference between the unilateral and bilateral TKA groups for pain scores, severity of side effects, and total drug use. However, there was a paradoxical increase in demand, delivery, and demand/delivery ratio of analgesics for unilateral rather than bilateral TKA. This was only noted in the first 12 hours. Both genders demanded more bolus doses than set by the standard protocol. Women with unilateral TKA received more delivery doses. All of the patients who received general anesthesia had a higher demand/delivery ratio while spinal anesthesia patients had no significant ratio difference. Conclusion: PCEA provided equal analgesia for patients with unilateral or bilateral TKA. However, the paradoxical increase in demand suggested that psychological factors may play a role in pain perception. A comprehensive pain management program that addresses gender and anesthesia methods in the first 12 hours will improve clinical efficacy and patient satisfaction of PCEA. © 2012 Elsevier Ltd.
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Knowledge transfer in surgery: Skills, process and evaluation
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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Introduction: Knowledge transfer is an essential element in the management of surgical health care. In a routine clinical practice, surgeons need to make changes to the health care they provide as new clinical evidence emerges. Materials and methods: The information was derived from the authors' experience and research in evidence-based practice, searching of the literature, teaching and organisation of various national and international workshops on evidence-based medicine. Discussion: This manuscript discusses principles of knowledge transfer in surgery including evaluation of recommended changes that can improve quality of health care in routine surgical practice. Skills, process and evaluation are carefully described. Continuous information delivery is required to enable surgeons to improve knowledge transfer and to keep up to date their knowledge
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0 |
Trigger fingers: A review
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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Trigger finger, or stenosing tendovaginitis, is a common problem that has its origin at the level of the first annular pulley of the digital flexor tendon sheath. A size discrepancy between the sheath and tendon interferes with the normal tendon gliding process, causing pain and/or snapping upon extension. This article reviews the most recent concepts of the normal anatomy, pathophysiology, epidemiology, and associated conditions, as well as diagnosis, and both surgical and nonsurgical management of trigger digits in adults and children. (copyright) 2006 by Begell House, Inc
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Recommendations on diagnosis and treatment in hepatobiliary surgery under 2019-nCoV epidemic
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Coronavirus Disease 2019 (COVID-19)
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2019 novel coronavirus pneumonia is a serious life-threatening disease and it has affected many people globally, especially the people who live in China. A high prevalence of hepatobiliary diseases has been observed in 2019-nCoV patients and some may require emergency surgery. In the context of the novel coronavirus pneumonia, new challenges have arisen for surgeons in terms of ways to effectively treat outpatients, safety of medical staffs in performing surgery treatment, and the lack of efficient postoperative management and follow-up procedure. It is hoped that through this article, surgeons will have a better system in hepatobiliary diseases classification, treatment selection, and protective measures to improve the clinical practice in accordance with the guidelines for the diagnosis and treatment of the novel coronavirus pneumonia.
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Human Immunodeficiency Virus and Total Joint Arthroplasty: The Risk for Infection Is Reduced
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PJI DX Updated Search
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BACKGROUND: Highly active antiretroviral therapy (HAART) has changed the face of human immunodeficiency virus (HIV) and allowed patients to live for many decades. HIV and HAART are known risk factors for osteonecrosis of bone, osteopenia, and osteoporosis. Therefore, the demand for total joint arthroplasty (TJA) in HIV-infected patients is on the rise. We attempted to determine whether modern treatments for HIV have impacted the rate of periprosthetic joint infection (PJI). METHODS: Conducting a systematic review, 25 studies with a total of 722 TJAs were identified. We extracted data on rates of PJI after primary TJA in HIV-infected patients with and without hemophilia and data on administration of HAART at the time of arthroplasty. RESULTS: Three hundred eighty-one TJAs were performed in 293 patients with HIV infection without hemophilia. The follow-up ranged between 1.5 months and 11 years. Nine patients developed PJI. In patients with both HIV and hemophilia, 341 primary TJAs were performed. Forty-five received treatment for PJI. Follow-up ranged between 1 year and 26 years. Rates of PJI were 2.28% and 10.98% for HIV-only patients and patients with HIV and hemophilia, respectively. This difference was statistically significant (P < .0001) with a 5.28 odds ratio for hemophilia. HAART was associated with fewer infections overall (odds ratio, 0.12). CONCLUSION: The rates of PJI after TJA in HIV-only patients are lower than those in patients with both HIV and hemophilia. Treatment of patients with HAART and optimization of underlying comorbidities appears to lower the rate of PJI in this patient population
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Treatment options other than total knee arthroplasty in young patients with knee osteoarthritis: Part II
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OAK 3 - Non-arthroplasty tx of OAK
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Symptomatic articular knee pathology is not isolated to the aged but also affects younger patients. Although total knee arthroplasty (TKA) remains the gold standard treatment, surgery for gonarthrosis is frequently eschewed in younger patients because of concerns over activity limitations and implant longevity. Furthermore, TKA may be an excessive treatment for some young patients with focally symptomatic lesions but otherwise normal knee joints. Fortunately, non-TKA surgical options such as osteotomy, patellofemoral arthroplasty, and cartilage-specific treatments are available and, given appropriate implementation, provide reliable pain relief, function, and quality of life. This article reviews the indications and recent publications regarding these non-TKA surgical treatments for symptomatic articular knee pathology.
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0 |
Gender differences in functional outcome of elderly hip fracture patients
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Hip Fx in the Elderly 2019
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AIM: The purpose of the present study was to investigate whether gender might affect functional outcome of hip fractured patients undergoing in-hospital rehabilitation.
METHODS: This was a retrospective chart review study comprising of 759 consecutive elderly patients suffering traumatic hip fracture. All patients underwent a standard orthogeriatric care of surgical hip repair and post-acute rehabilitation care. Functional outcome (female vs male gender) was assessed by motor and total Functional Independence Measurement (FIM) scores on discharge. Data was analyzed by t-tests chi(2) -test and multiple linear regression analyses.
RESULTS: A total of 574 (75.6%) out of all patients were females. There were no differences in admission FIM scores; however, male patients had a higher prevalence of comorbidities. FIM scores on discharge were higher in female patients (motor FIM, P=0.007; motor FIM gain, P=0.001; compared with males). A multiple linear regression analysis showed that female gender was independently associated with higher total FIM at discharge (beta coefficient=0.056, P=0.008), higher motor FIM at discharge (beta coefficient=0.071, P=0.007) and higher total FIM gain at discharge (beta coefficient=0.11, P=0.008).
CONCLUSION: The findings suggest that absolute discharge FIM scores of females are higher, compared with male patients. After adjusting for possible covariates, female gender still emerged as an independent predictor for higher FIM at discharge, suggesting that male gender should be considered as adversely affecting rehabilitation outcome of hip fracture male patients.
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Early experiences of breast-conservation treatment combined with tamoxifen and CAF chemotherapy for breast cancer of stages I and II
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MSTS 2018 - Femur Mets and MM
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A total of 39 patients with breast cancer of stages I and II received breast-conservation treatment (BCT) combined with tamoxifen and systemic chemotherapy (CAF) from August 1989 to March 1993. All of these patients visited the outpatient clinic of the Department of Radiology of Kochi Medical School Hospital, with an obvious desire to undertake BCT. During this period, another two patients with the same desire were treated with modified radical mastectomy, because of obviously positive surgical margins in frozen sections obtained at surgery. The percentage of patients treated by BCT was, therefore, 95.1%. All of the patients were females, and their average age was 49.9 years. Thirty-six of these 39 patients underwent lumpectomy, and another three patients with large-sized tumor or suspected extensive intraductal component underwent quadrantectomy or wide local excision. Nineteen of these 39 patients who were over 70 years old or had no clinically detectable axillary lymph node swelling received tangential field radiotherapy to their ipsilateral axillary region instead of axillary dissection. At the end of May 1993, the mean follow-up time was 22.4 months. Until now, one patient (T2N1M0, stage IIB) has died of distant metastases of breast cancer to bone, liver, lung, and brain, and another patient, aged 81, died of pneumonia with no evidence of breast cancer progression. The overall survival rates were, therefore, 100% (30/30), 90.0% (18/20), and 75.0% (6/8) at 1 year, 2 years, and 3 years, respectively. Cause-specific survival rates were 100% (30/30), 94.7% (18/19), and 85.7% (6/7) at 1, 2, and 3 years, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)
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The effects of radioisotope therapy and radiotherapy in subjects with breast cancer with bone metastases
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MSTS 2018 - Femur Mets and MM
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Background: Metastatic bone disease is found in 80-90% of patients examined after death and is a serious problem in everyday practice. The aim of the study was the evaluation of the survival time of patients with bone metastases in relation to the prognostic group and applied treatment. Material and Methods: The authors analyzed 84 patients treated in the Radiotherapy Division of Lower Silesian Oncology Centre during the years 1997-2004, Radioisotope treatment was conducted in the Department of Nuclear Medicine of the 4th Military Clinical Hospital in WrocÅ?aw. The average age of the patients was 53.1 years, The women differed in staging at the moment of diagnosis. The patients were divided into two groups with different clinical prognoses. In addition to systemic treatment (biphosphonates, chemotherapy or hormonotherapy), 32 (38,1%) patients were treated with teletherapy and 20 (23.8%) underwent radioisotope therapy. In 32 (38.1%) patients both methods were applied. The analysis of results included the estimation of overall survival (OS) meaning the time of survival from the onset of disease to one of the end points. End points of the observation were defined by the authors as the patient's death or last control visit. The Kaplan-Meier method was used. Results: The outcomes of the observation are closely connected with particular prognostic groups. The Kaplan-Meier's diagrams presented here indicate that teletherapy combined with radioisotope therapy was the most beneficial for the patients with metastases in bones and other organs. Conclusions: The best effects of the treatment measured by overall survival were obtained with combined treatment: radiotherapy and radioisotopes, in the group with bone and extra-skeletal metastases. Copyright © 2006 Via Medica.
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Bone marrow microvascular density and angiogenic growth factors in multiple myeloma
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MSTS 2018 - Femur Mets and MM
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There is evidence that angiogenesis plays an important role in the progression of multiple myeloma (MM). Hepatocyte growth factor (HGF) and tumor necrosis factor-α (TNF-α) are cytokines that potently stimulate angiogenesis. We evaluated the microvascular density (MVD) of bone marrow biopsies (after immunostaining with anti-CD34 antibodies) and serum levels of HGF and TNF-α in 43 patients with newly diagnosed MM. Twenty-four of these patients reached a plateau phase after treatment and were re-evaluated for MVD, HGF and TNF-α. MVD values and serum levels of HGF and TNF-α were elevated in newly diagnosed MM patients in comparison with healthy controls. Pre-treatment MVD, HGF and TNF-α increased with advancing stage of MM disease. In patients reaching the plateau phase, a significant reduction in MVD, HGF and TNF-α levels occurred. A positive correlation was noted between pre-treatment MVD and serum levels of TNF-α and lactic dehydrogenase but not with HGF. However, HGF strongly correlated with β2-microglobulin (β 2M), TNF-α and lactate dehydrogenase (LDH). We conclude that angiogenesis in MM, as expressed by the bone marrow MVD and the serum levels of angiogenic molecules such as HGF and TNF-α. increases with advancing clinical stage and decreases after effective chemotherapy. © 2004 by Walter de Gruyter.
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Leukocyte and Platelet Rich Plasma (L-PRP) Versus Leukocyte and Platelet Rich Fibrin (L-PRF) For Articular Cartilage Repair of the Knee: A Comparative Evaluation in an Animal Model
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OAK 3 - Non-arthroplasty tx of OAK
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BACKGROUND: Articular cartilage injuries of the knee are among the most debilitating injuries leading to osteoarthritis due to limited regenerative capability of cartilaginous tissue. The use of platelet concentrates containing necessary growth factors for cartilage healing has recently emerged as a new treatment method.
OBJECTIVES: The efficacy of two types of different platelet concentrates were compared in the treatment of acute articular cartilage injuries of the knee in an animal model.
MATERIALS AND METHODS: Eighteen adult Iranian mixed breed male dogs were used to conduct this experimental study. Full thickness articular cartilage defects (diameter 6 mm, depth 5 mm) were created in the weight bearing area of femoral condyles of both hind limbs in all dogs (n = 72). Twelve dogs were randomly selected to receive treatment and their right and left hind limb defects were treated by L-PRP and L-PRF implantation respectively, while no treatment was undertaken in six other dogs as controls. The animals were euthanized at 4, 16 and 24 weeks following surgery and the resultant repair tissue was investigated macroscopically and microscopically. At each sampling time, 4 treated dogs and 2 control dogs were euthanized, therefore 8 defects per group were evaluated.
RESULTS: Mean macroscopic scores of the treated defects were higher than the controls at all sampling times with significant differences (P < 0.05) observed between L-PRF treated and control defects (10.13 vs. 8.37) and L-PRP treated and control defects (10 vs. 8.5) at 4 and 16 weeks, respectively. A similar trend in mean total microscopic scores was observed with a significant difference (P < 0.05) between L-PRP treated and control defects at 4 (9.87 vs. 7.62) and 16 (13.38 vs. 11) weeks. No significant difference was observed between the platelet concentrate treated defects in either mean macroscopic scores or mean total microscopic scores.
CONCLUSIONS: Both L-PRP and L-PRF could be used to effectively promote the healing of articular cartilage defects of the knee.
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Bilateral gluteal compartment syndrome following right total knee revision: a case report
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PJI DX Updated Search
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BACKGROUND: Gluteal compartment syndrome is a rare occurrence traditionally found in settings of extended immobilization. Thrombolytics and medications with myositis as a potential side effect have also been implicated in a few isolated cases of spontaneous compartment syndrome. Early signs are pain on passive stretching and pain out of proportion to physical examination findings. Failure to recognize and definitively treat compartment syndrome within the first 24 to 36 hours can lead to permanent limb loss and morbidity from a host of systemic complications such as hyperkalemia, renal failure, and sepsis. CASE REPORT: We report a case of bilateral gluteal compartment syndrome in a 52-year-old patient following a right total knee revision. On postoperative day 2, physical examination after the patient became agitated and in severe distress from bilateral buttock pain showed that the right and left gluteal regions were tense, hard, and erythematous. Creatinine phosphokinase and liver function tests were significantly elevated. Following emergency fasciotomy, physicians thoroughly reviewed the operative course, medication history, and imaging studies. We withdrew simvastatin, a medication associated with spontaneous compartment syndrome, from our patient's daily medications. By day of discharge, both creatinine phosphokinase and liver function problems were decreasing, and the gluteal pain had significantly resolved. The etiology of bilateral gluteal compartment syndrome in our patient could have been a combination of intraoperative length and positioning with simvastatin-induced myositis. Obesity presented an additional risk factor. CONCLUSION: This case highlights the importance of identifying patients at increased risk of compartment syndrome in the preoperative assessment and following them with more intensive intraoperative and postoperative monitoring
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CXCL12 chemokine expression suppresses human pancreatic cancer growth and metastasis
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MSTS 2018 - Femur Mets and MM
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Pancreatic ductal adenocarcinoma is an unsolved health problem with nearly 75% of patients diagnosed with advanced disease and an overall 5-year survival rate near 5%. Despite the strong link between mortality and malignancy, the mechanisms behind pancreatic cancer dissemination and metastasis are poorly understood. Correlative pathological and cell culture analyses suggest the chemokine receptor CXCR4 plays a biological role in pancreatic cancer progression. In vivo roles for the CXCR4 ligand CXCL12 in pancreatic cancer malignancy were investigated. CXCR4 and CXCR7 were consistently expressed in normal and cancerous pancreatic ductal epithelium, established cell lines, and patient-derived primary cancer cells. Relative to healthy exocrine ducts, CXCL12 expression was pathologically repressed in pancreatic cancer tissue specimens and patient-derived cell lines. To test the functional consequences of CXCL12 silencing, pancreatic cancer cell lines stably expressingthe chemokine were engineered. Consistent with a role for CXCL12 as a tumor suppressor, cells producing the chemokine wereincreasingly adherent and migration deficient in vitro and poorly metastatic in vivo, compared to control cells. Further, CXCL12 reintroduction significantly reduced tumor growth in vitro, with significantly smaller tumors in vivo, leading to a pronounced survival advantage in a preclinical model. Together, these data demonstrate a functional tumor suppressive role for the normal expression of CXCL12 in pancreatic ducts, regulating both tumor growth andcellulardissemination to metastatic sites.
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Anesthesia for the patient undergoing total knee replacement: current status and future prospects
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AAHKS (9/10) Regional Nerve Blocks
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Total knee arthroplasty (TKA) has become one of the most common orthopedic surgical procedures performed nationally. As the population and surgical techniques for TKAs have evolved over time, so have the anesthesia and analgesia used for these procedures. General anesthesia has been the dominant form of anesthesia utilized for TKA in the past, but regional anesthetic techniques are on the rise. Multiple studies have shown the potential for regional anesthesia to improve patient outcomes, such as a decrease in intraoperative blood loss, length of stay, and patient mortality. Anesthesiologists are also moving toward multimodal analgesia, which includes peripheral nerve blockade, periarticular injection, and preemptive analgesia. The goal of multimodal analgesia is to improve perioperative pain control while minimizing systemic narcotic consumption. With improved postoperative pain management and rapid patient rehabilitation, new clinical pathways have been engineered to fast track patient recovery after orthopedic procedures. The aim of these clinical pathways was to improve quality of care, minimize unnecessary variations in care, and reduce cost by using streamlined procedures and protocols. The future of TKA care will be formalized clinical pathways and tracks to better optimize perioperative algorithms with regard to pain control and perioperative rehabilitation.
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Treatment Outcomes of Lesser Tuberosity Osteotomy Nonunion After Total Shoulder Arthroplasty
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Glenohumeral Joint OA
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Introduction: Lesser tuberosity osteotomy (LTO) during anatomic total shoulder arthroplasty has a 13% nonunion rate. Treatment for LTO nonunion is controversial and poorly described in the literature. The purpose of this study was to compare the surgical and nonsurgical treatment outcomes of LTO nonunion. Methods: A retrospective case series of 9 consecutive patients with LTO nonunion after primary anatomic shoulder arthroplasty at 1 institution from 2010 to 2016 were studied. Outcomes measured were radiographic evaluation of LTO on axillary X-ray, clinical range of motion (ROM), subscapularis strength, and pain at the time of LTO nonunion diagnosis and after either conservative care or surgical repair of the LTO nonunion. Results: LTO nonunion was treated surgically in 4 and conservatively in 5 patients with average follow-up of 30 and 22 months, respectively. There were no significant differences in age, sex, or smoking status between groups. Treatment decision was a shared model of surgeon and patient. Displaced LTO nonunion was treated surgically in 2 and conservatively in 3 patients. There were no differences in LTO union rate of 50% in the surgical versus 60% in the conservative group. Abdominal compression test was abnormal in 50% of surgical versus 40% of conservative groups. At follow-up, ROM was lower in the surgical group with 128° forward elevation (FE) and 33° external rotation (ER) compared to 148° FE and 62° ER. Only 1 patient with LTO nonunion required conversion to reverse replacement. Conclusion: LTO nonunion after shoulder arthroplasty is rare. Surgical repair of LTO nonunion does not significantly improve clinical or radiographic outcomes compared to conservative care.
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0 |
Hereditary hemochromatosis as a risk factor for joint replacement surgery
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Surgical Management of Osteoarthritis of the Knee CPG
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OBJECTIVE: Hemochromatosis is an inherited disease with iron overload and joint involvement resembling osteoarthritis. To determine the rate of joint replacement surgery in patients with hemochromatosis, we performed a cross-sectional cohort study. METHODS: A total of 199 individuals with hereditary hemochromatosis were included. The prevalence of joint replacement surgery in hip, knee, and ankle joints because of secondary osteoarthritis was assessed. Data were compared with 917 healthy subjects from the population-based Bruneck study. RESULTS: A total of 32 of 199 individuals with hemochromatosis received joint replacement surgery with a total number of 52 joints replaced. Compared with expected rates in healthy individuals, patients with hemochromatosis had a significantly higher risk for joint replacement surgery (odds ratio 9.0; confidence interval, 4.6-17.4). Joint replacement occurred significantly earlier in life in patients with hemochromatosis; 21.9% of the patients with hemochromatosis and 1.7% of healthy individuals required joint replacement before the age of 50 years (P=.0027). Moreover, patients with hemochromatosis were more likely to require multiple joint replacements (8.5%) than the control group (expected rate 0.3%; P=.0001). CONCLUSION: Hemochromatosis is a risk factor for joint replacement surgery because of severe secondary osteoarthritis
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0 |
Effects of a short-term vitamin D and calcium supplementation on body sway and secondary hyperparathyroidism in elderly women
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Management of Hip Fractures in the Elderly
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Long-term vitamin D and calcium supplementation is effective in reducing nonvertebral fractures in elderly people. Increased bone fragility caused by secondary hyperparathyroidism (sHPT) and impaired balance are known risk factors for hip fractures. The hypothesis is that short-term therapy with calcium and vitamin D may improve body sway as well as sHPT more effectively than calcium monotherapy. The effects of 8 weeks of supplementation with vitamin D (cholecalciferol) and calcium on body sway and biochemical measures of bone metabolism were measured. The sample consisted of 148 women (mean [+/-SD] age, 74 +/- 1 years) with a 25-hydroxycholecalciferol level below 50 nmol/liter. They received either 1200 mg of calcium plus 800 IU of vitamin D or 1200 mg of calcium per day. We measured intact parathyroid hormone (PTH), markers of bone turnover, and body sway before and after treatment. Falls and fractures among the participants were followed over a 1-year period. Compared with calcium mono, supplementation with vitamin D and calcium resulted in an increase in serum 25-hydroxyvitamin D of 72% (p < 0.0001), a decrease in the serum PTH of 18% ( p = 0.0432), and a decrease in body sway of 9% (p = 0.0435). The mean number of falls per subject during a 1-year follow-up period was 0.45 for the calcium mono group and 0.24 for the calcium and vitamin D group (p = 0.0346). Short-term supplementation with vitamin D and calcium improves sHPT and body sway and therefore may prevent falls and subsequent nonvertebral fractures in elderly women
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0 |
Prevalence of carpal tunnel syndrome in pregnancy
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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Introduction: Carpal Tunnel Syndrome (CTS) is one of the complications that may occur during pregnancy and puerperium, most commonly in the third trimester of pregnancy. This dysfunction is due to the median nerve compression in the carpal tunnel and the symptoms usually presented are tingling, pain and paresthesia in the hands and wrist regions. Objective: Estimate the prevalence of CTS in pregnancy in post-natal women and those who have recently given birth, in Botucatu/SP city, and identify factors associated to CTS occurrence in pregnancy. Methods: Populational cross sectional study carried out in the two maternity hospitals in Botucatu, Brazil, with 203 post-natal women. It was used an assessment protocol containing patient's personal data, the Tinnel and Phalen tests, sensitiveness evaluation through estesiometria and the Boston Questionnaire. Results: Out of the individuals interviewed, 81.8 % (166) presented no CTS clinical symptom (CTS-), but 18.2 % (37) presented (CTS+). At maternal age, CTS- group presented higher percentage of women at age 16-25 (57.2 %) and CTS+ from 26 to 31 years old (32.4 %). As for the number of children, 41 % (68) of women in CTS- were primiparous, while 37.8 % (14) of women with CTS+ were pregnant for the second time. 31.9 % of women with CTS- gained from 10 to 15 kg, while in the CTS+ group, 35.1 % gained from 5 to 10 kg, but this difference was statistically non-significant. The CTS+ group presented positive Tinnel in the right hand in 35.1 % of cases and 24.3 % in the left hand. The Phalen test was positive in 40.5 % in the right hand and 37.8 % in the left hand, a statistically non-significant difference. The beginning of CTS symptoms in the 8th month of pregnancy was reported by 43.2 % of women. In the sensitive evaluation, most women CTS+ (74 %) presented normal sensitiveness in the assessed dermatomes. In the Boston Questionnaire, the CTS+ group presented normal responses to the questions related to pain (78 %) and to the daily life activities (38 %), results that did not differ significantly from those in the CTS- group. However, concerning the questions that quantified tingling and worse of symptoms at night, in the group CTS+ 30 % reported intense increase in them. Conclusions: In this study, the prevalence of CTS was 18.2 %, with higher onset of the symptoms from the 8th month of pregnancy
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Periodontal infections and cardiovascular disease--how strong is the association?
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Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures
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In the past decade there has been renewed interest in the old hypothesis that infections increase the risk of developing cardiovascular disease and stroke. There is now a convincing body of evidence that atherosclerosis has a major inflammatory component and is much more than the simple vascular accumulation of lipids. Infectious agents that have been linked to an increased risk of coronary heart disease (CHD) include Chlamydia pneumoniae, Helicobacter pylori, cytomegalovirus, and herpesviruses. The concept has emerged that each of these agents is an independent risk factor for CHD and that common chronic infections are important. In addition, periodontal infections have also been implicated as one of several factors contributing to the development of CHD. Evidence supporting a causative role of chronic infections in CHD is largely circumstantial. However, the evidence is sufficiently strong to warrant further examination of the possible link between chronic infections and CHD. In this review the lines of evidence for a causative role of C. pneumoniae in the development of CHD are summarized and contrasted with the lines of evidence suggesting a periodontal infection--CHD association. If common or widespread chronic infections are truly important risk factors for CHD, it is unlikely that a single infection will be shown to be causative. It is likely that the entire microbial burden of the patient from several simultaneous chronic infections is more important (e.g., H. pylori-caused gastric ulcers + C. pneumoniae-caused bronchitis + periodontitis). Increased cooperation between cardiologists and periodontists will be required to determine if, and what, combinations of common chronic infections are important in the pathogenesis of CHD and stroke
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Surgery for weight loss in adults
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Surgical Management of Osteoarthritis of the Knee CPG
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Background: Bariatric (weight loss) surgery for obesity is considered when other treatments have failed. The effects of the available bariatric procedures compared with medical management and with each other are uncertain. This is an update of a Cochrane review first published in 2003 and most recently updated in 2009.Objectives: To assess the effects of bariatric surgery for overweight and obesity, including the control of comorbidities.Search methods: Studies were obtained from searches of numerous databases, supplemented with searches of reference lists and consultation with experts in obesity research. Date of last search was November 2013.Selection criteria: Randomised controlled trials (RCTs) comparing surgical interventions with non-surgical management of obesity or overweight or comparing different surgical procedures.Data collection and analysis: Data were extracted by one review author and checked by a second review author. Two review authors independently assessed risk of bias and evaluated overall study quality utilising the GRADE instrument.Main results: Twenty-two trials with 1798 participants were included; sample sizes ranged from 15 to 250. Most studies followed participants for 12, 24 or 36 months; the longest follow-up was 10 years. The risk of bias across all domains of most trials was uncertain; just one was judged to have adequate allocation concealment.All seven RCTs comparing surgery with non-surgical interventions found benefits of surgery on measures of weight change at one to two years follow-up. Improvements for some aspects of health-related quality of life (QoL) (two RCTs) and diabetes (five RCTs) were also found. The overall quality of the evidence was moderate. Five studies reported data on mortality, no deaths occurred. Serious adverse events (SAEs) were reported in four studies and ranged from 0% to 37% in the surgery groups and 0% to 25% in the no surgery groups. Between 2% and 13% of participants required reoperations in the five studies that reported these data.Three RCTs found that laparoscopic Roux-en-Y gastric bypass (L)(RYGB) achieved significantly greater weight loss and body mass index (BMI) reduction up to five years after surgery compared with laparoscopic adjustable gastric banding (LAGB). Mean end-of-study BMI was lower following LRYGB compared with LAGB: mean difference (MD) -5.2 kg/m² (95% confidence interval (CI) -6.4 to -4.0; P < 0.00001; 265 participants; 3 trials; moderate quality evidence). Evidence for QoL and comorbidities was very low quality. The LRGYB procedure resulted in greater duration of hospitalisation in two RCTs (4/3.1 versus 2/1.5 days) and a greater number of late major complications (26.1% versus 11.6%) in one RCT. In one RCT the LAGB required high rates of reoperation for band removal (9 patients, 40.9%).Open RYGB, LRYGB and laparoscopic sleeve gastrectomy (LSG) led to losses of weight and/or BMI but there was no consistent picture as to which procedure was better or worse in the seven included trials. MD was -0.2 kg/m² (95% CI -1.8 to 1.3); 353 participants; 6 trials; low quality evidence) in favour of LRYGB.  No statistically significant differences in QoL were found (one RCT). Six RCTs reported mortality; one death occurred following LRYGB. SAEs were reported by one RCT and were higher in the LRYGB group (4.5%) than the LSG group (0.9%). Reoperations ranged from 6.7% to 24% in the LRYGB group and 3.3% to 34% in the LSG group. Effects on comorbidities, complications and additional surgical procedures were neutral, except gastro-oesophageal reflux disease improved following LRYGB (one RCT). One RCT of people with a BMI 25 to 35 and type 2 diabetes found laparoscopic mini-gastric bypass resulted in greater weight loss and improvement of diabetes compared with LSG, and had similar levels of complications.Two RCTs found that biliopancreatic diversion with duodenal switch (BDDS) resulted in greater weight loss than RYGB in morbidly obese patients. End-of-study mean BMI loss was greater following BDDS: MD -7.3 kg/m² (95% CI -9.3 to -5.4); P < 0.00001; 107 participants; 2 trials; moderate quality evidence). QoL was similar on most domains. In one study between 82% to 100% of participants with diabetes had a HbA1c of less than 5% three years after surgery. Reoperations were higher in the BDDS group (16.1% to 27.6%) than the LRYGB group (4.3% to 8.3%). One death occurred in the BDDS group.One RCT comparing laparoscopic duodenojejunal bypass with sleeve gastrectomy versus LRYGB found BMI, excess weight loss, and rates of remission of diabetes and hypertension were similar at 12 months follow-up (very low quality evidence). QoL, SAEs and reoperation rates were not reported. No deaths occurred in either group.One RCT comparing laparoscopic isolated sleeve gastrectomy (LISG) versus LAGB found greater improvement in weight-loss outcomes following LISG at three years follow-up (very low quality evidence). QoL, mortality and SAEs were not reported. Reoperations occurred in 20% of the LAGB group and in 10% of the LISG group.One RCT (unpublished) comparing laparoscopic gastric imbrication with LSG found no statistically significant difference in weight loss between groups (very low quality evidence). QoL and comorbidities were not reported. No deaths occurred. Two participants in the gastric imbrication group required reoperation.Authors' conclusions: Surgery results in greater improvement in weight loss outcomes and weight associated comorbidities compared with non-surgical interventions, regardless of the type of procedures used. When compared with each other, certain procedures resulted in greater weight loss and improvements in comorbidities than others. Outcomes were similar between RYGB and sleeve gastrectomy, and both of these procedures had better outcomes than adjustable gastric banding. For people with very high BMI, biliopancreatic diversion with duodenal switch resulted in greater weight loss than RYGB. Duodenojejunal bypass with sleeve gastrectomy and laparoscopic RYGB had similar outcomes, however this is based on one small trial. Isolated sleeve gastrectomy led to better weight-loss outcomes than adjustable gastric banding after three years follow-up. This was based on one trial only. Weight-related outcomes were similar between laparoscopic gastric imbrication and laparoscopic sleeve gastrectomy in one trial. Across all studies adverse event rates and reoperation rates were generally poorly reported. Most trials followed participants for only one or two years, therefore the long-term effects of surgery remain unclear
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Walking recovery after a hip fracture: a prospective follow-up study among community-dwelling over 60-year old men and women
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Hip Fx in the Elderly 2019
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PURPOSE: Recovery of walking outdoors after hip fracture is important for equal participation in the community. The causes of poor recovery are not fully understood. This study investigates recovery of walking outdoors and associated determinants after hip fracture.
METHODS: A prospective follow-up study, among clinical sample of 81 community-dwelling hip fracture patients over 60 years. Perceived difficulty in walking outdoors and 500 meters was assessed before fracture, at discharge to home (3.2 +/- 2.2 weeks after surgery), and on average 6.0 +/- 3.3 weeks after discharge. Potential determinants for walking recovery were assessed. Linear latent trajectory model was used to analyse changes during follow-up. Association between walking trajectories and potential determinants was analysed with a logistic regression model.
RESULTS: Two trajectories, No-to-minor-difficulty and Catastrophic, were found. Thirty-eight percent of the participants ended up in the Catastrophic trajectory for walking outdoors and 67% for 500 meters. Multivariate logistic regression analysis revealed that use of walking aid and indoor falls before fracture and prolonged pain were independently associated with catastrophic decline in both primary outcomes: difficulty in walking outdoors and 500 meters.
CONCLUSIONS: A large proportion of community-dwelling older people recovering from hip fracture experienced catastrophic decline in outdoor walking. Acknowledging recovery prognoses at early stage enables individualized rehabilitation.
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Biopsy vs. peripheral computed tomography to assess bone disease in CKD patients on dialysis: differences and similarities
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Distal Radius Fractures
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Results from bone biopsy and high-resolution peripheral quantitative computed tomography (HR-pQCT) were compared in 31 CKD patients. There was an agreement mainly for cortical compartment that may represent a perspective on the fracture risk assessment. HR-pQCT also provided some clues on the turnover status, which warrants further studies.
INTRODUCTION: Chronic kidney disease (CKD) patients are at high risk of bone disease. Although bone biopsy is considered the best method to evaluate bone disease, it is expensive and not always available. Here we have compared, for the first time, data obtained from bone biopsy and HR-pQCT in a sample of CKD patients on dialysis.
METHODS: HR-pQCT and dual-energy X-ray absorptiometry (DXA) were performed in 31 CKD patients (30 on dialysis). Biopsies were analyzed by quantitative histomorphometry, and classified according to TMV.
RESULTS: We have found an inverse correlation between radius cortical density measured by HR-pQCT, with serum, as well as histomorphometric bone remodeling markers. Trabecular density and BV/TV measured through HR-pQCT in the distal radius correlated with trabecular and mineralized trabecular bone volume. Trabecular number, separation, and thickness obtained from HR-pQCT and from bone biopsy correlated with each other. Patients with cortical porosity on bone histomorphometry presented lower cortical density at the distal radius. Cortical density at radius was higher while bone alkaline phosphatase was lower in patients with low turnover. Combined, these parameters could identify the turnover status better than individually.
CONCLUSIONS: There was an agreement between HR-pQCT and bone biopsy parameters, particularly in cortical compartment, which may point to a new perspective on the fracture risk assessment for CKD patients. Besides classical bone resorption markers, HR-pQCT provided some clues on the turnover status by measurements of cortical density at radius, although the significance of this finding warrants further studies.
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Two-stage revision arthroplasty of the hip for infection using an interim articulated Prostalac hip spacer: a 10- to 15-year follow-up study
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PJI DX Updated Search
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We report the outcome at ten to 15 years of two-stage revision for hip infection in 99 patients using the Prostalac articulated hip spacer system. All the patients were contacted to determine their current functional and infection status using the Oxford-12, Short form-12, and Western Ontario and McMaster University Osteoarthritis Index questionnaires. A total of 11 of the 99 patients had a further infection, of whom seven responded to repeat surgery with no further sequelae. The mean interval between the stages was five months (1 to 36). We were able to review 48 living patients, with a mean age of 72 years (46 to 86), 34 (71%) of whom provided health-related quality-of-life outcome scores. The mean follow-up was 12 years (10 to 15). The long-term success rate was 89% and with additional surgery this rose to 96%. The mean global Western Ontario and McMaster University Osteoarthritis Index score was 80.6 (sd 18.3). The mean Oxford-12 score was 74.0 (sd 22.3), and the mean Short form-12 score was 53.1 (sd 9.4) (mental) and 33.5 (sd 13.5) (physical). The mean satisfaction score was 90.5 (sd 15.3). Two-stage revision for hip infection using a Prostalac interim spacer offers a predictable and lasting solution for patients with this difficult problem
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Hip fracture risk in older US adults by treatment eligibility status based on new National Osteoporosis Foundation guidance
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Management of Hip Fractures in the Elderly
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Summary: This analysis of National Health and Nutrition Examination Survey III data found a significant risk of incident hip fracture in adults aged 65 years and older who are candidates for treatment to lower fracture risk, according to the new National Osteoporosis Foundation Clinician's Guide. Introduction: The relationship between treatment eligibility by the new National Osteoporosis Foundation (NOF) Guide to the Prevention and Treatment of Osteoporosis and the risk of subsequent hip fracture is unknown. Methods: The study sample consisted of 3,208 men and women ages 65 years and older who were examined in the third National Health and Nutrition Examination Survey (NHANES III, 1988-1994), a nationally representative survey. Risk factors used to define treatment eligibility at baseline were measured in NHANES III or were simulated using World Health Organization study cohorts. Incident hip fractures were ascertained using linked mortality and Medicare records that were obtained for NHANES III participants through December 31, 2000. Cox proportional hazards models were used to estimate the relative risk (RR) of hip fracture by treatment eligibility status. Results: The RR for subsequent hip fracture was 4.9 (95% CI 3.30, 7.94) in treatment-eligible vs treatment-ineligible persons. The increased risk for treatment-eligible persons remained statistically significant when examined by sex or age: RR(men)=5.5 (2.6, 11.4) and RR (women)=4.3 (2.2, 8.4); RR(65-79 y)=4.8 (2.6, 8.7) and RR (80+ y)=4.6 (2.1, 10.1). Conclusions: Treatment-eligible persons were about five times more likely to experience a subsequent hip fracture than the non-eligible persons. The new NOF guidelines appear to predict future hip fracture risk equally in men as in women, and fracture risk prediction did not appear to diminish with age. (copyright) 2010 International Osteoporosis Foundation and National Osteoporosis Foundation
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Single dose oral dexibuprofen [S(+)-ibuprofen] for acute postoperative pain in adults
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SR for PM on OA of All Extremities
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Background: This review is an update of a previously published review in The Cochrane Database of Systematic Reviews Issue 3, 2009 on single dose oral dexibuprofen (S(+)-ibuprofen) for acute postoperative pain in adults.Dexibuprofen is a non-steroidal anti-inflammatory drug (NSAID) licensed for use in rheumatic disease and other musculoskeletal disorders in the UK, and widely available in other countries worldwide. It is an active isomer of ibuprofen. This review sought to evaluate the efficacy and safety of oral dexibuprofen in acute postoperative pain, using clinical studies in patients with established pain, and with outcomes measured primarily over four to six hours, using standard methods. This type of study has been used for many decades to establish that drugs have analgesic properties.Objectives: To assess the efficacy and adverse effects of single dose oral dexibuprofen for acute postoperative pain using methods that permit comparison with other analgesics evaluated in standardised studies using almost identical methods and outcomes.Search methods: Searches were run for the original review in 2009 and subsequent searches have been run in August 2013. We did not find any new published studies as a result of the updated search.We searched for randomised studies of dexibuprofen in acute postoperative pain in MEDLINE, EMBASE, and CENTRAL (The Cochrane LIbrary), and for clinical trial reports and synopses of published and unpublished studies from Internet sources.Selection criteria: Randomised, double blind, placebo-controlled clinical studies of oral dexibuprofen for relief of acute postoperative pain in adults.Data collection and analysis: Two review authors independently assessed study quality and extracted data. We extracted pain relief or pain intensity data and converted it into the dichotomous outcome of number of participants with at least 50% pain relief over four to six hours, from which relative risk and number needed to treat to benefit (NNT) were calculated. Numbers of participants using rescue medication over specified time periods, and time to use of rescue medication, were sought as additional measures of efficacy. We collected information on adverse events and withdrawals.Main results: New data were identified for this update in one unpublished trial synopsis (BR1160 1995) in addition to the single study (Dionne 1998) that was included in the original review. In both studies dexibuprofen gave high levels of response, with 51/96 (53%) participants experiencing at least 50% pain relief with dexibuprofen 200 mg and 35/50 (70%) with dexibuprofen 400 mg, compared with 75/147 (51%) with racemic ibuprofen 400 mg, and 12/62 (13%) with placebo. The numbers of participants was too small to calculate NNTs with any meaning. The median time to additional analgesic use was greater than four hours for all active therapies, but about two hours for placebo.Adverse events were generally of mild or moderate intensity and consistent with events normally associated with anaesthesia and surgery. There were no serious adverse events or deaths.Additional data did not alter the conclusions from the earlier review.Authors' conclusions: The information from these two studies in acute postoperative pain suggested that dexibuprofen may be a useful analgesic, but at doses not very different from racemic ibuprofen, for which considerably more evidence exists
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Hip fractures in two health care regions in Finland in 1989: an analysis of treatment
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HipFx Supplemental Cost Analysis
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We studied prospectively the demographic data, fracture types and modes of treatment in 390 patients with acute traumatic hip fractures in two health care regions in Finland, the Middle Finland region and the Kymenlaakso region in 1989. In Middle Finland population (251,203 inhabitants) 199 patients with a hip fracture were admitted to two acute care hospitals, while 191 patients were admitted in Kymenlaakso (population 189,726) to four acute hospitals. There were no significant differences in the sex- and age-specific incidences between the two regions. In Middle Finland, 70% of the fractures were of the femoral neck, 28% were trochanteric and 2% subtrochanteric. The corresponding figures in Kymenlaakso were 57%, 38% and 5% (P < 0.05). In Middle Finland, 73% of the femoral neck fractures were treated primarily with a hemiendoprosthesis, 2% with primary total hip replacement and 25% by osteosynthesis. The corresponding figures in Kymenlaakso were 81%, 7% and 12% (P < 0.001). The mean duration of hospital stay was 14 days in Middle Finland and 21 days in Kymenlaakso (P < 0.01)
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Unsatisfactory outcome of arthrodesis performed after septic failure of revision total knee arthroplasty
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DoD LSA (Limb Salvage vs Amputation)
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BACKGROUND: Periprosthetic infection is one of the most dreaded orthopaedic complications. Current treatment procedures include one-stage or two-stage revision total knee arthroplasty. If the periprosthetic infection is no longer controllable after several revision total knee arthroplasties, many surgeons regard knee arthrodesis as a promising option. The aim of our study was to ascertain whether intramedullary nailing results in the suppression or eradication of an infection and to identify risk factors for persistent infection. METHODS: All patients who had undergone intramedullary nailing following septic failure of revision total knee arthroplasty between 1997 and 2013 were included in the study. Pathogens, risk factors predisposing to persistent infection, and the rate of persistent infections were recorded. In addition, a visual analog scale (VAS) and Knee injury Osteoarthritis Outcome Score (KOOS), Knee Society Score (KSS), Lysholm, Short Form-36 (SF-36), and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) questionnaires were completed to assess clinical outcomes and quality of life. RESULTS: Twenty-six patients were included in the study. Thirteen (50%) had a persistent infection requiring additional revision surgery. Nineteen patients (73%) reported persistent pain (VAS score of >3). All scores showed marked impairment of quality of life. CONCLUSIONS: Intramedullary nailing following septic failure of revision total knee arthroplasty must be regarded with skepticism, and we cannot recommend it. Repeat revision total knee arthroplasty or amputation should be considered as an alternative in such difficult cases.
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Free tissue transfer: an advanced strategy for postinfection soft-tissue defects in the upper extremity
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DoD LSA (Limb Salvage vs Amputation)
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Surgical treatment of severe, necrotizing infections frequently leave compound defects that require complex reconstructive procedures. In the upper extremity, local flap coverage is limited because of the size of the lesions. Regarding the results of early microsurgical coverage of complex postinfectious defects of the lower extremity, the goal of this study was to evaluate the role of free tissue transfer in the treatment of severe infections in the upper extremity. Between 1994 and 1999, 24 patients with major defects as a result of severe necrotizing infections in the upper extremity underwent free tissue transfer. Parameters assessed included the success of infection control, flap survival rate, salvage of the extremity, and an outcome analysis by the Disability of Arm-Shoulder-Hand score and a visual analog scale. Patient age ranged from 17 to 75 years (average age, 50.8 years). Previous treatment of 11 patients in outlying hospitals included 4.2 operative procedures and a delay of admission to the authors' unit of 89 days. The average defect size after debridement was 10.0 x 14.4 cm. Twenty-four free flaps including 16 muscle or musculocutaneous flaps, 4 chimeric flaps from the subscapular system, and 4 osteocutaneous flaps were performed for reconstruction. The overall flap survival was 95.8%. One temporalis fascia flap (TPF) was lost as a result of vascular thrombosis, and three flaps underwent successful revision of the anastomoses. Eight patients required further minor surgical treatment. The Disability of Arm-Shoulder-Hand score yielded an average of 41.5 points, which represents a moderate impairment of activities of daily living. Visual analog scale assessment demonstrated an overall high satisfaction (9.5 points; range, 1-10 points). The data demonstrate that even in severe necrotizing infections resulting in complex acute or chronic defects, limb salvage and infection control can be achieved successfully with radical debridement and early free tissue transfer.
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Arthroscopic Capsular Plication in Patients With Labral Tears and Borderline Dysplasia of the Hip: Analysis of Risk Factors for Failure
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Developmental Dysplasia of the Hip 2020 Review
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BACKGROUND: Hip arthroscopy for the treatment of instability in the setting of borderline dysplasia is controversial. Capsular management in such cases is an important consideration, and plication has been described as a reliable technique, with good midterm outcomes reported when indications are appropriate. HYPOTHESIS: Patients with borderline dysplasia who have a lower lateral center-edge angle (LCEA) and greater age will be at a higher risk of failure after arthroscopic capsular plication. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: Data were retrospectively reviewed for all patients between 15 and 40 years of age who underwent hip arthroscopy from November 2008 to January 2015. Inclusion criteria were an LCEA between 18° and 25°, Tönnis grade �1, primary case with capsular plication, and minimum 2-year follow-up. Patients were excluded if they had any history of ipsilateral hip procedure or conditions such as Legg-Calve-Perthes disease, slipped capital femoral epiphysis, rheumatologic disease, and Tönnis grade �2. Age, sex, and body mass index data were retrieved for each patient. Patient-reported outcomes (PROs)-including modified Harris Hip Score (mHHS), Non-Arthritic Hip Score (NAHS), Hip Outcome Score-Sports Specific Subscale, and a visual analog scale (VAS) for pain (0-10)-were obtained preoperatively and at a minimum of 2 years postoperatively, in addition to the postoperative International Hip Outcome Tool-12. The "success" group consisted of all patients who achieved the patient acceptable symptomatic state of mHHS �74 and had no ipsilateral hip surgery subsequent to their index arthroscopy. The "failure" group was composed of patients who were below the patient acceptable symptomatic state at latest follow-up or required secondary arthroscopy or conversion to total hip arthroplasty. Patient satisfaction and minimal clinically important difference were also calculated. Mean age for the failure group was applied as a cutoff age for subanalysis, and relative risk for failure was determined. RESULTS: Ninety patients (97 hips; 79.5%) met criteria for the success group, and 25 patients (25 hips) met criteria for the failure group. No significant differences in preoperative baseline scores or VAS were found. However, there did appear to be a trend that the failure group had lower mean preoperative scores for all PRO measures and a higher VAS score. The differences in preoperative mHHS and NAHS closely approached significance ( P = .053). Postoperative PRO, VAS, and patient satisfaction scores of the success group were significantly higher than the failure group. The failure group was significantly older than the success group (28.5 ± 7.8 vs 23.5 ± 7.5 years, P = .005). Patients >35 years old were 2.25 times more likely to fail according to relative risk (95% CI, 1.10-4.60; P = .0266). LCEA did not differ between the groups, and no other risk factors for failure were identified. CONCLUSION: Stringent criteria for patient selection and meticulous repair or augmentation of the static stabilizers of the hip yielded favorable clinical outcomes in this study cohort with borderline dysplasia. Within this carefully selected group, the analysis revealed that increased age was the main risk factor for failure in the management of borderline hip dysplasia via isolated primary arthroscopic hip surgery with capsular plication.
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Failure characteristics of the isolated distal radius in response to dynamic impact loading
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Distal Radius Fractures
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We examined the mechanical response of the distal radius pre-fracture and at fracture under dynamic impact loads. The distal third of eight human cadaveric radii were potted and placed in a custom designed pneumatic impact system. The distal intraarticular surface of the radius rested against a model scaphoid and lunate, simulating 45° of wrist extension. The scaphoid and lunate were attached to a load cell that in turn was attached to an impact plate. Impulsive impacts were applied at increasing energy levels, in 10 J increments, until fracture occurred. Three 45° stacked strain gauge rosettes were affixed along the length of the radius quantifying the bone strains. The mean (SD) fracture energy was 45.5 (16) J. The mean (SD) resultant impact reaction force (IRFr) at failure was 2,142 (1,229) N, resulting in high compressive strains at the distal (2,718 (1,698) με) and proximal radius (3,664 (1,890) με). We successfully reproduced consistent fracture patterns in response to dynamic loads. The fracture energy and forces reported here are lower and the strains are higher than those previously reported and can likely be attributed to the controlled, incremental, dynamic nature of the applied loads. © 2011 Orthopaedic Research Society. Published by Wiley Periodicals, Inc.
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What factors are associated with outcomes scores after surgical treatment of ankle fractures with a posterior malleolar fragment?
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DoD SSI (Surgical Site Infections)
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BackgroundPsychosocial factors, such as depression and catastrophic thinking, might account for more disability after various orthopaedic trauma pathologies than range of motion and other impairments. However, little is known about the influence of psychosocial aspects of illness on long-term symptoms and limitations of patients with rotational-type ankle fractures, including a posterior malleolar fragment. Knowledge of the psychosocial factors associated with long-term outcome after operative treatment of trimalleolar ankle fractures might improve recovery.Questions/purposes(1) Which factors related to patient demographics, physical exam, diagnosis, or psychological well-being (in particular, depression), if any, are associated with better or worse scores on validated lower-extremity outcomes instruments after surgical treatment for rotational ankle fractures (including a posterior malleolar fragment) at long-term followup?MethodsBetween 1974 and 2002, 423 patients underwent open reduction internal fixation for rotational ankle fractures with posterior malleolar fragments according to the basic principles of the AO (Arbeitsgemeinshaft für Osteosynthesfragen). Minimum followup for inclusion here was 10 years (range, 12.5-39.4 years). When posterior malleolar fragments involved more than 25% of the articular surface as assessed on plain lateral radiographs, the fracture was generally fixed with AP or posterior-anterior (PA) screws. Of those treated surgically during the period in question, 319 were lost to followup, had too much missing data to include, or declined to participate in this study (or could not because of reasons of mental illness) (68%), leaving 104 (32%) for analysis in this retrospective study. Independent observers not involved in patient care measured disability using the patient-based Foot and Ankle Ability Measure questionnaire and using the subscale Activities in Daily Living (ADL) and pain score of the Foot and Ankle Outcome Score. General physical and mental health status was evaluated using the SF-36. Depressive symptoms were measured with the Center for Epidemiologic Studies-Depression scale score (range, 0-60 points). A score above 16 indicated a depressive disorder. Misinterpretation or overinterpretation of nociception was measured with the Pain Catastrophizing Scale score. Scores above 13.9 were considered abnormal. Statistical analyses included uni- A nd multivariate regression analysis. In general, patients in this series reported good to excellent outcomes; the mean ± SD scores were 91 ± 15 for Foot and Ankle Ability Measure, 93 ± 16 for Foot and Ankle Outcome Score (ADL), 91 ± 15 for Foot and Ankle Outcome Score (pain), 49 ± 9 for SF-36 mental component score, and 52 ± 9 for SF-36 physical component score.ResultsImplant removal (ß =-8.199, p < 0.01) was associated with worse Foot and Ankle Ability Measure scores. Better flexion/extension arc (ß = 0.445, p < 0.01) and lower Center for Epidemiologic Studies-Depression scores (ß =-0.527, p < 0.01) were associated with better Foot and Ankle Ability Measure scores. Osteoarthritis (ß =-4.823, p < 0.01) was associated with worse Foot and Ankle Outcome Score (pain) scores. Better flexion/extension arc (ß = 0.454, p < 0.01) and lower Center for Epidemiologic Studies-Depression scores (ß =-0.596, p < 0.01) were associated with better Foot and Ankle Outcome Score (pain) scores. Better flexion/extension arc (ß =-0.431, p < 0.01) and lower Center for Epidemiologic Studies-Depression scores (ß =-0.557, p < 0.01) were associated with better Foot and Ankle Outcome Score (ADL) scores. Finally, we found that a better inversion/eversion arc (ß = 0.122, p = 0.024) was associated with better SF-36 physical component score and that a lower Center for Epidemiologic Studies-Depression score (ß =-0.567, p < 0.01) was associated with better SF-36 mental component score.ConclusionsPsychological aspects of recovery from musculoskeletal injury merit greater attention, perhaps even over objective, unmodifiable predictors. A mean of 24 years after surgical treatment of ankle fractures with a posterior malleolar fragment, patient-reported outcome measures have little to do with pathophysiology; they mostly reflect impairment and depression symptoms. Further research is needed to determine whether early indentification and treatment of at-risk patients based on psychosocial factors can improve long-term outcomes.
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Histone modifications in the interluekin-6 gene promoter region of rheumatoid arthritis synovial fibroblasts
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Surgical Management of Osteoarthritis of the Knee CPG
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Background/Purpose: Rheumatoid arthritis (RA) is a disease of unknown origin, which develops continuous inflammation and progressive joint destruction resulting from an autoimmune response mainly occurred in the joints. Although genetic factors in RA have been reported, another factors might be important for RA because of low concordance rate of monozygotic twins. Additionally, it is well known that environmental factors, for example smoking and infections, are involved in the pathogenesis of RA. Recently, epigenetic abnormalities in acquired chronic disorders including RA have been reported. DNA methylations, microRNAs, and histone modifications are major epigenetic abnormalities. DNA methylations and microRNAs in RA have been well characterized, however, evidences of histone modifications in RA are limited. Histone modifications are associated with gene transcriptions. In promoter regions of target genes, high-level histone acetylation and histone H3 lysine 4 trimethylation (H3K4me3) exist. One of the major pathological conditions in RA may be overproduction of interleukin (IL)-6 from RA synovial fibroblasts (SFs) stimulated by tumor necrosis factor (TNF)-alpha derived from activated macrophages. The purpose of this study is to clarify the relation of histone modifications in the IL-6 gene promoter region and IL-6 gene transcription in RASFs. Methods: Synovial fibroblasts from the patients with RA and osteoarthritis (OA) as a control were harvested on the occasion of total knee arthroplasty in our hospital and were used for passages 4 through 8. Histone modifications (histone H3 acetylation (H3ac), H3K4me3) in the IL-6 gene promoter region were compared between RASFs and OASFs by chromatin immunoprecipitation (ChIP) assay. IL-6 mRNA and protein levels after stimulation with 10 ng/ml of TNF-alpha were detected using reverse transcription-polymerase chain reaction and enzyme-linked immunosorbent assay. Furthermore, we investigated how a treatment of histone acetyltransferase inhibitor (HATi) before stimulation with TNFalpha had an influence on H3ac in the IL-6 gene promoter region and IL-6 mRNA in RASFs. Results: IL-6 mRNA of RASFs were significantly increased compared with OASFs. In ChIP assay, both H3ac and H3K4me3 in the IL-6 gene promoter region of RASFs were significantly higher than those of OASFs. IL-6 mRNA and protein levels of RASFs were significantly increased more than those of OASFs after stimulation with TNF-alpha. Taken together, it is suggested that high levels of H3ac and H3K4me3 in the IL-6 gene promoter region of RASFs lead to be accessible for transcription factors to bind the region. In order to obtain more confirmed evidence of H3ac in the IL-6 gene promoter region in RASFs, we examined H3ac in the IL-6 gene promoter region and IL-6 mRNA of RASFs treated by HATi, curcumin. Both H3ac in the IL-6 promoter region and IL-6 mRNA of
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Acute knee effusions: a systematic approach to diagnosis
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AMP (Acute Meniscal Pathology)
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Knee effusions may be the result of trauma, overuse or systemic disease. An understanding of knee pathoanatomy is an invaluable part of making the correct diagnosis and formulating a treatment plan. Taking a thorough medical history is the key component of the evaluation. The most common traumatic causes of knee effusion are ligamentous, osseous and meniscal injuries, and overuse syndromes. Atraumatic etiologies include arthritis, infection, crystal deposition and tumor. It is essential to compare the affected knee with the unaffected knee. Systematic physical examination of the knee, using specific maneuvers, and the appropriate use of diagnostic imaging studies and arthrocentesis establish the correct diagnosis and treatment. [References: 20]
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0 |
Future of 34 meniscectomies after bucket-handle meniscus tear: a retrospective study with a follow-up over 22 years
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AMP (Acute Meniscal Pathology)
|
After a bucket-handle meniscus tear, a partial meniscectomy by arthroscopy is recommended, when a meniscal suture is impossible. Short-term results of meniscectomy after bucket-handle meniscus tear, without cartilage or ligament additional injury, are mostly excellent: pain and blocking disappear, return to sports activities is possible. The aim of this retrospective study is to follow a partial meniscectomy evolution with a long follow-up between March 1990 and April 1994, and a senior surgeon operated 34 meniscectomies for bucket-handle meniscus tear by 34 patients (29 male and 5 female) with a mean age of 31.7 years (16-52 years) at time of surgery. The bucket-handle meniscus tear had a traumatic etiology on a knee with no cartilage lesion. The functional results were assessed by IKDC subjective score (International Knee Documentation Committee) and ARPEGE score (Association pour la Recherche et la Promotion de l'Etude du Genou). These scores were obtained by phone call questionnaire in March 2014 with a mean follow-up of 22.7 years (20-24 years). In this study, patients were reviewed and got a clinical examination to determine the Lequesne score, a radiological knee assessment according to Ahlback classification and a weight-bearing teleradiography. With an IKDC mean score of 85.8 after surgery, we observed that 29 patients go back to sports activities with the same level as before injury. The level of sports activity, with a regular practice after a mean follow-up of 22.7 years, was the same as immediately after surgery or just the level under for 85.3 % of patients. With ARPEGE score, 48.5 % of patients had a global excellent result and 38.2 % had a global good result after a long follow-up. With a mean Lequesne score of 2.38, osteoarthritis of knee is still clinical minimal after meniscectomy at long term. The score was worse after external meniscectomy (EM) than after an internal meniscectomy (IM). 57.7 % of patients have osteoarthritis on X-rays. In our study, functional results after partial meniscectomy for bucket-handle meniscus tear are similar than in the literature. More than half of our patients, reviewed after a long follow-up, had radiological osteoarthritis of knee with a variable clinical result, but often minimal to moderate, intensity modulated by the lower limb axis.
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0 |
Elastase from polymorphonuclear leukocyte in articular cartilage and synovial fluids of patients with rheumatoid arthritis
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Surgical Management of Osteoarthritis of the Knee CPG
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Objective was to study the significance and the mechanism of action of elastase from polymorphonuclear leukocyte (PMN elastase) in patients with rheumatoid arthritis (RA). The experiments conducted consisted of two phases. Firstly, articular cartilage and synovia from 8 patients with RA undergoing total knee replacement were obtained, and the gelatinolytic enzyme activity was extracted with 2M guanidine hydrochloride. The gelatinolytic activity of each tissue was measured to confirm that the activity was due to PMN elastase by using an antihuman leukocyte elastase antibody. Secondly, the levels of PMN elastase-alpha 1 proteinase inhibitor complex (EIC) in the blood and synovial fluid of 170 patients with RA were measured by immunoassay. The results were as follows: 1. Gelatinolytic activity was shown to be mainly due to PMN elastase, and found to be highest in cartilage and synovia in RA joints. 2. The EIC levels in plasma of RA patients were significantly higher than those in gout and osteoarthritis (OA), and the EIC levels increased according to the stage of articular cartilage destruction. Moreover, the EIC levels in synovial fluid of RA patients were higher compared to those of OA patients. The activity of PMN elastase was elevated in destructive joints of RA. With the progression of articular cartilage destruction, EIC levels in plasma of RA patients increased as well. We suggest that PMN elastase may play a significant role in RA disease
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0 |
Double-blind randomized controlled trial of flurbiprofen-SR (ANSAID-SR) and diclofenac sodium-SR (Voltaren-SR) in the treatment of osteoarthritis
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OAK 3 - Non-arthroplasty tx of OAK
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A six week, doubleâ?blind, randomized, parallel group, multicentre study was conducted in 85 patients with osteoarthritis of the knee and hip to compare the efficacy, tolerability, and safety of Flurbiprofenâ?SR 200 mg with Diclofenac Sodiumâ?SR 100 mg. Between group comparisons, based on change scores from baseline, we detected no significant differences between the two drugs with respect to efficacy for the majority of outcome measures. There was no significant difference between the groups in the proportion of patients experiencing at least one adverse medical event or in terminations from treatment. We conclude that Flurbiprofenâ?SR 200 mg is similar in efficacy, tolerability, and safety to Diclofenac Sodiumâ?SR in this trial.
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0 |
Can preoperative scoring systems be applied to Asian hip fracture populations? Validation of the Nottingham Hip Fracture Score (NHFS) and identification of preoperative risk factors in hip fractures
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Hip Fx in the Elderly 2019
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INTRODUCTION: Hip fractures in the elderly are a major cause of morbidity and mortality. Determining which patients will benefit from hip fracture surgery is crucial to reducing mortality and morbidity. Our objectives are: 1) to define the rate of index admission, 1-month and 1-year mortality in all hip fracture patients, and 2) to apply the Nottingham Hip Fracture Score (NHFS) to determine validity in an Asian population.
MATERIALS AND METHODS: This is a prospective cohort study of 212 patients with hip fractures above 60 years from September 2009 to April 2010 for 1-year. Sociodemographic, prefracture comorbidity and data on functional status was collected on admission, and at intervals after discharge. The main outcome measures were mortality on index admission, 1 month and 12 months after treatment.
RESULTS: In our study, the overall mortality at 1-month and 1-year after surgery was 7.3% and 14.6% respectively. Surgically treated hip fracture patients had lower odds ratio (OR) for mortality as compared to conservatively treated ones. The OR was 0.17 during index admission, 0.17 at 1-month, and 0.18 at 12-months after discharge. These were statistically significant. Adjustments for age, gender, and duration to surgery were taken into account. The NHFS was found to be a good predictor of 1-month mortality after surgery.
CONCLUSION: Surgically treated hip fracture patients have a lower OR for mortality than conservatively managed ones even up to 1-year. The NHFS has shown to predict 1-month mortality accurately for surgically treated hip fracture patients, even for our Asian population. It can be used as a tool for clinicians at the individual patient level to communicate risk with patients and help plan care for fracture patients.
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0 |
Structural changes in muscle and glenohumeral joint deformity in neonatal brachial plexus palsy
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Glenohumeral Joint OA
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BACKGROUND: Internal rotation contracture of the shoulder is common in children with neonatal brachial plexus palsy. A long-standing contracture may cause osseous deformities in the developing shoulder. The purpose of the study was to evaluate the relationship between osseous deformities of the glenohumeral joint and structural differences due to muscle denervation in the rotator cuff muscles.
METHODS: One hundred and two children with residual neonatal brachial plexus palsy underwent magnetic resonance imaging of both shoulders. The glenoid version and posterior, medial, and superior subluxation of the humeral head were measured. The shapes of the glenoid and the humeral head were categorized, and the infraspinatus, supraspinatus, subscapularis, and deltoid muscles were scored as being normal, atrophic, or atrophic with fatty degeneration.
RESULTS: Muscle degeneration was most prominent in the subscapularis muscle. Glenoid version correlated with the structural differences in the subscapularis muscle. Posterior subluxation of the humeral head and the shape of the glenoid correlated with all abnormal rotator cuff muscles. Superior humeral subluxation correlated only with changes in the supraspinatus muscle. Medialization and the shape of the humeral head were not associated with atrophic changes of the rotator cuff. Regeneration of the rotator cuff muscles was not significantly different in patients with a C5-C6 (C7) or a complete brachial plexus lesion. However, the changes in glenoid version, the degree of posterior humeral subluxation, and the degree of medial humeral subluxation were significantly more severe in patients with a C5-C6 (C7) lesion compared with those in patients with a complete lesion of the brachial plexus.
CONCLUSIONS: Structural differences in the rotator cuff muscles alter the direction of the humeral head forces on the developing glenoid fossa and can lead to osseous deformities. Glenohumeral deformities are significantly greater with a C5-C6 (C7) lesion than with a complete brachial plexus lesion in which the large internal rotators are also affected. Reducing the muscular imbalance that occurs with a C5-C6 (C7) lesion could diminish glenohumeral joint incongruency and may improve the outcome of subsequent soft-tissue release or tendon transfer surgery.
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0 |
Current issues and regulations in tendon regeneration and musculoskeletal repair with mesenchymal stem cells
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AMP (Acute Meniscal Pathology)
|
Mesenchymal stem cells are multipotent stromal cells residing within the connective tissue of most organs. Their surface phenotype has been well described. Most commonly, mesenchymal stem cells demonstrate the ability to differentiate into mesenchymal tissues (bone, catailge, fat, etc.), however, under the proper conditions these cells can differentiate into epithelial cells and neuroectoderm derived lineages. Their developmental plasticity also depends on the ability of mesenchymal stem cells to alter the tissue microenvironment by secreting soluble factors, as well as their capacity for differentiation in tissue repair. It is the cell-matrix interaction which defines the tissue characteristics. The molecular and functional heterogeneity of this cell population may confound interpretation of their differentiation potential, but it is this heterogeneity that is believed to provide for their therapeutic efficacy. Stem cell therapies are an attractive therapeutic approach for soft tissues as they offer a vehicle for repair and regeneration at the end of a needle. The early introduction of stem cell treatments into the therapeutic armamentarium involves both commercial and non-commercial multidisciplinary partnerships and has occurred in a climate of regulatory reform, so not all the relevant information resides in the public domain, but early clinical studies have shown promising results. Against this backdrop, novel techniques and early results of a small series of tendon and musculotendinous junction interventions are being published and other ongoing studies are yet to report their results. The issue of ensuring governance of these novel technologies falls upon both the scientific community and the established licensing authorities. © 2012 Bentham Science Publishers.
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1 |
The use of epidural morphine in patients undergoing total knee arthroplasty
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Surgical Management of Osteoarthritis of the Knee CPG
|
Sixty-six patients undergoing total knee arthroplasty were offered epidural morphine as a method of postoperative analgesia. Of the 66 patients, 50 completed the minimum protocol of 3 days in a special epidural monitoring unit and were thus available for study. In this study group, 86% stated that they obtained 75-100% relief of pain with each epidural injection. Greater than 90% of the patients rated the overall experience with epidural analgesia as excellent or good. Ninety percent stated that they would choose epidural morphine analgesia again if given the choice. Nausea and vomiting were the most common adverse effects, occurring in 34%. One patient experienced respiratory depression, which was reversed with Narcan. The most frequent complaint related to the procedure itself was the use of an apnea monitor; 18% of the patients considered this monitoring device intolerable. The progress of total knee arthroplasties in the epidural unit was monitored by range of motion achieved. At 72 hours the average motion was 10 degrees-87 degrees and at the end of the hospital stay was 6 degrees-98 degrees. The total hospital bill for epidural morphine analgesic patients was $469 more than for a conventional arthroplasty patient, though the mean duration of hospital stay was 1.7 days less for the epidural morphine patients. Epidural morphine provided excellent but inconsistent postoperative pain relief. When relief was present, aggressive in-house rehabilitation could be instituted, and a shorter overall hospital stay was achieved when compared with conventional analgesia. Nonetheless, the related adverse effects and inconsistent pain relief on many patients may preclude the use of epidural morphine as a single postoperative analgesic agent
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0 |
Epidemiology and management of osteoporosis in the People's Republic of China: current perspectives
|
Hip Fx in the Elderly 2019
|
With the progressive aging of the population, osteoporosis has gradually grown into a global health problem for men and women aged 50 years and older because of its consequences in terms of disabilities and fragility fractures. This is especially true in the People's Republic of China, which has the largest population and an increasing proportion of elderly people, as osteoporosis has become a serious challenge to the Chinese government, society, and family. Apart from the fact that all osteoporotic fractures can increase the patient's morbidity, they can also result in fractures of the hip and vertebrae, which are associated with a significantly higher mortality. The cost of osteoporotic fractures, moreover, is a heavy burden on families, society, and even the country, which is likely to increase in the future due, in part, to the improvement in average life expectancy. Therefore, understanding the epidemiology of osteoporosis is essential and is significant for developing strategies to help reduce this problem. In this review, we will summarize the epidemiology of osteoporosis in the People's Republic of China, including the epidemiology of osteoporotic fractures, focusing on preventive methods and the management of osteoporosis, which consist of basic measures and pharmacological treatments.
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0 |
Bone marrow edema in the knee in osteoarthrosis and association with total knee arthroplasty within a three-year follow-up
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Surgical Management of Osteoarthritis of the Knee CPG
|
OBJECTIVE: The purpose of this study was to determine if a correlation exists between magnetic resonance imaging (MRI) findings of bone marrow edema (BME) in osteoarthrosis (OA) of the knee joint and need for total knee arthroplasty (TKA) within a follow-up period of 3 years. MATERIALS AND METHODS: The entire database of knee MR studies over a 3-year period was used to select individuals with knee OA. A chart review was conducted to identify and include only those who had a 3-year follow-up appointment from the time of the initial MR study. There were 25 patients in the OA-only group (four men and 21 women; age range, 28-75; average age, 49.3 years). The OA and BME group had 48 patients (23 men and 25 women; average age, 55.5 years). The MRs were reviewed and interpreted by a musculoskeletal radiologist and were classified into one of four patterns of BME: none, focal, global, or cystic pattern. Meniscal tear and degree of cartilage loss were also assessed. RESULTS: Subjects who had BME of any pattern type were 8.95 times as likely to progress rapidly to a TKA when compared to subjects with no BME (p = 0.016). Subjects with a global pattern of BME were 5.45 times as likely to have a TKA compared to subjects with focal, cyst, or no BME (p < 0.05). Subjects with a global edema pattern were 13.04 times as likely to have a TKA than subjects with no marrow edema in the knee (p < 0.01). There was no correlation of TKA with meniscal tear or cartilage loss. The group of subjects who had a TKA were 12.6 years older than those who did not have a TKA (p < 0.001). However, the BME results were still significant after accounting for the age difference. CONCLUSION: Our classification of patterns into global, focal, cystic, and absence of BME is an attempt to further define edema in osteoarthrosis and how it relates to clinical progression. Patients with BME and OA have an increased risk of TKA as opposed to OA and no marrow edema. The BME pattern with the worst prognosis for the knee is the global pattern
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0 |
Does statin use have a disease modifying effect in symptomatic knee osteoarthritis? Study protocol for a randomised controlled trial
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OAK 3 - Non-arthroplasty tx of OAK
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Background: Osteoarthritis (OA) is a major clinical and public health problem, with no current medications approved as having disease modifying effects. HMG-CoA reductase inhibitors, or "statins", a drug class widely used to prevent cardiovascular events, could potentially affect OA progression via a number of mechanisms including their effects on lipid metabolism and inflammation. The aim of this multicentre, randomised, double-blind, placebo-controlled trial is to determine whether atorvastatin reduces the progression of knee structural changes and symptoms over 2 years in patients with symptomatic knee OA. Methods/design: 350 patients with symptomatic knee OA will be recruited through the OA Clinical Trial Network (in Melbourne, Hobart and Adelaide). They will be randomly allocated to the two arms of the study, receiving either 40 mg of atorvastatin or identical placebo once daily for 2 years. Magnetic resonance imaging of the knee will be performed at baseline and 2 years later. Knee structure, symptoms and function will be assessed using validated methods. The primary outcome is annual percentage change in knee cartilage volume. Secondary outcomes include progression of cartilage defects, bone marrow lesions, knee pain and function. The primary analysis will be by intention to treat, but per protocol analyses will also be performed. Discussion: The study will provide high-quality evidence to address whether atorvastatin has a novel disease modifying effect in OA by delaying the structural and symptomatic progression of knee OA. Thus, the trial has major public health and clinical importance, as if found to be beneficial, atorvastatin could produce substantial cost savings by delaying and possibly reducing the need for joint replacement surgery, and provide marked improvements in quality of life for people with OA. Trial registration: Australian New Zealand Clinical Trials Registry: ACTRN12613000190707 , registered on 18 February 2013.
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0 |
A novel biomarker in patients with knee osteoarthritis: adropin
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OAK 3 - Non-arthroplasty tx of OAK
|
Adropin is newly discovered peptide hormone. Osteoarthritis (OA) is a kind of joint disease characterized by progressive joint cartilage loss and joint pain. The present study was carried out to investigate adropin and tumor necrosis factor alpha (TNF-alpha) levels and the relationship between adropin in patients with knee OA classified by Kellgren-Lawrence (KL). A total of 60 knee OA patients and 30 healthy controls were included in this study. KL grading was carried out using the radiographic findings. Demographic characteristics and laboratory parameters were recorded. Adropin and TNF-alpha levels were determined by using enzyme-linked immunosorbent assay (ELISA). Adropin level was lower in the knee OA patients compared with the healthy controls (p < 0.001), whereas TNF-alpha level was higher (p < 0.001). Adropin level was negatively correlated with TNF-alpha level, blood white blood cell (WBC) count, and neutrophil-lymphocyte ratio (NLR). However, there was a significant decrease in adropin level and an increase in TNF-alpha level parallel to the increase in the KL grade. In addition, serum adropin level was found to be significantly lower in KL grade 1 groups compared with healthy controls (p < 0.01). There was a decrease in adropin level parallel to the increase in the body mass index (BMI), and there was a statistically significant decrease in adropin level in knee OA patients higher than BMI > 30 (p < 0.01). Mean NLR of KL grade 4 was significantly increased compared with other grades (p < 0.05). The consequence of the present study suggested that serum adropin level could be used as a new biomarker indicating the early grade of knee OA.
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1 |
Control of postoperative pain following total knee arthroplasty: Is it necessary to associate sciatic nerve block to femoral nerve block?
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AAHKS (9/10) Regional Nerve Blocks
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BACKGROUND AND OBJECTIVES: Total knee arthroplasty (TKA) causes severe tissue trauma, leading to severe postoperative pain. Good postoperative analgesia is fundamental and one should consider that early mobilization of the joint is an important aspect to obtain good results. There is a controversy in the literature on the efficacy of isolated femoral nerve block. The objective of this study was to evaluate postoperative analgesia with the association of sciatic and femoral nerve block. METHODS: Seventeen patients undergoing TKA under spinal anesthesia were divided in two groups: A and B. In Group A (n = 9), femoral nerve block was performed, while in Group B (n = 8), femoral and sciatic nerve block were done. The blockades were done in the immediate postoperative period with 20 mL of 0.5% of ropivacaine. Pain was evaluated in the first 24 hours using the Visual Analog Scale and the verbal scale. The length of time between the nerve block and the first complaint of pain (M1) was also evaluated. RESULTS: The median of the duration of analgesia (M1) in Group A was 110 min, while in Group B it was 1285 min (p = 0.0001). There were no complications related to the technique used. CONCLUSIONS: Sciatic nerve block, when associated with femoral nerve block, under the conditions of the present study, improved significantly the quality of postoperative analgesia in TKA. © Sociedade Brasileira de Anestesiologia, 2007.
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0 |
Risk of falls in patients with knee osteoarthritis undergoing total knee arthroplasty: A systematic review and best evidence synthesis
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OAK 3 - Non-arthroplasty tx of OAK
|
Objectives: Falls occur frequently in patients with impaired ambulation and may dramatically affect the elderly population. Aim was to document the incidence of falls in knee osteoarthritis (OA) patients undergoing total knee arthroplasty (TKA), and to identify factors and treatments that may influence the risk of falls.
Methods: A systematic literature search was conducted on three medical electronic databases, PubMed, PeDRO, and Cochrane Collaboration. The Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines were used. Risk of bias analysis and best evidence synthesis were performed. The main aspects related to falls were analyzed: prevalence, risk factors, correlation with clinical outcome, effect of treatments.
Results: The systematic review identified 11 papers on 1237 patients. Pre-operative fall prevalence ranged from 23% to 63%, while post-operative values ranged from 12% to 38%. Moderate evidence was found on no influence of clinical scales, no BMI differences between "faller" and "non-faller", and on influence of limited pre-operative range of motion. Conflicting evidence was found for sex, history of previous falls, age, kyphosis, muscle weakness, fear of falling, depression, balance, gait impairment. No evidence was found for the effectiveness of surgical or rehabilitative strategies on falls reduction.
Conclusions: OA patients undergoing TKA are at high risk of falls, which is reduced but still present after surgery. Although some risk factors were identified, there are no studies demonstrating the possibility of reducing the incidence of this deleterious event, which warrants further research efforts to better manage this fragile population of elderly patients.
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0 |
Posterior tibial slope accuracy with patient-specific cutting guides during total knee arthroplasty: A preliminary study of 50 cases
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OAK 3 - Non-arthroplasty tx of OAK
|
BACKGROUND: Patient-specific cutting guides were recently introduced to facilitate total knee arthroplasty (TKA). Their accuracy in achieving optimal implant alignment remains controversial. The objective of this study was to evaluate postoperative radiographic outcomes of 50 TKA procedures with special attention to posterior tibial slope (PTS), which is difficult to control intraoperatively. We hypothesized that patient-specific cutting guides failed to consistently produce the planned PTS.
MATERIAL AND METHODS: The SignatureTM patient-specific cutting guides (Biomet) developed from magnetic resonance imaging data were used in a prospective case-series of 50 TKAs. The target PTS was 2degree. Standardised digitised radiographs were obtained postoperatively and evaluated by an independent reader. Reproducibility of the radiographic measurements was assessed on 20 cases. The posterior cortical line of the proximal tibia was chosen as the reference for PTS measurement. Inaccuracy was defined as an at least 2degree difference in either direction compared to the target.
RESULTS: The implant PTS was within 2degree of the target in 72% of knees. In the remaining 28%, PTS was either excessive (n=10; maximum, 9degree) or reversed (n=4; maximum, -6degree). The postoperative hip-knee-ankle angle was 0degree +/- 3degree in 88% of knees, and the greatest deviation was 9degree of varus.
CONCLUSION: These findings support our hypothesis that patient-specific instrumentation decreases PTS accuracy. They are consistent with recently published data. In contrast, patient-specific instrumentation provided accurate alignment in the coronal plane.
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0 |
Serum C-reactive protein and procalcitonin kinetics in patients undergoing elective total hip arthroplasty
|
PJI DX Updated Search
|
BACKGROUND: The sensitivity and the specificity of different methods to detect periprosthetic infection have been questioned. The current study aimed to investigate the kinetics of C-reactive protein (CRP) and procalcitonin (PCT) in patients undergoing uncomplicated elective total hip arthroplasty (THA), to provide a better interpretation of their levels in noninfectious inflammatory reaction. METHODS: A total of 51 patients were included. Serum CRP and PCT concentrations were obtained before surgery, on the 1st, 3rd, and 7th postoperative days and after discharge on the 14th and 30th days and at 2 years. RESULTS: Both markers were confirmed to increase after surgery. The serum CRP showed a marked increase on the 3rd postoperative day while the peak of serum PCT was earlier, even if much lower, on the first day. Then, they declined slowly approaching the baseline values by the second postoperative week. PCT mean values never exceed concentrations typically related to bacterial infections. CONCLUSIONS: CRP is very sensitive to inflammation. It could be the routine screening test in the follow-up of THA orthopaedic patients, but it should be complemented by PCT when there is the clinical suspicion of periprosthetic infection
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0 |
Bartonella (Rochalimaea) quintana infection in a seronegative hemodialyzed patient
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Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures
|
Bartonella quintana is a reemerging pathogen responsible for trench fever, endocarditis, bacteremia, and bacillary angiomatosis. We previously reported the first case of a patient with B. quintana-induced chronic adenomegaly, and here we present a report on a second patient. A hemodialyzed patient with Sjogren's syndrome presented with mediastinal adenomegalies and secondary pancytopenia. All diagnostic investigations remained negative, except that a Bartonella-like microorganism was isolated from a bone marrow biopsy. The isolate was identified as B. quintana by a specific mouse polyclonal antibody and by determination of a partial gltA (citrate synthase-encoding) gene and 16S rRNA gene sequences. DNA of the pathogen was also detected in the adenomegaly and in the serum of the patient by PCR amplification of the gltA gene. Anti-B. quintana antibodies were never detected in the patient's serum throughout the 12-month follow-up but were detected in the serum of the patient's cat. The patient's outcome was favorable after treatment with gentamicin. Chronic adenomegaly in seronegative patients is a new clinical entity due to B. quintana
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0 |
Analysis of inpatient costs in patients with knee osteoarthritis treated by implantation of total condylar knee endoprosthesis
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OAK 3 - Non-arthroplasty tx of OAK
|
Background/Aim. Total knee replacement is an elective and high cost surgical procedure which is performed more frequently as a result of increasing prevalence of knee osteoarthritis. The aim of this study was to provide insight into the value and structure of inpatient costs associated with total knee replacement in Serbia. Methods. This study was conducted as an in-depth, bottom-up, retrospective, case series analysis of services consumption patterns and costs associated with inpatient treatment of patients with knee osteoarthritis by implantation of primary total condylar knee endoprosthesis from perspective of the national Republic Health Insurance Fund. We obtained data on 97 patients treated with primary unilateral or bilateral total knee replacement in 2014 at the Clinic for Orthopaedic Surgery and Traumatology of the Military Medical Academy in Belgrade, a tertiary health care university hospital. Results. Mean age of entire study sample was 67.89 years. Majority of patients (60 patients; 61.9%) had unilateral implantation of total condylar knee endoprosthesis. Bilateral implantation was performed in 37 (38.1%) patients. Mean total inpatient cost per patient for both unilateral and bilateral implantation of total condylar knee endoprosthesis was EUR 2,709.1, ranging from EUR 1,685.2 to EUR 5,356.6. Mean total inpatient cost per patient was EUR 2,093.8 for unilateral implantation and EUR 3,706.8 for bilateral implantation. Two major cost drivers were surgery specific material and surgery. Cost of implants was the highest single cost driver in all observed groups of patients. Conclusion. Our findings imply that inpatient costs associated with implantation of primary total condylar knee endoprosthesis are substantial. It seems that the most important cost drivers are surgery and surgery specific material, with implants being the highest single cost driver. Further research should be focused on analyzing factors that influence these costs in order to develop effective strategies which could contribute to substantial savings in the future.
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0 |
Mesenchymal cells inhibit expansion but not cytotoxicity exerted by gamma-delta T cells
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MSTS 2018 - Femur Mets and MM
|
BACKGROUND: Multipotent mesenchymal stromal cells (MSCs) exert a relevant immunosuppressive activity by inhibiting T- and B-lymphocytes, natural killer (NK) cells and dendritic cell expansion. Nevertheless, a possible activity on gamma/delta T cells has still not been evaluated. Gamma-delta T lymphocytes play an important role in the control of cancer and they have been shown to be implicated in graft-vs.-host disease. Thus, modulation of activation and proliferation of these cells could be relevant for therapeutic purposes.
MATERIALS AND METHODS: Peripheral blood mononuclear cells from 21 healthy donors were used as source for gamma-delta T cells, expanded in presence of 10 IU mL(-1) interleukin-2 (IL-2) and 1 microM zoledronate. MSCs were recovered from patients undergoing routine total hip replacement surgery, and characterised by flow cytometry. Cytotoxicity on multiple myeloma and melanoma cell lines was assessed by measuring dilution of the carboxyfluorescein diacetate succinimydylester dye (CFSE). Gamma-delta T cells were then incubated with MSCs in contact cultures, and with addition of MSC-conditioned medium.
RESULTS: In this article we confirmed that (1) in vitro expanded gamma-delta T cells play a significant anti-proliferative effect on multiple myeloma and melanoma cells and (2) multipotent mesenchymal stromal cells effectively suppress the ex vivo expansion of T cells carrying a specific T-cell receptor gene (TCR) rearrangement, Vgamma9/Vdelta2, induced by the combination of IL-2 and zoledronate, without interfering with their cytotoxic activity.
DISCUSSION: These findings contribute to explain the activity of ex vivo expanded mesenchymal cells, suggesting that MSCs would interact with gamma-delta T lymphocytes.
CONCLUSION: This effect could be relevant in separating graft-vs.-host from the graft-vs.-tumour effect, especially considering the possibility of modulating T-lymphocytes activity by the immunomodulating drugs now available.
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0 |
Long-term results of high tibial osteotomy for medial osteoarthritis of the knee
|
Surgical Management of Osteoarthritis of the Knee CPG
|
We reviewed retrospectively the results in patients who had undergone one hundred and four high tibial lateral osteotomies. The operations were all performed between 1985 and 1993. Each one of fifty men and forty nine women demonstrated a varus deformity of the knee with a coexistent medial osteoarthritis. Results were reviewed in 49 patients (62 knees) with an average follow-up of 10.2 years (range 6-14 years). Of the remaining 42 patients, 8 were lost to follow-up, 10 had died, and 24 were subsequently treated with total knee arthroplasty at an average 4.7 years after having had a high tibial osteotomy. Clinical results were evaluated using the Hospital for Special Surgery Score (HSS) and the Knee Society Score. Radiographs were systematically analysed to evaluate osteoarthritis and leg axis. Forty four (90 per cent) of the forty nine patients stated the results met their expectations and given the same circumstances, they would have the operation once again. In these patients the knee score results were excellent. The same patients had excellent HSS and Knee Society Scores. Five patients (10 per cent) had a poor result and twenty four patients were treated later by total knee arthroplasty because of pain. The following factors set these patients apart from those with more favorable results: previous arthroscopic debridement, obesity, lateral knee osteoarthritis, insufficient valgus correction, and an age of more than 55 years. High tibial valgus osteotomy provides good pain relief and improved function in carefully selected patients. Our results support this conclusion
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0 |
Bisphosphonates in oncology: physiopathologic bases and clinical activity
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MSTS 2018 - Femur Mets and MM
|
Osteoclastic activation is the ultimate way of bone resorption in neoplasia, induced by the combined effects of tumor-secreted humoral factors (especially parathyroid hormone-related peptides) and osteoclastic-osteoblastic interaction. Bisphosphonates inhibit the osteoclast activity and reduce bone resorption and are a valuable supportive measure for bone disease of neoplasms. Experimental models also suggest an activity of bisphosphonates against cancer cells. Controlled studies, especially in advanced breast cancer and multiple myeloma, indicate different effectiveness against the distinct skeletal-related events. Intravenous clodronate and, especially, pamidronate and zoledronate are the first-choice drugs for hypercalcemia, and they play a significant role in reducing metastatic bone pain. Their prolonged use delays, without hampering, the progression of bone disease, including the appearance of osteolysis and the occurrence of pathologic fractures. This effect is probably more valuable when bisphosphonates are administered early in the course of the disease. The evidence that adjuvant bisphosphonates improve survival needs to be confirmed in ongoing studies. Although poorly absorbed by the gastrointestinal tract, oral bisphosphonates are effective in preventing and treating cancer-induced osteoporosis in long-living patients with operable breast cancer. At present, there is little hope that newer bisphosphonates are more effective than those currently used. [References: 169]
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0 |
Ultrasound versus synovial fluid analysis for the diagnosis of calcium pyrophosphate dihydrate deposition disease: Is IT CPPD? Ask US!
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Surgical Management of Osteoarthritis of the Knee CPG
|
Background The diagnosis of calcium pyrophosphate crystal (CPP) deposition disease (CPPD) is mainly based on the synovial fluid analysis and Xrays. US has demonstrated high sensitivity and specificity values for diagnosing
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