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1 | Comparison between surgery and physiotherapy in the treatment of small and medium-sized tears of the rotator cuff: A randomised controlled study of 103 patients with one-year follow-up | Optimizing the Management of Full-Thickness Rotator Cuff Tears | In order to compare the outcome from surgical repair and physiotherapy, 103 patients with symptomatic small and medium-sized tears of the rotator cuff were randomly allocated to one of the two approaches. The primary outcome measure was the Constant score, and secondary outcome measures included the self-report section of the American Shoulder and Elbow Surgeons score, the Short Form 36 Health Survey and subscores for shoulder movement, pain, strength and patient satisfaction. Scores were taken at baseline and after six and 12 months by a blinded assessor. Nine patients (18%) with insufficient benefit from physiotherapy after at least 15 treatment sessions underwent secondary surgical treatment. Analysis of between-group differences showed better results for the surgery group on the Constant scale (difference 13.0 points, p - 0.002), on the American Shoulder and Elbow surgeons scale (difference 16.1 points, p < 0.0005), for pain-free abduction (difference 28.8 degrees , p = 0.003) and for reduction in pain (difference on a visual analogue scale -1.7 cm, p < 0.0005) |
0 | Bilateral osteochondritis dissecans of lateral femoral condyle | Diagnosis and Treatment of Osteochondritis Dissecans AUC | A 20-year-old male with bilateral osteochondritis dissecans (OD) of the distal lateral femoral condyle is presented. OD can occur in many joints; however, the medial femoral condyle of the knee is the most common. Bilateral OD of the distal lateral femoral condyle is extremely rare. In our case, the lesion on the right side was traumatic and the lesion on the left side was self-induced. We performed open surgery for both knees. The fragments were stabilized with multiple Herbert screws. This case supports the theory that a defect in the ossification center of the distal lateral femoral condyle plays a role in the etiology of osteochondritis dissecans |
0 | Characterization of arthralgia induced by PD-1 antibody treatment in patients with metastasized cutaneous malignancies | OAK 3 - Non-arthroplasty tx of OAK | BACKGROUND: PD-1 antibodies (PD1ab) are increasingly used in metastatic melanoma and other malignancies. Arthralgia is an underestimated side effect of PD-1 antibody treatment with unknown cause. Our aim was to characterize PD1ab-induced arthralgia.
PATIENTS AND METHODS: We retrospectively included patients with metastatic cutaneous malignancies treated with pembrolizumab or nivolumab +/- ipilimumab at the National Center for Tumor Diseases (Heidelberg) between 01/2013 and 09/2016. Arthralgia was characterized by laboratory diagnostics, imaging, and if indicated, rheumatologic consultation.
RESULTS: 26 of 195 patients (13.3%) developed arthralgia. The median onset of symptoms was 100 days (7-780 days). Most frequently, arthralgia involved large joints (shoulders, knees) in a predominantly symmetrical pattern. Only two patients were seropositive for rheumatoid factor and/or anti-citrullinated protein antibodies. Ten patients developed the clinical picture of arthritis, with seven of them showing synovitis in MRI or PET/CT. Five patients showed inflammation in joints pre-damaged by osteoarthritis. In 11 patients arthralgia could not be specified. The majority of patients was satisfactorily treated with non-steroidal anti-inflammatory drugs (NSAIDs), 23.1% required additional low-dose corticosteroids and only 7.6% of our patients received further immunosuppressive treatment. Patients with arthralgia showed a better treatment response and improved PFS and OS.
CONCLUSION: Arthralgia is frequent during PD1ab treatment. The clinical picture varies between synovitis of predominantly large joints, progressive osteoarthritis and arthralgia without evident joint damage. Vast majority of cases can be satisfactorily managed by NSAID and/or low-dose corticosteroids. |
0 | Can drains be avoided in lipo-abdominoplasty? | Panniculectomy & Abdominoplasty CPG | Context: Seroma formation is a common complication after lipoabdominoplasty. Conventionally, drains have been placed to prevent seroma; however, there are problems with drains, namely, pain, compromised mobilisation, breakage, tissue irritation and infection. Strategies to prevent seroma, such as the use of glue or quilting sutures have all been attempted with variable and unpredictable benefit. Aims: The author extrapolated the experience with own liposuction protocols to lipoabdominoplasty and began doing away with drains from the year 2006 onwards unless absolutely indicated. Incidence of complications is evaluated here. Settings and Design: This retrospective study is the report of our experience with 204 lipoabdominoplasties performed since 2006 upto December 2016. Subjects and Methods: Consecutive abdominoplasty patients were evaluated for seroma formation, wound dehiscence till suture removal. Nuances of operative details that helped avoid drains were contemplated. Results: Only one patient who had drainless abdominoplasty had seroma formation and wound dehiscence. Conclusions: We found that (a) 'toilet liposuction', (a term the author would like to introduce) (b) multilayer wound closure without tension, (c) avoidance of gliding surfaces d) continuous use of pressure garment for 4 days post-operative and (e) reducing the amount of infiltration are the key factors in avoidance of collections and thus seroma formation. If such a technique is diligently followed, desired results are obtained; yet there is no need to insert drains in most patients. Reducing the need of drains permits early ambulation and better patient comfort without seroma and other complications. |
1 | Cementless surface replacement arthroplasty of the shoulder for osteoarthritis: results of fifty Mark III Copeland prosthesis from an independent center with four-year mean follow-up | Glenohumeral Joint OA | PURPOSE: Few studies have reported the outcome of cementless surface replacement (CSRA). We initiated this study to analyze results of the Mark III Copeland prosthesis used as a hemiarthroplasty in patients with glenohumeral osteoarthritis.
MATERIALS AND METHODS: We retrospectively reviewed 53 consecutive Mark III Copeland CRSA hemiarthroplasties in 46 patients (30 women, 16 men) with glenohumeral osteoarthritis from an independent institution by a single surgeon. Patients were a mean age of 69 years (range, 45-94 years). Mean follow-up was 4.2 years (range, 2-8 years). Fifty uncemented hemiarthroplasties were available for review.
RESULTS: Mean (range) age-adjusted Constant and Oxford scores improved from 38.5 (15-61) and 22 (9-31) to 75.1 (38-87) and 42 (18-48), respectively. Anterosuperior escape of the humeral head developed in 1 patient who had an oversized humeral component due to progressive rotator cuff failure at 2 years. Moderate glenoid erosion was present in 12% and correlated with oversizing of the humeral component. There was one revision to a stemmed cemented hemiarthroplasty for periprosthetic fracture. No patients have required revision for aseptic loosening, rotator cuff failure, or glenoid erosion to date.
CONCLUSIONS: Copeland surface replacement hemiarthroplasty for glenohumeral osteoarthritis can provide functional results similar to modular stemmed prostheses, with a relatively low revision rate at 4.2 years of follow-up; however, there is high rate of glenoid erosion that may complicate future revision surgery, and we did not achieve the same functional improvement as that achieved from the designer's institution. |
0 | Efficacy and tolerability of diclofenac dispersible in painful osteoarthrosis | OAK 3 - Non-arthroplasty tx of OAK | A multicentre, twelveâ?week, doubleâ?blind, randomized trial was conducted to evaluate the efficacy and tolerability of diclofenac dispersible in patients suffering from osteoarthrosis of the knee and/or hip. Symptomatic adult patients (N = 129) of either sex were treated with diclofenac dispersible or the conventional entericâ?coated tablet of diclofenac sodium 50 mg orally, thrice daily. Both formulations of diclofenac led to comparable and clinically significant reductions in the intensities of pain at rest and during activity within 1 week of therapy initiation. More than 70% of patients in both treatment groups had no or mild pain on full passive movement by the end of the study with the Lequesne Index showing a reduction of around 50% from initial values. Overall assessments of efficacy by the patient and the investigator indicated a positive response rate for both diclofenac formulations ranging between 71% and 82%. The proportion of patients reporting adverse effects, predominantly gastroâ?intestinal, was slightly higher in the dispersible group, 40.3%, compared to 37.3% with entericâ?coated diclofenac sodium. |
1 | Primary care management of carpal tunnel syndrome | Diagnosis and Treatment of Carpal Tunnel Syndrome CPG | Carpal tunnel syndrome of mild to moderate severity can often be effectively treated in a primary care environment. Workplace task modification and wrist splints can reduce or defer referral to hospital for surgical decompression. Nerve and tendon gliding exercises may also be of benefit. Steroid injections to the mouth of the carpal tunnel are particularly useful for symptomatic women in the third trimester of pregnancy. However inadvertent neural injection may cause disabling chronic pain. Referral to a minority of practitioners trained in the technique would ensure sufficient patient numbers to maintain skill levels |
0 | Reduction mammaplasty-An eclectic approach | Reduction Mammoplasty for Female Breast Hypertrophy | In a series of 200 personally performed mammaplasties, two main approaches were used: (a) small, ptotic, and moderately hypertrophic breasts were treated by elliptical wedge excision either vertical or oblique; and (b) large hypertrophic breasts were treated by Arie-Pitanguy wedge excision, ending with an inverted T suture line. The results are discussed. |
0 | Evolving indications and reported complications suggest total knee arthroplasty after acute and complex periarticular fractures remains a high-risk operation: A systematic review | Hip Fx in the Elderly 2019 | Importance: Complex periarticular fractures of the knee can be difficult to reconstruct with osteosynthesis, can result in poor function and can lead to increased morbidity and mortality - particularly in the elderly. Primary acute total knee arthroplasty (TKA) is a surgical option which is rarely performed, but thought to have high rates of complication postoperatively. Objective: To investigate the literature regarding optimal patient selection for TKA after acute fracture with particular emphasis on postoperative outcomes and complications. Evidence review: A literature search of the MEDLINE, EMBASE and Cochrane Databases using established methodology for conducting systematic reviews investigating acute TKA after trauma. Two reviewers screened citations using the methodological index for non-randomi zed studies score to determine inclusion, methodological quality assessment and data extraction. Findings: Eighteen papers met the inclusion criteria; totalling 284 acute arthroplasty procedures. The majority of cases were performed in elderly females and the most common fracture pattern was the Arbeitsgemeinschaft für Osteosynthesefragen type C. Inclusion criteria for acute arthroplasty - whether fracture or patient specific - was poorly defined. Modular, stemmed and highly constrained (condylar or hinged) prostheses were used. Complications were often seen including 44 deaths within 5 years of surgery and three instances of above knee amputation. Conclusion and relevance: Acute knee arthroplasty can be considered as primary management for an acute periarticular fracture in some cases, although patient selection is vital. These patients should also be viewed similar to fractured neck of femur patients and cared for appropriately. |
0 | Deep-Frozen Allogeneic Onlay Bone Grafts for Reconstruction of Atrophic Maxillary Alveolar Ridges: A Preliminary Study | Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures | Purpose: The purpose of this article was to evaluate the suitability of deep-frozen allograft for ridge augmentation procedures in severely atrophic maxillae and to evaluate the clinical success of dental implants inserted after grafting and before prosthetic rehabilitation. Patients and Methods: This study included 13 patients (3 men and 10 women) aged 36 to 65 years. All the patients selected for this study required bone augmentation procedures because of severe alveolar ridge atrophy and were scheduled for onlay bone allograft and titanium implants in a 2-stage procedure. The dental implants were inserted 5 months after grafting. The follow-up period for the implants was 6 months after placement at the second stage of implant surgery. Results: A total of 24 onlay block allografts were used to augment atrophic maxillae in 13 patients. Of the 24 onlay block allografts, 5 were scheduled for vertical alveolar ridge augmentation and the remaining 19 for horizontal alveolar ridge augmentation. Early exposure of the onlay bone graft was observed in 2 patients. All the block grafts showing early exposure had to be completely removed because of infection. All the observed complications were associated with onlay bone grafts placed to increase the vertical dimension of the alveolar ridges. Thirty-eight implants ranging in length from 10 to 15 mm were placed in the area of bone augmentation. All implants inserted achieved satisfactory primary stability. Two implants failed to integrate 6 months after placement during the second stage of surgery. The failed implants were successfully replaced without any need for additional bone grafting. Conclusions: The use of block allografts to treat maxillary atrophy yielded successful outcomes. Moreover, the augmentation procedure allowed the insertion of implants in the grafted area 5 months after surgery. Therefore, on the basis of this preliminary study, deep-frozen bone allograft can be considered a promising treatment for severe maxillary atrophy, with more extensive follow-up studies being needed to confirm these preliminary data. (copyright) 2009 American Association of Oral and Maxillofacial Surgeons |
1 | Carpal tunnel syndrome. Priorities for prevention | Diagnosis and Treatment of Carpal Tunnel Syndrome CPG | Carpal tunnel syndrome (CTS) has gained attention as an occupationally related illness due to the dramatic increase in its incidence, the accompanying direct and indirect financial costs to employers, and the emotional and physical costs to employees diagnosed with CTS. Application of epidemiologic principles provides a frame-work for understanding the interrelationship of agent, host, and environmental factors that contribute to CTS. Once identified, these factors provide the foundation for implementing prevention and control strategies. Modification of the work environment to decrease occupational stresses and minimize awkward postures and positions is an effective strategy to prevent CTS by improving the worker-job interplay. Occupational health nurses, through their understanding of the workplace environment (work stations, work processes) and the dynamics of the worker population, play a critical role in the interdisciplinary approach needed to prevent and decrease the incidence of carpal tunnel syndrome effectively |
0 | Treatment of trochanteric fractures with Ender's nailing in Chinese patients | Management of Hip Fractures in the Elderly | A prospective series of 100 Chinese patients with trochanteric fractures treated by Ender's nailing is reported. The average age of the patients was 79 years (range from 57 to 105 years). The follow-up period ranged from 4 to 18 months, with an average of 81/2 months. The mortality rate was 6 per cent. There was no incidence of non-union, delayed union or deep wound infection. Some special procedures in the operative technique to prevent complications are discussed. Weight-bearing walking could be started in the first week after operation in 63 per cent of the patients. The functional result at 6 months was good in 73 per cent. This method of limited operative trauma gave good functional results to patients, limited the blood loss during operation and reduced the operative time. The suitability of the currently available nails to the Chinese patients are discussed |
0 | Gender differences for initiating teriparatide therapy: baseline data from the Direct Assessment of Nonvertebral Fracture in the Community Experience (DANCE) study | Management of Hip Fractures in the Elderly | The prospective, observational Direct Assessment of Nonvertebral Fracture in the Community Experience (DANCE) study shows that, among patients with risk factors for osteoporosis, women are more likely to be screened and to receive appropriate treatment than men. There needs to be greater awareness that osteoporosis affects both men and women. INTRODUCTION: The prospective, observational DANCE study evaluated teriparatide use in the mainland USA and Puerto Rico in patients with osteoporosis in a community setting. This analysis compares baseline characteristics of women and men that may contribute to differences in initiation of teriparatide therapy. METHODS: Investigators prescribed teriparatide 20 mug/day subcutaneous injection for </=24 months to 3,698 patients (3,342 women, 356 men) whom they considered appropriate candidates for therapy. Study entry was guided by product labeling. Specific timing and frequency of office visits were not mandated. Treatment decisions were based on the clinical judgment of study investigators and local standards of care. RESULTS: At baseline, similar proportions of women and men had prior fragility fractures (57% and 59%, respectively) and comorbid conditions that increase fracture risk (83% and 84%, respectively). Women were older than men (mean age 68 vs. 65 year; P < 0.0001) and more likely to have received prior osteoporosis therapy (88% vs. 62%; P < 0.0001). Investigators prescribed teriparatide more often for women than men based on general frailty (21% vs. 16%; P = 0.0151), low body mass index (17% vs. 10%; P = 0.0005), and an inadequate response (58% vs. 36%; P < 0.0001) or intolerance to previous therapy (23% vs. 12%; P < 0.0001). Chronic glucocorticoid therapy was the reason investigators cited most frequently for initiating therapy more often in men than in women (17% vs. 10%; P < 0.0001) CONCLUSIONS: These results suggest that patients' gender may influence the reasons physicians initiate teriparatide therapy in a community setting |
0 | Nonunion of tibial shaft fractures treated with locked intramedullary nailing without bone grafting | DoD SSI (Surgical Site Infections) | Twenty-five nonunions of tibial fractures were treated with Grosse-Kempf slotted, locked nails in 20 men and 5 women 6 to 54 months after fracture. No bone grafts were performed in connection with nailing. For better alignment, opening of the nonunion site, fibular osteotomy/resection, or both were used. In one patient reoperation with nailing and bone grafting was necessary after the first nail broke. There were three postoperative infections (12%), two with persistent drainage. All nonunions healed. In one patient an external rotatory malalignment was corrected by a later osteotomy. In no case was the function of the ankle or foot impaired by the index operation. Static locking was not unfavorable for healing. We conclude that bone grafting is rarely needed and function is restored early after locked nailing of tibial nonunions. |
0 | Pain control with ibandronate for bone marrow oedema of the knee | AMP (Acute Meniscal Pathology) | INTRODUCTION: Bone marrow oedema is a disabling disease characterised by severe bone pain (with or without prior trauma), insufficient response to analgesics, and reduction of weight bearing. Several studies showed promising results after using bisphosphonates to inhibit osteoclast activity. The aim of this study was to investigate the association between ibandronate administration and pain relief in patients with bone marrow oedema of the knee, and to precisely describe its presentation in magnetic resonance imaging (MRI). METHODS: This is a single-centre, retrospective analysis of 18 patients who received intravenous ibandronate due to bone marrow oedema of the knee between April 2012 and February 2016. Information has been extracted from our clinical database and a questionnaire. Furthermore, an experienced radiologist reassessed all MRI diagnoses. RESULTS: Our results showed a significant reduction of pain from 7.4 to 3.8 points on the visual analogue scale (p = 0.0001; median follow-up 41.5 months). Furthermore, the disability in daily life also significantly decreased (p = 0.008); 55.6% of the participants stated to be pain-free in the follow-up, and the same percentage also did not use alternative therapies after completing therapy with ibandronate (e.g., regular use of analgesics, operation, or local infiltration). However, there was no significant correlation between pain and specific radiologic findings. CONCLUSIONS: Participants with bone marrow oedema of the knee showed a significant pain reduction after an administration of ibandronate, independently of the severity showed in MRI. If the first administration leads to an insufficient control of pain, the administration of a second dose may be helpful. As bone marrow oedema syndrome is a self-limiting disease, prospective studies with a comparison group are needed to distinguish between the natural course of the disease and the beneficial effects of bisphosphonates. |
0 | MR imaging of patellar retinacular ligament injuries | AMP (Acute Meniscal Pathology) | Seventeen patients with patellar retinacular ligament injuries were evaluated with magnetic resonance (MR) imaging. MR findings were correlated with clinical, surgical, and arthroscopic findings. The injuries involved the medial retinacular ligament in 16 of 17 patients and the medial and lateral retinacular ligament in one patient. Nine of 17 patients showed MR evidence of a patellar dislocation. In these patients, a triad of findings that included focal impaction injuries involving the lateral femoral condyle, osteochondral injuries of the medial patellar facet, and injuries of the medial retinacular ligament were seen. Seven of the nine patients with patellar dislocation injuries had frank osteochondral injuries. The injured retinaculum had an indistinct, irregular appearance associated with edema and hemorrhage. The patellar dislocations were clinically unsuspected in the initial evaluation of eight of these nine patients. In eight of 17 patients, the mechanism of injury was a patellar tendon tear (n = 1) or valgus hyperextension (n = 7). In the seven patients with hyperextension injuries, three had associated meniscal and cruciate ligament tears. MR imaging can help define patellar retinacular and associated osteochondral injuries, which may be clinically useful information. |
1 | Human acellular dermal matrix (AlloDerm®) dimensional changes and stretching in tissue expander/implant breast reconstruction | Acellular Dermal Matrix | BACKGROUND: Human acellular dermal matrix (HADM) is widely used for post-mastectomy tissue expander/implant breast reconstruction. Since HADM has been shown to stretch following placement in other surgical settings, we hypothesised that stretching would occur in breast reconstruction as well. The goal of the study was to quantify the in situ stretch properties of HADM over time in patients undergoing this procedure. METHODS: This was an open-label, prospective case series in adult women who underwent post-mastectomy tissue expander/implant breast reconstruction using HADM. HADM construct size was determined at postoperative day 1 and month 3 via ultrasound tracking of metallic 3-mm vessel clips embedded in the graft. Dimensional changes were further examined in four equally sized segments (medial, lateral and two central) of the matrix. Patient satisfaction was evaluated at month 3 (a modified version of the Breast Q™ patient questionnaire) and compared with satisfaction reported by a non-HADM reconstruction cohort. RESULTS: A total of 31 patients underwent breast reconstruction with HADM. Mean (standard deviation) perimeter increased from 38 (6) cm on postoperative day 1-42 (7) cm at month 3 (+11%; P=0.002). Surface area increased from 73 (22) to 88 (28) cm2 (+21%; range, 4-35%; P=0.002). The greatest expansion occurred in the HADM medial and lateral segments (range, 18-30% across the four segments). Patient satisfaction was comparable with that of non-HADM patients. Complications in the HADM group included late seroma, red breast syndrome and urinary tract infection. Complications in the non-HADM cohort included cellulitis, expander explantation, delayed wound healing and skin necrosis. CONCLUSIONS: During short-term follow-up, HADM exhibited a modest degree of stretching during tissue expander/implant breast reconstruction and was associated with few complications and a high level of patient satisfaction. |
0 | Assessment of Vascular Injuries and Reconstruction | DoD LSA (Limb Salvage vs Amputation) | BACKGROUND: Trauma is the third leading cause of death. In this regard, vascular injury plays a leading role in of morbidity and mortality rates. OBJECTIVES: The present study aimed to assess the prevalence of vascular injuries and results of vascular reconstruction at a referral hospital in northern Iran. PATIENTS AND METHODS: A retrospective observational study assessed 88 consecutive patients with vascular injury admitted to Poursina Hospital, Rasht in northern Iran, from October 2007 to October 2009. All study information was collected retrospectively from hospital charts. RESULTS: Most of the affected patients (87/88) were male with a mean age of 29.12 +/- 11.20 years. The mechanism of injury in 39.8% was blunt trauma and penetrating trauma in the rest. Of the 53 injured by penetrating trauma (60.2%), the most common cause was stabbing (94.3%). The most common cause of blunt trauma was road traffic accidents (93.1%). The most common mechanism for vascular injuries in upper extremities was penetrating trauma (86.0%) and in lower extremities was blunt trauma (60.0%). Fasciotomy was performed in 16 patients (18.2%) mostly in the lower extremities. Major amputation was required in 10% of the patients. In upper extremities, the most common type of revascularization was end to end anastomosis, followed by inter-position graft. The most common type of reconstruction in the lower extremity was bypass graft. All patients who underwent major amputation were admitted to the center with a delay of more than 6 hours after injury. CONCLUSIONS: Major vascular injuries in our center occurred in young men, frequently because of stab wounds. Popliteal injuries mostly caused by motor vehicle accidents was the second most common arterial injury, followed by combined ulnar and radial injuries. Vascular reconstruction in the first hours after trauma may prevent many unnecessary and preventable amputation procedures. |
0 | Endocarditis due to Neisseria sicca: report of one case | Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures | Many species of the Neisseria, which are respiratory commensals in humans, have been regarded as being nonpathogenic or as causing disease in only immunocompromised hosts. We report a case in which Neisseria sicca was the cause of infective endocarditis in a child with a ventricular septal defect and review the literature on endocarditis due to N. sicca infection. Most of these patients had an underlying heart disease. Dental caries and poor oral hygiene may be two factors that predispose patients to the infection. N. sicca endocarditis usually results in a subacute onset of symptoms and, if not diagnosed early and treated, is associated with a high rate of embolic complications |
0 | Fast pinless external fixation for open tibial fractures: preliminary report of a prospective study | PJI DX Updated Search | A major drawback of conventional fixator system is the penetration of fixator pins into the medullary canal. The pins create a direct link between the medullary cavity and outer environment, leading to higher infection rates on conversion to intramedullary nailing. This study was designed to prospectively evaluate the role of new rapid pinless external fixators in primary stabilization of open tibial shaft fractures. In our study, a prospective study of 96 consecutive patients of open tibial shaft fractures treated with new rapid pinless external fixator and reamed intramedullary nail was carried out. The bone healing status, ability to maintain alignment were examined for radiologic outcome, whereas initial management, length of hospital stay, associated morbidity, range of knee and ankle motion, time to partial and full weight-bearing, employment status and perioperative and postoperative complications were used for clinical evaluation. We followed up for over two years for the patients underwent clinical and radiologic after the surgery. The mean hospital stay was 15 days (ranges, 8-68). Bone healing was achieved for all cases except 3 patients who were lost to follow-up study. No patient suffered compartment syndromes. There was no statistically significance in range of motion among the knees of injury and uninjured limbs at final follow-up (P > 0.05). To the last follow-up, there were no cases of deep infection or implant-related fractures. Seventy-one patients who were employed before the injury returned to work after the operation, 16 had changed to less strenuous work. We concluded that better results can be achieved on clinical and radiologic evaluation of primary stabilization with rapid pinless external fixator and early exchange reamed intramedullary nail for suitable patients with open tibial shaft fractures. The incident rate of relative complications is low. The rapid pinless external fixator can be combined favorably with the reamed intramedullary nail and is a valuable addition to the conventional external fixator systems |
0 | Bone defect reconstruction with autologous bone inactivated with liquid nitrogen after resection of primary limb malignant tumors: An observational study | DoD SSI (Surgical Site Infections) | Surgical treatment of malignant bone tumors comprises tumor resection and reconstruction. The most commonly used reconstruction method is prosthesis replacement, which achieves good early function, but has a high long-term incidence of complications. Another reconstruction option is autologous bone replantation, which has the advantages of anatomical matching and no need for large bone bank support. Few studies have evaluated reconstruction with liquid nitrogen-inactivated autogenous bone. The present study aimed to evaluate the oncological results, bone healing results, complications, and indications of reconstruction with liquid nitrogen-inactivated autogenous bone grafts. The study population comprised 21 consecutive patients. The tumor site was the tibia in 9 cases, femur in 8, and humerus in 4. There were 37 osteotomy ends in total. After freezing and rewarming, the medullary cavity of the autogenous bone was filled with antibiotic bone cement. Seventeen patients received bilateral plate fixation, 2 received intramedullary nail and distal plate fixation, and 2 received single plate fixation. The average follow-up was 31 +/- 6 months. Eighteen patients survived without tumors, and the 3-year survival rate was 80.4%. All cases had adequate surgical margins, but recurrence developed in 1 patient. Metastasis occurred in 3 patients, who all died of metastasis. Intraoperative inactivated bone fracture occurred in 1 patient, and screw breakage was found in 1 patient. Nonunion occurred at 1 humeral diaphysis osteotomy site, and 1 patient was lost to follow-up; the average healing time of the other 35 ends was 13 +/- 6 months, and the bone healing rate was 97.2%. The average bone healing times in the metaphysis and diaphysis were 9 +/- 3 months and 15 +/- 6 months (P = .003). The average bone healing times in the upper and lower limbs were 16.6 +/- 7.4 months and 12.3 +/- 5.8 months (P = .020). The average Muscle and Skeletal Tumor Society score was 28 +/- 3 (21-30) in the 18 survivors.Liquid nitrogen-inactivated autologous bone replantation for primary malignant limb tumor was safe and effective, as shown by the relatively low complication rate, high bone healing rate, and satisfactory postoperative function. This is a reliable biological reconstruction method for malignant bone tumors with specific site and bone destruction characteristics. |
0 | Treatment of knee joint arthritis in the middle-aged patient | AMP (Acute Meniscal Pathology) | Degenerative arthritis of the knee joint is a common problem of the middle-aged patient. Primary arthritis has to be distinguished from secondary disease caused by malalignment, instability or trauma. The key symptom is pain at the jointline on weight-bearing. Diagnosis is established from history, clinical and radiological examination. Treatment options are chosen depending on the severity of symptoms and the demands of the patient. They range from modification of sports- and recreational activities, nonoperative therapy to operative options such as resecting arthroscopic procedures, repair of damaged articular cartilage, osteotomy and unicompartmental knee arthroplasty. However, the patient has to be made aware that a cure for this disease remains to be found. |
0 | Perioperative Timing of Infliximab and the Risk of Serious Infection After Elective Hip and Knee Arthroplasty | AAHKS (2) Corticosteroids | OBJECTIVE: The optimal timing of tumor necrosis factor antagonists before elective surgery is unknown. This study evaluated the association between infliximab timing and serious infection after elective hip or knee arthroplasty.
METHODS: A retrospective cohort study evaluated US Medicare patients with rheumatoid arthritis, inflammatory bowel disease, psoriasis, psoriatic arthritis, or ankylosing spondylitis who received infliximab within 6 months of elective knee or hip arthroplasty from 2007 to 2013. Propensity-adjusted analyses examined whether infliximab stop timing (time between the most recent infusion and surgery) was associated with hospitalized infection within 30 days or prosthetic joint infection (PJI) within 1 year.
RESULTS: Hospitalized infection within 30 days occurred after 270 of 4,288 surgeries (6.3%). Infliximab stop timing <4 weeks versus 8-12 weeks was not associated with an increase in infection within 30 days (propensity-adjusted odds ratio [OR] 0.90 [95% confidence interval (95% CI) 0.60-1.34]). The rate of PJI was 2.9 per 100 person-years and was not increased in patients with stop timing <4 weeks versus 8-12 weeks (hazard ratio [HR] 0.98 [95% CI 0.52-1.87]). Glucocorticoid dosage >10 mg/day was associated with increased risk of 30-day infection (OR 2.11 [95% CI 1.30-3.40]) and PJI (HR 2.70 [95% CI 1.30-5.60]). Other risk factors for infection included elderly age, comorbidities, revision surgery, and previous hospitalized infection.
CONCLUSION: Administering infliximab within 4 weeks of elective knee or hip arthroplasty was not associated with a higher risk of short- or long-term serious infection compared to withholding infliximab for longer time periods. Glucocorticoid use, especially >10 mg/day, was associated with an increased infection risk. |
0 | Arterial embolization of bone metastases: is it worthwhile? | MSTS 2022 - Metastatic Disease of the Humerus | Arterial embolization was performed in ten skeletal metastases occurring in nine patients: eight patients presented with renal cell carcinoma and one with bronchogenic carcinoma. Five metastatic lesions were located in the spine, one in the pelvis, three in the proximal humerus and one in the proximal femur. Selective arterial embolization was performed preoperatively in seven cases and as a palliative treatment in three cases. The embolic material used was polyvinyl alcohol particles, gelatin sponge and coils or a combination of these. Arterial embolization was technically successful in all patients achieving subtotal (> 90%) tumour devascularization in five metastases and a 75% devascularization in the remaining five lesions. In operative patients, median intra-operative volume of blood transfusion was 510 mL. Palliative embolization was followed by major pain relief in two cases and moderate relief in one case lasting from 7 to 26 months. Arterial embolization is an effective and safe adjunctive treatment of hypervascular bone metastases. |
0 | Differences in wound healing between ultrasound-assisted lipoplasty and suction-assisted lipoplasty in inverted T-pattern breast reduction surgery and chest wall contouring | Panniculectomy & Abdominoplasty CPG | BACKGROUND: Inverted T-pattern breast reduction does not directly address axillary or lateral chest wall fullness. Lipoplasty of this tissue has been advocated by some surgeons to reduce additional scarring. OBJECTIVE: A prospective study was designed to examine the differences in wound healing of the breast reduction skin flaps when ultrasound-assisted lipoplasty (UAL) and suction-assisted lipoplasty (SAL) were each used as an adjunct to inverted T-pattern breast reduction surgery. METHODS: The prospective study involved 15 consecutive nonsmoking female patients undergoing a standard inferior pedicle, central mound breast reduction and contouring of the lateral chest wall. Contouring of the left lateral chest wall and axilla was done with UAL and contouring of the right lateral chest wall with SAL. Lipoplasty was not used elsewhere in the breast tissue. The height and length of skin ischemia or necrosis at the inverted T incision was measured at postoperative day 2 or 3. Patients were placed on dressing changes and followed frequently until fully healed. RESULTS: The amount of breast tissue removed and the amount of UAL/SAL axillary aspirate were not significantly different from side to side (for the mean UAL side, tissue 828 +/- 190 g and aspirate 195 +/- 102 mL; for the mean SAL side, tissue 780 +/- 187 g and aspirate 194 +/- 94 mL; P > .05). The mean area of lateral skin flap ischemia at the inverted T incision was significantly less on the UAL side than on the SAL side (UAL, 47 +/- 128 mm(2); SAL, 361 +/- 500 mm(2); P = 0.02). The time to complete skin wound healing of the lateral flap was significantly less in the UAL-treated flaps than in the SAL-treated flaps (UAL, 9.6 +/- 8.6 days; SAL, 22.1 +/- 22 days; P = .02). The study was terminated once these resounding differences in lateral skin flap necrosis and time of wound healing became obvious. CONCLUSIONS: UAL offers significant benefits in comparison with SAL as an adjunct to standard breast reduction surgery for contouring of lateral chest wall fullness. |
0 | Pain evaluation after all-inside anterior cruciate ligament reconstruction and short term functional results of a prospective randomized study | PJI DX Updated Search | PURPOSE: To assess post-operative pain in patients who underwent arthroscopic anterior cruciate ligament (ACL) reconstruction by the all-inside technique. METHODS: A prospective randomized comparative parallel trial was performed in 2010-2011 including all patients who underwent an ACL reconstruction in an orthopaedic department in accordance with the CONSORT statement 2010. Patients were randomized to the surgical procedure, all-inside or classical, and were blinded to the surgical technique. Primary evaluation criterion was pain assessed on the Visual Analogical Scale 1 month after surgery. Secondary parameters were analgesic consumption, tunnel positioning on X-ray according to Aglietti's criteria and functional evaluation at six months with IKDC score. None of the patients was lost to follow-up. RESULTS: 46 consecutive patients were included, 23 in each group, mean age 29.3+/-9 years. Two patients were excluded due to postoperative complications that required early revision surgery. Forty-four patients were analyzed, 22 in each group. At one month, the pain level was 3.2+/-5.5 for the all-inside group and 8.6+/-10 for the classical group, p=0.057 (95%CI 0.5-10.4). Postoperative analgesic consumption was similar. The position of the tibial tunnels was better with the all-inside method, p=0.002 (95%CI 1.9-6.6%). There was no significant difference in the mean IKDC subjective score at six months, p=0.92 (95%CI-9.7 to 9.2). CONCLUSION: At one month, the pain level seemed lower in the all-inside group than in the classical group, at the limit of statistical significance because the study was underpowered. The all-inside technique is a reliable procedure with very good results for pain, stability and knee function. LEVEL OF EVIDENCE: I; Therapeutic study |
1 | Osteochondral scaffold reconstruction for complex knee lesions: a comparative evaluation | Diagnosis and Treatment of Osteochondritis Dissecans AUC | BACKGROUND: The primary aim of the present study is to evaluate the results obtained in challenging knee lesions with the implant of an osteochondral scaffold and concomitant treatment of all comorbidities. The secondary aim is to compare the results obtained with those found when a chondral scaffold was applied. MATERIALS AND METHODS: Patients affected by complex lesions of the knee articular surface were included. "Complex cases" were defined according to the following criteria: previous clinical history of intra-articular fracture, lesion located at the tibial plateau, concurrent knee axial realignment procedure, concurrent meniscal scaffold or allograft implantation, and multiple articular surface lesions treated. Thirty-three patients were treated with the implantation of an osteochondral scaffold. The results of a homogeneous group of 23 patients previously treated and prospectively evaluated after implantation of a chondral scaffold were analyzed and compared. RESULTS: IKDC subjective score improved significantly from pre-operative (40.4+/-14.1) to 12months' follow-up (69.6+/-17.0; p<0.0005) with a further improvement at the final evaluation at 24months (75.5+/-15.0; p=0.038). The same positive trend was confirmed by the VAS and Tegner scores. At final follow-up the group treated with the osteochondral scaffold presented a better subjective IKDC score with respect to the group treated with the chondral scaffold (p=0.034). CONCLUSIONS: A regenerative procedure to address the entire osteochondral unit, together with the treatment of all comorbidities, might offer good results also in complex cases otherwise doomed to non-biological resurfacing. LEVEL OF EVIDENCE III: Comparative study |
0 | Baclofen in the treatment of persistent hiccup: A case series | PJI DX Updated Search | Background Persistent hiccup is a worrying symptom both for patients, because of reduced quality of life, and for physicians, because of frustration for unsuccessful treatments. Aim To test baclofen administration for the treatment of persistent hiccup. Method We report a series of seven patients affected by persistent hiccup successfully treated with baclofen. Results Hiccup stopped in all patients after a single administration of the drug. Conclusions Baclofen is a GABA(B) receptor agonist. It is conceivable that the reduction of dopamine release by GABA(B) receptor stimulation is able to interrupt hiccup's reflex arc. é 2013 John Wiley & Sons Ltd |
0 | Postoperative malrotation of humeral shaft fracture after plating compared with intramedullary nailing | Glenohumeral Joint OA | OBJECTIVE: We supposed difference of rotation alignment of postoperative humeral shaft fracutres between open reduction and internal fixation (ORIF) and intramedullay nailing (IMN) could be identified and the difference might influence the involved shoulder. This study evaluated and compared the extent of malrotation and shoulder function after humeral shaft fractures treated operatively with IMN or ORIF.
MATERIALS AND METHODS: Fifty humeral shaft fractures were randomly allocated into 2 groups. Group I underwent antegrade IMN and group II underwent ORIF. Malrotation was measured postoperatively by computed tomography scan (CT). Fracture union and functional outcomes were recorded at 12 months.
RESULTS: The final analysis comprised 45 patients. Group I had lower functional scores than group II (P < .05). Internal malrotation of 20degree or more (humeral head internally rotated) was found in 27.2% of group I patients, but there was no malrotation in group II. The internal and external range of motion of the involved shoulder was significantly correlated with the degree of malrotation (P < .01).
DISCUSSION: This study comprehensively evaluated the degree of malrotation using CT scanning for every patient. These data bring to light some unexpected results about poor shoulder function and degeneration after humeral shaft fracture. The study can provide baseline data for larger series and longer follow-up periods.
CONCLUSIONS: Patients who underwent IMN had lower functional scores and a decreased range of motion postoperatively and also had a greater degree of malrotation than the ORIF group, which had none. The degree of malrotation correlated with a decreased range of motion and may possibly be a reason for degenerative arthritis at long-term follow-up. |
1 | Health resource utilization associated with skeletal-related events: results from a retrospective European study | MSTS 2018 - Femur Mets and MM | BACKGROUND: Bone complications, also known as skeletal-related events (SREs), are common in patients with bone metastases secondary to advanced cancers.
OBJECTIVE: To provide a detailed estimate of the health resource utilization (HRU) burden associated with SREs across eight European countries.
METHODS: Eligible patients from centers in Austria, the Czech Republic, Finland, Greece, Poland, Portugal, Sweden, and Switzerland with bone metastases or lesions secondary to breast cancer, prostate, or lung cancer or multiple myeloma who had experienced at least one SRE (defined as radiation to bone, long-bone pathologic fracture, other bone pathologic fracture, surgery to bone or spinal cord compression) were entered into this study. HRU data were extracted retrospectively from the patients' charts from 3.5 months before the index SRE until 3 months after the index SRE (defined as an SRE preceded by an SRE-free period of at least 6.5 months).
RESULTS: Overall, the mean number of inpatient stays per SRE increased from baseline by approximately 0.5-1.5 stays, with increases in the total duration of inpatient stays of approximately 6-37 days per event. All SREs were associated with substantial increases from baseline in the frequency of procedures and the number of outpatient and day-care visits.
CONCLUSIONS: SREs are associated with substantial HRU owing to considerable increases in the number and duration of inpatient stays, and in the number of procedures, outpatient visits, and day-care visits. These data collectively provide a valuable summary of the real-world SRE burden on European healthcare systems. |
0 | The first case of primary hypertrophic osteoarthropathy with soft tissue giant tumors caused by HPGD loss-of-function mutation | Reduction Mammoplasty for Female Breast Hypertrophy | BACKGROUND: Primary hypertrophic osteoarthropathy (PHO) is a rare genetic multi-organic disease characterized by digital clubbing, periostosis and pachydermia. Two genes, HPGD and SLCO2A1, which encodes 15-hydroxyprostaglandin dehydrogenase (15-PGDH) and prostaglandin transporter (PGT), respectively, have been reported to be related to PHO. Deficiency of the aforementioned 2 genes leads to failure of prostaglandin E2 (PGE2) degradation and thereby elevated levels of PGE2. PGE2 plays an important role in tumorigenesis. Studies revealed a tumor suppressor activity of 15-PGDH in tumors, such as lung, bladder and breast cancers. However, to date, no HPGD mutated PHO patients presenting concomitant tumor has been documented. In the present study, we reported the first case of HPGD mutated PHO patient with soft tissue giant tumors at lower legs and evaluated the efficacy of selective COX-2 inhibitor (Etorcoxib) treatment in the patient. METHODS: In this study, we summarized the clinical data, collected the serum and urine samples for biochemical test, and analyzed the HPGD gene in our patient. RESULTS: A common HPGD mutation c.310_311delCT was identified in the patient. In addition to typical clinical features (digital clubbing, periostosis and pachydermia), the patient demonstrated a new clinical manifestation, a giant soft tissue tumor on the left lower leg which has not been reported in HPGD-mutated PHO patient before. After six-month treatment with Etoricoxib, the patient showed decreased PGE2 levels and improved PHO related symptoms. Though the soft tissue tumor persisted, it seemed to be controlled under the Etoricoxib treatment. CONCLUSION: This finding expanded the clinical spectrum of PHO and provided unique insights into the HPGD-mutated PHO. |
0 | Implications of expanding indications for drug treatment to prevent fracture in older men in United States: Cross sectional and longitudinal analysis of prospective cohort study | Hip Fx in the Elderly 2019 | Objectives: To quantify incremental effects of applying different criteria to identify men who are candidates for drug treatment to prevent fracture and to examine the extent to which fracture probabilities vary across distinct categories of men defined by these criteria. Design: Cross sectional and longitudinal analysis of a prospective cohort study. Setting: Multicenter Osteoporotic Fractures in Men (MrOS) study in the United States. Participants: 5880 untreated community dwelling men aged 65 years or over classified into four distinct groups: osteoporosis by World Health Organization criteria alone; osteoporosis by National Osteoporosis Foundation (NOF) but not WHO criteria; no osteoporosis but at high fracture risk (at or above NOF derived FRAX intervention thresholds recommended for US); and no osteoporosis and at low fracture risk (below NOF derived FRAX intervention thresholds recommended for US). Main outcome measures: Proportion of men identified for drug treatment; predicted 10 year probabilities of hip and major osteoporotic fracture calculated using FRAX algorithm with femoral neck bone mineral density; observed 10 year probabilities for confirmed incident hip and major osteoporotic (hip, clinical vertebral, wrist, or humerus) fracture events calculated using cumulative incidence estimation, accounting for competing risk of mortality. Results: 130 (2.2%) men were identified as having osteoporosis by using the WHO definition, and an additional 422 were identified by applying the NOF definition (total osteoporosis prevalence 9.4%). Application of NOF derived FRAX intervention thresholds led to 936 (15.9%) additional men without osteoporosis being identified as at high fracture risk, raising the total prevalence of men potentially eligible for drug treatment to 25.3%. Observed 10 year hip fracture probabilities were 20.6% for men with osteoporosis by WHO criteria alone, 6.8% for men with osteoporosis by NOF (but not WHO) criteria, 6.4% for men without osteoporosis but classified as at high fracture risk, and 1.5% for men without osteoporosis and classified as at low fracture risk. A similar pattern was noted in observed fracture probabilities for major osteoporotic fracture. Among men with osteoporosis by WHO criteria, observed fracture probabilities were greater than FRAX predicted probabilities (20.6% v 9.5% for hip fracture and 30.0% v 17.4% for major osteoporotic fracture). Conclusions and relevance: Choice of definition of osteoporosis and use of NOF derived FRAX intervention thresholds have major effects on the proportion of older men identified as warranting drug treatment to prevent fracture. Among men identified with osteoporosis by WHO criteria, who comprised 2% of the study population, actual observed fracture probabilities during 10 years of follow-up were highest and exceeded FRAX predicted fracture probabilities. On the basis of findings from randomized trials in women, these men are most likely to benefit from treatment. Expanding indications for treatment beyond this small group has uncertain value owing to lower observed fracture probabilities and uncertain benefits of treatment among men not selected on the basis of WHO criteria. |
0 | Reliability and concurrent validity of three-dimensional ultrasound for quantifying knee cartilage volume | AMP (Acute Meniscal Pathology) | Purpose: Cartilage degradation, a hallmark of knee osteoarthritis (OA), has motivated efforts to characterize disease severity through measuring loss of femoral articular cartilage (FAC). Clinical assessments and longitudinal monitoring of knee OA are commonly performed by x-ray radiography and magnetic resonance imaging (MRI). However, x-ray imaging is not capable of assessing joint inflammation due to a lack of soft-tissue contrast. MRI is not feasible for point-of-care disease classification due to high manufacturing and operating costs, long acquisition times, and is inaccessible to some patients. There is currently a tremendous clinical need for an objective imaging-based tool that can overcome these limitations to assess knee OA status, progression, and response to treatment at the patient’s bedside. Conventional two-dimensional (2D) ultrasound (US) imaging is an inexpensive, portable, and high-resolution imaging modality, but 2D US images are subject to detection bias and challenges with repeatedly measuring the same location over time with high accuracy. 2D US is also subject to operator dependencies and interpretations. We have developed an inexpensive handheld mechanical 3D US device to monitor OA-induced FAC degradation. Our 3D US device operates by continually acquiring conventional 2D US images at regular spatial intervals while the transducer is mounted to a drive mechanism and translated over a distance of 4 cm. The aim of this study is to assess the reliability and validity of our handheld 3D US device for measuring the volume of FAC in healthy volunteers compared to the current clinical standard of MRI. Methods: Bilateral knee images of healthy volunteers (n = 25) were acquired using MRI and 3D US. MR images were acquired using a 3.0 Tesla MRI GE Healthcare scanner with an HD T/R Knee Array Coil (8 channels). The excitation flip angle was 5° with a repetition time (TR) of 30 ms and an echo time (TE) of 11.71 ms. 3D US images were acquired using a Canon Aplio i800 US machine equipped with a 14L5 linear transducer with a 58 mm footprint length and an operating frequency of 10 MHz (frequency range 3.8 MHz - 10.0 MHz). The conventional 2D US transducer was mounted to our mechanical scanning device via a 3D-printed transducer mold. The trochlear FAC was manually segmented from MRI and 3D US by two raters after receiving training from a rheumatologist possessing extensive diagnostic and interventional musculoskeletal ultrasonography experience (Fig. 1). Five knees were randomly selected by each rater to conduct repeated segmentations during sessions separated by a two-week washout period for intra-rater reliability analysis. Intra- and inter-rater reliabilities were assessed using intraclass correlation coefficients (ICCs) calculated from FAC segmentation volumes. Relationships between MRI and 3D US segmentation volumes were assessed using Spearman correlation and linear regression (n = 25). Results: The mean age of volunteers included in this study was 29.9 ± 14.5 and mean BMI was 23.4 ± 3.3, with 15 females and 10 males. MRI intra-rater ICCs were 0.97 [(0.79, 1.00), p = 0.001] and 0.90 [(0.25, 0.99), p = 0.002] for each rater with an inter-rater ICC of 0.83 [(0.48, 0.94), p < 0.0001]. 3D US intra-rater ICCs were 1.00 [(0.98, 1.00), p < 0.0001] and 0.98 [(0.84, 1.00), p = 0.0003] for each rater with an inter-rater ICC of 0.96 [(0.90, 0.98), p < 0.0001]. Spearman correlation between MRI and 3D US segmentation volumes revealed a strong correlation with ? = 0.88 [(0.75, 0.95), p < 0.0001] and linear regression revealed R2 = 0.85 [(0.75, 0.95), p < 0.0001]. Similar mean segmentation volumes and mean absolute volume differences between intra- and inter-rater comparisons were observed using the same modality for each rater (Table 1). Conclusions: We have demonstrated that 3D US FAC segmentations are associated with excellent intra- and inter-rater reliabilities (ICC > 0.90) and possess strong agreement with MRI FAC volume measurements. The development of a andheld 3D US device that is capable of imaging patients more rapidly than MRI while providing similar or greater volumetric measurement accuracy will improve the workflow of arthritis clinics and provide a more accessible alternative than MRI. Future work will assess the longitudinal construct validity of 3D US measurements in patients diagnosed with knee OA. Future work will also assess the intra- and inter-rater reliabilities of 3D US FAC measurements in a longitudinal study to monitor the progression of FAC change and degradation for early detection of knee OA. [Formula presented] [Formula presented] |
1 | Developmental care for promoting development and preventing morbidity in preterm infants | Developmental Dysplasia of the Hip CPG | BACKGROUND: Preterm infants experience a range of morbidity related to the immaturity of their organ systems and to concurrent disease states. There is concern that an unfavourable environment in the neonatal intensive care unit (NICU) may compound this morbidity. Modification of the environment could minimize the iatrogenic effects. Developmental care is a broad category of interventions designed to minimize the stress of the NICU environment. These interventions may include elements such as control of external stimuli (vestibular, auditory, visual, tactile), clustering of nursery care activities, and positioning or swaddling of the preterm infant. Individual strategies have also been combined to form programs, such as the 'Newborn Individualized Developmental Care and Assessment Program' (NIDCAP) (Als 1986). OBJECTIVES: In preterm infants, do developmental care interventions reduce neurodevelopmental delay, poor weight gain, length of hospital stay, length of mechanical ventilation, physiological stress and other clinically relevant adverse outcomes? SEARCH METHODS: The Neonatal Review Group search strategy was utilized. Searches were made of MEDLINE from 1966 to June, 2005 and of CINAHL, The Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 1, 2005), and conference and symposia proceedings in the English language from 1990 to June, 2005. A search of EMBASE was also made from 2003 to June 2005. A list of all relevant articles was sent to two experts in the field to identify any omissions or additional unpublished studies. SELECTION CRITERIA: Randomized trials in which elements of developmental care are compared to routine nursery care for infants < 37 weeks gestation and that measured clinically relevant outcomes. Reports were in English or a language for which a translator was available.Computerized searches were conducted and all potentially relevant titles and abstracts were extracted. Retrieved articles were assessed for relevance independently by two reviewers, based on predetermined criteria. Articles that met all criteria for relevance were assessed for methodological quality based on predetermined criteria. Articles judged to have the appropriate quality by both reviewers were included in the analysis. DATA COLLECTION AND ANALYSIS: Data were extracted independently by the two authors. Meta-analyses were conducted for each intervention where the same outcome measures and/or instruments were used within comparable time points. MAIN RESULTS: This review detected 36 eligible randomized controlled trials involving four major groups of developmental care interventions, 19 sub-groups and multiple clinical outcomes. In addition, the long-term outcomes of a previously included trial were added to the review.The results of the review indicate that developmental care interventions demonstrate limited benefit to preterm infants with respect to: decreased moderate-severe chronic lung disease, decreased incidence of necrotizing enterocolitis and improved family outcome. Conversely, an increase in mild lung disease and an increase in the length of stay were demonstrated in infants receiving developmental care compared to controls. There is also very limited evidence of the long-term positive effect of NIDCAP on behavior and movement at 5 years corrected age but no effect on cognition. Other individualized developmental care interventions have also demonstrated some effect in enhancing neurodevelopmental outcome. Although a limited number of other benefits were demonstrated, those results were from single studies with small sample sizes. The lack of blinding of the assessors was a significant methodological flaw in half of the studies. The cost of the interventions and personnel was not considered in any of the studies. AUTHORS' CONCLUSIONS: Because of the inclusion of multiple interventions in most studies, the determination of the effect of any single intervention is difficult. Although there is evidence of limited benefit of developmental care interventions overall, and no major harmful effects reported, there were a large number of outcomes for which no or conflicting effects were demonstrated. The single trials that did show a significant effect of an intervention on a major clinical outcome were based on small sample sizes, and the findings were often not supported in other small trials.Before a clear direction for practice can be supported, evidence demonstrating more consistent effects of developmental care interventions on important short- and long-term clinical outcomes is needed. The economic impact of the implementation and maintenance of developmental care practices should be considered by individual institutions. DEVELOPMENTAL CARE FOR PROMOTING DEVELOPMENT AND PREVENTING MORBIDITY IN PRETERM INFANTS: Developmental care interventions may help preterm infants cope better with the environment of the Neonatal Intensive Care Unit (NICU). Preterm infants (babies born before 37 weeks) can develop a range of problems because their organs are not mature. There is concern that an unfavourable environment in the NICU can add to these problems and negatively affect the infant's growth, with the brain being particularly vulnerable. Developmental care refers to a range of strategies designed to reduce the stresses of the NICU. These include reducing noise and light, minimal handling and giving longer rest periods. The review of trials suggests that these interventions may have some benefit to the outcomes of preterm infants; however, there continues to be conflicting evidence among the multiple studies. Before a clear direction for practice can be supported, evidence demonstrating more consistent effects of developmental care interventions on important short- and long-term clinical outcomes is needed. The economic impact of the implementation and maintenance of developmental care practices should be considered by individual institutions |
0 | Comparison of low field (0.2T) and high field (1.5T) MR imaging in the differentation of torned from intact menisci | AMP (Acute Meniscal Pathology) | Purpose: To evaluate the usefulness of a low field MRI system (0.2T; Esaote, Biomedical) for the evaluation of meniscal tears with regard to anatomic site, and to compare the results with findings from a high field unit (1.5T; Siemens, Erlangen). Material and Methods: MRI was performed in 25 patients in a low field (0.2T; Esaote, Biomedica), and a high field (1.5T; Siemens, Erlangen) MRI unit. The images were analyzed for the presence or absence of meniscal tears and the confidence of decision making. Results were further analyzed for the number of identical and unidentical findings on both imaging modalities. In seven patients, arthroscopy was performed and the findings compared with the results from MR imaging. Statistical analysis was performed by X2-test, Wilcoxon test and Friedman analysis. Results: Qualitative evaluation of the level of confidence in decision making was significantly superior on high field strength images. When comparing the evaluations from both image modalities in 21 of 25 patients (84%), the diagnosis concerning the presence or absence of meniscal tears was identical. Conclusion: Although low field MR imaging might offer diagnostic potential concerning the presence or absence of meniscal tears, the level of confidence in decision making is significantly superior with high field strength imaging, probably reflecting the higher conspicuity of lesions from high field strength units. |
0 | Cumulative Long-Term Incidence of Postoperative Periprosthetic Femoral Fractures Using an Uncemented Tapered Titanium Hip Stem: 26- to 32-Year Results | Developmental Dysplasia of the Hip 2020 Review | Background: Although falling is becoming a major problem in the elderly, little is known about the long-term incidence of postoperative periprosthetic femoral fractures (PFF) after total hip arthroplasty (THA) using uncemented stems with a minimum follow-up of 26 years postoperatively. Methods: In a consecutive series, the cumulative incidence of PFF after uncemented THA using a straight, collarless, tapered titanium stem was retrospectively reviewed in 354 hips (326 patients). After a mean follow-up of 28 (26-32) years postoperatively, 179 hips had died and 5 hips had been lost to follow-up. Kaplan-Meier survival analysis was used to estimate cumulative percentage probability of PFF. Results: At final follow-up, a total of 27 fractures in 27 patients had occurred. In 15 hips, the stem had to be revised, and in 10 the fracture was treated by open reduction and internal fixation. Two patients declined further surgery. The cumulative percentage probability of PFF was 1.6% (95% confidence interval, 0.7 to 3.8) at 10 years and 13.2% (95% confidence interval, 8.5 to 20.2) at 29 years after primary THA. There was no association between the occurrence of fracture and gender, age at primary THA, cup revision, or canal fill index. Conclusion: Our findings indicate that PFF is the major mode of failure in the long term after uncemented THA using a tapered titanium stem. More research is needed to evaluate the reasons and risk factors for PFF after THA, thus providing better prophylaxis for those at risk and to compare the long-term incidence using different fixation methods and implants. Level of evidence: IV. |
1 | Two-team management of vascular injuries concomitant with osteo-articular injuries in 36 patients over six years | DoD LSA (Limb Salvage vs Amputation) | BACKGROUND: Patients with both vascular and osteoarticular injuries require multidisciplinary management. Vascular injuries may be function- and/or life-threatening. The lower limbs are predominantly affected. Traffic, domestic, and work-related accidents contribute most of the cases. The primary objective of this study was to describe the management of patients with concomitant vascular and osteo-articular injuries, with special attention to the rates of amputation and fasciotomy. The secondary objective was to suggest a management sequence to optimise our surgical practice. HYPOTHESIS: The management sequence is a crucial consideration in patients with both vascular and osteo-articular injuries. MATERIAL AND METHODS: A 6-year, retrospective, observational study was conducted in patients with concomitant vascular and osteo-articular injuries. RESULTS: The study included 36 patients with a mean age of 40.6+/-22.1 years. The main sources of injury were traffic accidents (n=19, 52.8%), crush injury (n=8, 22.2%), and falls (n=5, 13.9%). A compound fracture was present in 20 (55.6%) patients. Evidence of ischaemia in 25 (69.4%) patients, and bleeding in 11 (30.6%) patients. Pre-operative imaging, by ultrasonography or computed tomography, was performed in 27 (75.0%) patients. The lower limb was involved in 30 (83.3%) patients, who had osteoarticular injuries to the femur and leg combined with injury to the popliteal artery. Fasciotomy was performed in 11 (30.6%) patients and secondary amputation in 7 (19.4%) patients. The limb salvage rate was 80.6%. Median patient survival was 9.3 [0-74.8] months. DISCUSSION: Coordinated work by two surgical teams is crucial to manage concomitant vascular and osteo-articular injuries. The management sequence must be defined clearly. Computed tomography angiography is the investigation of choice and should be performed at the slightest suspicion of vascular injury. LEVEL OF EVIDENCE: IV, retrospective observational study. |
0 | The association between hospital care intensity and surgical outcomes in medicare patients | Hip Fx in the Elderly 2019 | IMPORTANCE Hospitals' care intensity varies widely across the United States. Payers and policy makers have become focused on promoting quality, low-cost, efficient health care. Copyright 2014 American Medical Association. All rights reserved. OBJECTIVE To evaluate whether increased hospital care intensity (HCI) is associated with improved outcomes following major surgery. DESIGN, SETTING, AND PARTICIPANTS Using national Medicare data in this retrospective cohort study, we identified 706 520 patients at 2544 hospitals who underwent 1 of 7 major cardiovascular, orthopedic, or general surgical operations. EXPOSURE The HCI Index, which is validated and publicly available through the Dartmouth Atlas of Healthcare. MAIN OUTCOMES AND MEASURES Risk- and reliability-adjusted mortality, major complication, and failure-to-rescue rates. RESULTS Hospital care intensity varied 10-fold. High-HCI hospitals had greater rates of major complications when compared with low-HCI centers (risk ratio, 1.04; 95%CI, 1.03-1.05). There was a decrease in failure to rescue at high compared with low-HCI hospitals (risk ratio, 0.95; 95%CI, 0.94-0.97). Using multilevel-models, HCI reduced the variation in failure-to-rescue rates between hospitals by 2.7%after accounting for patient comorbidities and hospital resources. Patients treated at high-HCI hospitals had longer hospitalizations, more inpatient deaths, and lower hospice use during the last 2 years of life. CONCLUSIONS AND RELEVANCE Failure-to-rescue rateswere lower at high-care intensity hospitals. Conversely, care intensity explains a very small proportion of variation in failure-to-rescue rates across hospitals. |
0 | Parental response to child injury: Examination of parental posttraumatic stress symptom trajectories following child accidental injury | DoD PRF (Psychosocial RF) | Objective: Trajectory analyses were used to empirically differentiate patterns of posttraumatic stress symptoms in parents following child accidental injury and explore the relationship between parent and child recovery patterns. Method: Parent (n = 189) self-reported symptoms from acute to 2 years post accident were examined to (1) identify distinct parent symptom trajectories; (2) identify risk factors; and (3) explore the patterns of children and parents together. Results: Analysis revealed three distinct symptom trajectory groups for parents: resilient (78%); clinical level acute symptoms that declined to below clinical level by 6 months (recovery 8%); and chronic subclinical (14%). Children of resilient parents were most likely to be resilient. Half of the children of parents with chronic subclinical trajectories were likely to have chronic trajectories. Conclusion: Clinicians cannot rely only on clinical level symptoms in parents to identify high risk families but include families where the parent has subclinical level symptoms. (PsycINFO Database Record (c) 2016 APA, all rights reserved) |
0 | Grip strength ratio: a grip strength measurement that correlates well with DASH score in different hand/wrist conditions | Distal Radius Fractures | BACKGROUND: Grip strength correlates with personal factors such as gender, age and nutritional status and has a good inter-rater reliability. It reflects fairly well how much people can use their hands.The Disabilities of the Arm, Shoulder and Hand (DASH) Outcome Measure 3 is a 30-item, self-report, questionnaire that reflects the patients' opinion on their disability due to upper-limb disorders. We assessed if grip strength and grip strength ratio correlate with DASH score.
METHODS: In 3 groups (20 healthy volunteers, 17 patients after distal radius fractures, 12 patients with different hand/wrist conditions) grip strength and DASH scores (items 1-21, 22-30 and total) were assessed. To exclude personal factors grip strengths in the injured or non-dominant hand and grip strength ratios (grip strength in the injured or non-dominant hand divided by grip strength in the non-injured or dominant hand) were assessed too. Results were analyzed groups using Pearson Correlation Coefficients and with a multivariate ANOVA.
RESULTS: Grip strength ratio was 0.97 in healthy volunteers, 0.52 in patients after distal radius fracture and 0.74 in patients with various other hand/wrist disorders.Significant correlations were found between the grip strength ratio and DASH as well as DASH subsections in all groups and between DASH scores and grip strength in some. The correlations between the ratio of the grip strength (GSR) and DASH were much stronger than the correlation between grip strength and DASH. This emphasizes the value of the GSR. Age showed no correlation with grip strength ratio using a multivariate ANOVA.
CONCLUSION: Grip strength ratio correlates well with the DASH score in different hand and wrist conditions. It is a valuable tool to assess patients that speak a different language and have problems with the non-dominant hand and probably easier to follow over time than the DASH score, which is time consuming to fill in and process. |
0 | Modified C7 neurotization for the treatment of obstetrical brachial plexus palsy | Diagnosis and Treatment of Carpal Tunnel Syndrome CPG | Contralateral C7 transfer is used rarely in infants with obstetrical brachial plexus palsy (OBPP). We aimed to determine the efficacy of contralateral C7 transfer to two different recipient nerves in infants with |
0 | Empty Sunrise Sign: An Arthroscopic Finding in Recurrent Patellar Dislocation | AMP (Acute Meniscal Pathology) | Patellar dislocation is a relatively common knee injury and can be challenging to diagnose. We describe an arthroscopic finding we noted in recurrent patellar dislocation. Arthroscopic photos were evaluated from 50 knees with a history patellar dislocation and 100 control patients. We quantified the amount of patellar subluxation seen on a single arthroscopic view and coined it Empty Sunrise Sign if the patella did not overlap the trochlea. Empty Sunrise Sign was found in 82% of 50 cases with recurrent patellar dislocation and none of the 100 control cases. The finding was 100% specific for identifying a recurrent patellar dislocator. High interobserver agreement was noted. Empty Sunrise Sign suggests significant capsular laxity. This may need to be considered in the surgical treatment of recurrent patellar dislocation. |
0 | Aesthetic Evaluation of Breast Reconstruction with Autologous Fat Transfer vs. Implants | Panniculectomy & Abdominoplasty CPG | BACKGROUND: Autologous fat transfer (AFT) seems to be a new minimal invasive method for total breast reconstruction, yet how patients, surgeons, and laymen evaluate cosmesis is lacking. The aim of this study was to evaluate the aesthetic outcome of AFT (intervention group) for total breast reconstruction post-mastectomy, as compared to implant-based reconstruction (IBR) (control group). METHODS: A random and blinded 3D photographic aesthetic outcome study was performed on a selection of 50 patients, scored by three panels: plastic surgeons, breast cancer patients, and laymen. Secondary outcomes included agreement within groups and possible patient characteristics influencing scoring. RESULTS: Breast cancer patients and plastic surgeons did not differ in the aesthetic scores between the treatment groups. In contrast, the laymen group scored AFT patients lower than IBR patients (- 1.04, p < 0.001). Remarkably, mean given scores were low for all groups and overall agreement within groups was poor (ICC < 0.50). Higher scores were given when subjects underwent a bilateral reconstruction and if a mamilla was present. CONCLUSION: Evaluation of aesthetic outcomes varies greatly. Hence, aesthetic outcome remains a very personal measure and this emphasizes the importance of thorough patient counseling including information on achievable aesthetic results before starting a reconstructive procedure. LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 . |
0 | Hip fracture prevention trial using hip protectors in Japanese nursing homes | Management of Hip Fractures in the Elderly | A method to protect the hips during falls could effectively reduce the incidence of hip fractures. We report the results of the first hip protector trial in Japan, performed between July 1996, and September 1999. One hundred and sixty-four elderly female residents of nursing homes, with Activities of Daily Living above the wheelchair level, agreed to participate in this study. Among them, 88 were randomly selected to wear a hip protector and 76 controls did not. All falls and resulting injuries were recorded daily. In anthropometric measurements and ultrasonic bone evaluation, no significant differences were found between the two groups, except in height. During an average of 377 days, the wearers and the non-wearers fell a total of 131 and 90 times, respectively. Among the wearers, there were two non-hip fractures and one hip fracture, so the annual hip fracture rate was calculated at 1.2%, against 8 hip fractures among the non-wearers, or 9.7% per year. The hip fracture rate was significantly lower among the wearers than non-wearers, while the annual number of falls per subject and the distribution of fallers remained the same. According to Cox's proportional hazard regression analysis, the effect of the hip protector on hip fracture prevention was independent of anthropometric data, ultrasonic bone assessment values or number of falls. Moreover, even after limiting the subjects to fallers only, the annual hip fracture rate in non-wearers was higher than in wearers (19.8% vs 2.0%) and the annual hip fracture rate per fall in wearers was lower than that in non-wearers (0.8% vs 8.2%). It was thus concluded that the hip protector is a beneficial device for the prevention of hip fractures |
0 | Healing of meniscal tissue by cellular fibrin glue: An in vivo study | AMP (Acute Meniscal Pathology) | Menisci represent fundamental structures for the maintenance of knee homeostasis, playing a key role in knee biomechanics. However, their intrinsic regenerative potential is poor. As a consequence, when a lesion occurs and the meniscus is partially removed by surgery, knee mechanics is subject to dramatic changes. These have been demonstrated to lead often to the development of early osteoarthritis. Therefore, menisci should be repaired whenever possible. In the last decades, tissue engineering approaches have been advocated to improve the reparative processes of joint tissues. In this study, the bonding capacity of an articular chondrocytes-fibrin glue hydrogel was tested as a biologic glue to improve the bonding between two swine meniscal slices in a nude mouse model. The composites were wrapped with acellular fibrin glue and implanted in subcutaneous pouches of nude mice for 4 weeks. Upon retrieval, a firm gross bonding was observed in the experimental samples while none of the control samples, prepared with acellular fibrin glue at the interface, presented any sign of bonding. This was consistent with the histological and scanning electron microscope findings. In particular, a fibrocartilaginous tissue was found at the interface between the meniscal slices, partially penetrating the native meniscus tissue. In order to overcome the lack of regenerative properties of the meniscus, the rationale of using cellular fibrin glue is that fibrin provides immediate stability while carrying cells in the site of lesion. Moreover, fibrin gel is recognized as an optimal scaffold for cell embedding and for promoting fibrocartilaginous differentiation of the cells which synthesize matrix having healing property. These results demonstrated the potential of this model for improving the meniscal bonding. However, further orthotopic studies in a large animal model are needed to evaluate its potential for clinical application. © 2009 Springer-Verlag. |
0 | Periacetabular osteotomy for acetabular dysplasia in patients older than 40 years: A preliminary study | PJI DX Updated Search | The functional outcomes of periacetabular osteotomy (PAO) and factors predicting outcome in the older patient with acetabular dysplasia are not well understood. We therefore retrospectively determined the functional outcome of 70 patients (87 hips) over age 40 treated with PAO in three institutions; we also determined whether preoperative factors, particularly the presence of osteoarthritis, influenced the survival of the hip or time to total hip arthroplasty after PAO. The average age at surgery was 43.6 years. The minimum followup was 2 years (mean, 4.9 years; range, 2-13 years). Twenty-one hips (24%) had undergone total hip arthroplasty (THA), at a mean of 5.2 years after PAO (range, 1.9-7.6 years). Surviving hips had a mean improvement in Harris hip score from 60.7 to 90.3 and in total WOMAC pain score from 8.7 to 3. We observed no differences in preoperative or postoperative radiographic measurements or preoperative clinical function scores (HHS, WOMAC) in hips surviving and hips having THA. The risk of THA at 5 years after PAO was 12% in hips with preoperative Tönnis Grade 0 or 1 and 27% for Tönnis Grade 2. Our preliminary study suggests that PAO will give satisfactory functional and pain scores in patients over age 40 having dysplastic hips with mild or no arthrosis. Level of Evidence: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence. é 2009 The Association of Bone and Joint Surgeons |
0 | Imaging features of Ewing's sarcoma: Special reference to uncommon features and rare sites of presentation | MSTS 2022 - Metastatic Disease of the Humerus | Context: Ewing's sarcoma (EWS) commonly involves long bones with a permeative pattern of bone destruction and aggressive interrupted periosteal new bone formation. However, radiological features show wide variation and some presentations are uncommon, leading to diagnostic confusion. This study is aimed at studying the imaging features of proven EWS and highlight the uncommon features and rare sites of presentation.
Materials and Methods: The imaging findings of 100 consecutive histopathologically proven EWS were analyzed retrospectively. All uncommon presentations with respect to age and site and morphology of lesion were observed.
Results: Most of the patients were below 20 years of age and 8% were younger than 5 years. Other than long bones, ribs, and pelvis, other sites considered to be rare and were noted in 25%. Extraosseous site involvement was 11%. Uncommon features included epiphyseal involvement (4%), sclerosis (4%), expansion of bone (8%), sunray spiculation (10%), calcification in soft tissue (8%), saucerization (4%), pathological fracture (5%), fluid-fluid level (2%), vertebra plana (2%), and lesion crossing the joint (13%).
Conclusions: The uncommon observations included incidence in children <5 years (8%) and occurrence in craniofacial bones, spine, scapula, and clavicles and in extraosseous sites such as retroperitoneum, adrenals, or extremity. Uncommon findings included epiphyseal involvement, sclerosis, saucerization, calcification in soft tissue component, and pathological fracture and lesion crossing the joint. |
0 | Cerebral Fat Embolism Syndrome After Simultaneous Bilateral Total Knee Arthroplasty. A Case Series | Surgical Management of Osteoarthritis of the Knee CPG | Total knee arthroplasty (TKA), particularly when performed as a simultaneous bilateral procedure, theoretically increases the risk for entry of fat globules into the blood stream. The frequency of cerebral fat embolism syndrome (CFES) was retrospectively investigated among 2345 simultaneous bilateral TKA procedures performed from August 2006 to May 2010. During that period, 9 patients presented with neurologic deficits after surgery and underwent brain magnetic resonance imaging. For identification of CFES among them, we used both magnetic resonance imaging findings and clinical criteria modified from the original one of Gurd and Wilson (J Bone Joint Surg Br 1974; 56B:408). Four patients fulfilled the modified criteria. The overall incidence of CFES occurring after simultaneous bilateral TKA was 0.17%. Cerebral fat embolism syndrome should be ruled out, although rare, in patients who present with neurologic impairment after TKA. (copyright) 2012 Elsevier Inc. |
1 | A pilot study on continuous femoral perineural catheter for analgesia after total knee arthroplasty: the effect on physical rehabilitation and outcomes | AAHKS (9/10) Regional Nerve Blocks | Two techniques of postoperative analgesia for primary total knee arthroplasty were compared retrospectively. Twenty-four patients received a femoral nerve catheter with continuous infusion of ropivacaine (FNC group), whereas 26 patients received intravenous (IV) opioids (IV opioid group). Pain and rehabilitation scores and hospital length of stay (LOS) were compared. On the first postoperative day, both groups reported similar pain scores. After 4 sessions of twice-daily rehabilitation, the FNC group used less IV patient-controlled opioids (29.1% vs 84.5%, P = .0001) and demonstrated better performance with knee flexion and mobility. Hospital LOS was significantly less in the FNC group (3.6 vs 4.2 days, P = .034). Femoral nerve catheters with continuous infusion of ropivacaine provide satisfactory analgesia, improve rehabilitation, and shorten hospital LOS. |
0 | Cortical networks for motion processing: effects of focal brain lesions on perception of different motion types | Upper Eyelid and Brow Surgery | Neuropsychological studies in humans provide evidence for a variety of extrastriate cortical areas involved in visual motion perception. Multiple mechanisms underlying processing of different motion types have been proposed, however, support for cortical specialization has remained controversial so far. We therefore studied motion perception in 23 patients with focal lesions to various cortical areas and considered translational motion, heading from radial flow, as well as biological motion. Patients' detection thresholds were compared with age-specific data from a large healthy control sample (n=122). Elevated thresholds and significant threshold asymmetries between both visual hemifields were defined as deficits. Contrary to prevalent opinion, we found a high prevalence of motion deficits in our sample. Impairment was restricted to a specific motion type in 10 patients, whereas only a single patient showed a deficit for multiple motion types. Functional areas were determined by lesion density plots and by comparison between patients with and without a specific deficit. Results emphasize a dissociation between basic motion processing and processing of complex motion. Anatomical analysis confirmed critical occipito-temporo-parietal areas for perception of translational motion. In contrast, heading perception from radial flow proved to be remarkably robust to most lesions. We exclusively identified the frontal eye fields as a critical structure. Biological motion perception relied on distinct pathways involving temporal, parietal, and frontal areas. Although precise functional roles of identified areas cannot be determined conclusively, results clearly indicate regional specialization for motion types of different complexity. We propose a network for motion processing involving widely distributed cortical areas. |
0 | Prevalence and associated risk factors of sarcopenia in female patients with osteoporotic fracture | Hip Fx in the Elderly 2019 | Background: We determined the prevalence of sarcopenia according to fracture site and evaluated the associated risk factors in female patients with osteoporotic fractures. Methods: A total of 108 patients aged 50 years or older with an osteoporotic fracture (hip, spine, or wrist) were enrolled in this retrospective observational study. A diagnosis of sarcopenia was confirmed using whole-body densitometry for skeletal muscle mass measurement. Logistic regression analysis was used to analyze the risk factors for sarcopenia. Results: Of 108 female patients treated for osteoporotic fractures between January 2016 and June 2017, sarcopenia was diagnosed in 39 (36.1%). Of these, 41.5% (17/41) had hip fractures, 35% (14/40) had spine fractures, and 29.6% (8/27) had distal radius fractures. Body mass index (BMI; P=0.036) and prevalence of chronic kidney disease (CKD; P=0.046) and rheumatoid arthritis (P=0.051) were significantly different between the groups. In multivariable analysis, BMI (odds ratio [OR], 0.76; 95% confidence interval [CI], 0.55-1.05, P=0.098) and CKD (OR 2.51; 95% CI, 0.38-16.2; P=0.233) were associated with an increased risk of sarcopenia; however, this was not statistically significant. Conclusions: This study evaluated the prevalence of sarcopenia according to the fracture site and identified associated risk factors in patients with osteoporotic fractures. A longterm, observational study with a larger population is needed to validate our results. |
0 | Endoprosthetic reconstruction for large extremity soft-tissue sarcoma with juxta-articular bone involvement: functional and survival outcome | Pediatric Supracondylar Humerus Fracture 2020 Review | BACKGROUND: Large extracompartmental limb soft-tissue sarcoma with juxta-articular bone involvement poses major challenges in disease management. Radical resection of sarcoma frequently requires concomitant bone resection and reconstruction. We describe the clinical outcomes of endoprosthetic reconstruction and the complications associated with this procedure. METHODS: Thirty patients with soft-tissue sarcomas with local juxta-articular bone involvement in an extremity underwent surgery at our center between May 2004 and October 2011, 20 for primary sarcomas and 10 for local recurrences. Clinical data from those patients were analyzed retrospectively. The bone affected included the proximal femur (10 cases), the distal femur (nine cases), the proximal humerus (eight cases), the proximal tibia (two cases), or the total femur (one case). Wide excision of the tumor and the bone tissue involved was performed on every patient, followed by reconstruction of the subsequent defect using tumor endoprosthesis. All patients underwent regular follow-up for an average of 25 (range, 3-84) mo. RESULTS: Three patients had poor wound healing. Implant fractures leading to additional revisions occurred in two cases. Local tumor recurrence developed in four patients. There were 15 patients with lung metastases, and 11 patients died of disseminated metastases. In the latest follow-up, 14 patients survived free of disease and five were alive with tumors. The mean Musculoskeletal Tumor Society functional analysis for proximal femur, distal femur, proximal tibia, proximal humerus, and total femur were 90%, 82%, 73%, 71%, and 60%, respectively. The 2- and 5- y survival rates were 61.6% and 30.0%, respectively. CONCLUSIONS: Endoprosthetic reconstruction could yield satisfactory results as a wide excision and limb salvage therapeutic strategy for patients with large extracompartmental soft-tissue sarcomas with juxta-articular bone involvement. Acceptable complications occurred in the present report. |
1 | Postarthroscopy osteonecrosis of the knee | OAK 3 - Non-arthroplasty tx of OAK | PURPOSE: Spontaneous subchondral osteonecrosis of the knee joint confined to a localized area of one condyle can occur after arthroscopic procedures. Meniscal tears, arthroscopic meniscectomy, and radiofrequency chondroplasty are aetiological factors in the development of osteonecrosis. The aim of this study was to investigate whether the incidence of osteonecrosis increased when mechanical or radiofrequency chondroplasty was used in conjunction with arthroscopic meniscectomy.
METHODS: In this prospective clinical trial, arthroscopic meniscectomy was the primary treatment in 75 patients (mean age 40 +/- 13) with stage II and III degenerative changes on the articular cartilage. Patients had to meet the following criteria: 1) have preoperative MRI and plain film radiographs showing no evidence of osteonecrosis; 2) be symptomatic for at least 6 weeks before the preoperative MRI; and 3) have arthroscopically confirmed stage II or III chondral lesion. A preoperative MRI was performed for all patients. For treatment of chondral lesions, debridement with a shaver or chondroplasty with a monopolar RF energy system was used. Patients were divided into three treatment groups. Partial meniscectomy of the medial or lateral (or both) menisci was performed on all patients, but patients in group 2 additionally received mechanical debridement of the chondral lesion, and those in group 3 were additionally treated with RF chondroplasty. Patients in group 1 were treated with partial meniscectomy alone. Patients were re-examined after 6 months, at which time a repeat MRI was performed.
RESULTS: Development of osteonecrosis was detected during the postoperative MRIs of five patients: two in group 1, two in group 2, and one in group 3.
CONCLUSION: The addition of mechanical or RF chondroplasty to meniscectomy did not increase the number of patients with osteonecrosis. Also, RF chondroplasty, which is commonly proposed to be an aetiological factor, resulted in a decrease in the number of patients that developed osteonecrosis.
Level of evidence: Ii. |
1 | Overgrowth of the Femur After Internal Fixation in Children With Femoral Shaft Fracture-A Multicenter Study | Pediatric Diaphyseal Femur Fractures 2020 Review | OBJECTIVES: To evaluate overgrowth after internal fixation for pediatric femur fracture and to identify any factors related with overgrowth in terms of fracture type and fixation method. DESIGN: Retrospective comparative study. SETTING: Multicenter, children's hospital and general hospital. PATIENTS/PARTICIPANTS: Eighty-seven children between 4 and 10 years of age were included. Length-stable fracture was noted in 49 children, and length-unstable fracture was found in 38 children. INTERVENTION: Thirty-six children were treated by minimal invasive plate osteosynthesis (MIPO), and elastic stable intramedullary nail fixation (ESIN) was used in 51 children. MAIN OUTCOME MEASUREMENTS: The degree of overgrowth after internal fixation compared to fracture type, fracture site, and surgical method. Multivariable logistic regression analysis was conducted to identify factors related with overgrowth. RESULTS: The average overgrowth of the femur was 10.5 ± 7.3 mm. There was no patient who required correction for final leg length discrepancy (>2 cm). There was no significant difference in overgrowth between ESIN (9.9 ± 7.2 mm) and MIPO (11.2 ± 7.6 mm) (P = 0.417). Overgrowth was similar among length-unstable fractures (12.3 ± 7.4 mm) and length-stable fractures (9.2 ± 7.0 mm), although it was statistically greater in length-unstable fractures (P = 0.048). In the MIPO group, length-unstable fractures were associated with an increased log odds of 6.873 for overgrowth of the femur (P = 0.042). CONCLUSIONS: Femur overgrowth after internal fixation seems to not be a clinically significant problem, regardless of whether that be for length-stable or length-unstable fractures and whether they were treated by MIPO or ESIN. Length-unstable fracture may be a risk factor for overgrowth in children. However, the difference is very small, and the postoperative overgrowth would likely not be a significant factor in deciding the surgical plan. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for authors for a complete description of levels of evidence. |
0 | Pediatric supracondylar fractures and pediatric physeal elbow fractures | The Treatment of Pediatric Supracondylar Humerus Fractures AUC | Elbow fractures in children are extremely common, making up approximately 15% of all fractures in pediatric patients. The unique radiographic anatomy of the pediatric elbow, along with the potential for neurovascular compromise, often provokes anxiety in orthopedic surgeons. A thorough understanding of the anatomy and treatment principles makes the care for these children more straightforward, however. The distal humerus makes up approximately 85% of all elbow fractures in children. The most common fractures of the distal humerus in children are supracondylar humerus fractures, lateral condyle fractures, medial epicondyle fractures, and transphyseal humerus fractures. Each of these fractures is discussed in detail, outlining their radiographic features, principles of treatment, and potential complications |
0 | Surgeon satisfaction agreement after total knee arthroplasty using a visual analogue scale: A single surgeon series | Surgical Management of Osteoarthritis of the Knee CPG | Introduction: The outcome of total knee arthroplasty (TKA) is traditionally rated by objective criteria such as the knee society clinical rating system (KSCRS). Subjective criteria, such as satisfaction, will be of more importance, because health-care is shifting towards a market model. The aim of this study was to investigate the agreement on satisfaction after TKA between two orthopaedics surgeons, when one of the surgeons reviews his own results. Patients and methods: We investigated a group of 57 patients (63 TKAs) using a visual analogue scale (VAS) for satisfaction. There were 53 TKAs available and were separately seen by the two orthopaedic surgeons for clinical follow-up. Results: After we split the satisfaction rate as excellent-good and fair-poor (VAS smaller or equal to 20 was excellent-good), we found a substantial agreement ((kappa) = 0.77) between the orthopaedic surgeons. However, we found that the surgeon who viewed his own results (B) scored a significantly lower satisfaction than surgeon A when analysing the complete group. Conclusions: The interobserver agreement of satisfaction, using a VAS, was high between the two orthopaedic surgeons. The satisfaction VAS is a simple tool to quantify satisfaction of surgeons and patients after TKA and could be used to evaluate quality. Comparison between studies could be more efficient and reliable using the satisfaction VAS method. (copyright) Springer-Verlag 2006 |
1 | Prolonged median sensory latency as a predictor of future carpal tunnel syndrome | Diagnosis and Treatment of Carpal Tunnel Syndrome CPG | The purpose of the study was to determine whether abnormal median sensory nerve conduction among asymptomatic workers was predictive of future symptoms suggestive of carpal tunnel syndrome (CTS). This was a prospective study involving 77 workers who were identified as asymptomatic cases with electrodiagnostic findings of median mononeuropathy compared to an age- and sex-matched control group. Follow-up was completed an average of 70 months later, and subjects who reported pain, numbness, tingling, or burning in the distribution of the median nerve, based upon a hand diagram, were classified as having CTS symptoms. The follow-up participation rate was 70%. Among subjects with abnormal median sensory latencies, 23% went on to develop symptoms consistent with CTS within the follow-up period, compared with 6% in the control group (P= .010). Age and hand repetition were also risk factors for CTS, but the majority of asymptomatic workers with a median mononeuropathy do not become symptomatic over an extended time |
0 | Long-term results in the treatment of fracture-dislocations of Galeazzi in adults. Report on twenty-nine cases | Distal Radius Fractures | The authors report 29 cases of a true Galeazzi fracture, (i.e. displaced fracture of the radial shaft and disruption of the distal radioulnar joint). In 1/4 of the cases, dislocation was overlooked and the injury was mistaken for a so-called "isolated" fracture of the radius. By accurate open reduction and compression plating of the fracture, both the torn radioulnar ligaments and the articular disc could be repaired and healed. Additional percutaneous Kirschner pinning across the ulna and the radius in order to avoid redislocation, does not seem to be necessary. It is important, however, to hold the reduction of the radioulnar dislocation in a plaster cast for 4-6 weeks, since the 8 persistent displacements of the ulnar head always resulted in a lack of pronosupination of more than 25 degrees. In these cases, pain and disability may require later surgical management. Late resection of the ulnar head or a Sauve-Kapandji procedure which yield an obvious cosmetic and functional improvement, are preferred to any immediate surgical repair of the radioulnar ligaments. This operation was carried out 3 times, but failed twice. Nevertheless out of 25 patients reviewed after a mean follow up time of 6.5 years, the results were gratifying in 20 who could resume their previous occupation 4 to 12 months postoperatively. |
1 | Effect of repeated high dose prophylaxis with amoxycillin on the resident oral flora of adult volunteers | Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures | Healthy adult volunteers received either single or repeated 3-g doses of amoxycillin by mouth at weekly intervals on three occasions. The salivary flora of each volunteer was monitored before, during and up to 11 weeks after the final dose of antibiotic. Viable counts of anaerobic bacteria, streptococci and streptococci resistant to amoxycillin 2 mg/L and 40 mg/L were determined in samples of saliva. All 20 volunteers harboured low numbers of streptococci resistant to amoxycillin 2 mg/L (mean count = 6.57 X 10(3) cfu/ml of saliva) before administration of the antibiotic; much lower carriage rates (45%) were observed for bacteria resistant to amoxycillin 40 mg/L (mean count = 116 cfu/ml of saliva). Each dose of amoxycillin had a rapid but transient effect on the numbers of salivary bacteria. A placebo lacking the antibiotic had no effect. A single 3-g dose of amoxycillin had little or no effect on the numbers of resistant streptococci and, therefore, it was concluded that in patients at risk of infective endocarditis a second prophylactic dose would not be invalidated. The numbers of resistant streptococci increased significantly after the second and third doses of amoxycillin, and persisted for 4-7 weeks. Consequently, in at-risk patients requiring repeated dental procedures liable to produce bacteraemia, either alternative antibiotic regimens should be used each time or intervals of at least 4 weeks should be left between treatment sessions |
1 | Hand-wrist disorders among investment casting plant workers | Diagnosis and Treatment of Carpal Tunnel Syndrome CPG | A survey of the prevalence of chronic soft tissue disorders of the hand and wrist was conducted 3 years after an initial survey of workers in a midwestern investment casting plant. The second survey of 136 (90%) of the original participants disclosed that (1) approximately 25% had different jobs in 1986, (2) 35% of those who had different jobs in 1986 reported transfers because of disorders, and (3) of those workers with the same job during both surveys, 11% reported temporary job changes due to disorders in the preceding 3 years. Workers with hand-wrist disorders in high-force and high-repetitive jobs tended to transfer out of these jobs more frequently than those in low-force-low-repetitive jobs. We failed to detect a relationship between ergonomic changes and change in prevalence of chronic hand-wrist disorders. This may be because the changes did not substantially alter the force and repetitiveness characteristics of the jobs |
0 | Rheumatoid arthritis patients are not at increased risk for 30-day cardiovascular events or infections following total joint arthoplasty | Surgical Management of Osteoarthritis of the Knee CPG | Background/Purpose: Although serious infection and cardiovascular disease are increased in patients with rheumatoid arthritis (RA), it is not known whether RA impacts the risk for these complications following total joint arthroplasty (TJA). We examined whether RA was associated with the occurrence of 30-day postoperative complications in a large population of patients undergoing TJA. Methods: Analyses included data from the Veterans Affairs (VA) Surgical Quality Improvement Program (VASQIP) for fiscal years 1999-2006. ICD9 codes and medication dispensing data were obtained from the VA Pharmacy Benefits Management (PBM) database. RA was defined for those with a corresponding ICD9 (714.0) plus receipt of at least one DMARD within 1 year before TJA. All other patients had an ICD9 (715.x) corresponding to osteoarthritis (OA). 30-day complications (major cardiovascular event, infection, and return to the operating room) were compared by diagnosis (RA vs. OA) using multivariate regression. Post-operative infections included systemic sepsis, pneumonia, urinary tract infection, superficial and deep wound surgical site infections. Cardiovascular events included cardiac arrest, myocardial infarction, stroke, pulmonary embolism, and deep vein thrombosis. All analyses were adjusted for age, sex, and clustering by site (n = 104 sites). Additional covariates included sociodemographics, comorbidities, health behaviors, and well defined operative risk factors (up to 44 covariates examined). Results: There were 37,103 patients (n = 888 with RA) undergoing TJA, with total knee arthroplasty being most common (64%), followed by hip (33%), shoulder (2%), and elbow (0.2%). Patients were predominantly men (96%) with a mean (SD) age of 64 (11) years. Among RA patients, the most frequently used DMARDs included methotrexate (59%), hydroxychloroquine (40%) and sulfasalazine (23%) while 41% were taking glucocorticoids and 24% biologic DMARDs. The frequency of select complications based on diagnosis is summarized in the table below. Compared to OA patients, those with RA were significantly more likely to require a return to the operating room but had similar rates of postoperative infection and cardiovascular events. Table. The frequency of select complications following TJA in patients with RA and OA (Table Presented) Conclusion: RA patients are not at an increased risk for short-term infectious complications or cardiovascular events following TJA. RA patients did have an increased rate of return to the operating room. Reasons for this difference and strategies to address it require further study |
1 | The effect of functional knee-braces on strain on the anterior cruciate ligament in vivo | Anterior Cruciate Ligament Injuries CPG | Functional knee-braces are widely used to protect injured or reconstructed anterior cruciate ligaments, despite the fact that few scientific data support their efficacy. We studied seven functional braces, representative of both the typical custom-fit and off-the-shelf designs. The braces were tested on subjects who had a normal anterior cruciate ligament and were scheduled for arthroscopic meniscectomy or exploration of the knee under local anesthesia. After the operative procedure, a Hall-effect strain-transducer was applied to the anterior cruciate ligament. Under low anterior shear loads, two braces provided some protective strain-shielding effect compared with no brace, but this strain-shielding effect did not occur at the higher anterior shear loads expected during the high-stress activities common to athletic events. The DonJoy, Townsend, C.Ti., and Lenox Hill braces demonstrated a strain-shielding effect on the anterior cruciate ligament with an internal torque of five newton-meters applied to the tibia. None of the braces had any effect on strain on the anterior cruciate ligament during active range of motion of the knee from 10 to 120 degrees or during isometric contraction of the quadriceps. Wearing of a brace did not produce an increase in the value for strain on the anterior cruciate ligament. For the activities that were evaluated in this study, none of the braces produced adverse effects on the anterior cruciate ligament, and there were no significant differences in the strain on the anterior cruciate ligament between the use of a custom-fit or an off-the-shelf brace design. There were no apparent advantages of the more expensive custom-made braces compared with the off-the-shelf designs |
0 | Clinical outcome after lipectomy in the management of patients with human immunodeficiency virus-associated dorsocervical fat accumulation: An observational cohort study | Panniculectomy & Abdominoplasty CPG | Lipo-accumulation of the dorsocervical fat pad ("buffalo hump") is a complication observed in people living with human immunodeficiency virus (HIV). We described the clinical outcome of people living with HIV with "buffalo hump" treated by excisional lipectomy.From April 2013 to March 2018, medical records of people living with HIV, who received care in our hospital have been evaluated. Among them, patients with dorsocervical fat accumulation treated by excisional lipectomy have been retrospectively assessed.Nine patients with "buffalo hump" among 2886 people living with HIV (3.1 per thousand, 9/2886) were included. Eight were women with a mean age of 47.9 +/- 8.0 years old (range, 36-60). Most of them have been infected by blood transfusion (77%, 7/9) and the mean duration of HIV infection was 14.1 +/- 5.5 years (range, 6-22). The mean duration for antiretroviral therapy was 8.8 +/- 2.1 years (range, 6-11). The mean pre-ART CD4+ T cell count was 91.3 +/- 76.5 cells/muL (range, 4-233) and 477.4 +/- 271.8 cells/muL (range, 114-926) at the time of surgery. All 9 patients underwent excisional lipectomy of their hypertrophied dorsocervical fat pad. The mean size of the excised specimens was 14 x 11 x 6 cm. The median follow-up time was 24 months (range, 2-60), all 9 patients reported satisfaction with their results, with no recurrence has been observed.Corrective surgery used to treat localized fat accumulations in people living with HIV with "buffalo hump" showed a favorable effect and can therefore be considered when necessary. Whereas drugs such as integrase inhibitors may avoid lipo-accumulation related syndrome and should be given to people living with HIV in China. |
0 | Subregional laminar cartilage MR spinâ??spin relaxation times (T2) in osteoarthritic knees with and without medial femorotibial cartilage loss â?? data from the Osteoarthritis Initiative (OAI) | OAK 3 - Non-arthroplasty tx of OAK | Objective To explore whether subregional laminar femorotibial cartilage spinâ??spin relaxation time (T2) is associated with subsequent radiographic progression and cartilage loss and/or whether one-year change in subregional laminar femorotibial cartilage T2 is associated with concurrent progression in knees with established radiographic OA (ROA). Methods In this case-control study, Osteoarthritis Initiative (OAI) knees with medial femorotibial progression were selected based on one-year loss in both quantitative cartilage thickness Magnetic resonance imaging (MRI) and radiographic joint space width (JSW). Non-progressor knees were matched by sex, Body mass index (BMI), baseline Kellgren-Lawrence-grade (2/3), and pain. Baseline and one-year follow-up superficial and deep cartilage T2 was analyzed in 16 femorotibial subregions using multi-echo spin-echo MRI. Results 37 knees showed medial femorotibial progression whereas 37 matched controls had no medial or lateral compartment progression. No statistically significant baseline differences between progressor and non-progressor knees in medial femorotibial cartilage T2 were observed in the superficial (48.9 ± 3.0 ms; 95% CI: [47.9, 49.9] vs 47.8 ± 3.6 ms; 95% CI: [46.6, 49.0], P = 0.07) or deep cartilage layer (40.8 ± 3.6 ms; 95% CI: [39.5, 42.0] vs 40.1 ± 4.7 ms; 95% CI: [38.5, 41.6], P = 0.29). Concurrent T2 change was more pronounced in the deep than the superficial cartilage layer. In the medial femorotibial compartment (MFTC), longitudinal change was greater in the deep layer of progressor than non-progressor knees (1.8 ± 4.5 ms; 95% CI: [0.3, 3.3] vs â??0.2 ± 1.9 ms; 95% CI: [â??0.8, 0.5], P = 0.02), whereas no difference was observed in the superficial layer. Conclusion Medial compartment cartilage T2 did not appear to be a strong prognostic factor for subsequent structural progression in the same compartment of knees with established ROA, when appropriately controlling for covariates. Yet, deep layer T2 change in the medial compartment occurred concurrent with medial femorotibial progression. |
0 | Timing of Adverse Events Following Geriatric Hip Fracture Surgery: A Study of 19,873 Patients in the American College of Surgeons National Surgical Quality Improvement Program | Hip Fx in the Elderly 2019 | This study uses a prospective surgical registry to characterize the timing of 10 postoperative adverse events following geriatric hip fracture surgery. There were 19,873 patients identified who were >=70 years undergoing surgery for hip fracture as part of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP). The median postoperative day of diagnosis (and interquartile range) for myocardial infarction was 3 (1-5), cardiac arrest requiring cardiopulmonary resuscitation 3 (0-8), stroke 3 (1-10), pneumonia 4 (2-10), pulmonary embolism 4 (2-11), urinary tract infection 7 (2-13), deep vein thrombosis 9 (4-16), sepsis 9 (4-18), mortality 11 (6-19), and surgical site infection 16 (11-22). For the earliest diagnosed adverse events, the rate of adverse events had diminished by postoperative day 30. For the later diagnosed adverse events, the rate of adverse events remained high at postoperative day 30. Findings help to enable more targeted clinical surveillance, inform patient counseling, and determine the duration of follow-up required to study specific adverse events effectively. Orthopedic surgeons should have the lowest threshold for testing for each adverse event during the time period of greatest risk. |
0 | Timing of total knee arthroplasty: A decision analysis | Surgical Management of Osteoarthritis of the Knee CPG | Background/Purpose: Total Knee Arthroplasty (TKA) reduces pain and restores mobility. However, replacement joints have limited durability and patients have to weight the benefits of having a knee replacement versus its lifespan, especially since revision arthroplasty has a higher complication rate and poorer outcomes. The objective of this study is to determine the trade-off between undergoing TKA versus delaying TKA and thereby reducing the chance of revision. Methods: A Markov state-transition model was constructed to assess wait-times in patients undergoing TKA. The model estimated the qualityadjusted- life-years (QALYs) for patients undergoing TKA at age 50 versus waiting until moderate or severe symptoms occur. The model simulated a hypothetical cohort of patients 50-years and older. The Western Ontario and McMaster Universities Arthritis Index (WOMAC) was used to classify mild, moderate and severe symptom levels. Probabilities and quality adjustment measures were extracted from published literature. Sensitivity analyses were performed on utilities for pain and wait time to undergo TKA. The model was simulated over the lifetime of an individual. Results: Compared to waiting until age 65, performing TKA at age 50 regardless of symptoms is the preferred strategy [22.73 QALYs versus 23.29 |
0 | Dislocation after total hip arthroplasty using the anterolateral abductor split approach | Management of Hip Fractures in the Elderly | The three basic surgical approaches used most commonly in total hip arthroplasty are transtrochanteric, posterior, and anterolateral. Complications related to each of these surgical approaches have been reported including dislocation, trochanteric nonunion, heterotopic ossification, neurovascular damage, postoperative limp, and implant malalignment. The anterolateral abductor split approach previously has been reported to allow ease of access into the hip joint, optimum joint visualization, protection of neurovascular structures of the hip, and predictable results for postoperative hip function restoration. Reviewing a large consecutive series of primary total hip arthroplasty cases (1518), the authors report an overall dislocation rate less than 1% (12:1518; 0.79%). Stratified by preoperative diagnosis, patients undergoing total hip arthroplasty after trauma, or presenting with congenital dysplastic hip are at the highest risk for postoperative dislocation. Primary total hip arthroplasty using the anterolateral, abductor split approach can minimize the rate of postoperative dislocation in the prevailing preoperative diagnostic categories |
0 | Integrating Oral Health into Primary Care | Dental Implant Infection | This article provides data on oral diseases as they relate to systemic health conditions. Research continues to identify biologic mechanisms that link oral diseases to systemic disease and vice versa. The Smiles for Life curriculum, developed for physicians, provides a systematic approach for incorporating an oral exam into your physical evaluation. Guidelines for the use of antibiotics for tooth pain and swelling, to prevent infective endocarditis, and for patients for total joint replacements are provided. Copyright 2021 by the Missouri State Medical Association. |
0 | Accelerated Knee Osteoarthritis Is Characterized by Destabilizing Meniscal Tears and Preradiographic Structural Disease Burden | OAK 3 - Non-arthroplasty tx of OAK | Objective: To determine whether accelerated knee osteoarthritis (KOA) is preceded by, and characterized over time by, destabilizing meniscal tears or other pathologic changes. Methods: We selected 3 sex-matched groups of subjects from the first 48 months of the Osteoarthritis Initiative, comprising adults who had a knee without KOA (Kellgren/Lawrence [K/L] radiographic grade <2) at baseline. Subjects in the accelerated KOA group developed KOA of K/L grade â?¥3, those with typical KOA showed increased K/L radiographic scores, and those with no KOA had the same K/L grade over time. An index visit was the visit when the radiographic criteria for accelerated KOA and typical KOA were met (the no KOA group was matched to the accelerated KOA group). The observation period was up to 2 years before and after an index visit. Radiologists reviewed magnetic resonance (MR) images of the index knee and identified destabilizing meniscal tears (root tears, radial tears, complex tears), miscellaneous pathologic features (acute ligamentous or tendinous injuries, attrition, subchondral insufficiency fractures, other incidental findings), and meniscal damage in >2 of 6 regions (3 regions per meniscus: anterior horn, body, posterior horn). In addition, bone marrow lesions (BMLs) and cartilage damage on MR images were quantified. Linear mixed regression models were performed to analyze the results. Results: At 1 year before the index visit, >75% of adults with accelerated KOA had meniscal damage in â?¥2 regions (odds ratio 3.19 [95% confidence interval 1.70â??5.97] versus adults with typical KOA). By the index visit, meniscal damage in â?¥2 regions was ubiquitous in adults with accelerated KOA, including 42% of subjects having evidence of a destabilizing meniscal tear (versus 14% of subjects with typical KOA). These changes corresponded to findings of larger BMLs and greater cartilage loss in the accelerated KOA group. Conclusion: Accelerated KOA is characterized by destabilizing meniscal tears in a knee compromised by meniscal damage in >2 regions, and also characterized by the presence of large BMLs and greater cartilage loss. |
0 | Subacute pain after total knee arthroplasty | Surgical Management of Osteoarthritis of the Knee CPG | Acute pain during and immediately after total knee arthroplasty (TKA) can be well controlled by spinal anesthesia, local infiltration analgesia, and peripheral nerve blocks; this enables early or fast-track rehabilitation. However, about half of patients have clinically significant pain in the following weeks. Active movements and rehabilitation of joint function, muscle strength, and ability to maintain balance and prevent falls all become more difficult when the joint is painful on movement. Intensive analgesic and antihyperalgesic treatment during the first few weeks after TKA surgery may reduce the risk of chronic pain after this operation, which is itself intended to remove the patient's chronic osteoarthritis pain. Spinal cord stimulation may be an effective option for patients with mainly neuropathic pain after TKA surgery |
0 | Who seeks physiotherapy or exercise treatment for hip and knee osteoarthritis? A cross-sectional analysis of the english longitudinal study of age cohort | OAK 3 - Non-arthroplasty tx of OAK | OBJECTIVES: To determine the characteristics of individuals with hip and/or knee osteoarthritis who are recommended to seek physiotherapy or exercise treatment, and to explore which people are more or less likely to follow such recommendations.
METHODS: All data were obtained from Wave 4 of the English Longitudinal Study of Ageing (ELSA) cohort (2008-2009), a prospectively collected community-based dataset. Eligibility was justified by a patient-reported diagnosis of hip and/or knee osteoarthritis with a visual analog scale (VAS) pain score of 1 or above. Data were collected from a self-completed questionnaire and nurse assessment visit. Prevalence of being recommended to physiotherapy or exercise (or not) and then the actioning of this recommendation (or not) were calculated and presented as 95% confidence intervals (CI). Data on characteristics of those recommended (or not) were explored using univariate analyses and then a forward selection logistic regression model.
RESULTS: In total, 1262 and 1877 individuals with hip and/or knee osteoarthritis pain were analyzed. This included 41% (95% CI: 0.38-0.44) who had been recommended to seek physiotherapy or exercise treatment. Subsequently, 83% of those recommended sought these treatments. Individuals who presented with isolated knee pain, those who reported "fair" self-reported general health and were younger had a greater chance of being recommended for physiotherapy or exercise treatment, respectively (P <= 0.02).
CONCLUSION: Encouragement should be given to formal and informal care providers of older people to highlight this inequality. This may then improve current and future access to evidence-based treatments for this population. |
0 | Advanced cosmetic procedures | Panniculectomy & Abdominoplasty CPG | Dermatology has changed in the past two decades. Surgery was always a part of the specialty of dermatology, including punch biopsies, minor excision, electrocautery, and other procedures. Mohs chemosurgery made a major impact on the management of all forms of skin cancer in the 1970s and 1980s. |
0 | Use of vacuum-assisted closure in pediatric open fractures with a focus on the rate of infection | DoD SSI (Surgical Site Infections) | The use of the vacuum-assisted closure device (VAC; KCI, San Antonio, Texas) has given the orthopedist a new tool for the successful management of severe traumatic wounds and open fractures. While the VAC's role in the adult population is proving itself as an improved therapy compared to "traditional wound care," it's role within pediatric orthopedics remains less well defined. Questions remain whether VAC therapy provides benefit regarding decreased infection rates as well as decreased need for extensive soft tissue coverage procedures. A review was therefore performed of a pediatric level I trauma center's experience using the VAC therapy for pediatric open fractures with a focus on the rate of superficial, deep, and chronic infection. A retrospective chart review spanning 4.5 years of all pediatric patients younger than 18 years with an open fracture initially treated with VAC therapy was conducted at a level I pediatric trauma center. This yielded 28 patients with 37 open fractures aged 2 to 17 years who were initially treated with wound VAC therapy. Subsequent chart review of these patients was performed examining in-hospital records, operative notes, and clinical follow-up visits for documented cases of superficial, deep, or chronic infection. Of 37 open pediatric fractures treated with a wound VAC, there were no cases of superficial infection and 2 cases of deep infection for an overall infection rate of 5%. Both infections resolved with surgical intervention and antibiotics without chronic infection development. When compared with historical controls, the use of VAC therapy for pediatric open fractures appears to be an equally safe and effective modality to help reduce infection in pediatric open fractures and should be considered a valuable tool in treating these injuries. |
0 | Voice quality after treatment of early vocal cord cancer: a randomized trial comparing laser surgery with radiation therapy | Reconstruction After Skin Cancer | OBJECTIVE: Early laryngeal cancer is usually treated with either transoral laser surgery or radiation therapy. The quality of voice achieved with these treatments has not been compared in a randomized trial.METHODS AND MATERIALS: Male patients with carcinoma limited to 1 mobile vocal cord (T1aN0M0) were randomly assigned to receive either laser surgery (n=32) or external beam radiation therapy (n=28). Surgery consisted of tumor excision with a CO2 laser with the patient under general anaesthesia. External beam radiation therapy to the larynx was delivered to a cumulative dose of 66 Gy in 2-Gy daily fractions over 6.5 weeks. Voice quality was assessed at baseline and 6 and 24 months after treatment. The main outcome measures were expert-rated voice quality on a grade, roughness, breathiness, asthenia, and strain (GRBAS) scale, videolaryngostroboscopic findings, and the patients' self-rated voice quality and its impact on activities of daily living.RESULTS: Overall voice quality between the groups was rated similar, but voice was more breathy and the glottal gap was wider in patients treated with laser surgery than in those who received radiation therapy. Patients treated with radiation therapy reported less hoarseness-related inconvenience in daily living 2 years after treatment. Three patients in each group had local cancer recurrence within 2 years from randomization.CONCLUSIONS: Radiation therapy may be the treatment of choice for patients whose requirements for voice quality are demanding. Overall voice quality was similar in both treatment groups, however, indicating a need for careful consideration of patient-related factors in the choice of a treatment option. |
0 | Survival and clinical prognostic factors in metastatic non-clear cell renal cell carcinoma treated with targeted therapy: A multi-institutional, retrospective study using the Korean metastatic renal cell carcinoma registry | MSTS 2022 - Metastatic Disease of the Humerus | Objectives: The optimal treatment strategy for metastatic non-clear cell renal cell carcinoma (mNCCRCC) is still elusive and mainly extrapolated from evidence available for metastatic clear cell renal cell carcinoma. The aim of the study was therefore to investigate the survival outcomes and prognostic factors affecting survival in patients with mNCCRCC treated with targeted therapy. Materials and methods: We analyzed a total of 156 patients (8.1%) with mNCCRCC among the total cohort of 1922 patients in the Korean metastatic RCC registry. We used Kaplan-Meier curve analysis to calculate the survival estimates for first-line progression-free survival (PFS), total PFS, and cancer-specific survival (CSS). We also used the log-rank test to compare the different groups and multivariate Cox-proportional hazard regression analyses to evaluate the prognostic factors for survival. Results: The mNCCRCC group had significantly inferior survival outcomes in terms of first-line PFS, total PFS, and CSS (all P < 0.05). We found survival benefits in patients treated with first-line vascular endothelial growth factor-tyrosine kinase inhibitors (VEGF-TKIs, first-line PFS, and total PFS, all P < 0.05), cytoreductive nephrectomy (CSS, P < 0.0001), metastasectomy (CSS, P = 0.0017), and patients with metachronous metastasis (first-line PFS, total PFS, and CSS, all P < 0.05). Liver metastasis was the only significant prognostic factor for both first-line PFS and CSS (all P < 0.05). Conclusions: In the current targeted therapy era, survival of mNCCRCC is still inferior in comparison with that of mCCRCC patients. We found survival benefits in patients treated with first-line VEGF-TKIs/CN/metastasectomy, and metachronous metastasis patients. |
0 | Which Are the Most Reliable Methods of Predicting the Meniscal Size for Transplantation? | AMP (Acute Meniscal Pathology) | BACKGROUND: Although the size of the meniscal allograft is crucial during meniscal transplantation, the accuracy of meniscal measurement methods is still under debate. A number of methods based on radiographic and magnetic resonance imaging (MRI) data as well as on anthropometric data have been proposed, but their reproducibility and reliability are still unclear.
PURPOSE: To compare meniscal length and width as measured by different techniques (anthropometric and plain radiographic) to establish which of these 2 methods is more reliable and cost-effective for determining the meniscal size in comparison to MRI.
STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 2.
METHODS: The MRI scans and plain radiographic films of 22 patients (44 knees) from a single institution were studied. The width and length of the medial and lateral menisci were measured using specific techniques. Data on sex, age, body weight, and height were used to develop a regression formula for meniscal measurements (comparing both imaging methods) to establish meniscal dimensions. Data validation was achieved using the Pearson correlation, the intraclass correlation coefficient, and the Wilcoxon nonparametric test for all variables, with a significance level established at 95%. Accuracy was established as a 10% measure discrepancy from the gold standard (MRI) and was considered an average between the right and left knees.
RESULTS: No statistically significant difference was observed between the right and left knees on radiographic and MRI measurements. The Pollard technique of radiographic measurement overestimated the width of the lateral meniscus when compared with anthropometric measurements (P < .001), considering MRI as the gold standard. The same was observed for MRI measurements of the length of the lateral meniscus in which not only anthropometric but also plain radiographic measurements using the Yoon technique were significantly smaller than those values found with the Pollard technique (P < .001). The anthropometric method underestimated the width and length of the medial meniscus with an accuracy of 68.2% and 63.6%, respectively. The radiographic method was comparable with MRI in establishing all medial meniscal measurements with an accuracy of 93.2% for length and 77.3% for width.
CONCLUSION: Some viable alternatives to MRI have been suggested. For the lateral meniscus, anthropometric data are an alternative for width, and the Yoon method can be used to assess length. For the medial meniscus, the Pollard method is considered a satisfactory alternative. This study emphasized the importance of measuring the width and length of the meniscus independently during preoperative sizing for a meniscal allograft transplantation procedure. Using MRI as a gold standard, the study also proposed other less costly and satisfactory methods of obtaining such measurements. |
0 | Clinical Characteristics of Fibromyalgia in a Chronic Pain Population | Glenohumeral Joint OA | OBJECTIVE: To compare fibromyalgia (FM) characteristics among patients identified in a community-based chronic pain cohort based on traditional International Classification of Diagnoses 9th revision (ICD-9) diagnostic coding, with that of patients identified using a novel predictive model.
METHODS: This retrospective study used data collected from July 1999 to February 17, 2015, in multiple chronic pain clinics in the United States. Patients were assigned to the FM case group based on specific inclusion criteria using ICD-9 codes or, separately, from results of a novel FM predictive model that was developed using random forest and logistic regression techniques. Propensity scoring (1:1) matched FM patients (cases) to nonmalignant chronic pain patients without FM (controls). Patient-reported measures (eg, pain, fatigue, quality of sleep) and clinical characteristics (ie, comorbidities, procedures, and regions of pain) were outcomes for analysis.
RESULTS: Nine ICD-9 clinical modification diagnoses had odds ratios with large effect sizes (Cohen's d > 0.8), demonstrating the magnitude of the difference between the FM and matched non-FM cohorts: chronic pain syndrome, latex allergy, muscle spasm, fasciitis, cervicalgia, thoracic pain, shoulder pain, arthritis, and cervical disorders (all P < 0.0001). Six diagnoses were found to have a moderate effect size (Cohen's 0.5 < d > 0.8): cystitis, cervical degeneration, anxiety, joint pain, lumbago, and cervical radiculitis.
CONCLUSIONS: The identification of multiple comorbidities, diagnoses, and musculoskeletal procedures that were significantly associated with FM may facilitate differentiation of FM patients from other conditions characterized by chronic widespread pain. Predictive modeling may enhance identification of FM patients who may otherwise go undiagnosed. |
0 | Serum biochemical and haematological markers of alcohol abuse in patients with femoral neck and intertrochanteric fractures | Management of Hip Fractures in the Elderly | Excessive alcohol intake causes bone loss. Alcohol abuse is a commonly associated disorder in femoral neck fractures in men, but little attention is given to such an association in women. Using serum biochemical and haematological markers (mean red cell volume MCV, gamma-glutamyl transpeptidase GGT, aspartate transaminase AST, uric acid UA and triglyceride TG) alcohol abuse was assessed in 14 men and 93 women with non-violent fractures of the hip. Abnormal elevations in one or more of the five test pairs known to correlate with increasing alcohol consumption (GGT/MCV, GGT/AST, AST/MCV, MCV/UA) were found in 7.1% of men, and 11.8% of women. When abnormal results in other test pairs were included the prevalence rose to 14.3% in men and 20.4% in women. These figures are higher than those reported for the general population of elderly people |
0 | Comparison of adductor canal block and IPACK block (interspace between the popliteal artery and the capsule of the posterior knee) with adductor canal block alone after total knee arthroplasty: a prospective control trial on pain and knee function in immediate postoperative period | AAHKS (4) Acetaminophen | Background: Adductor canal block (ACB) is a peripheral nerve blockade technique that provides good pain control in patients undergoing total knee arthroplasty which however does not relieve posterior knee pain. The recent technique of an ultrasound-guided local anesthetic infiltration of the interspace between popliteal artery and the capsule of posterior knee (IPACK) has shown promising results in providing significant posterior knee analgesia without affecting the motor nerves. Materials and methods: A prospective study was conducted from September 2016 to March 2017 in a total of 120 patients undergoing unilateral total knee arthroplasty. The initial 60 consecutive patients received ACB + IPACK (Group 1, n = 60), and the subsequent 60 patients received ACB alone (Group 2, n = 60). All patients were evaluated with VAS score for pain recorded at 8Â h, postoperative day (POD) 1 and POD 2 after the surgery. The secondary outcome measures assessed were the range of movement (ROM) and ambulation distance. Results: VAS score showed significantly (p < 0.005) better values in ACB + IPACK group compared to the ACB group. The mean ROM of knee and ambulation distance also showed significantly better values in ACB + IPACK group compared to the ACB group. Conclusion: ACB + IPACK is a promising technique that offers improved pain management in the immediate postoperative period without affecting the motor function around the knee joint resulting in better ROM and ambulation compared to ACB alone. |
0 | Surgical fixation of displaced midshaft clavicle fractures: elastic intramedullary nailing versus precontoured plating | DoD SSI (Surgical Site Infections) | BACKGROUND: This prospective comparative study was done to evaluate the effectiveness of implants of different design (titanium elastic intramedullary nail versus anatomical precontoured dynamic compression plate) in treatment of displaced midshaft clavicular fractures. MATERIALS AND METHODS: Sixty-six patients between 18 and 65 years of age were included in this study. They were randomized in two groups to be treated with either elastic intramedullary nail (EIN) or plate. Clinical and radiological assessments were performed at regular intervals. Outcomes and complications of both groups over 2 years of follow-up time were compared. RESULTS: Length of incision, operation time, blood loss and duration of hospital stay were significantly less for the EIN group. American Shoulder and Elbow Surgeons (ASES) and Constant Shoulder scores were significantly higher (p < 0.05) in the plating group than the EIN group for the first 2 months but there was no significant difference found between the two groups regarding functional and radiological outcome at the 2-year follow-up. Significantly higher rates of refracture after implant removal (p = 0.045) in the plating group was observed. Infection and revision surgery rates were also higher in the plate group, but this difference was insignificant (p > 0.05). CONCLUSIONS: EIN is a safe, minimally invasive surgical technique with a lower complication rate, faster return to daily activities, excellent cosmetic and comparable functional results, and can be used as an equally effective alternative to plate fixation in displaced midshaft clavicle fractures. LEVEL OF EVIDENCE: Level 2. |
0 | Compliance With the AAOS Guidelines for Treatment of Osteoarthritis of the Knee: A Survey of the American Association of Hip and Knee Surgeons | OAK 3 - Non-arthroplasty tx of OAK | INTRODUCTION: The American Academy of Orthopaedic Surgeons (AAOS) published a series of evidence-based guidelines for treatment of knee osteoarthritis (OA). We studied compliance with these guidelines among orthopaedic surgeons.
METHODS: We sent a survey to members of the American Association of Hip and Knee Surgeons. It included five clinical vignettes based on the Kellgren-Lawrence radiographic system for classification of knee OA. Respondents selected treatment currently supported or not supported by the AAOS guidelines.
RESULTS: Of 345 responses, the frequency of use of recommended interventions was 80%, 82%, 21%, 50%, and 98% for OA at stages 0 through 4, respectively. For stage 2 and stage 3 OA, intra-articular hyaluronic acid was the most commonly selected intervention not recommended by the AAOS.
DISCUSSION: Apparently, AAOS guidelines on the treatment of OA have not reached the orthopaedic community, resulting in lack of treatment consensus and continued use of modalities with no proven patient benefits.
CONCLUSIONS: Management of moderate to severe knee OA does not align with AAOS guidelines. We encourage researchers to conduct clinical trials to identify the role of intra-articular corticosteroids in treating this condition. |
0 | Incidence of and risk factors for falls and injurious falls among the community-dwelling elderly | DoD PRF (Psychosocial RF) | To determine the frequency of and risk factors for falls and injurious falls in the noninstitutionalized elderly, the authors conducted a follow-up study of 409 community-dwelling persons aged 65 years or more in west-central Montreal, Quebec, Canada, from May 1987 to October 1988. Following an initial at-home interview, each subject was telephoned every 4 weeks for 48 weeks for collection of data on falls experienced since the last contact. Each of the 12 follow-up interviews was completed by at least 90% of the subjects eligible for interview. Data were also collected in the follow-up interviews on time-varying exposures. Twenty-nine percent of the subjects fell during follow-up; 17.6% fell once, and 11.5% fell two or more times. The incidence rate for falls was 41.4 falls per 1,000 person-months. The majority of falls resulted in no injury or in minor injury only. Potential risk factors investigated included sociodemographic variables, physical activity, alcohol consumption, acute and chronic health problems, dizziness, mobility, and medications. Multivariate analyses showed that the following factors were statistically significantly associated with an increased rate of falls: dizziness (incidence rate ratio (IRR) = 2.0), frequent physical activity (IRR = 2.0), having days on which activities were limited because of a health problem (IRR = 1.8), having trouble walking 400 m (IRR = 1.6), and having trouble bending down (IRR = 1.4). Factors which were protective included diversity of physical activities (IRR = 0.6), daily alcohol consumption (IRR = 0.5), having days spent in bed because of a health problem (IRR = 0.5), and taking heart medication (IRR = 0.6). Risk factors for injurious falls were similar. |
0 | Reducing mortality in hip fracture patients using a perioperative approach and " Patient- Centered Medical Home" model: A prospective cohort study | HipFx Supplemental Cost Analysis | Background: Hip fracture patients experience high morbidity and mortality rates in the first post-operative year after discharge. We compared mortality, utilization, costs, pain and function between two prospective cohorts of hip fracture patients, both managed with identical perioperative protocols and one group subsequently managed via a " Patient-Centered Medical Home" (PCMH) primary care management model.Methods: We analyzed 6 and 12-month outcomes from two matched cohorts of patients who were surgically treated for hip fracture from January 1, 2010 to June 30, 2011 at two hospitals (n = 194). Controls did not receive PCMH and were matched to cases on surgery date, sex, age, and comorbidities. Mortality and healthcare utilization were the primary outcomes studied, with medical costs, quality of life, pain and function at 12 months assessed as secondary outcomes in a subgroup. Survival analysis, regression and Student-t testing were used with p < 0.05 considered significant.Results: At 6 months, PCMH patients had significantly lower mortality than patients receiving standard care (11% vs. 26%, p < 0.01). At 12 months, a difference persisted (23% vs. 30%, p = 0.12) but was no longer statistically significant. Mean quality of life scores were similar (0.73 vs. 0.76, p = 0.49) and Harris Hip score was slightly improved for PCMH (73 vs. 64, p = 0.04). Mean costs per patient per month were lower for PCMH but not significantly different ($69 vs. $141, p = 0.20 for pharmacy costs; $1212 vs. $1452, p = 0.45 for non-pharmacy costs).Conclusions: Patients receiving aggressive post-discharge care from a PCMH program showed significant benefits in terms of reduced mortality at 6 months, with similar costs and functional outcomes at 12 months. PCMH was not shown to improve all outcomes studied, but these results suggest that ongoing Medical Home management can have some benefit for patients without negatively impacting function or cost. (copyright) 2014 Graham et al.; licensee BioMed Central Ltd |
0 | Musculoskeletal injuries associated with physical activity in older adults | AMP (Acute Meniscal Pathology) | In order to compare the clinical presentation of overuse injuries in older and younger athletes, retrospective patient chart data were obtained from cases which had been referred to an outpatient sports medicine clinic over a 5-yr period. A total of 1,407 cases were studied comprising two populations separated by significantly (P less than 0.001) different ages: 685 "old" (mean age = 56.9 +/- 6.1 yr) and 722 "young" (mean age = 30.4 +/- 8.1 yr). Although the two subpopulations demonstrated modest differences in sport activity at the time of injury, specific diagnoses, and anatomic location of injury, many similarities existed between the groups. Running, fitness classes, and field sports were more commonly associated with injury in the younger group, while racquet sports, walking, and low intensity sports were more commonly associated with injury in the older group. The frequency of tendinitis was similar in both age groups, while metatarsalgia, plantar fasciitis, and meniscal injury were more common in the older population, and patellofemoral pain syndrome (PFPS) and stress fracture/periostitis were more common in the younger population. Anatomically, injury sites in the foot were more frequent in the older group, while injury sites in the knee were more frequent in the younger group. In the older population, the prevalence of osteoarthritis was 2.5 times higher than the frequency of osteoarthritis as the source of activity-related pain. In the older group, 85% of the diagnoses were overuse injuries known to respond to conservative treatment, 14.4% of the cases required consultative referral, and only 4.1% required surgery. [References: 41] |
1 | Performance, treatment pathways, and effects of alternative policy options for screening for developmental dysplasia of the hip in the United Kingdom | Developmental Dysplasia of the Hip CPG | AIMS: To compare, using a decision model, performance, treatment pathways and effects of different newborn screening strategies for developmental hip dysplasia with no screening. METHODS: Detection rate, radiological absence of subluxation at skeletal maturity and avascular necrosis of the femoral head, as favourable and unfavourable treatment outcomes respectively, were compared for the following strategies: clinical screening alone using the Ortolani and Barlow tests; the addition of static and dynamic ultrasound examination of the hips of all infants (universal ultrasound) or restricted to infants with defined risk factors (selective ultrasound); "no screening" (that is, clinical diagnosis only). RESULTS: Universal or selective ultrasound detects more more affected children (76% and 60% respectively) than clinical screening alone (35%), results in a higher proportion of affected children with favourable treatment outcomes (92% and 88% respectively) than clinical screening alone (78%) or no screening (75%), and the highest proportion of these achieved without recourse to surgery (64% and 79% respectively) compared with clinical screening alone (18%). However, ultrasound based strategies are also associated with the highest number of unfavourable treatment outcomes arising in unaffected children treated following a false positive screening result. The detection rate of clinical screening alone becomes similar to that reported for universal ultrasound when based on studies using experienced examiners (80%) rather than junior medical staff (35%). CONCLUSION: From the largely observational data available, ultrasound based screening strategies appear to be most sensitive and effective but are associated with the greatest risk of potential adverse iatrogenic effects arising in unaffected children |
0 | CD147 induces angiogenesis through a vascular endothelial growth factor and hypoxia-inducible transcription factor 1alpha-mediated pathway in rheumatoid arthritis | OAK 3 - Non-arthroplasty tx of OAK | OBJECTIVE: Rheumatoid arthritis (RA) is an inflammatory and angiogenic disease. However, the molecular mechanisms that promote angiogenesis in RA have not been clearly identified. Our objective was to study the role of CD147 in angiogenesis and determine whether the strategy in which CD147 is suppressed might be useful in reducing angiogenesis in RA.
METHODS: Correlations among expression levels of CD147, vascular endothelial growth factor (VEGF), and hypoxia-inducible factor 1alpha (HIF-1alpha) were determined by immunohistochemistry staining. RA fibroblast-like synoviocytes (FLS) cells were cultured under various conditions, and the production of VEGF and HIF-1alpha was examined by real-time polymerase chain reaction and enzyme-linked immunosorbent assay. The SCID mouse coimplantation model of RA (SCID-HuRAg) was established, mice were treated with CD147 monoclonal antibody, infliximab, or both CD147 and infliximab, and the volume of the grafts and the average vascular density were measured and analyzed. Western blot analyses were performed to examine the potential signaling pathways.
RESULTS: The expression levels of CD147 showed significantly positive correlations with VEGF and HIF-1alpha levels, as well as with vascular density, in RA synovium. After small interfering RNA transfection or after addition of specific antibodies for CD147, the production of VEGF and HIF-1alpha were significantly reduced. The expression of VEGF and HIF-1alpha decreased more after CD147 inhibition than after infliximab treatment in the engrafted tissues in SCID-HuRAg mice. The phosphatidylinositol 3-kinase/Akt pathway may be involved in this process.
CONCLUSION: CD147 induces up-regulation of VEGF and HIF-1alpha in RA FLS, further promotes angiogenesis, and leads to the persistence of synovitis. Inhibition of CD147 may be a promising target for novel therapeutic strategies. |
0 | Improvements in cardiovascular risk profile with large-volume liposuction: a pilot study | Panniculectomy & Abdominoplasty CPG | In this study, the authors investigated the physiologic effects of the altered body composition that results from surgical removal of large amounts of subcutaneous adipose tissue. Fourteen women with body mass indexes of greater than > 27 kg/m2 underwent measurements of fasting plasma insulin, triglycerides, cholesterol, body composition by dual-energy x-ray absorptiometry (DXA), resting energy expenditure, and blood pressure before and after undergoing large-volume ultrasound-assisted liposuction. There were no significant intraoperative complications. Body weight had decreased by 5.1 kg (p < 0.0001) by 6 weeks after liposuction, with an additional 1.3-kg weight loss (p < 0.05) observed between 6 weeks and 4 months after surgery, for a total weight loss of 6.5 kg (p < 0.00006). Body mass index decreased from (mean +/- SEM) 28.8 +/- 2.3 to 26.8 +/- 1.5 kg/m2 (p < 0.0001). This change in body weight was primarily the result of decreases in body fat mass: as assessed by DXA, lean body mass did not change (43.8 +/- 3.1 kg to 43.4 +/- 3.6 kg, p = 0.80), whereas DXA total body fat mass decreased from 35.7 +/- 6.3 to 30.1 +/- 6.5 kg (p < 0.0001). There were significant decreases in fasting plasma insulin levels (14.9 +/- 6.5 mIU/ml before liposuction versus 7.2 +/- 3.2 mIU/ml 4 months after liposuction, p < 0.007), and systolic blood pressure (132.1 +/- 7.2 versus 120.5 +/- 7.8 mmHg, p < 0.0002). Total cholesterol, high-density lipoprotein cholesterol, plasma triglycerides, and resting energy expenditure values were not significantly altered after liposuction. In conclusion, over a 4-month period, large-volume liposuction decreased weight, body fat mass, systolic blood pressure, and fasting insulin levels without detrimental effects on lean body mass, bone mass, resting energy expenditure, or lipid profiles. Should these improvements be maintained over time, liposuction may prove to be a valuable tool for reducing the comorbid conditions associated with obesity. |
0 | The synovial fluid neuropeptide PACAP may act as a protective factor during disease progression of primary knee osteoarthritis and is increased following hyaluronic acid injection | OAK 3 - Non-arthroplasty tx of OAK | The correlation of serum and synovial fluid (SF) pituitary adenylate cyclase-activating polypeptide (PACAP) levels with disease progression of primary knee osteoarthritis (OA) was explored. Radiographic severity of OA was determined by Kellgrenâ??Lawrence (K-L) grades. PACAP levels were measured by ELISA before treatment, and 4 and 8 wk following hyaluronic acid (HA) injection. Levels of IL-1β and MMP-3 were also detected. The numeric pain scale (NPS), revised Oxford Knee Score (OKS), and American Knee Society Score (AKSS) were employed to evaluate to symptomatic severity. Receiver-operating-characteristic (ROC) curve analysis was carried out to compare the diagnostic value of PACAP, IL-1β, and MMP-3 for the K-L grade. PACAP concentrations in SF but not serum were significantly lower in OA patients compared with controls. SF PACAP levels were negatively associated with K-L grades and higher NPS as well as worse AKSS and OKS. Further analysis demonstrated that PACAP concentration in SF was negatively correlated with expressions of IL-1β as well as MMP-3 and may act as a marker for radiographic progression along with MMP-3. Last, we found SF PACAP levels exhibited an incremental trend after HA injection. These findings confirmed the crucial role of PACAP deficiency in the development of primary knee OA. |
0 | Management of multiple myeloma | MSTS 2018 - Femur Mets and MM | After a sequence of standard and intensive therapies, approximately 70% of patients with multiple myeloma achieve a remission of good quality and of many months duration. Yet the disease remains incurable because the high residual burden of approximately 1010 tumor cells cannot be eradicated. Initial disease control, followed by long unmaintained or maintained remissions and by repeated recontrol of relapsing disease, provides the best chance for a long survival time of good quality. Since melphalan-prednisone became available, many other chemotherapy programs have been studied. For selected groups of patients, the most useful regimens are VAD, high-dose dexamethasone, high-dose alkylating agent therapy, and myeloablative therapy plus autologous cell transplantation. Other programs, such as treatments using combinations of alkylating agents in standard doses or interferon alfa, remain unproven despite prolonged study. Until the mortality rate associated with allogeneic bone marrow transplantation can be reduced substantially, the role of intensive treatment supported by this procedure will be limited. Current testing of agents such as paclitaxel, new agents that suppress MDR, topoisomerase I inhibitors, and myeloablative bone-seeking isotopes may lead to future improvements. |
1 | Uncemented total knee replacement - The favourable influence of low over high pressure drainage | Surgical Management of Osteoarthritis of the Knee CPG | The post-operative blood loss following an uncemented total knee replacement is substantial and can be affected by the vacuum pressure in the suction drains. One hundred and nine patients undergoing 122 uncemented total knee replacements were monitored to ascertain the influence of high or low vacuum drains on blood loss. Low volume drains produced a statistically significant reduction in blood loss compared to high vacuum drains [mean 1364 ml vs. mean 1695 ml (P<0.0062)]. Our findings revealed that high suction pressure drains are not necessary, and may be detrimental when used following uncemented total knee replacement. Copyright (C) 2000 Elsevier Science B.V |
0 | Missed injuries and unplanned readmissions in pediatric trauma patients | DoD SSI (Surgical Site Infections) | Background We sought to determine the incidence and characteristics of missed injuries and unplanned readmissions at a Level-1 pediatric trauma center. Methods We conducted a retrospective review of all trauma patients who presented to our ACS-verified Level-1 pediatric trauma center from 2009 to 2014. Results Overall, there were 27 readmissions and 27 missed injuries (0.38%). Patients who were unplanned readmissions had a greater Injury Severity Score (ISS) (8.6 vs 5.2, p = 0.03), had longer hospitalizations (4.9 vs 2.5 days, p = 0.02), and were more likely to have required operative intervention (51.9% vs 32.3%, p = 0.04). Similarly, patients identified with missed injuries had a higher ISS (15.2 vs 5.2, p < 0.0001), greater length of stay (12.7 vs 2.5 days, p < 0.0001), and were also more likely to be intubated (25.9% vs 3.6%, p < 0.0001) or require critical care (48.1% vs 10.3%, p < 0.0001). Seven missed injuries were in patients who were deemed nonaccidental trauma (25.9%) and significantly altered their hospital course while 10 patients (37%) required operative intervention. On multivariate analysis, only ISS was found to be an independent risk factor for readmissions and missed injuries. Conclusions Missed injuries and unplanned readmissions were rare occurrences among our pediatric patient population. These events, however, did result in longer hospitalizations and additional procedures. Patients with multisystem injuries and compromised physical exam are at higher risk. Level of Evidence: IV. |
0 | Patients' expectations of screening and preventive treatments | Management of Hip Fractures in the Elderly | An informed decision to accept a health care intervention requires an understanding of its likely benefit. This study assessed participants' estimates of the benefit, as well as minimum acceptable benefit, of screening for breast and bowel cancer and medication to prevent hip fracture and cardiovascular disease. Three general practitioners sent questionnaires to all registered patients aged 50 to 70 years. Patients agreeing to participate in the study were asked to estimate the number of events (fractures or deaths) prevented in a group of 5,000 patients undergoing each intervention over a period of 10 years, and to indicate the minimum number of events avoided by the intervention that they considered justified its use. The proportions of participants that overestimated each intervention's benefit were calculated, and univariate and multivariable analyses of predictors of response were performed. The participation rate was 36%: 977 patients were invited to participate in the study, and 354 returned a completed questionnaire. Participants overestimated the degree of benefit conferred by all interventions: 90% of participants overestimated the effect of breast cancer screening, 94% overestimated the effect of bowel cancer screening, 82% overestimated the effect of hip fracture preventive medication, and 69% overestimated the effect of preventive medication for cardiovascular disease. Estimates of minimum acceptable benefit were more conservative, but other than for cardiovascular disease mortality prevention, most respondents indicated a minimum benefit greater than these interventions achieve. A lower level of education was associated with higher estimates of minimum acceptable benefit for all interventions. Patients overestimated the risk reduction achieved with 4 examples of screening and preventive medications. A lower level of education was associated with higher minimum benefit to justify intervention use. This tendency to overestimate benefits may affect patients' decisions to use such interventions, and practitioners should be aware of this tendency when discussing these interventions with patients |
0 | Does acute whole-body vibration training improve the physical performance of people with knee osteoarthritis? | OAK 3 - Non-arthroplasty tx of OAK | The purpose of this study was to determine the effects of a single session of whole-body vibration training (WBVT) on the physical performance of individuals with knee osteoarthritis (OA) in 3 tests designed to simulate activities of daily living (ADLs). Fifteen individuals with symptomatic knee OA completed the Timed-Up-and-Go Test, step test, 20-m walk test, and visual analog scale (VAS) recordings of knee pain intensity. A main effect was detected for time to complete the step test (F[2,28] = 6.243, p = 0.006, (Equation is included in full-text article.)). Post hoc analyses revealed that the time to complete the step test at 5 minutes after WBVT improved significantly (p = 0.042) from that of the pretest. A moderate correlation (r = 0.465, p = 0.001) was found between the VAS scores and the time to complete the step test across all trials. A main effect was found for time to complete the walk test (F[2,28] = 4.370, p = 0.022, (Equation is included in full-text article.)). Post hoc analyses did not indicate significant improvements from pretest seen at 5 minutes after WBVT (p = 0.110) and 1 hour after WBVT (p = 0.224). The WBVT was well tolerated in nearly all the participants, and we observed that an acute bout of WBVT was effective in improving the ability of individuals with knee OA to perform a step test and 20-m walk test. Our findings suggest that WBVT may be an effective nonpharmacologic modality to treat some knee OA symptoms and improve ADLs. |
0 | Outcomes of Patients With Primary Sacral Chordoma Treated With Definitive Proton Beam Therapy | Hip Fx in the Elderly 2019 | Purpose: To evaluate the efficacy and safety of definitive proton beam therapy (PBT) for primary sacral chordoma. Methods and Materials: We conducted a retrospective analysis of the clinical outcomes of eligible patients with primary sacral chordoma who had undergone definitive PBT with 70.4 Gy (relative biological effectiveness) in 32 fractions at our institution from September 2009 to October 2015. Local progression-free survival, distant metastasis-free survival, disease-free survival, cause-specific survival, and overall survival were evaluated. To explore the factors that influenced local progression, the following parameters were analyzed: sex, the presence of a spacer (Gore-Tex sheets), gross tumor volume, and extent of cranial tumor extension. Adverse events were evaluated using the Common Terminology Criteria for Adverse Events, version 4.0. To assess the impact of PBT on pain relief, the change in pain grades was investigated between the initiation of PBT and the last follow-up visit. Results: Thirty-three eligible patients were analyzed. The median follow-up period was 37 months. The 3-year estimated local progression-free survival, distant metastasis-free survival, disease-free survival, cause-specific survival, and overall survival rates were 89.6%, 88.2%, 81.9%, 95.7%, and 92.7%, respectively. No significant association was between the patientsâ?? clinicopathologic characteristics and local progression-free survival. Four patients developed grade 3 adverse events, including acute dermatitis (n = 1), ileus (n = 1), and pain due to sacral insufficiency fractures (n = 2). The pain grades had improved, were unchanged, or had deteriorated in 15, 7, and 11 patients, respectively. Conclusions: Definitive PBT with 70.4 Gy (relative biological effectiveness) in 32 fractions is an effective treatment with acceptable toxicity for primary sacral chordoma and has the potential to reduce pain. |
1 | Extramedullary fixation of 569 unstable intertrochanteric fractures: a randomized multicenter trial of the Medoff sliding plate versus three other screw-plate systems | Management of Hip Fractures in the Elderly | We compared the efficacy of the Medoff sliding plate (MSP) with 3 other screw-plate systems for fixation of unstable intertrochanteric fractures in a randomized multicenter trial of 569 elderly patients. The MSP has biaxial dynamic capacity along both the neck and the shaft of the femur unlike the other systems, which lack dynamic capacity along the shaft. 268 fractures were operated on with the MSP, and 301 with the dynamic hip screw (DHS), with or without a trochanteric stabilizing plate (DHS/TSP) or with the dynamic condylar screw (DCS). The MSP had recently been shown to the surgeons. The patients in the groups were similar as regards age, domestic situation, preinjury walking ability and type of fracture. We followed the patients clinically and radiographically for at least 1 year. There was no significant difference in walking ability at follow-up or rate of return to home. Fixation failure occurred in 18/268 fractures operated on with the MSP, in 8/238 with the DHS, in 3/49 with the DHS/TSP and in 1/14 with the DCS. The difference in the rate of fixation failure was not statistically significant when the MSP group was compared to the 3 other groups. In 14 of the 18 fixation failures in the MSP group, the biaxial dynamic capacity of the MSP had not been used due to technical errors by surgeons, unfamiliar with the new method. No selection bias was found regarding fracture types in the 2 subgroups of patients with correct or inadequate biaxial dynamization. Extramedullary fixation of unstable intertrochanteric fractures with these implants showed a low failure rate. When using the MSP, biaxial dynamization must be correctly performed |
0 | The distribution of vascular endothelial growth factor in human meniscus and a meniscal injury model | OAK 3 - Non-arthroplasty tx of OAK | BACKGROUND: The meniscus plays an important role in controlling the complex biomechanics of the knee. Meniscus injury is common in the knee joint. The perimeniscal capillary plexus supplies the outer meniscus, whereas the inner meniscus is composed of avascular tissue. Angiogenesis factors, such as vascular endothelial growth factor (VEGF), have important roles in promoting vascularization of various tissues. VEGF-mediated neovascularization is beneficial to the healing of injured tissues. However, the distribution and angiogenic role of VEGF remains unclear in the meniscus and injured meniscus. We hypothesized that VEGF could affect meniscus cells and modulate the meniscus healing process.
METHODS: Menisci were obtained from total knee arthroplasty patients. Meniscal injury was created ex vivo by a microsurgical blade. VEGF mRNA and protein expression were detected by the polymerase chain reaction and immunohistochemical analyses, respectively.
RESULTS: In native meniscal tissue, the expression of VEGF and HIF-1alpha mRNAs could not be detected. However, VEGF and HIF-1alpha mRNAs were found in cultured meniscal cells (VEGF: outer > inner; HIF-1alpha: outer = inner). Injury increased mRNA levels of both VEGF and HIF-1alpha, with the increase being greatest in the outer area. Immunohistochemical analyses revealed that VEGF protein was detected mainly in the outer region and around injured areas of the meniscus. However, VEGF concentrations were similar between inner and outer menisci-derived media.
CONCLUSIONS: This study demonstrated that both the inner and outer regions of the meniscus contained VEGF. HIF-1alpha expression and VEGF deposition were high in injured meniscal tissue. Our results suggest that injury stimulates the expression of HIF-1alpha and VEGF that may be preserved in the extracellular matrix as the healing stimulator of damaged meniscus, especially in the outer meniscus. |
1 | Can the use of an evidence-based algorithm for the treatment of intertrochanteric fractures of the hip maintain quality at a reduced cost? | HipFx Supplemental Cost Analysis | In March 2012, an algorithm for the treatment of intertrochanteric fractures of the hip was introduced in our academic department of Orthopaedic Surgery. It included the use of specified implants for particular patterns of fracture. In this cohort study, 102 consecutive patients presenting with an intertrochanteric fracture were followed prospectively (post-algorithm group). Another 117 consecutive patients who had been treated immediately prior to the implementation of the algorithm were identified retrospectively as a control group (pre-algorithm group). The total cost of the implants prior to implementation of the algorithm was $357 457 (mean: $3055 (1947 to 4133)); compared with $255 120 (mean: $2501 (1052 to 4133)) after its implementation. There was a trend toward fewer complications in patients who were treated using the algorithm (33% pre- versus 22.5% post-algorithm; p = 0.088). Application of the algorithm to the pre-algorithm group revealed a potential overall cost saving of $70 295. The implementation of an evidence-based algorithm for the treatment of intertrochanteric fractures reduced costs while maintaining quality of care with a lower rate of complications and re-admissions |
0 | Patient morbidity seen from injection sites | Panniculectomy & Abdominoplasty CPG | This paper presents the patient morbidity related to various injection sites. A common complaint was that of an unsightly scar. The degree of the reaction to the injected material is dependent on the product injected, the site used and factors intrinsic to the patient. These include the natural healing tendencies of the individual patient, their race and age. Extrinsic factors can also influence the final scar, including the injection technique itself, the product injected and complications such as infection. All these factors must be considered prior to injecting the patient and the patient should be warned of scar formation. When a scar is likely or inevitable, the patient should be offered a less conspicuous injection site than the outer aspect of the arm provided that the alternative site does not alter the efficacy of the product being injected. This paper aims to document patient morbidity encountered amongst a series of patients relating to injection sites. Where scarring is inevitable, alternative injection sites are proposed that do not alter the efficacy of the drug. Options to prevent or correct contour anomalies caused by steroid and insulin therapy are reviewed. © Springer-Verlag 2004. |
1 | Antibiotic prophylaxis for dental procedures at risk of causing bacteremia among post-total joint arthroplasty patients: a survey of Canadian orthopaedic surgeons and dental surgeons | Dental Implant Infection | To elicit current practice and attitudes toward use of antibiotic-prophylaxis among TJA patients prior to dental procedures, a cross-sectional survey of practicing Canadian orthopaedic (OS) and dental surgeons (DS) was undertaken. Of respondents, 77% of OS and 71% of DS routinely prescribe antibiotic-prophylaxis, but while 63% of OS advocate lifelong use, only 22% of DS choose to do so (P<0.0001). Both groups nonetheless recognize the importance of treatment within 2-years post-TJA as per AAOS/ADA guidelines. However, greater duration of practice pointed to potential inadequacy of these guidelines based on reported experience with late-hematogenous infection post-TJA. While discrepancies in attitude toward antibiotic-prophylaxis between surgeon groups remain, both groups agreed that the evidence to support decision making regarding antibiotic-prophylaxis for TJA patients undergoing dental procedures remains inadequate. Copyright © 2014 Elsevier Inc. All rights reserved. |
0 | Inferior results after revision ACL reconstructions: a comparison with primary ACL reconstructions | OAK 3 - Non-arthroplasty tx of OAK | PURPOSE: Anterior cruciate ligament (ACL) ruptures are common, especially among young athletes, and such injuries may have considerable impact on both sport careers and everyday life. ACL reconstructions are successful for most patients, but some suffer from persistent giving-way symptoms and/or re-ruptures requiring revision surgery. The aim of this study was to evaluate the results after revision ACL reconstructions and compare them with the results in a control group consisting of primary ACL reconstructions.
METHODS: This retrospective study included 56 patients undergoing revision ACL reconstruction and 52 patients receiving primary ACL reconstructions. The follow-up evaluation included clinical examination, instrumented laxity testing, testing of muscle strength, Tegner activity score, Lysholm score, Knee injury and osteoarthritis outcome score (KOOS) and radiological grading of osteoarthritis.
RESULTS: The median time from the last ACL reconstruction to follow-up was 90 months in the revision ACL reconstruction group and 96 months in the primary ACL reconstruction group. The revision group had significantly inferior KOOS and Lysholm scores compared with the primary group. Patients in the revision group also showed greater laxity measured with the pivot shift test, a larger reduction in the Tegner activity score, reduced muscle strength in the injured knee, and more severe radiological osteoarthritis; however, no difference in anterior-posterior translation was found.
CONCLUSION: Inferior results were found on several of the testing parameters in the revision group compared with the primary group. Patients should receive this information prior to revision ACL reconstructions.
Level of evidence: Iii. |
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