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0 | Early prognostic factors in distal radius fractures in a younger than osteoporotic age group: a multivariate analysis of trauma radiographs | Distal Radius Fractures | BACKGROUND: Treatment of distal radius fractures in patients of a younger than osteoporotic age is complex, because they often are the result of a high-energy trauma and have intra-articular fractures and associated injuries. As yet no fracture classification exists that predicts outcome. Our aim was to find the earliest possible prognostic factor by testing which radiological parameter on the trauma radiograph would have the greatest impact on clinical outcome in a younger than osteoporotic age group.
METHODS: We assessed 66 patients (34 F) with unilateral fractures of the distal radius from a non-Osteoporotic age group. The median age was 42 years, (10th -90th percentile 20-54). Pre-reduction antero-posterior and lateral wrist radiographs were obtained and fracture pattern, radiocarpal joint surface tilt, radial length, radial inclination and ulnar variance were measured. Clinical outcome was assessed with the subjective part as well as the complete modified Gartland and Werley score. Multivariate analysis of those parameters was performed to assess which radiological parameter would best predict outcome.
RESULTS: It was found that post-traumatic ulna + (>2 mm) was the single factor that significantly correlated with a bad outcome. An intra-articular fracture pattern may also be a strong marker; however this was not statistically significant (RR 95% conf interval 0.94 - 20.59).
CONCLUSIONS: The present study showed that post-traumatic ulna + is the most important factor in predicting bad outcome in non-osteoporotic patients, but that especially intra-articular fractures and to a lesser extent dorsal tilt may be of importance too. |
0 | The Effects of Fat Harvesting and Preparation, Air Exposure, Obesity, and Stem Cell Enrichment on Adipocyte Viability Prior to Graft Transplantation | Panniculectomy & Abdominoplasty CPG | BACKGROUND: Adipocyte viability is affected by fat preparation and processing methods, but rigorous and objective studies of these relationships are lacking. OBJECTIVES: The authors conducted a comprehensive evaluation of variables affecting adipocyte viability prior to injection of fat at the recipient site. METHODS: Lipoaspirates from 48 patients were processed by high or low vacuum pressure, decantation, electric or manual centrifugation, concentration with cotton gauze, washing, repeated syringe transfer, exposure to lidocaine, and exposure to air. The effects of these variables on adipocyte viability in vitro were ascertained with the MTT assay. The influences of patient obesity (ie, a body mass index [BMI] >30 kg/m(2)) and enrichment with stem cells on adipocyte viability also were determined. RESULTS: High vacuum pressure decreased adipocyte viability. Decantation yielded the highest cell viability, followed by washing, concentration with cotton gauze, and centrifugation. Exposure to concentrated lidocaine ambient air exposure, and transfer between syringes significantly decreased viability. Patient obesity was predictive of lower adipocyte viability regardless of processing method, whereas stem cell enrichment significantly improved viability (P < .0001). CONCLUSIONS: To maximize adipocyte viability, fat should be obtained with dilute local anesthetics and low vacuum pressure, and the lipoaspirate should be maintained in a closed system. To clear cellular debris and blood, the lipoaspirate should be prepared by washing, and the fat should be enriched with adipose stem cells. Decreased adipocyte viability should be expected when fat is harvested from patients with high BMIs. |
0 | Assessment of stability in children's minimally displaced lateral humeral condyle fracture by magnetic resonance imaging | The Treatment of Pediatric Supracondylar Humerus Fractures AUC | We studied 12 children who had minimally displaced lateral humeral condyle fractures. Bony gaps at the fracture site were <2 mm on the anteroposterior view of plain radiographs. To determine the stability of the fractures, we used a magnetic resonance imaging (MRI) study of the distal humerus and elbow joint. In the results, two types of fractures were classified by the extent of the fracture line in MRI. Type I showed that the line coursed from the lateral metaphysis to the growth plate but not through it. In type II, the line crossed the growth plate to enter the joint space. We concluded that the MRI study distinguished the potentially unstable fracture (type II) from the minimally displaced fracture and recommend the use of a percutaneous pin fixation for the expected unstable fracture |
0 | Long-term outcomes following lower extremity sarcoma resection and reconstruction with vascularized fibula flaps in children | DoD SSI (Surgical Site Infections) | BACKGROUND: Limb salvage operations in patients with bony oncologic defects carry technical challenges and may require long recoveries. This study aimed to evaluate functional outcomes, donor-site morbidity, and complications in lower limb bony oncologic defects reconstructed with vascularized fibula flaps in children.
METHODS: The authors performed a retrospective review of consecutive pediatric patients undergoing this procedure between 1994 and 2012. Data on operative details, functional outcomes, and complications were analyzed. A telephone survey was conducted to assess patient satisfaction and quality of life.
RESULTS: Eighteen patients who underwent 19 reconstructions were included. Mean age at resection was 10 years (range, 1.5 to 17 years). No patients developed local recurrence, although two patients had metastatic lung nodules resected. All patients were alive at last review, with a mean follow-up of 57 months (range, 10 to 145 months). Flap survival was 95 percent. Median time to bony union was 24 months (range, 9 to 72 months). The fibula flap fracture rate was 52.6 percent. At the end of the study period, 72 percent of patients were fully weight-bearing, all school-age children had returned to full-time school, and 50 percent were involved in sports. Fifty-six percent of patients participated in the follow-up telephone survey; of these, 90 percent expressed satisfaction with the outcome of the surgery.
CONCLUSIONS: This study demonstrates that the vascularized fibula flap is an excellent option for reconstruction of lower limb oncologic defects in children. Despite complications, long-term follow-up suggests that most children are able to lead active lifestyles.
CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV. |
1 | Low-dose heparin for prevention of venous thromboembolism in total hip arthroplasty and surgical repair of hip fractures | Management of Hip Fractures in the Elderly | Sixty-seven hip-arthroplasty and fifty-two hip-fracture patients participated in a placebo-controlled randomized double-blind study on the effects of low-dose heparin prophylaxis in the prevention of venous thromboembolism. In this study, a positive thromboembolic event meant a positive test by: (1) daily 125I-fibrinogen scanning, (2) contrast venography on the tenth postoperative day, or (3) radionuclide perfusion lung scan in confirmation of suspected clinical pulmonary emboli. Nineteen (59.4 per cent) of thirty-two placebo-treated arthroplasty patients showed evidence of a thromboembolic event in contrast with eight (22.9 per cent) of thirty-five heparin-treated patients (p less than 0.003). Heparin-treated arthroplasty patients required mean blood transfusions of 4.7 units, contrasted with a mean 3.2-unit transfusion requirement for placebo-treated patients (p less than 0.05). The incidence of observed bleeding complications was higher among the heparin-treated patients. Of the twenty-three placebo-treated patients with fracturs, 39.1 per cent had a thromboembolic event, while 41.4 per cent of the twenty-nine who received heparin showed evidence of thromboembolism, demonstrating that low-dose heparin afforded no protection, nor did it affect the incidence of bleeding complications or transfusion requirements in fracture patients |
0 | Unicompartmental or total knee replacement: the 15-year results of a prospective randomised controlled trial | Surgical Management of Osteoarthritis of the Knee CPG | Between 1989 and 1992 we had 102 knees suitable for unicompartmental knee replacement (UKR). They were randomised to receive either a St Georg Sled UKR or a Kinematic modular total knee replacement (TKR). The early results demonstrated that the UKR group had less complications and more rapid rehabilitation than the TKR group. At five years there were an equal number of failures in the two groups but the UKR group had more excellent results and a greater range of movement. The cases were reviewed by a research nurse at 8, 10 and 12 years after operation. We report the outcome at 15 years follow-up. A total of 43 patients (45 knees) died with their prosthetic knees intact. Throughout the review period the Bristol knee scores of the UKR group have been better and at 15 years 15 (71.4%) of the surviving UKRs and 10 (52.6%) of the surviving TKRs had achieved an excellent score. The 15 years survivorship rate based on revision or failure for any reason was 24 (89.8%) for UKR and 19 (78.7%) for TKR. During the 15 years of the review four UKRs and six TKRs failed. The better early results with UKR are maintained at 15 years with no greater failure rate. The median Bristol knee score of the UKR group was 91.1 at five years and 92 at 15 years, suggesting little functional deterioration in either the prosthesis or the remainder of the joint. These results justify the increased use of UKR |
0 | Early history of operative treatment of patellar fractures | DoD LSA (Limb Salvage vs Amputation) | The presented overview shows that the first efforts to address patellar fractures by operative treatment, although sporadic, emerged in the pre-antiseptic era. Introduction of Listerâ??s antiseptic method in Great Britain, Germany and the USA in 1877â??1882 contributed to a new, progressive trend in the treatment of fractures of the patella as well as of other bones. The authors, using Listerâ??s antiseptic method, evaluated three basic aspects in their operations, namely healing of the surgical wound without infective complications, achievement of bony union and a good functional outcome, i.e. restoring the range of motion in the knee, even if limited in most cases. The majority of them used a longitudinal incision and fixation by a silver wire. |
0 | Dynamic risk stratification for medullary thyroid cancer according to the response to initial therapy | MSTS 2018 - Femur Mets and MM | Detecting persistent/recurrent disease of medullary thyroid carcinoma (MTC) is important. The tumor-node-metastasis (TNM) staging system is useful for predicting disease-specific mortality, but is a static system and does not include postoperative serum calcitonin levels. We have focused on the clinical usefulness of dynamic risk stratification (DRS) using the best response to the initial therapy in MTC patients. A total of 120 MTC patients were classified into three DRS groups based on their responses to initial therapy. Clinical outcomes were assessed according to TNM staging and DRS. In the DRS, 70, 23 and 7 % of the MTC patients were classified into excellent, biochemical incomplete, or structural incomplete response groups, respectively. On TNM staging, 37, 16, 13 and 35 % of patients were stages I-IV, respectively. There were significant differences in survivals according to TNM staging (p = 0.03) and DRS (p = 0.005). During the median follow-up of 6.2 years, 75 patients (63 %) demonstrated no evidence of disease (NED). About 60 and 17 % of patients in stages III and IV were NED, respectively. DRS predicted NED better than TNM staging according to the proportion of variance explained (PVE) (49.1 vs. 28.7 %, respectively). At the final follow-up, 88, 4 and 0 % of patients in excellent, biochemical incomplete, and structural incomplete response groups attained NED, respectively. DRS based on the best response to the initial therapy can provide useful prognostic information in addition to initial TNM staging for predicting of mortality, as well as the likelihood of NED in MTC patients. |
0 | Methadone for chronic non-cancer pain in adults | SR for PM on OA of All Extremities | Background: Methadone belongs to a class of analgesics known as opioids, that are considered the cornerstone of therapy for moderate-to-severe pain due to life-threatening illnesses; however, their use in chronic non-cancer pain (CNCP) is controversial. Methadone has many characteristics that differentiate it from other opioids, which suggests that it may have a different efficacy and safety profile.Objectives: To assess the analgesic effectiveness and safety of methadone in the treatment of CNCP.Search methods: We identified both randomized controlled trials (RCTs) and non-randomized studies of methadone use in chronic pain by searching the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library 2011, issue 11, MEDLINE (1950 to November 2011), and EMBASE (1980 to November 2011), together with reference lists of retrieved papers and reviews.Selection criteria: We included RCTs with pain assessment as either the primary or secondary outcome. Quasi-randomized studies, cohorts and case-control trials were also considered for inclusion because we suspected that the beneficial and harmful effects of methadone in CNCP may not be adequately addressed in RCTs.Data collection and analysis: Two review authors independently extracted efficacy and adverse event data and assessed risk of bias.Main results: We included two RCTs and one non-randomized study, involving a total of 181 participants. Both RCTs were cross-over studies, one involving 19 participants with diverse neuropathic pain syndromes, the other involving 76 participants with postherpetic neuralgia. Study phases were 20 days and approximately eight weeks, respectively. The non-randomized study retrospectively evaluated 86 outpatients over an average of 8.8 ± 6.3 months.One RCT reported average pain intensity and pain relief, and found statistically significant improvements versus placebo for both outcomes, with 10 mg and 20 mg daily doses of methadone. The second RCT reported differences in pain reduction between methadone and morphine and found morphine to be statistically superior. The non-randomized study found that in patients initially prescribed methadone it was effective in fewer participants than in those initially prescribed other long-acting opioids (28% versus 42%, 33% and 50% for morphine, oxycodone and transdermal fentanyl, respectively).One RCT compared incidences for several individual adverse events, but found a difference between methadone and placebo for only one event, dizziness (P = 0.041).Authors' conclusions: The three studies provide very limited evidence of the efficacy of methadone for CNCP, and there were too few data for pooled analysis of efficacy or harm, or to have confidence in the results of the individual studies. No conclusions can be made regarding differences in efficacy or safety between methadone and placebo, other opioids, or other treatments |
0 | Oxidative stress and some antioxidant parameters in postmenopausal osteoporotic women with fractures: A case control study | Management of Hip Fractures in the Elderly | Introduction: Oxidative stress plays an important role in the pathogenesis of postmenopausal osteoporosis (PMO). Antioxidants have the ability to mitigate the damaging effects of reactive oxygen species (ROS). Materials and Method: This study evaluated the plasma levels of two selected antioxidant defenses: vitamin C and superoxide dismutase (SOD) and Malondialdehyde (MDA) the lipid peroxidation byproduct and oxidative stress indicator in >45 years old postmenopausal osteoporotic women (n=40) as compared to non-osteoporotic controls (n=20). Subjects underwent a full history taking, clinical examination and bone mineral density (BMD) of the proximal femur and measurement of plasma vitamin C, SOD and MDA. Results: The study showed that women with PMO had significantly lower levels of plasma vitamin C and SOD and higher MDA levels as compared to the controls (p<0.05). A significant positive correlation (p<0.01) was found between plasma vitamin C, SOD and Femoral neck BMD while a significant but negative correlation was found between MDA and femoral neck BMD. Conclusion: Oxidative stress and decreased antioxidant defenses have an important role in the pathogenesis of PMO and MDA may be an important indicator for bone loss in postmenopausal women, necessitating further research |
0 | Total ankle arthroplasty: a radiographic outcome study | PJI DX Updated Search | OBJECTIVE: Total ankle arthroplasty (TAA) is becoming a popular alternative to arthrodesis for patients with end-stage ankle arthrosis. Prior outcome studies have primarily focused on surgical findings. Our purpose is to determine the radiographic outcome of TAA and to correlate it with clinical outcome. MATERIALS AND METHODS: In a 9-year retrospective review of patients with TAA, all available ankle radiographs and clinical data were reviewed. Data analysis included descriptive statistics, Fisher exact test, and Kaplan-Meier survival curves for radiographic and clinical survival. RESULTS: Two hundred sixty-two TAAs in 260 patients were reviewed; 55% were in women, and the mean patient age was 61.5 years. The mean radiographic follow-up was 142 weeks, with an average of six radiographs per patient. One hundred sixty-three patients (62.2% of TAAs) developed one or more radiographic complications, including periprosthetic lucency (34.0%), hardware subsidence (24.4%), perihardware fracture (11.1%), syndesmotic screw loosening (10.3%), and screw fracture (6.5%). One hundred nineteen patients (45.4% of TAAs) developed symptoms of ankle pain or instability, and 71 patients (27.1% of TAAs) underwent at least one reoperation. In patients with radiographic complications, 41.7% developed ankle pain and 5.1% developed ankle instability, compared with 23.7% and 2.2%, respectively, of patients with no radiologic complications (p < 0.05). Of the patients with radiographic complications, 33.1% had at least one additional surgery compared with 17.1% of patients without radiographic complications (p < 0.05). CONCLUSION: Radiographic complications are common in patients after total ankle arthroplasty. There is a strong positive association between postoperative radiographic findings and clinical outcome. Knowledge of common postoperative radiographic findings is important for the practicing radiologist |
1 | Diagnostic performance of low field MRI in acute knee injuries | Anterior Cruciate Ligament Injuries CPG | The diagnostic performance of low field (0.1 T) magnetic resonance imaging (MRI) was studied prospectively and double-blindly among 33 patients with acute knee injuries. The subsequent arthroscopy was the golden standard. For lesions of the medial meniscus low field MR had a sensitivity of 88% and a specificity of 80%; for lesions of the lateral meniscus the sensitivity was 25% and the specificity 97%. For anterior cruciate ligament tears, low field MRI had a sensitivity of 83% and a specificity of 85%. The specificity for posterior cruciate ligament tears was 97%. The performance of low field MRI equalled that reported earlier for high field MRI, the only exception being the sensitivity for lateral meniscus lesions |
0 | Extraskeletal benefits and risks of calcium, vitamin D and anti-osteoporosis medications | MSTS 2018 - Femur Mets and MM | Summary: Drugs used for the prevention and the treatment of osteoporosis exert various favourable and unfavourable extra-skeletal effects whose importance is increasingly recognized notably for treatment selection. Introduction: The therapeutic armamentarium for the prevention and the treatment of osteoporosis is increasingly large, and possible extra-skeletal effects of available drugs could influence the choice of a particular compound. Methods: The present document is the result of a national consensus, based on a systematic and critical review of the literature. Results: Observational research has suggested an inverse relationship between calcium intake and cardiovascular diseases, notably through an effect on blood pressure, but recent data suggest a possible deleterious effect of calcium supplements on cardiovascular risk. Many diverse studies have implicated vitamin D in the pathogenesis of clinically important non-skeletal functions or diseases, especially muscle function, cardiovascular disease, autoimmune diseases and common cancers. The possible effects of oral or intravenous bisphosphonates are well-known. They have been associated with an increased risk of oesophageal cancer or atrial fibrillation, but large-scale studies have not found any association with bisphosphonate use. Selective oestrogen receptor modulators have demonstrated favourable or unfavourable extra-skeletal effects that vary between compounds. Strontium ranelate has a limited number of non-skeletal effects. A reported increase in the risk of venous thromboembolism is not found in observational studies, and very rare cases of cutaneous hypersensitivity reactions have been reported. Denosumab has been introduced recently, and its extra-skeletal effects still have to be assessed. Conclusion: Several non-skeletal effects of bone drugs are well demonstrated and influence treatment choices. © 2012 The Author(s). |
1 | Acellular Dermal Matrix Versus Inferior Deepithelialized Flap Breast Reconstruction: Equivalent Outcomes, with Increased Cost | Acellular Dermal Matrix | BACKGROUND: Approximately 250,000 new cases of breast cancer are diagnosed yearly in the U.S. resulting in more postmastectomy breast reconstructions (PMBRs). The acellular dermal matrix (ADM) expander-implant method became popular in the mid-2000s, but newer techniques such as the inferior deepithelialized flap (IDF) has more recently been described. We hypothesize that ADMs and IDFs provide comparable aesthetic outcomes, with no difference in complication rates and operative characteristics. METHODS: A retrospective, single-institution study was performed between July 1, 2012, and June 30, 2014, examining all PMBR's (ADM and IDF). Outcomes were categorized as clinical (e.g., complications requiring surgical intervention) or aesthetic. RESULTS: A total of 65 patients (41 ADM; 24 IDF; mean age, 53.4?±?10.7 years) were included, with 101 PMBR's evaluated (63 ADM and 38 IDF). Patients who underwent IDFs had higher body mass index (32 versus 25; P < 0.01) and higher grades of breast ptosis. Major complication rates were similar between ADM and IDF groups (22% versus 31.5%; P = 0.34). There were no differences in aesthetic outcomes between groups (rater intraclass correlation, 0.92). The average IDF breast reconstruction took nearly 30 minutes longer per reconstructed side (192 minutes versus 166 minutes; P = 0.02), but operative costs were more expensive for the ADM breast reconstruction. CONCLUSIONS: The IDF procedure took 30 minutes longer for each reconstructed side, without significant differences in complications or aesthetic outcomes between the 2 PMBRs. IDF reconstructions may be more suitable for patients with grade 3 breast ptosis and higher body mass index. Further studies should focus on long-term outcomes and value-based approaches to PMBR. |
0 | Comparative fasting bioavailability and pharmacokinetic properties of 2 formulations of glucosamine hydrochloride in healthy Chinese adult male volunteers | OAK 3 - Non-arthroplasty tx of OAK | Glucosamine (CAS 66-84-2) hydrochloride is an amino monosaccharide indicated for the treatment of arthrosis, especially osteoarthritis of the knee joint. This study was conducted to assess and compare the pharmacokinetic (PK) properties, bioavailability of a newly developed dispersible tablet formulation (test) of glucosamine hydrochloride with those of an established branded capsule formulation (reference) in healthy Chinese adult male volunteers.This single-dose, randomized, open-label, 2-period crossover study was conducted in 18 healthy Chinese adult male volunteers under fasting condition. Plasma samples were collected at pre-specified times over a 12-h period following administration in each period and analyzed the plasma glucosamine concentrations by Liquid Chromatography coupled with Tandem Mass Spectrometry (LC/MS/MS) method. The mean (SD) PK parameters of Cmax, Tmax, AUC0-12, and AUC0- after administration of the test and reference formulations were, respectively, as follows: Cmax, 907.01 (444.22) vs. 944.40 (429.89) ng/mL, Tmax, 3.03 (0.95) vs. 3.30 (0.99) hours, AUC0-12, 2891.41 (1352.30) vs. 2889.69 (925.48) ng/mL/h, and AUC0-, 3029.90 (1321.36) vs. 3091.87 (870.36) ng/mL/h. The mean (SD) t1/2 was 1.10 (0.52) hours for the test formulation and 1.50 (1.17) hours for the reference formulation. On ANOVA, neither period nor sequence effects were observed for any PK properties. The relative bioavailability of the test formulation was 98.3% assessed by AUC0-12. The 90% CIs of glucosamine for the log-transformed ratios of Cmax, AUC0-12, and AUC0- were 78.4-113.9%, 80.8-108.5% and 80.8-105.8%, respectively, meeting the predetermined criteria for bioequivalence of SFDA. |
0 | Knee arthrodesis: Indications and results of treatment | Surgical Management of Osteoarthritis of the Knee CPG | Arthodesis of the knee as a treatment for primary arthritis is most often indicated for young, active patients with high functional demands, neuropathic arthropathy, and major soft tissue deficiencies. Failure of total knee arthroplasty is currently the most common indication for knee fusion. Intramedullary fixation is the procedure of choice for most patients. External fixation and dual plating may also be used if access to the medullary canal is not possible. Multiple revisions for total knee replacements that fail may result in conditions that preclude successful clinical outcome with any arthrodesis technique |
1 | Suture repair versus arrow repair for symptomatic meniscus tears of the knee: a systematic review | AMP (Acute Meniscal Pathology) | A healthy meniscus is important for normal function of the knee. Numerous studies support that the repair of a torn meniscus is important to prevent degenerative changes in the knee. The ability to repair torn menisci is based on several factors including location, tear orientation, chronicity, and concomitant ligamentous knee injuries. In this systematic review, meniscal repair technology is evaluated. Specifically, the retear rates are compared between the arrow repair and the suture repair techniques. After searching three databases (PubMed, Cochrane Central Register of Controlled Trials, and Embase) and reviewing annual meeting abstracts from the American Orthopaedic Society for Sports Medicine (2005 to 2010), four studies (two observational and two randomized controlled trials) were selected for this systematic review. Due to the limited study number and variability between studies (study design, sample population, outcome measures, and surgical technique), a meta-analysis was not performed. The overall quality of the literature was poor and thus conclusions are limited. No clear superiority of one technique was determined by this review. |
0 | Volumetric modulated arc therapy as an example of the advanced capability of modern radiotherapy | MSTS 2018 - Femur Mets and MM | Background: Family physicians and internal medicine specialists play an essential role in treating cancer patients. Modern technological advances in radiotherapy are not widely appreciated by primary care physicians. Bone metastases are a frequent complication of cancer. Palliative radiation therapy, as a component of modern advances in radiation treatments, should not subject normal bodily structures to excessive doses of irradiation. The sacrum is a common destination site for bone metastases, yet its concave shape along with its proximity to the rectum, intestines, and femoral heads creates treatmentplanning challenges. Objectives: To investigated whether the volumetric modulated arc therapy (VMAT) technique is preferable to more conventional radiation strategies. Methods: The study comprised 22 patients with sacral metastases who were consecutively treated between 2013 and 2014. Two plans were generated for the comparison: threedimensional (3D) and VMAT. Results: The planning target volume (PTV) coverage of the sacrum was identical in VMAT and 3D planning. The median values for the rectal dose for 3D and VMAT were 11.34 ± 5.14 Gy and 7.7 ± 2.76 Gy, respectively. Distal sacral involvement (S4 and S5) was observed in only 2 of 22 cases, while the upper pole of the rectum ended at the level above S3 in just 3 cases. Conclusions: Radiation therapy continues to be an integral component of the palliative armamentarium against painful metastases. Radiation oncologist, in conjunction with referral physicians, can tailor treatment plans to reflect the needs of a given patient. |
0 | Long-term evaluation of posterior lateral meniscus root tears left in situ at the time of anterior cruciate ligament reconstruction | AMP (Acute Meniscal Pathology) | BACKGROUND: The long-term radiographic and subjective results of patients with posterior lateral meniscus root tears left in situ at the time of anterior cruciate ligament reconstruction has not been reported.
HYPOTHESIS: The authors hypothesized that patients who had posterior lateral meniscus root tears left in situ would have statistically significantly lower subjective scores and greater joint-space narrowing as compared with a control group.
STUDY DESIGN: Cohort study; Level of evidence, 3.
METHODS: Thirty-three patients who had isolated posterior lateral meniscus root tear and >5 years objective and subjective follow-up were evaluated and compared with a matched control group without meniscal tears based on sex, chronicity of tear, age, and follow-up time. Patients were evaluated subjectively and objectively using the International Knee Documentation Committee criteria.
RESULTS: The mean objective follow-up time was 10.6 +/- 4.5 years. The mean subjective total score was 84.6 +/- 14 in the study group versus 90.5 +/- 13 in the control group (P = .09). Radiographs showed lateral joint-space narrowing rated as normal in 19, mild in 10, moderate in 3, and severe in 1 versus the control group, which was normal in 28 and mild in 5 patients. The measured amount of lateral joint-space narrowing compared with the other knee was 1.0 +/- 1.6 mm in the study group versus 0 +/- 1.1 mm in the controls on 45degree flexed posteroanterior radiographs (P < .006).
CONCLUSION: At a mean of 10 years' follow-up of posterior lateral meniscus root tears left in situ, mild lateral joint-space narrowing was measured without significant differences in subjective or objective scores compared with controls. This study provides a baseline that can be used to compare the results of procedures used to treat these tears in other manners. |
0 | The Anatomic Feasibility of a Functional Chimeric Flap in Complex Abdominal Wall Reconstruction | Panniculectomy & Abdominoplasty CPG | BACKGROUND: Dynamic and functional abdominal wall reconstruction (FAWR) remains a complex challenge. The ideal flap should have a minimal donor-site morbidity and cover a large surface area with motor and sensory capabilities. The goal was to investigate the feasibility of using a free chimeric flap with anterolateral thigh (ALT) and rectus femoris (RF) components pedicled only on the motor nerve branch. METHODS: Ten fresh cadavers were dissected with a designed chimeric thigh flap including ALT and RF flaps. Anterolateral thigh was designed and raised with the lateral femoral cutaneous nerve integrated, and the descending branch of the lateral circumflex femoral artery was preserved. Rectus femoris was elevated and the common pedicle was dissected up to the femoral origin. Accompanying motor nerve branches were carefully dissected to their femoral origin. RESULTS: Twenty RF flaps were dissected and 9 were harvested as a true chimeric flap with ALT. The mean number of neurovascular bundles associated with RF flap was 2.11 ± 0.47, and the mean primary motor nerve average length was 9.40 ± 2.42 cm. The common vascular bundle in all 9 chimeric flaps was ligated, and the flap was rotated toward the abdomen pedicled only by primary motor nerve of the RF muscle. Nerve length was adequate for reach up to xiphoid area in all 20 flaps. CONCLUSIONS: This study demonstrates the feasibility of the chimeric ALT/RF muscle free flap pedicled only by the motor nerve branch, with adequate flap rotation. Even with the limitations in a live patient, this flap would be an excellent option for FAWR in the right patient. |
1 | Circumferential approach to contouring of the trunk | Panniculectomy & Abdominoplasty CPG | BACKGROUND: Body contouring usually involves the lower and upper abdomen, flanks, hips, and back. Several techniques are available with which to achieve suitable simultaneous correction of all these aesthetic units. OBJECTIVE: We review the techniques available for contouring of the trunk. Excisional procedures are abdominoplasty, abdominohemiflankplasty or extended abdominoplasty, abdominoflankplasty, and flankplasty. Indications for excisional surgery and its combination with ultrasound-assisted lipoplasty and conventional lipoplasty with excisional surgery are discussed. METHODS: A series of 102 consecutive patients underwent contouring surgery of the trunk between 1998 and 2003. Detailed preoperative evaluation of the entire trunk area was performed to determine the most appropriate surgical procedure for each patient. The key surgical principles defining the technique used included high lateral tension with minimal central tension, direct limited undermining to a central triangle, discontinuous cannula undermining, and anchoring of the scar so as to avoid migration. RESULTS: a circumferential approach to contouring of the trunk area offered excellent outcomes and a high level of patient satisfaction. Significant improvement in body contour was achieved, with a low rate of complications. CONCLUSIONS: Excisional techniques for body contouring involve major surgery that results in a relatively large scar. Carried out with maximal preoperative, intraoperative, and postoperative care, it offers a safe way to achieve significant improvement in body contour with minimal risk to the patient. |
0 | The application of precisely controlled functional electrical stimulation to the shoulder, elbow and wrist for upper limb stroke rehabilitation: A feasibility study | Pediatric Supracondylar Humerus Fracture 2020 Review | Background: Functional electrical stimulation (FES) during repetitive practice of everyday tasks can facilitate recovery of upper limb function following stroke. Reduction in impairment is strongly associated with how closely FES assists performance, with advanced iterative learning control (ILC) technology providing precise upper-limb assistance. The aim of this study is to investigate the feasibility of extending ILC technology to control FES of three muscle groups in the upper limb to facilitate functional motor recovery post-stroke. Methods. Five stroke participants with established hemiplegia undertook eighteen intervention sessions, each of one hour duration. During each session FES was applied to the anterior deltoid, triceps, and wrist/finger extensors to assist performance of functional tasks with real-objects, including closing a drawer and pressing a light switch. Advanced model-based ILC controllers used kinematic data from previous attempts at each task to update the FES applied to each muscle on the subsequent trial. This produced stimulation profiles that facilitated accurate completion of each task while encouraging voluntary effort by the participant. Kinematic data were collected using a Microsoft Kinect, and mechanical arm support was provided by a SaeboMAS. Participants completed Fugl-Meyer and Action Research Arm Test clinical assessments pre- and post-intervention, as well as FES-unassisted tasks during each intervention session. Results: Fugl-Meyer and Action Research Arm Test scores both significantly improved from pre- to post-intervention by 4.4 points. Improvements were also found in FES-unassisted performance, and the amount of arm support required to successfully perform the tasks was reduced. Conclusions: This feasibility study indicates that technology comprising low-cost hardware fused with advanced FES controllers accurately assists upper limb movement and may reduce upper limb impairments following stroke. © 2014 Meadmore et al.; licensee BioMed Central Ltd. |
0 | Pelvis and hip joint injuries as a reconstructive factors in car-to-pedestrian accidents | Management of Hip Fractures in the Elderly | The pelvic girdles of 371 pedestrian victims of road traffic accidents were evaluated during postmortem examinations. Additionally, 144 hip joints were opened. The pelvic injuries were found in 28% of the pedestrians hit exclusively in their upright position and 52% of the victims run over by a vehicle. The side of the body hit by a car was determined on the basis of the location of blood suffusions within the subcutaneous tissues and muscles of lower limbs as well as the character of injuries found in the knee and upper ankle joints. The findings were verified with the data from court records. It was shown that the injuries of the sacroiliac joints or vertical fractures of the posterior parts of iliac bones were useful parameters for determining the side (left or right) of the body hit by a vehicle. Moreover, it was found that a direct impact on the hip region was evidenced by the ipsilaterally localized fractures of the iliac ala, central hip fractures and intraosseous blood suffusions within the greater trochanter of the femur. The external dislocations of the hip joints (always) and bilateral injuries to the sacroiliac joints (usually) were observed in the victims run over by vehicles |
0 | Association between Single Nucleotide Polymorphisms of SMAD3 and BMP5 with the Risk of Knee Osteoarthritis | OAK 3 - Non-arthroplasty tx of OAK | INTRODUCTION: The role of genetic factors influencing osteoarthritis (OA) susceptibility is well documented and several candidate genes have been identified to be associated with it. Among these genes are Bone Morphogenetic Protein 5 (BMP5) and Smad family member 3 (SMAD3), all involved in Transforming Growth Factor (TGF) signaling pathway. The knee is the commonly affected joint, and knee OA has an especially high prevalence in Asian population.
AIM: To investigate associations between Single Nucleotide Polymorphisms (SNPs) rs12901499 in SMAD3 and rs921126 in the BMP5 gene with knee OA susceptibility in and around Lucknow, Uttar Pradesh, India.
MATERIALS AND METHODS: SNPs rs12901499 in SMAD3 and rs921126 in BMP5 were genotyped in patients with knee OA and age- sex matched OA-free controls from our population. A total of 450 patients with knee OA and 458 controls were enrolled in the study. Venous blood samples were obtained from all cases as well as controls for PCR-RFLP (Polymerase Chain Reaction- Restriction Fragment Length Polymorphism). Data was collected and entered in excel sheets. Statistical analyses of the data were performed using statistical software package SPSS version 16.0. Chi-square, Student's t-test and logistic regression tests were used to analyse the data.
RESULTS: GA and GG genotypes of both SNPs (rs12901499 and rs921126), and variant G, were associated with a significantly increased risk of knee OA. A significantly increased risk of knee OA was associated with the genotype GG and GA of rs12901499 (p < 0.03 and p <0.004 respectively) and rs921126 (p< 0.0001 and p<0.001 respectively) compared with the AA genotype. In addition, those bearing at least one G allele (GG + GA) had a significantly increased risk of knee OA compared with those without the G allele (AA) in rs921126 (p< 0.0001). However, in rs12901499, significant association with the risk of knee OA was not found (p<0.4). On age and gender based stratification, the association between the risk of OA and rs921126 GG mutant compared with AA homozygotes was strong in both gender (adjusted OR= 2.93 for male and 2.25 for female) and in those aged >55 years (adjusted OR= 3.4), similarly in rs12901499, GG mutant compared with AA homozygote was strong in female (adjusted OR= 1.5) and in those aged >55 years (adjusted OR= 1.5).
CONCLUSION: The results showed that both in SMAD3 rs12901499 and BMP5 921126, G allele is significantly associated with knee OA. A to G change and variant G genotype may contribute to knee OA risk in our study population of Lucknow. |
0 | Usefulness of simple biomarkers at admission as independent indicators and predictors of in-hospital mortality in older hip fracture patients | Hip Fx in the Elderly 2019 | INTRODUCTION: The data on predictive value of the routinely obtained preoperative biochemical parameters in hip fracture (HF) patients are limited. The aims of this study were to examine in older HF patients (1) the relationships between a broad set of routine laboratory parameters at admission and in-hospital mortality, and (2) evaluate the prognostic value the biomarkers and clinical characteristics (alone or in combination) provide to predict a fatal outcome.
PATIENTS AND METHODS: In 1820 consecutive patients with low-trauma osteoporotic HF aged >60years (mean age 82.8+/-8.1years; 76.4% women; 65% community-dwelling) 35 laboratory variables along with 20 clinical and socio-demographic characteristics at admission were analysed. The validation cohort included data on 455 older (>=60 years of age) HF patients (mean age 82.1+/-8.0years, 72.1% women).
RESULTS: The mortality rate was 6% (n=109). On univariate analysis 14 laboratory and 8 clinical parameters have been associated with in-hospital mortality. Multiple regression analyses determined 7 variables at admission as independent indicators of a fatal outcome: 4 biomarkers (albumin <33g/L; alanine aminotransferase/gamma-glutamyl transferase ratio [GGT/ALT] >2.5; parathyroid hormone [PTH] >6.8pmol/L; 25(OH)vitamin D<25nmol/L) and 3 pre-fracture clinical conditions (history of myocardial infarction, chronic kidney disease [GFR <60ml/min/1.73m<sup>2</sup>] and chronic obstructive pulmonary disease); the area under the receiver operating characteristic curve (AUC) was 0.75 (95%CI 0.70-0.80). The risk of in-hospital death was 1.6-2.6 times higher in subjects with any of these risk factors (RFs), and increased by 2.6-6.0-fold in patients with any two RFs (versus no RFs). The mortality rate increased stepwise as the number of RFs increased (from 0.43% -none RF to 16.8%- >=4RF). The prognostic value of a single RF was low (AUC <=0.635) but combination of 2 or more RFs improved the prediction significantly; AUC reached 0.84(95%CI 0.77-0.90) when >=4 RFs (versus 0-1RF) were present. In the validated and main cohorts the number of predicted by 1, 2, 3 or >=4 RFs and observed deaths were practically similar.
CONCLUSIONS: In HF patients, seven easily identifiable at admission characteristics, including 4 biomarkers, are strong and independent indicators of in-hospital mortality and can be used for risk stratification and individualised management. |
0 | Tendon Transfer Surgery for People With Tetraplegia: An Overview | Pediatric Supracondylar Humerus Fracture 2020 Review | After cervical spinal cord injury, the loss of upper limb function is common. This affects an individual's ability to perform activities of daily living and participate in previous life roles. There are surgical procedures that can restore some of the upper limb function lost after cervical spinal cord injury. Tendon transfer surgery has been performed in the tetraplegic population since the early 1970s. The goals of surgery are to provide a person with tetraplegia with active elbow extension, wrist extension (if absent), and sufficient pinch and/or grip strength to perform activities of daily living without the need for adaptive equipment or orthoses. These procedures are suitable for a specific group, usually with spinal cord impairment of C4-8, with explicit components of motor and sensory loss. Comprehensive team assessments of current functioning, environment, and personal circumstances are important to ensure success of any procedure. Rehabilitation after tendon transfer surgery involves immobilization for tendon healing followed by specific, targeted therapy based on motor learning and goal-orientated training. Outcomes of tendon transfer surgery are not limited to the improvements in an individual's strength, function, and performance of activities but have much greater life affects, especially with regard to well-being, employment, and participation. This article will provide an overview of the aims of surgery, preoperative assessment, common procedures, postoperative rehabilitation strategies, and outcomes based on clinical experience and international published literature. |
0 | The current management of tibial fractures: are clinical guidelines effective? | DOD - Acute Comp Syndrome CPG | BACKGROUND: The production of clinical guidelines is increasing and will continue to do so with the introduction of clinical governance. In 1997, the British Orthopaedic Association (BOA) and the British Association of Plastic Surgeons (BAPS) published joint guidelines on the management of open tibial fractures. It is not known whether these guidelines reached their target audience, or indeed influenced clinical practice.
METHODS: We determined the effectiveness of these guidelines by sending a postal questionnaire survey to 172 orthopaedic surgeons.
RESULTS: Only 57% of consultants were aware of the guidelines, 70% of registrars and 25% of staff grades. Less than 29% of orthopaedic consultants would choose to consult the plastic surgical team pre-operatively in the management of an open tibial fracture and only 43% would seek plastic surgical involvement at all. The primary aim of increasing multidisciplinary communication has not been achieved.
CONCLUSIONS: The awareness of, and adherence to, these guidelines is sub-optimal. This clearly has implications for both the future management of open tibial fractures and the further production of guidelines. |
0 | Case 04/12 - A 44-year-old male with rheumatic valvular heart disease with multiple previous surgeries of aortic valve replacement admitted for treatment of congestive heart failure | Surgical Management of Osteoarthritis of the Knee CPG | Male, 44 years old, with a history of rheumatic attacks in childhood and adolescence and multiple aortic valve replacement surgeries, was admitted with decompensated heart failure. The present illness began with rheumatic attacks characterized by fever, arthritis of the right knee, when he was 7-11 old. At age 15, paroxysmal palpitations appeared. At age 16, the patient initiated follow-up at the outpatient services at InCor. Double aortic lesion and rheumatic disease activity were diagnosed. At the time, the electrocardiogram (ECG) revealed severe left ventricular hypertrophy; a chest radiograph revealed cardiomegaly +++/ 4+. At age 17, the palpitations became more frequent, dyspnea on moderate exertion appeared. Physical examination in primary care (May 1977) revealed pulse rate of 80 bpm, blood pressure 100/0 mmHg; auscultation was normal, cardiac auscultation revealed systolic murmur +++/ 4+ in the aortic area and diastolic murmur in the left sternal border. There was also the presence of a third heart sound; the abdomen showed no changes, no edema, and the pulse was of rapid ascent and descent. The patient was under use of digoxin (0.25 mg daily) and prophylaxis of rheumatic fever with benzathine penicillin 1.2 million units intramuscularly (IM) every two weeks. Surgical treatment of the aortic valve was prescribed. After the indication for surgical treatment, there were several attempts of hospitalization. However, these were frustrated by frequent episodes of fever and arthralgia of the knees treated as rheumatic disease activity and, due to the persistence of this condition, an investigation was conducted |
0 | Total hip replacement after medial-displacement osteotomy of the proximal part of the femur | Management of Hip Fractures in the Elderly | Intertrochanteric osteotomy has been recommended as an alternative to total hip replacement for the treatment of osteoarthrosis of the hip in younger patients because of the higher risk of mechanical loosening after total hip replacement in this age-group. The results of 112 consecutive cemented total hip replacements that were performed after a medial-displacement intertrochanteric osteotomy had failed (the conversion group) were compared with the results of 262 consecutive primary total hip replacements with cement (the control group). The mean length of follow-up was fifty-six months for the first group and fifty-four months for the second. The mean time between the osteotomy and the total hip replacement was six years. Two hundred and four Muller prostheses and 170 Lubinus hip prostheses were used. Pain was satisfactorily relieved in 89 per cent of the group that had a conversion and in 91 per cent of the control group. There were only minor differences in the range of motion of the hip and in walking performance between the two groups. The femoral component was more frequently in a varus position in the control group (p less than 0.05). The radiographic findings, including migration of the stem and radiolucency around the stem, were not inferior in the group that had a conversion. The rate of intraoperative fracture was significantly greater in the group that had a conversion, and it was correlated with the amount of displacement of the osteotomy. There were four failures (1.5 per cent) in the control group and one (0.9 per cent) in the group that had a conversion.(ABSTRACT TRUNCATED AT 250 WORDS) |
0 | The spherocentric knee: a re-evaluation and modification | Surgical Management of Osteoarthritis of the Knee CPG | The purpose of this study was to assess prospectively the initial results of total knee replacement with the standard spherocentric component and to identify retrospectively the pathogenesis of any unsatisfactory results. As a consequence of this study, the femoral component was modified. Thirty-six knees were reviewed twenty-two to fifty-two months after a standard spherocentric total knee replacement, with a mean follow-up of thirty-five months. Twenty-five (70 per cent) of the knees had significant relief of pain and improved function. Eleven knees were not improved because of confirmed loosening in five, supracondylar fracture in two, infection in one, and suspected loosening in three. Ten of these eleven complications became manifest within the first postoperative year. Alignment in the coronal plane was not consistently precise and hyperextension was a recurrent problem in twelve of the thirty-six knees. A modification in the femoral component was made: the stem was lengthened to 10.0 centimeters and the body was reoriented so that there was 5 degrees of valgus and 15 more degrees of posterior rotation than the original design. This modified prosthesis was used in twenty-five additional knees, with definite improvement in alignment, but the follow-up was insufficient to ascertain the effect of the modification on lossening and fracture |
0 | Premature changes in trabecular and cortical microarchitecture result in decreased bone strength in hemophilia | Distal Radius Fractures | Low bone density is a growing concern in aging men with hemophilia and may result in high-morbidity fragility fractures. Using high-resolution peripheral quantitative computed tomography (HR-pQCT), we demonstrate low trabecular and cortical bone density contributing to lower volumetric bone mineral density (BMD) at both distal radius and tibia in patients with hemophilia compared with age- and sex-matched controls. The low trabecular bone density found in hemophilia is attributed to significantly decreased trabecular number and increased separation; the lower cortical bone density results from thinner cortices, whereas cortical porosity is maintained. Microfinite element analysis from three-dimensional HR-pQCT images demonstrates that these microarchitectural deficits seen in patients with hemophilia translate into significantly lower estimated failure load (biomechanical bone strength) at the distal tibia and radius when compared with controls. In addition, an inverse association of joint score with BMD and failure load suggests the negative role of hemophilic arthropathy in bone density loss. |
1 | Critical evaluation of mangled extremity severity scoring system in Indian patients | DoD LSA (Limb Salvage vs Amputation) | Amputation of a mangled extremity is repugnant to the patient and the surgeon. However, prolonged unsuccessful attempts at salvage are costly, highly morbid and sometimes lethal. Much discussion has taken place regarding which criteria predict successful salvage, and predictive indices have been proposed in an attempt to identify limbs for which attempted salvage is unlikely to succeed. The mangled extremity severity score, or MESS system is the most thoroughly validated of the various classification systems, but at present there is no predictive scale that can be used with confidence to determine whether to amputate or attempt to salvage a mangled lower extremity. MESS system based on four significant criteria (with increasing points with worsening prognosis) i.e. skeletal injury, limb ischaemia, shock and patient age, has become a standard method to determine which one of the mangled extremities will eventually undergo amputation or salvage. Keeping in view the paucity of studies on Indian patients, a prospective trial of MESS was done in 50 patients who had 56 mangled extremities during the last 3 years. A significant difference between the MESS value of salvaged limbs (4.7) and amputated limbs (8.6) was found. MESS value of more than 7 was most specific and was found to have a positive predictive value of 100%. The results have been compared with Western literature and authors suggest that nerve injuries and irreparable soft tissue loss should be given an extra point each. In bilateral cases, the MESS value of each limb should be properly assessed (especially when patient is in shock), as the score may increase because of the other injured limb. |
0 | Dry Needling as a Treatment Modality for Tendinopathy: a Narrative Review | PRPs for Lateral Epicondylitis/Elbow Tendinopathies | Purpose of Review: Tendinopathy describes a combination of pain, swelling, and impaired performance of the tendon and around structures. There are various treatment options for tendinopathy with unclear efficacy. Dry needling involves inserting needles into the affected tendon, and it is thought to disrupt the chronic degenerative process and encourage localized bleeding and fibroblastic proliferation. The purpose of this review is to review the use of dry needling as a treatment modality for tendinopathy. Recent Findings: The effectiveness of dry needling for treatment of tendinopathy has been evaluated in 3 systematic reviews, 7 randomized controlled trials, and 6 cohort studies. The following sites were studied: wrist common extensor origin, patellar tendon, rotator cuff, and tendons around the greater trochanter. There is considerable heterogeneity of the needling techniques, and the studies were inconsistent about the therapy used after the procedure. Most systematic reviews and randomized controlled trials support the effectiveness of tendon needling. There was a statistically significant improvement in the patient-reported symptoms in most studies. Some studies reported an objective improvement assessed by ultrasound. Two studies reported complications. Summary: Current research provides initial support for the efficacy of dry needling for tendinopathy treatment. It seems that tendon needling is minimally invasive, safe, and inexpensive, carries a low risk, and represents a promising area of future research. In further high-quality studies, tendon dry needling should be used as an active intervention and compared with appropriate sham interventions. Studies that compare the different protocols of tendon dry needling are also needed. |
1 | Closure of chronic abdominal wall defects: A long-term evaluation of the components separation method | Panniculectomy & Abdominoplasty CPG | Incisional hernias and abdominal wall defects are frequently iatrogenic problems that have been found to complicate as many as 11% of all abdominal operations. Current techniques for closure of large, chronic abdominal wall defects have limitations. The use of local musculofascial flaps rather than fascial patches (i.e., the tensor fascia lata) or synthetic material for the repair of chronic abdominal wall defects is preferable. The superiority of innervated muscle flaps that provide dynamic abdominal support has been demonstrated. This report focuses on patients with chronic abdominal wall defects in whom previous techniques have failed. An algorithmic approach to planned reconstruction is presented utilizing the 'components separation' technique as its foundation. Thirty-seven patients who underwent abdominal reconstruction following this algorithm are reviewed and their clinical course is outlined. The components separation technique provides a compound innervated and vascularized muscle flap for dynamic support of the reconstructed abdominal wall. The experience documented here and by others suggests that this technique is a safe and effective method for reconstructing the abdominal wall in patients with recurrent herniation. Enterocutaneous fistulas, however, continue to present a challenge to the surgeon. |
0 | Mid-to long-term results of total hip arthroplasty after contralateral lower extremity amputation | OAK 3 - Non-arthroplasty tx of OAK | OBJECTIVE: There is limited literature concerning the outcomes and role of THA as a surgical option for amputee patients. The aim of this study is to determine the mid-to long-term survival and complication rates of cementless total hip arthroplasty (THA) in patients with contralateral below knee amputations. METHODS: A retrospective review of 54 patients with below knee amputation were perfomed who underwent THA for osteoarthritis of the contralateral hip over a 5-year period between 1999 and 2014. Patients were monitored for at least 5 years and assessed with the Harris Hip Score and activities of daily living scale and by evaluating migration or osteolysis around the acetabular cup and femoral stems (amputee group). The amputee group was compared with a control group (non-amputee group) with the same number of patients. RESULTS: Differences in the Harris Hip Score (p = 0.021) and activities of daily living scale (p = 0.043) between the two groups were statistically significant lower in the amputee group at 3 months after surgery. However, no differences were found between the groups from 6 months postoperatively to the last follow-up (Harris Hip Score p = 0.812, activities of daily living scale p = 0.885). Radiologically, any cups or stems showed no signs of migration or osteolysis. In the amputee group, dislocation was found in 1 patient 2 months after arthroplasty (p = 0.315) and long stem revision surgery were performed on two patients due to periprosthetic fracture (p = 0.153). CONCLUSIONS: THA performed on the contralateral side of patients with below knee amputation is considered to be an effective treatment with good clinical and radiological results at mid-to long-term follow-up. LEVEL OF EVIDENCE: Level IV, therapeutic study. |
0 | Meniscal Root Tears | OAK 3 - Non-arthroplasty tx of OAK | Meniscus root tears are a specific type of meniscal injury that have gained attention over the past 5 years and have been reported to account for 10% to 21% of all meniscal tears, affecting nearly 100,000 patients annually. Meniscal root tears either are defined as an avulsion of the insertion of the meniscus attachment or complete radial tears that are located within 1 cm of the meniscus insertion. Biomechanical studies have demonstrated that meniscal root injuries interrupt the continuity of the circumferential fibers, and hence lead to failure of the normal meniscal function to convert axial loads into transverse hoop stresses. The most common presenting symptoms in meniscal root tears are posterior knee pain and joint line tenderness, especially with deep squatting. Another common symptom is a popping sound heard while participating in light activities such as ascending stairs or squatting. Magnetic resonance imaging signs of medial meniscus root tears include: (1) medial meniscal extrusion of â?¥3 mm in a coronal section; (2) high signal indicating a disruption of the posterior meniscal root region in an axial view; and (3) a â??ghost sign,â? which is the absence of an identifiable meniscus in the sagittal plane, or increased signal replacing the normally dark meniscal tissue signal at the posterior root attachment. Active patients, regardless of age, should be referred early and considered for a meniscal root repair. Indications for a meniscal root repair include acute, traumatic root tears in patients with nearly normal or normal cartilage and chronic symptomatic root tears in young or middle-aged patients without significant preexisting osteoarthritis. Meniscal root repair has been demonstrated to have high satisfaction rates and superior outcomes to arthroscopic meniscectomy for root tears. To restore the function of the meniscus after medial meniscus root tears, a transosseous meniscal root repair technique is most commonly used. The advantage of this technique is the ability to reduce and fix the meniscal root to the broad anatomic footprint to maximize its healing potential. In addition, the transtibial tunnels may contribute to the release of biological factors that can enhance the healing of the meniscal root repair. |
1 | Clinical values in computer-assisted total knee arthroplasty | Surgical Management of Osteoarthritis of the Knee CPG | Thirty posterior stabilized total knee prostheses implanted using a computed tomography-free navigation system were compared to a control group of 30 matched total knee prostheses of the same type implanted via a classical, surgeon-controlled technique. The accuracy of the implantations in relation to the mechanical axis in the navigation group was superior to that of the manual group. Early two-year clinical results including range of motion and Knee Society Clinical Rating Score were equally good compared to the manual group. However, potential long-term outcome and functional improvement require further investigation |
0 | Chronic Use of Opioids Before and After Total Knee Arthroplasty: A Retrospective Cohort Study | AAHKS (4) Acetaminophen | BACKGROUND: Opioids are commonly used for the management of preoperative and postoperative pain among patients undergoing total knee arthroplasty (TKA). There is limited literature on the chronic use of opioids pre-TKA and post-TKA. The aim of this study was to characterize the use of opioids in TKA patients before and after surgery and identify risk factors of chronic opioid use.
METHODS: Opioid use among 15,020 patients undergoing TKA (01/01/2001-31/12/2012) was examined. Generalized estimating equations assessed change in total oral morphine equivalents pre-TKA and post-TKA, and logistic regression estimated risk factors of chronic opioid use.
RESULTS: Of the total sample, 7782 (52.0%) patients had at least 1 opioid (38.6% pre-TKA and 34.4% post-TKA). The most commonly prescribed opioids were oxycodone, codeine + acetaminophen, and tramadol. Pre-TKA, 720 (4.8%) patients were chronic opioid users, of which 241 (33.5%) stopped being chronic users after surgery and 479 (66.5%) continued but had a 16% reduction (incidence rate ratio = 0.84; 95% confidence interval, 0.78-0.90) in total oral morphine equivalents. Of the 5077 (33.8%) occasional opioid user pre-TKA, 2407 (47.4%) stopped after surgery. Compared to nonopioid users, chronic users were younger, were female, had more comorbidity, and had longer hospital stays. Older age was associated with ceasing chronic opioid use post-TKA.
CONCLUSION: There was a reduction in opioid use following TKA. Almost 50% of occasional users and more than 30% of chronic users pre-TKA ceased opioids postoperatively. There was a reduction in use for those chronic users who continued to take opioids postsurgery. |
0 | Hospital costs and severity of illness in three types of elective surgery | Surgical Management of Osteoarthritis of the Knee CPG | BACKGROUND: If patients who are more severely ill have greater hospital costs for surgery, then health-care reimbursements need to be adjusted appropriately so that providers caring for more seriously ill patients are not penalized for incurring higher costs. The authors' goal for this study was to determine if severity of illness, as measured by either the American Society of Anesthesiologists Physical Status (ASA PS) or the comorbidity index developed by Charlson, can predict anesthesia costs, operating room costs, total hospital costs, or length of stay for elective surgery. METHODS: The authors randomly selected 224 inpatients (60% sampling fraction) having either colectomy (n = 30), total knee replacement (n = 100), or laparoscopic cholecystectomy (n = 94) from September 1993 to September 1994. For each surgical procedure, backward-elimination multiple regression was used to build models to predict (1) total hospital costs, (2) operating room costs, (3) anesthesia costs, and (4) length of stay. Explanatory candidate variables included patient age (years), sex, ASA PS, Charlson comorbidity index (which weighs the number and seriousness of coexisting diseases), and type of insurance (Medicare/Medicaid, managed care, or indemnity). These analyses were repeated for the pooled data of all 224 patients. Costs (not patient charges) were obtained from the hospital cost accounting software. RESULTS: Mean total hospital costs were $3,778 (95% confidence interval +/- 299) for laparoscopic cholecystectomy, $13,614 (95% CI +/- 3,019) for colectomy, and $18,788 (95% CI +/- 573) for knee replacement. The correlation (r) between ASA PS and Charlson comorbidity scores equaled 0.34 (P < .001). No consistent relation was found between hospital costs and either of the two severity-of-illness indices. The Charlson comorbidity index (but not the ASA PS) predicted hospital costs only for knee replacement (P = .003). The ASA PS, but not the Charlson index, predicted operating room and anesthesia costs only for colectomy (P < .03). CONCLUSIONS: Severity of illness, as categorized by ASA PS categories 1-3 or by the Charlson comorbidity index, was not a consistent predictor of hospital costs and lengths of stay for three types of elective surgery. Hospital resources for these lower-risk elective procedures may be expended primarily to manage the consequences of the surgical disease, rather than to manage the patient's coexisting diseases |
0 | Comparing Complications and Costs of Total Hip Arthroplasty and Hemiarthroplasty for Femoral Neck Fractures: A Propensity Score-Matched, Population-Based Study | DoD SSI (Surgical Site Infections) | Background:Although the prevalence of displaced femoral neck fractures in the elderly population is increasing worldwide, there remains controversy as to whether these injuries should be managed with hemiarthroplasty or total hip arthroplasty. Although total hip arthroplasties result in better function, they are more expensive and may have higher complication rates. Our objective was to compare the complication rates and health-care costs between hemiarthroplasty and total hip arthroplasty for displaced femoral neck fractures in the elderly population.Methods:A population-based, retrospective cohort study was performed on adults (=60 years of age) undergoing either hemiarthroplasty or total hip arthroplasty for hip fracture between April 1, 2004, and March 31, 2014. We excluded patients who resided in long-term care facilities prior to the injury and those who were discharged to these facilities after the surgical procedure. Patients who underwent a hemiarthroplasty and those who underwent a total hip arthroplasty were matched using a propensity score encompassing patient demographic characteristics, patient comorbidities, and provider factors. After matching, we compared the rates of medical and surgical complications, as well as the perioperative and postoperative health-care costs in the year following the surgical procedure. The primary outcome was the occurrence of a medical complication (acute myocardial infarction, deep venous thrombosis, pulmonary embolism, ileus, pneumonia, renal failure) within 90 days or a surgical complication (dislocation, infection, revision surgical procedure) within 1 year. Additionally, we examined the change in health-care costs in the year following the surgical procedure, including costs associated with the index admission, relative to the year before the surgical procedure.Results:Among 29,121 eligible patients, 2,713 (9.3%) underwent a total hip arthroplasty. After successfully matching 2,689 patients who underwent a total hip arthroplasty with those who underwent a hemiarthroplasty, the patients who underwent a total hip arthroplasty were at an increased risk for dislocation (1.7% compared with 1.0%; p = 0.02), but were at a decreased risk for revision (0.2% compared with 1.8%; p < 0.0001), relative to patients who underwent a hemiarthroplasty. Furthermore, the overall increase in the annual health-care expenditure in the year following the surgical procedure was approximately $2,700 in Canadian dollars lower in patients who underwent a total hip arthroplasty (p < 0.001).Conclusions:Among elderly patients with displaced femoral neck fractures, total hip arthroplasty was associated with lower rates of revision surgical procedures and reduced health-care costs during the index admission and in the year following the surgical procedure, relative to hemiarthroplasty.Level of Evidence:Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence. |
0 | Gerontology forum: An update on the literature | MSTS 2018 - Femur Mets and MM | New treatments and treatment protocols for diseases affecting the elderly are evolving as we strive to meet the needs of an aging society. To help you keep up to date with the latest advances worldwide on all aspects of drug therapy and patient management, this section of the journal brings you information selected from the rapid drug news alerting service Inpharma Weekly1. Each issue contains easy-to-read summaries of the most important research and development news, clinical studies, treatment guidelines, and pharmacoeconomic news. |
0 | Effects of task precision demands on behavioral and physiological changes during a repetitive asymmetric lifting activity | DoD PRF (Psychosocial RF) | Objective: This study investigated the effects of task precision demands on behavioral and physiological changes during repetitive asymmetric lifting. Background: Repetitive lifting encountered in manual material handling leads to muscle fatigue and is a documented risk factor for low back disorder. Method: A total of 17 healthy volunteers performed repetitive asymmetric lifting for 60 min (10 lifts/min). Task precision demands were imposed by varying the entry width onto the destination conveyor. Physiological changes were assessed using near-infrared spectroscopy obtained from the erector spinae muscles. Three-dimensional spine kinematics and moment responses were quantified to understand behavioral changes during the lifting activity. Results: Task precision demands showed no effect on erector spinae muscle oxygenation levels. Behavioral changes associated with repetitive lifting included increases in the overall lift duration, peak forward bending motion, and three-dimensional movement velocities of the spine, along with a decrease in the lateral bending moment. Relative to low precision demands, high precision demands resulted in 20% longer placement periods, which, in turn, resulted in a 12% increase in the time-integrated twisting postures and a 10% increase in the time-integrated lateral bending moments during load placement. Conclusion: The elevated risk of low back injury when lifting under greater precision demands is likely due to the sustained spine twisting and the sustained lateral bending moment on the spine in the final phase of these lifts. Application: Understanding behavioral changes to repetitive asymmetric lifting, especially for tasks requiring greater precision can be used to support injury prevention efforts. (PsycINFO Database Record (c) 2016 APA, all rights reserved) |
0 | NC-stat as a screening tool for carpal tunnel syndrome in industrial workers | Diagnosis and Treatment of Carpal Tunnel Syndrome CPG | OBJECTIVE: The initial purpose of this study was to establish a normal data set for median nerve studies in industrial workers using NC-stat technology. METHODS: Sixteen hundred ninety-five persons applying for employment at a single heavy industry plant without symptoms of carpal tunnel syndrome (CTS) were studied. RESULTS: Values for median distal motor latency (DML), amplitude, and F-waves were recorded in the dominant limbs. The DML was 3.81 +/- 0.57 milliseconds, with a 95% cut-off value of 4.75 milliseconds. Amplitude of the compound muscle action potential was 0.95 +/- 0.46 mV, reflecting the use of volume conduction by this technology. Most of the workers who were characterized as having borderline, prolonged, or very prolonged distal motor latencies according to NeuroMetrix automated report actually fell below the 95% cut-off of this independent data analysis. CONCLUSION: NC-stat technology using DML appears to be no more sensitive or specific than a traditionally performed DML for the diagnosis of CTS. Until recently promoted sensory studies using NC-stat technology are better defined, this technology cannot be recommended for screening or diagnosis of CTS in an industrial population |
0 | Total knee replacement in an amputee patient: A case report | Surgical Management of Osteoarthritis of the Knee CPG | Osteoarthritis is the most prevalent and more disabling of the rheumatic diseases. One of the most effective forms of treatment of severe osteoarthritis is total joint arthroplasty. Although studies suggest that the incidence of osteoarthritis is higher in prosthetic users, research supporting total joint arthroplasty as an option for treating amputee patients with advanced osteoarthritis is lacking. We report the case of a 76- year-old man with right transtibial amputation who had an excellent outcome after undergoing bilateral total knee replacements for advanced osteoarthritis. (C) 2000 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation |
0 | Causes of a block to forearm rotation after distal radius fractures | Distal Radius Fractures | Three cases of a block to forearm rotation after a distal radius fracture were presented. The unique feature is that the surgeon should be diligent in seeking and rectifying causes of distal radioulnar joint (DRUJ) instability and rotation loss after fracture treatment. Copyright © 2013 by Thieme Medical Publishers, Inc. |
0 | Health professional consultation and use of conservative management strategies in patients with knee or hip osteoarthritis awaiting orthopaedic consultation | OAK 3 - Non-arthroplasty tx of OAK | The aim of this study was to determine the extent to which patients with hip and knee osteoarthritis (OA) referred for orthopaedic consultation at a large Australian public hospital reported using conservative management strategies as recommended by current practice guidelines. A therapist-assisted questionnaire was employed within the context of a standard physiotherapy assessment in a consecutive cohort of patients with hip or knee OA. Two hundred and two patients with hip or knee OA comprised the included sample. Thirty-nine percent (n=79) reported having only previously consulted their general practitioner. Only 20% (n=41) felt that they had been sufficiently educated about the diagnosis, their treatment options and prognosis. Thirty-three percent (n=66) had not previously engaged in any non-pharmacological management strategy considered a core clinical practice guideline recommendation. The findings of this study suggest that several inconsistencies may exist between current Australian clinical practice and OA clinical guideline recommendations. Identification of the barriers to the use of conservative management requires timely investigation coupled with a national implementation framework to support the translation of guideline recommendations into practice. |
0 | Arthritic knees with more than 10° valgus can have soft-tissue imbalance in flexion | AMP (Acute Meniscal Pathology) | PURPOSE: Valgus knees have inferior outcomes compared to varus knees. There is little data regarding soft-tissue balance in flexion which may influence outcome in valgus knees undergoing TKA. The purpose of this study was to evaluate whether there is imbalance between medial and lateral flexion gaps in valgus deformity. A secondary aim was to compare soft-tissue balance in knees with valgus deformity less than 10° with those exceeding 10°. The null hypothesis was that there was no soft-tissue imbalance in 90° of flexion irrespective of magnitude of deformity. METHODS: 64 valgus knees (52 female and 12 male) with deformity from 0.5 to 27.5° (mean 188.77, SD 6.21) were studied in 54 patients (mean age 67.81 y, SD 8.69) undergoing navigated TKA. Medial and lateral gaps in extension and at 90° of flexion were compared (using Independent-samples t test) between knees with valgus?<?10° with those?>?10° using a validated dynamic method after resection of cruciates, menisci and osteophytes, and then after final trialling. RESULTS: Mean initial medial-lateral (ML) gap difference in extension was 2.63 mm (SD 2.63) and 2.09 mm (SD 3.78) in flexion, being tighter laterally. Initial ML gap differences in extension and flexion correlated with valgus deformity (R?=??-?0.514; p?=?0.00001; R?=??-?0.325; p?=?0.01, respectively). Initial ML gap differences in extension correlated with those in flexion (R?=?0.42; p?=?0.0005). Mean ML flexion and extension gap differences were 1.30 mm (SD 3.67) and 1.26 mm (SD 1.92) in knees with?<?10° valgus, and 3.17 mm (SD 3.71) and 4.29 mm (SD 2.45) in those?>?10° valgus; p values were 0.026 and?<?0.001 respectively. CONCLUSION: The lateral flexion gap in valgus knees may be narrower than the medial flexion gap, especially in knees with?>?10° deformity. This contrasts with native and varus knees, in which it exceeds the medial gap. This novel study indicates the need to identify valgus knees with lateral flexion gap tightness by distracting the posterior femoral condyles from the proximal tibia by dynamic stressing of the soft-tissues after resection of cruciates, menisci, and osteophytes, with the knee flexed to 90°. These findings, highlighting the need for restoring flexion gap balance, may improve the inferior outcomes in valgus knees.IV. |
1 | COVID-19 coronavirus: recommended personal protective equipment for the orthopaedic and trauma surgeon | Coronavirus Disease 2019 (COVID-19) | With the COVID-19 crisis, recommendations for personal protective equipment (PPE) are necessary for protection in orthopaedics and traumatology. The primary purpose of this study is to review and present current evidence and recommendations for personal protective equipment and safety recommendations for orthopaedic surgeons and trauma surgeons. |
0 | Rituximab use in young adults diagnosed with juvenile idiopathic arthritis unresponsive to conventional treatment: Report of 6 cases | AAHKS (2) Corticosteroids | Juvenile idiopathic arthritis (JIA) is the most common rheumatic disease in childhood. Without an effective therapy, patients may progress quickly to functional disability. Recently, depletion of B cells emerged as a new approach for the treatment of autoimmune diseases, including JIA. We describe six cases of JIA patients followed at a referral center for Rheumatology and Pediatric Rheumatology, submitted to treatment with rituximab (RTX) after refractoriness to three anti-TNF agents. Patients received RTX cycles with two infusions every six months. Response to treatment was assessed by DAS28, HAQ/CHAQ, and an overall assessment by the doctor and the patient. Of our six patients, four were girls (mean age at onset of disease: 6.1 years; mean disease evolution time: 15.1 years; mean age upon receiving RTX: 21.6 years). Four patients belonged to polyarticular subtype (1 rheumatoid factor [RF]-negative, 3 FR-positive), a patient with systemic JIA subtype with a polyarticular course and arthritis related to enthesitis. Of our six patients, five responded to treatment; and during the course of 12 months, the clinical response was maintained, although not sustained. However, discontinuation by infusion reactions caused the withdrawal of RTX in two patients. The use of RTX in JIA is restricted to cases refractory to other biological agents and, even considering that this study was held in a small number of advanced patients, RTX proved to be an effective therapeutic option. |
0 | Residual subluxation of the elbow after dislocation or fracture-dislocation: Treatment with active elbow exercises and avoidance of varus stress | Glenohumeral Joint OA | During a 6-year period, 2 surgeons prescribed active elbow exercises and avoidance of shoulder abduction (varus stress) for 23 patients (15 men, 8 women) with a mean age of 43 years (range, 19-74 years) who had slight residual subluxation of a dislocated elbow after either nonoperative (3 simple dislocations and 2 fracture-dislocations) or operative treatment (18 fracture-dislocations). A stable elbow was achieved in all 23 patients, although 1 patient, treated late, had a very slight residual posterior subluxation of the radial head on radiographs. After a mean of 24 months (range, 12-45 months), the average flexion arc was 113°, with mean flexion of 132° and mean flexion contracture of 20°. The mean Broberg-Morrey score was 90 points (range, 61-100 points). Ratings were excellent in 9 patients, good in 10, and fair in 4. Mild radiographic signs of arthrosis (type 1 Broberg-Morrey) were present in 2 patients. Slight postreduction subluxation of the elbow, without detrimental contact of the articular surfaces, a type of pseudosubluxation of the elbow sometimes referred to as the "drop sign," can be treated with active exercises and avoidance of varus stress. © 2008 Journal of Shoulder and Elbow Surgery Board of Trustees. |
1 | In with the new, out with the old? Comparison of two approaches for psoas compartment block | Surgical Management of Osteoarthritis of the Knee CPG | We compared the approaches of Winnie and Capdevila for psoas compartment block (PCB) performed by a single operator in terms of contralateral spread, lumbar plexus blockade, and postoperative analgesic efficacy. Sixty patients underwent PCB (0.4 mL/kg levobupivacaine 0.5%) and subsequent spinal anesthesia for primary joint arthroplasty (hip or knee) in a prospective, double-blind study. Patients were randomly allocated to undergo PCB by using the Capdevila (group C; n = 30) or a modified Winnie (group W; n = 30) approach. Contralateral spread and lumbar plexus blockade were assessed 15, 30, and 45 min after PCB. Contralateral spread (bilateral from T4 to S5) and femoral and lateral cutaneous nerve block were evaluated by sensory testing, and obturator motor block was assessed. Bilateral anesthesia occurred in 10 patients in group C and 12 patients in group W (P = 0.8). Blockade of the femoral, lateral cutaneous, and obturator nerves was 90%, 93%, and 80%, respectively, for group C and 93%, 97%, and 90%, respectively, for group W (P > 0.05). No differences were found in PCB procedure time, pain scores, 24-h morphine consumption, or time to first morphine analgesia |
0 | Effect of low-fat and/or low-energy diets on anthropometric measures in participants of the women's diet study | Management of Hip Fractures in the Elderly | OBJECTIVE: To compare the effects of low-fat, low-energy and combination low-fat/low-energy intervention on changes in six anthropometric measures in Caucasian and African-American free-living women.METHODS: The effects of dietary counseling strategies for fat and/or energy reduction were examined on anthropometric measures in 86 pre-menopausal women, average BMI of 28 kg/m2, who participated in a 12-week intervention trial called the Women's Diet Study. The dietary goals were 15% of energy from fat and/or 25% reduction in energy intake, relative to reported baseline intake, using a 2 x 2 factorial design. Analysis of covariance models were constructed to evaluate changes in anthropometric measures over the 12 weeks of study.RESULTS: The biggest difference by race was in women who were relatively heavier at baseline, in which case African-American women lost significantly less weight but decreased their waist:hip ratio to a significantly greater extent than Caucasian women. With regard to the effects of diet arm, weight loss varied depending on baseline weight, and in women with higher baseline weights, the combination low-fat/low-energy diet resulted in the most weight loss (6.7 kg, p < 0.05). Decreases in the other anthropometric measures at week 12 were more uniform across diet arms and did not depend on baseline values. After controlling for previous weight history and race, the decreases in BMI, percent body fat and waist circumference after 12 weeks were statistically equivalent with the low-fat, low-energy or combination low-fat/low-energy diets. The relatively greater decreases in percent body fat and waist circumference with the combination diet versus the low-fat or low-energy diets were not statistically significant.CONCLUSION: The low-fat, low-energy and combination diets all resulted in similar and statistically significant decreases in BMI, percent body fat and waist circumference over 12 weeks of intervention. The extent of weight loss, however, varied depending on baseline weight, and the combination diet was the only intervention to result in significant weight loss for women who were heavier at baseline. This indicates that, although there may be an advantage for reducing dietary fat in initially heavier women, any of these counseling strategies could be effective for improving anthropometric predictors of health risks associated with overweight status. This is useful since flexibility in dietary choices may facilitate adherence to dietary counseling in some individuals |
0 | Chronic compartment syndrome | DOD - Acute Comp Syndrome CPG | Chronic compartment syndrome typically affects young people who are engaged in endurance sports. The primary clinical feature is a sensation of tightness or aching pain in a defined compartment of the affected limb, starting during activity or hours after activity ceases and lasting for varying lengths of time. The diagnosis is based on the history and on measurement of compartmental pressures. Fasciotomy or partial fasciectomy is the definitive treatment. |
0 | Management of Newly Diagnosed Myeloma | MSTS 2018 - Femur Mets and MM | The treatment of multiple myeloma has changed dramatically in the last decade with the introduction of thalidomide, bortezomib, and lenalidomide. Patients eligible for autologous stem cell transplantation (ASCT) are treated with non-alkylating agent-containing regimens as initial therapy; typically thalidomide-dexamethasone or lenalidomide-dexamethasone. For patients not eligible for ASCT, the current standard of care is melphalan, prednisone, and thalidomide. Ongoing trials will soon assess if combinations including melphalan and prednisone plus bortezomib or MP plus lenalidomide may be considered an attractive option. Patients who have risk factors, such as deletion 13 or translocation t(4;14) or t(14;16), are candidates for novel, more aggressive treatments. © 2007 Elsevier Inc. All rights reserved. |
0 | Hyperphosphatemic Tumoral Calcinosis after Total Knee Arthroplasty | Glenohumeral Joint OA | We report a case of hyperphosphatemic tumoral calcinosis (TC) that occurred after total knee arthroplasty. A 64-year-old Japanese man presented with painful swellings in both shoulders, the left elbow, and the right hip that developed after he underwent total knee arthroplasty (TKA). The pathology of the patient's bone at the time of TKA included a thick osteoid seam with calcareous deposition at the margin of the trabecular bone, which is not generally seen in osteoarthritis. Computed tomography scans of the swollen joints demonstrated leaflet and amorphous calcification masses around the joints. We diagnosed the patient with TC. The present case highlights that TC lesions are rare but should be considered in the differential diagnosis of subcutaneous soft and hard masses around the joint. |
0 | Clinical outcomes in elective total hip arthroplasty in Parkinson’s disease: a systematic review of the literature | Hip Fx in the Elderly 2019 | Parkinson’s disease (PD) is a neurodegenerative disorder characterized by the loss of dopaminergic neurons in the substantia nigra pars compacta in the midbrain.1 The clinical manifestations can often be insidious and involve tremor, bradykinesia, rigidity contractures, dystonia and flexed posture.1,2 The burden of the disease has risen exponentially over the past decade and is estimated in 6.1 million individuals globally,3 with 1 million people suffering from the disease in the US alone.4 |
0 | Wnt signaling in bone formation and its therapeutic potential for bone diseases | MSTS 2018 - Femur Mets and MM | The Wnt signaling pathway plays an important role not only in embryonic development but also in the maintenance and differentiation of the stem cells in adulthood. In particular, Wnt signaling has been shown as an important regulatory pathway in the osteogenic differentiation of mesenchymal stem cells. Induction of the Wnt signaling pathway promotes bone formation while inactivation of the pathway leads to osteopenic states. Our current understanding of Wnt signaling in osteogenesis elucidates the molecular mechanisms of classic osteogenic pathologies. Activating and inactivating aberrations of the canonical Wnt signaling pathway in osteogenesis results in sclerosteosis and osteoporosis respectively. Recent studies have sought to target the Wnt signaling pathway to treat osteogenic disorders. Potential therapeutic approaches attempt to stimulate the Wnt signaling pathway by upregulating the intracellular mediators of the Wnt signaling cascade and inhibiting the endogenous antagonists of the pathway. Antibodies against endogenous antagonists, such as sclerostin and dickkopf-1, have demonstrated promising results in promoting bone formation and fracture healing. Lithium, an inhibitor of glycogen synthase kinase 3β, has also been reported to stimulate osteogenesis by stabilizing β catenin. Although manipulating the Wnt signaling pathway has abundant therapeutic potential, it requires cautious approach due to risks of tumorigenesis. The present review discusses the role of the Wnt signaling pathway in osteogenesis and examines its targeted therapeutic potential. © The Author(s) 2012. |
0 | Operative technique for transconjunctival lower blepharoplasty | Panniculectomy & Abdominoplasty CPG | In the past 3 years, more than 125 patients have undergone primary and secondary lower blepharoplasty by the transconjunctival method. The ability to adequately remove fat with this approach has been impressive. Exposure of the central and medial fat compartments is excellent. The lateral fat pad area is not as easy to visualize, and care must be taken to assure that adequate fat removal is achieved. Although one might suspect that postoperative conjunctival irritation could be a problem with this procedure, this has been notably absent in our patient population. In addition, there have been remarkably few patients with dry eye complaints following transconjunctival lower blepharoplasty. The question of skin resection must also be addressed. Currently, we believe that the majority of patients seeking improvement of the lower eyelids benefit most by a transconjunctival blepharoplasty without skin resection (Figs. 3 and 4). When there is obvious skin excess, we believe that it is best approached by removing the fat through the transconjunctival incision and then removing skin with a simple skin flap or skin pinch technique. This must be done considerably more conservatively than has been recommended in the past, to retain a natural palpebral fissure. Secondary skin removal, if necessary, is a straightforward procedure that can be readily done under local anesthesia at a later date. Transconjunctival lower blepharoplasty has not been associated with prolonged (exceeding 1 month) lower lid retraction problems in any of our patients. The technique is easy to learn but does require some experience with the anatomy. The technique should become the basic procedure for correction of excess fat in the lower eyelids. |
0 | No-scar Asian epicanthoplasty: a subcutaneous approach | Upper Eyelid and Brow Surgery | PURPOSE: The epicanthal fold is a normal finding in the medial portion of the upper eyelid in many Asians. We describe a simple technique of removing the excess muscle and softening or eliminating the epicanthal fold without making incisions in the medial canthal region, thus avoiding complications such as scarring or web formation METHODS: Interventional case series. The subcutaneous epicanthoplasty was performed on all Asian patients undergoing concurrent upper eyelid blepharoplasty or aponeurotic ptosis repair. RESULTS: Thirty-eight Asian patients underwent epicanthal fold correction between January 1996 and December 2000. All patients had softening of the epicanthal fold; however, some cases of mild undercorrection were noted. CONCLUSIONS: Softening or elimination of the Asian epicanthal fold can be accomplished without making skin incisions in the medial canthal region. Our technique is a simple, graded procedure that can be performed in conjunction with upper blepharoplasty or ptosis repair. |
1 | Nonpharmacological approaches to improve bone health and reduce osteoporosis | Hip Fx in the Elderly 2019 | PURPOSE OF REVIEW: With an aging population, osteoporosis has become a public health concern and an area of increased awareness among both patients and medical practitioners. Timely screening and pharmacologic treatment of low bone mass effectively reduces fracture risk. Nonpharmacologic interventions, however, deserve equal emphasis both in the prevention and treatment of osteoporosis.
RECENT FINDINGS: Recent advances in bone biology have established that exercise in the form of short, repetitive mechanical loading leads to the greatest gains in bone strength. As demonstrated by both observational and randomized exercise intervention trials, these gains are best achieved in childhood but can be maintained in adulthood with continued regular weight-bearing exercise. In the later years, evidence supports the implementation of balance training to decrease fall risk, especially in elderly patients with low bone mass. Following an osteoporotic fracture, a multidisciplinary rehabilitation program with an emphasis on early mobilization, fall prevention, use of orthoses, and noninvasive surgical procedures is emerging as a promising approach.
SUMMARY: Clinically, these findings should imply greater emphasis on high impact exercise during skeletal growth and on maintenance of weight bearing and balance training in the later years. Future research should examine the effect of these interventions on fracture prevention. [References: 46] |
0 | Fresh osteochondral allografts for patellofemoral arthritis: long-term followup | Surgical Management of Osteoarthritis of the Knee CPG | Treatment of patellofemoral osteoarthritis in young patients is a challenge for orthopaedic surgeons. Concern about loosening and wear in active young people render arthroplasty more suitable for older patients. Osteochondral allografts may be a good alternative, but reports of experience with such grafts in patellofemoral joints are limited. We retrospectively reviewed our results with fresh osteochondral allografts. Our hypothesis was that these grafts provide relief from osteoarthritis, improve knee function, and delay prosthetic knee replacement. From 1986 to 1999, 14 fresh patellofemoral or patellar allografts were implanted in knees of 11 patients younger than 55 years and diagnosed with advanced secondary osteoarthritis. At last followup (average, 10 years; range, 2.5-17.5 years), eight grafts were in place, four for more than 10 years and two for more than 5 years. Of the nonsurviving allografts, three survived more than 10 years. Radiographs of the knees with intact allografts showed mild or no degenerative changes. Average Knee Society scores improved (preoperative to last followup), with knee scores improving from 46 points (range, 38-60 points) to 82 points (range, 35-100 points) and functional scores from 30 points (range, 10-60 points) to 75 points (range, 20-100 points). Fresh osteochondral allografts can provide relief from the arthritic condition, improve knee function, and delay prosthetic knee replacement. Level of Evidence: Therapeutic study, Level IV (case series). See the Guidelines for Authors for a complete description of levels of evidence |
0 | Personal experience with ultrasound-assisted lipoplasty: a pilot study comparing ultrasound-assisted lipoplasty with traditional lipoplasty | Panniculectomy & Abdominoplasty CPG | Body contouring with traditional suction-assisted lipoplasty is currently the most commonly performed aesthetic surgical procedure. In competent hands, traditional lipoplasty has a low complication rate, a short recovery period, and a high patient satisfaction rate. Body contouring with ultrasound-assisted lipoplasty has recently gained considerable attention, and its proponents have claimed many benefits over the traditional method. This pilot study consists of one surgeon's clinical experience with ultrasound-assisted lipoplasty in 100 cases. In 63 of these patients, ipsilateral traditional lipoplasty and contralateral ultrasound-assisted lipoplasty were done on one or more body areas. These patients were blinded in the study. Complication rates, lipocrits from the aspirate, postoperative ecchymosis, postoperative swelling, patient satisfaction, and surgeon satisfaction were then compared for each patient studied. Ten randomly selected patients were also evaluated by an independent panel of reviewers who compared ecchymosis and swelling in ultrasound-assisted versus traditional lipoplasty-treated areas. Their observations in this subset of 10 patients were subjected to statistical analysis. This initial pilot study failed to prove most of the benefits attributed to ultrasound-assisted lipoplasty by other surgeons. However, the method is an evolving technology, and the authors remain optimistic about the role of ultrasound in body sculpting surgery. |
0 | Disparities in Acute Pain Treatment by Cognitive Status in Older Adults with Hip Fracture | Hip Fx in the Elderly 2019 | BACKGROUND: We examined the disparities in emergency department (ED) pain treatment based on cognitive status in older adults with an acute hip fracture.
METHODS: Observational study in an academic ED in the Bronx, New York. 144 adults aged 65 years and older with acute hip fracture were administered the TICS (Telephone Interview for Cognitive Status) while in the emergency department. The primary outcome was receipt of any parenteral analgesic. The risk factor of interest was cognitive impairment (TICS <= 25). Secondary outcomes included receipt of any opioid, receipt of any analgesic, total dose of analgesics in intravenous morphine equivalent units (MEQ), and time to receiving first analgesic.
RESULTS: Of the 87 (60%) study patients who were cognitively impaired, 60% received a parenteral analgesic compared to 79% of the 57 cognitively unimpaired patients (RR 0.76 (95% CI 0.61, 0.94)). The effect of cognitive impairment on receiving any opioids (RR: 0.81, 95% CI 0.67, 0.98) and any analgesic (RR: 0.85; 95% CI: 0.71, 1.01) was similar. The median analgesic dose in cognitively impaired patients was significantly lower than in cognitively unimpaired patients (4 MEQ vs. 8 MEQ, p=0.003).
CONCLUSION: Among older adults presenting to the ED with acute hip fracture, cognitive impairment was independently associated with lower likelihood of receiving analgesia and lower amount of opioid analgesia. |
0 | Hardiness and psychological distress in a cohort of police officers | DoD PRF (Psychosocial RF) | Since police officers are frequently exposed to high stress situations, individual differences in the response to stress and trauma are of interest. We examined the association of hardiness components (commitment, control and challenge) with depression, posttraumatic stress disorder (PTSD) symptoms, and symptoms of general psychological distress in police officers. The random sample included 105 officers (40 women and 65 men) from the Buffalo Cardio-Metabolic Police Stress (BCOPS) study baseline visit. Components of hardiness were measured using a 15-item hardiness scale. Depressive symptoms were measured using the Center for Epidemiological Studies Depression scale (CES-D), PTSD symptoms were measured using the impact of events scale (IES), and symptoms of general psychological distress were measured using the Brief Symptoms Inventory (BSI). Associations were assessed using linear regression analysis. Models were adjusted for age, education and marital status. Because of significant gender interactions, analyses were stratified by gender. The hardiness control dimension was significantly and negatively associated with CES-D for both genders but was not associated with IES. Hardiness commitment was significantly and negatively associated with both CES-D and IES in women. Men had negative but non-significant associations for commitment with CES-D and IES. Hardiness commitment was negatively associated with the overall BSI score for both men and women but the association was only significant for men, though the strength of the association was stronger for women. This is likely a result of the impact of the smaller sample size for women. The magnitude of gender differences in these associations shows that for depressive and PTSD symptoms, the commitment dimension of hardiness may be more protective in female police officers than in male officers. |
0 | Familial carpal tunnel syndrome with onset in childhood | Diagnosis and Treatment of Carpal Tunnel Syndrome CPG | Within three generations of one family four patients were found to have the carpal tunnel syndrome. In father and son, symptoms commenced in the first decade, and in both patients the median nerves were found to be constricted under the transverse carpal ligaments. The only other operative finding was considerably thickening of the transverse carpal ligaments in the father. Thickening of the transverse carpal ligaments is unusual in patients with the carpal tunnel syndrome but is a common finding in the relatively few patients with familial carpel tunnel syndrome so far described in the literature. It is suggested that thickening of the ligaments may constitute a familial disorder that can give rise to the carpal tunnel syndrome in childhood or later in life |
1 | Factors influencing the cost of chronic low back injuries: An analysis of data from independent medical examinations | DoD PRF (Psychosocial RF) | Cost factors were examined in 157 patients with work-related spine injuries who were referred to a second opinion program between 1985 and 1991. The independent medical examination (IME) included a history, physical examination, and review of imaging and other studies. A standard measure of psychological status (Low Back Pain Symptom Check List) was filled out. Data on treatment, final resolution, and cost were obtained from computerized files of the insurance company. The total cost incurred was $6,551,139. This averaged to $41,727 per case. More expensive cases were associated with a surgical intervention, psychological disturbance, litigation, motor weakness, and positive radiographs. These five variables accounted for 48% of the cost variance. Surgery accounted for 19.9% of the variance and contained the most expensive cases ($68,310 vs $31,423). Psychological disturbance was detected in 27% of the sample and accounted for 10.5% of the cost variance. Litigation was present in 72% of the cases and accounted for 9.1% of the cost variance. Motor strength and radiographs taken together accounted for 8.4% of the variance. The usefulness of this information was explored from an actuarial and medical perspective. (PsycINFO Database Record (c) 2016 APA, all rights reserved) |
0 | Tissue engineered biological augmentation for tendon healing: A systematic review | PRPs for Lateral Epicondylitis/Elbow Tendinopathies | Introduction: Tendon injuries give rise to significant morbidity. In the last few decades, several techniques have been increasingly used to optimize tendon healing. Sources of data: We performed a comprehensive search of PubMed, Medline, Cochrane, CINAHL and Embase databases using various combinations of the commercial names of each scaffold and the keywords 'tendon', 'rotator cuff', 'supraspinatus tendon', 'Achilles tendon', 'growth factors', 'cytokines', 'gene therapy', 'tissue engineering', 'mesenchymal' and 'stem cells' over the years 1966-2009. All articles relevant to the subject were retrieved, and their bibliographies were hand searched for further references in the context to tissue-engineered biological augmentation for tendon healing. Areas of agreement: Several new techniques are available for tissue-engineered biological augmentation for tendon healing, growth factors, gene therapy and mesenchimal stem cells. Areas of controversy: Data are lacking to allow definitive conclusions on the use of these techniques for routine management of tendon ailments. Growing points: The emerging field of tissue engineering holds the promise to use new techniques for tendon augmentation and repair. Preliminary studies support the idea that these techniques can provide an alternative for tendon augmentation with great therapeutic potential. Areas timely for developing research: The optimization strategies discussed in this article are currently at an early stage of development. Although these emerging technologies may develop into substantial clinical treatment options, their full impact needs to be critically evaluated in a scientific fashion. © 2011 The Author. |
0 | Effectiveness of continuous versus pulsed short-wave diathermy in the management of knee osteoarthritis: A randomized pilot study | OAK 3 - Non-arthroplasty tx of OAK | Background: Short-wave diathermy (SWD) is an electrotherapeutic modality used in the conservative treatment of knee osteoarthritis (KOA). Electromagnetic radiation delivered in continuous (cSWD) or pulse (pSWD) mode provides a deep heating effect on tissues. There is no consensus on outcomes of treatment with cSWD versus pSWD in KOA. The aim of this study was to compare the effects of cSWD versus pSWD on pain, functionality and walking distance in KOA. Methods: 34 female patients aged 49-65 with KOA were randomized into two groups. A total of 27 patients completed the study. One group (n=11) was treated with cSWD, the other (n=16) with pSWD for three weeks. Patients were assessed before, after and at one month post therapy. Outcome measures included visual analogue scale (VAS) for knee pain, Western Ontario and Mcmaster University Osteoarthritis Index (WOMAC) and a six-minute walking test (6MWT). Results: Based on the minimal clinically important improvement (MCII), there was a reduction in VAS and WOMAC scores in both cSWD and pSWD groups post treatment (-37.3mm, 31.2mm respectively for VAS and 26%, 23% respectively for WOMAC) and at one month post treatment. There was no difference in pre and post treatment VAS for pain, WOMAC or 6MWT scores between the two groups. There was a small post treatment effect size on between- group 6MWT scores (Cohen's d: 0.238). Conclusion: Both treatment options appear to be efficacious in reducing pain and improving functionality in KOA. There was no between-group difference. A larger study must be conducted to consolidate these findings. |
0 | A placebo-controlled study assessing the tolerability and plasma concentrations of ascending doses of fasitibant in patients with osteoarthritis of the knee | OAK 3 - Non-arthroplasty tx of OAK | INTERVENTION: Product Name: Fasitibant chloride bisâ?hydrochloride Pharmaceutical Form: Solution for injection INN or Proposed INN: Fasitibant chloride (as bisâ?hydrochloride) CAS Number: 883969â?00â?4 Current Sponsor code: MEN 16132 Concentration unit: mg/ml milligram(s)/millilitre Concentration type: equal Concentration number: 1â? Pharmaceutical form of the placebo: Solution for injection Route of administration of the placebo: Intraarticular use Product Name: Fasitibant chloride bisâ?hydrochloride Pharmaceutical Form: Solution for injection INN or Proposed INN: Fasitibant chloride (as bisâ?hydrochloride) CAS Number: 883969â?00â?4 Current Sponsor code: MEN 16132 Concentration unit: mg/ml milligram(s)/millilitre Concentration type: equal Concentration number: 2.5â? Pharmaceutical form of the placebo: Solution for injection Route of administration of the placebo: Intraarticular use Product Name: Fasitibant chloride bisâ?hydrochloride Pharmaceutical Form: Solution for injection INN or Proposed INN: Fasitibant chloride (as bisâ?hydrochloride) CAS Number: 883969â?00â?4 Current Sponsor code: MEN 16132 Concentration unit: mg/ml milligram(s)/millilitre Concentration type: equal Concentration number: 5â? Pharmaceutical form of the placebo: Solution for injection Route of administration of the placebo: Intraarticular use Trade Name: HYALART Product Name: Sodium hyaluronate Pharmaceutical Form: Solution for injection in preâ?filled syringe INN or Proposed INN: Sodium Hyaluronate CAS Number: 9067â?32â?7 Concentration unit: mg/ml milligram(s)/millilitre Concentration type: equal Concentration number: 10â? CONDITION: Ostoarthritis of the knee ; MedDRA version: 14.1 Level: LLT Classification code 10023476 Term: Knee osteoarthritis System Organ Class: 100000004859 Therapeutic area: Diseases [C] â? Musculoskeletal Diseases [C05] PRIMARY OUTCOME: Main Objective: To evaluate the safety and tolerability of fasitibant up to 5 mg formulated as 1 mL solution to be given as single intraâ?articular (IA) administration to patients with knee osteoarthritis. Primary end point(s): Safety and tolerability of study treatments:; â?Changes in vital signs (blood pressure, pulse rate, respiratory rate, body temperature; 12â?lead electrocardiogram (ECG) parameters; laboratory safety battery tests, and physical examination at End of Study versus baseline. ; â?Incidence and severity of adverse events occurring between randomisation and End of Study.; Secondary Objective: 1) To assess main plasma pharmacokinetic parameters, including doseâ?proportionality of fasitibant monocomponent (up to 5 mg), of its main metabolite MEN 19148, and of fasitibant 5 mg in extemporaneous combination with sodium hyaluronate in patients with knee osteoarthritis (OA).; 2) To evaluate changes in plasma or serum levels, as appropriate,of OA biomarkers and preliminary efficacy data in knee OA patients following IA single up to 5 mg doses of fasitibant alone and in combination with Sodium Hyaluronate. Timepoint(s) of evaluation of this end point: Between randomisation (T0) and two weeks after administration of study treatments (T14 +/â? 2 Days). SECONDARY OUTCOME: Secondary end point(s): Pharmacokinetics of the study treatments in terms of absorption, distribution, metabolism and elimination of the study treatments, including analysis of dose proportionality. ; This includes also the pharmacokinetic analysis of the main metabolite of fasitibant (MEN 19148), the monoâ?hydroxylated derivative formed by oxidative metabolism by the cytochrome P450 enzyme. ; ; Pharmacodynamics of the study treatments: ; Analysis of Biomarkers of osteoarthritis, inflammation and cartilage degeneration. ; ; Clinical Efficacy of study treatments: ; Assessment of OA symtoms (pain, walking pain, stiffness) using validated standard questionnaires (WOMAC 3.1 NR). ; Assessment of pain at rest and after 15 metres walk ; Patients' and Physicians' global assessment of efficacy. ; Timepoint(s) of evaluation of this end point: Pharmacokinetics: ; Between time of dosing (T0) and def ned time points until 1 week (T7 +/â?2 days) after treatment adminsitration. ; ; Pharmacodynamics: ; OA Biomarkers: Between time of dosing (T0) and 1 week (T7 +/â?2 days) after treatment adminsitration. ; ; Clinical Efficacy: ; Between time of dosing (T0), 1 week (T7 +/â?2 days) and 2 weeks (T14 +/â?2 days) after treatment adminsitration. ; ; INCLUSION CRITERIA: 1.Written informed consent. 2.Male or female patients = 30 years old and a BMI < 30 kg/m². 3.Women of childbearing potential are eligible to participate in the study if their pregnancy test is negative at screening, they are not nursing, and they use an effective method of contraception. 4. Symptomatic primary or secondary knee osteoarthritis for which IA treatment is indicated. 5. Pain score >5 points assigned to the index knee at WOMAC NR 3.1â?A1. 6. Pain score >12 points assigned to the index knee at WOMAC NR 3.1 A subscore. 7. Pain in the index knee on at least 50% of the days in the month preceding the screening. 8. Minimum flexion of 90 degrees in both knees. 9. Ability to perform the 15 m walk test without the support of crutches or other assistive devices. 10. Willingness to discontinue all pain or OA medication. 11. Willingness to refrain from paracetamol use 48 hours prior to each study visit. Are the tri |
0 | Periosteal nerve blocks for distal radius and ulna fracture manipulation--the technique and early results | Distal Radius Fractures | BACKGROUND: We present a pilot series of patients with distal forearm fractures manipulated following a proximal periosteal nerve block with local anaesthesia. This is a novel technique which can be utilised in adults and children and is described herein.
METHODS: With a median of 40 years (range 10-81 years), 42 patients (16 children) with distal radial and ulnar fractures were included. Of these patients, 40 underwent periosteal blocks in the emergency room or fracture clinic; 2 were already inpatients. Fractures were manipulated routinely and immobilised with plaster. Mobile fluoroscopy was not used for patients in the emergency department or fracture clinic.
RESULTS: Of the 42 patients, 40 patients (95%) had successful fracture manipulation and did not require subsequent treatment. Two patients (5%) needed subsequent surgery, one for K-wire stabilisation of their fracture and the second for volar plate fixation. The procedure was described as painless in 35 (83%) patients (visual analogue scale/VAS score 0), with 6 (14%) suffering minimal pain (VAS 1-3). In the 12-16-year age group, 15 patients (94%) described the manipulation as painless; 1 patient described the procedure as minimally painful. No additional analgesia of any kind was given. There were no direct complications from any of the periosteal nerve blocks.
CONCLUSIONS: Local anaesthetic periosteal nerve blocks injected proximally to the fracture sites are a simple and yet very effective new technique which provide good/excellent analgesia and facilitate the reduction of distal radial and ulnar fractures. |
0 | Open proximal & distal fractures of tibia treated with Naseer Awais external Fixator with T-clamp | DoD SSI (Surgical Site Infections) | Objective: To compare the outcome of the open proximal and distal fractures of tibia treated by Nasser Awais External Fixtator with T-clamp. Methods: The descriptive case series was conducted from August 2009 to July 2012 at Department of Orthopaedic Surgery & Traumatology, Liaquat University of Medical & Health Sciences, Jamshoro, and comprised in-patients of open proximal and distal fractures of tibia who were divided into two equal groups: group A had distal and group B had proximal patients. All patients had extra-articular open fractures Gustilo I, II, IIIA and IIIB of proximal and distal end of tibia between 15 and 60 years of age who had arrived within 8 hours of the injury. Below-knee plaster cast was applied for 02 to 03 weeks after the removal of Nasser Awais External Fixtator and all patients were followed up for 12 months. SPSS 17 was used for statistical analysis. Results: Overall, there were 30 patients; 15(50%) in each of the two groups. The mean age in group A was 28.9±9.43 years and 34.3±14.60 years in group B. There were 11(73.3%) males and 4(26.7%) females in group A, and 15(100%) males in-group B. Mean fracture union time in group A was 17.20±2.93 weeks (range: 11-23 weeks) and in group B it was 23.53±2.44 weeks (range: 19-28 weeks). Ankle joint stiffness occurred in 2(6.7%) cases that were in group A, and knee joint stiffness was seen in 2(6.7%) cases and they were in group B. Conclusion: Nasser Awais External Fixator with T-Clamp was a safe technique and promoted the union with a low complication rate with less union time in distal tibial fracture compared to proximal fracture. |
0 | Recurrence rate of basal cell carcinoma with positive histopathological margins and related risk factors | Reconstruction After Skin Cancer | Background:The best way to approach surgically removed basal cell carcinoma with positive histopathological margins is a controversial issue. Some authors believe that the more appropriate treatment is an immediate reoperation while others prefer a periodic follow up. The rates of recurrence are variable in literature, between 10% and 67%. Objective: To define the recurrence rate of basal cell carcinoma with positive margins after surgery. Secondarily, identify morphological aspects that can suggest a more frequent tumoral recurrence. Methods: This was a retrospective and observational study made by analysis of medical records of 487 patients between January 2003 and December 2009 in Hospital de Clinicas da Universidade Federal do Parana (HC-UFPR). From 402 basal cell carcinomas surgically treated, 41 fulfilled inclusion criteria and were evaluated for five years or more. Recurrence rate of these tumors was analyzed in all patients and clinical characteristics such as sex, age, tumor size, tumor site, ulceration, and histological type were evaluated in order to find if they were related to more common tumoral recurrence. Results: The rate of positive margins after surgery was 12.18%. There were five cases of tumoral recurrence in the observation group and three cases in the re-excision group. Tumor size, site, histological type, ulceration and type of positive margin did not differ statistically between groups. It was not possible to consider if these factors were important in recurrence rates. Study limitations: Ideally, a prospective study with a larger sample would be more accurate. Conclusion: The treatment of choice in basal cell carcinoma with positive margins must be individualized to reduce recurrence rates. Copyright © 2017 by Anais Brasileiros de Dermatologia. |
0 | Low-energy distal radius fractures in middle-aged and elderly women-seasonal variations, prevalence of osteoporosis, and associates with fractures | Distal Radius Fractures | UNLABELLED: There is a lack of data on the prevalence of osteoporosis in patients with distal radius fractures occurring at the various seasons. The prevalence of osteoporosis is high, both in patients with indoor and outdoor fractures and higher than in controls. All female distal radius fracture patients >or=50 years should be referred for osteoporosis assessment.
INTRODUCTION: The objectives of this study in female distal radius fracture patients were to investigate seasonal differences, estimate the prevalence of osteoporosis, and identify factors associated with distal radius fractures compared with controls.
METHODS: In a 2-year period, 263 women >/=50 years suffered a low-energy distal radius fracture in the geographic catchment area. The 214 women who met for osteoporosis assessment were age-matched with 191 controls. Bone mineral density was assessed by dual energy X-ray absorptiometry at femoral neck, total hip, and lumbar spine. Demographic and clinical data were collected.
RESULTS: The prevalence of indoor fractures showed no seasonal variance. For outdoor fractures, the prevalence was highest in the winter months. The prevalence of osteoporosis among patients with indoor fractures was higher (58.5%) than outdoor fractures without (38.6%) and with snow/ice (36.0%; p < 0.001). The prevalence of osteoporosis was higher in fracture patients (42.5%) than controls (24.1%; p < 0.001), this was also found in the youngest age group 50-59 years (22.2% vs 1.8%; p < 0.001). In conditional logistic regression analyses osteoporosis, current use of glucocorticoids, and living alone were independently associated with distal radius fractures.
CONCLUSIONS: Our study highlights that environmental factor, as well as osteoporosis are associated with distal radius fractures in middle-aged and elderly women. Osteoporosis is also frequently found in outdoor patients, thus, all female distal radius fracture patients >or=50 years should be referred for osteoporosis assessment. |
1 | Viscosupplementation with hyaluronic acid in the treatment for cartilage lesions: A review of current evidence and future directions | Glenohumeral Joint OA | Diseases involving the articular cartilage are one of the leading causes of physical impairment among the adult population. While surgical technique and advancement have allowed us effective means at treating these diseases, this is not without significant risk and morbidity. With a very solid safety profile, viscosupplementation with hyaluronic acid (HA) derivatives has become an excellent modality for treating diseased articular cartilage. Recent literature supports the use of HA not only in the management of the pain associated with osteoarthritis but also as a disease-modifying agent as well. Further studies have started to define exciting new roles for viscosupplementation in the treatment for acute injuries to the joint microenvironment. © 2012 Springer-Verlag. |
1 | Does the quality of preoperative closed reduction of displaced ankle fractures affect wound complications after surgical fixation? | DoD SSI (Surgical Site Infections) | BACKGROUND: Displaced ankle fractures are initially closed reduced and splinted with the goal of restoring gross ankle alignment. The benefits of an exact closed reduction are unclear and possibly detrimental and unnecessary if multiple attempts are made. The purpose of this study was to determine whether the quality of preoperative closed reduction in patients with operative ankle fractures affects post-operative wound complications.
METHODS: A retrospective analysis was performed of patients with isolated, closed, operative ankle fractures treated at two level 1 trauma centers who had an initial closed reduction performed on presentation. Patient demographics, fracture characteristics, data pertinent to the reduction, and post-operative wound complications were collected. A novel grading system to assess reduction quality was developed, applied, and evaluated for inter- and intra-observer agreement.
RESULTS: 161 patients met inclusion criteria for analysis. 17% (27/161) sustained a post-operative wound complication. There was no statistically significant association between wound complications and quality of preoperative closed reduction (p = 0.17) nor with multiple reduction attempts (p = 0.887). However, patients with poor initial reductions had a decreased mean time to surgery (1.4 +/- 2.9 versus 4.7 +/- 6.3 days, p = 0.03), which may have been protective. Interclass correlation coefficients for inter- and intra-rater reliability of the classification schema was 0.942 and 0.922, respectively, demonstrating excellent agreement.
CONCLUSION: There was no association between preoperative closed reduction quality and incidence of post-surgical wound complications in patients with operative ankle fractures when analyzing the variables assessed in this investigation. While initial ankle reduction is still recommended, multiple attempts to achieve a perfect reduction are likely unnecessary. |
1 | Qigong and Musculoskeletal Pain | OAK 3 - Non-arthroplasty tx of OAK | Purpose of Review: Musculoskeletal pain is a widespread symptom that commonly produces considerable disability, particularly in later life. This brief review strove to summarize and critically review the recent research base concerning the use of Qigong as a possible strategy for alleviating longstanding or chronic musculoskeletal pain states. Methods: Research reports and literature reviews specifically focusing on Qigong and its impact on various forms of musculoskeletal pain between 2015 and 2019 were sought and analyzed, along with related data. Results: Collectively, these data reveal that while more research is indicated, Qigong practice may help to attenuate pain in varying degrees among adults with different forms of chronic pain with few side-effects. Conclusion: More research is needed to ensure health professionals working with adults who have chronic unrelenting musculoskeletal pain may safely recommend these exercises as one possible remedy for reducing intractable musculoskeletal pain. |
0 | Discrimination of total body bone mineral density measured by dexa in vertebral osteoporosis | Management of Hip Fractures in the Elderly | The assessment of bone mineral density (BMD) is the usual study to detect patients at risk for developing osteoporosis. The aim of this study was to compare the discriminative ability of total body BMD and its different subregions with the more usual measurements of BMD of the lumbar spine and femoral neck in women with osteoporotic fractures of the spine. The BMD was determined in 61 osteoporotic (at least one vertebral wedge fracture visible in the lateral X-ray film of the thoracic or lumbar spine) and 61 age-matched control women. Measurements were made by dual X-ray absortiometry (DXA) with a total body scanner. The BMD of the osteoporotic women was significantly lower at all skeletal areas compared with control (P < 0.001). The diminution was less pronounced but still significant at the arms (P < 0.05). The areas with the largest Z score in the osteoporotic group were antero-posterior lumbar spine (-1.78), femoral neck (-1.71), legs (-1.67), and total body (-1.59). There was no significant difference among the Z scores of the four above-mentioned measurements. The Z score of the arms (-0.79), spine (-1.12), and head (-1.29) were significantly lower than the Z score of the total body. The Z score of the pelvis was lower than the Z score of the total body but the difference only approached statistical significance (0.05 > P < 0.1).(ABSTRACT TRUNCATED AT 250 WORDS) |
0 | CSF neurotransmitter changes in the perioperative period in patients undergoing total knee replacement surgery | Surgical Management of Osteoarthritis of the Knee CPG | Introduction : While total knee replacement (TKR) has been of enormous benefit to patients with knee osteoarthritis, acute postoperative pain and even persistent postoperative pain can be severe and difficult to manage (Pain 2003;106:393;Anesth Analg 2010;110:199). The role that the major spinal cord neurotransmitters play in the acute postoperative period is not clear and has been studied infrequently in humans. Methods : All patients had an intrathecal catheter placed for spinal anesthesia during TKR, and for continuous spinal analgesia during the postop period using fentanyl and bupivacaine. The same catheter was used to sample cerebrospinal fluid (CSF) presurgery and at 2, 4, 8, 12, 24, and 32 h after catheter placement. CSF samples were assayed for norepinephrine, substance P, calcitonin gene related peptide (CGRP) and glutamate. The bodily pain scale of the SF-36 health survey was measured presurgery, and numerical rating scale (NRS) pain scores and intrathecal analgesic consumption were recorded postsurgery. We performed a randomized, placebocontrolled, double-blind trial with 3 drug groups (N=16/gp): placebo; single-dose pregabalin (150 mg administered p.o. prior to surgery); and multi-dose pregabalin (150 mg administered p.o. presurgery and 12 and 24 h later); to determine the effect of an antihyperalgesic drug on spinal neurotransmitters. Results : Prior to surgery, increased bodily pain was correlated with increased CSF norepinephrine and CGRP concentrations. In patients receiving placebo, norepinephrine levels at the early time points (2 and 4 h) were lower than the presurgery baseline value, and in both pregabalin groups this reduction lasted 12 h. Substance P levels had an early peak value (at 2 h) in all 3 groups, and then returned to baseline. CGRP levels only decreased at the 32-h time point in the placebo group but in both pregabalin groups, CGRP levels decreased over the 4-32 h period. In the placebo group only, glutamate decreased over the 4-32 h period. However, there was no difference in the CSF neurotransmitter concentrations between the three treatment groups over the 32-h sampling period. In the placebo group, the early NRS pain score area under-curve, AUC [0-12 h], was positively correlated (R=0.67, P=0.0088) to the late CSF norepinephrine concentration AUC [12-24 h]; but none of the other neurotransmitters were correlated with NRS. None of the neurotransmitter levels were correlated to postoperative analgesic consumption or range of motion. Discussion : In the perioperative period, the concentration change of each spinal neurotransmitter has a distinct time course, both with and without pregabalin administration |
1 | Treatment of limb arterial injuries caused by traffic accidents | DoD LSA (Limb Salvage vs Amputation) | OBJECTIVE: To analyze the features, diagnosis and treatment of limb arterial injuries caused by traffic accidents. METHODS: A total of 43 patients with limb arterial injury admitted in our department over the past 30 years (about 50% of them happened during the last 10 years) were analyzed retrospectively in this article. The popliteal, femoral and brachial arteries were mainly involved, accounting for 43.2%, 20.5% and 20.5% respectively of all the involvements. There were 35 cases of open injury and 9 of close injury. The involved vessels were transected in 43.2% of the cases and contused in 40.9%. All the patients had various complications, such as fractures, dislocations and severe soft tissue injuries. The injured vessels were repaired by means of end-to-end anastomosis in 10 cases, autogenous vein graft in 23 cases and intraluminal hydraulic dilatation in 4 cases. RESULTS: Successful limb salvage was achieved in 34 cases initially, whereas 10 amputations were carried out due to injuries to popliteal arteries in 7, femoral arteries in 2 and humeral artery in 1 and severe soft tissue damages in 9 cases. Twenty-nine patients were followed up for 1-156 months, with the average of 48.8 months. There was good circulation in 22 cases and certain ischemia in 5 cases. Two amputations were carried out in the late stage because of popliteal artery thrombosis after repair in 2 cases. There was no death in this series. CONCLUSIONS: The limb arterial injuries caused by traffic accidents are severe and complicated. It is proposed that particular attentions should be paid to the features in diagnosis and treatment for this type of injury and special efforts should be made for both life saving and limb salvage. |
1 | Impact of peripheral nerve block with low dose local anesthetics on analgesia and functional outcomes following total knee arthroplasty: a retrospective study | AAHKS (8) Anesthetic Infiltration | OBJECTIVE: While the safety and efficacy of peripheral nerve blocks for postoperative pain management has been established in several well controlled prospective trials, the local anesthetic (LA) concentration and volume used in these studies was associated with a significant increase muscle weakness due to motor nerve block. The purpose of the present retrospective study of patients undergoing total knee arthroplasty was to assess the relative analgesic efficacy and functional outcomes of the low concentration, low volume of LA used in peripheral nerve blocks for postoperative pain management.
METHODS: Twenty-four months of deidentified patient data were extracted from an electronic medical record system. All patients received opioids with or without continuous femoral and sciatic nerve block infusions for postoperative analgesia. Pain (resting and with activity), cumulative opioid and LA use were primary endpoints, participation in physical therapy (PT), muscle strength deficits and length of hospital stay (LOS) were secondary endpoints.
RESULTS: Postoperative pain and opioid use were significantly lower in patients with peripheral nerve blocks (n = 1,329) than those with opioids alone (n = 439). There was no detectable decrease in strength associated with nerve blocks, while a significantly greater proportion of patients with nerve blocks were able to participate in PT on postoperative day 1 (96.4% vs 57.1%). These differences were not due to the impact of the surgeon per se, but whether or not the surgeon used nerve blocks for pain management. There was a small but statistically significant decrease in the average LOS in patients with blocks.
CONCLUSION: This analysis supports the use of low concentration, low volume of LA based peripheral nerve blocks for postoperative pain management. |
0 | Denosumab: In the prevention of skeletal-related events in patients with bone metastases from solid tumours | MSTS 2018 - Femur Mets and MM | Denosumab, a fully human monoclonal antibody, binds to the receptor activator of nuclear factor-κB ligand (RANKL) and thereby inhibits RANKL-mediated bone resorption. In various individual countries, subcutaneous denosumab is indicated for the prevention of skeletal-related events in patients with bone metastases from solid tumours (featured indication), andor for the treatment of postmenopausal osteoporosis andor of cancer treatment-induced bone loss in prostate or breast cancer patients.In three, pivotal, double-blind, multinational trials in adult patients with cancer-related bone metastases (total n>5700), including trials in patients with advanced breast or prostate cancer, subcutaneous denosumab (120mg every 4 weeks) was shown to be noninferior to intravenous zoledronic acid (4mg every 4 weeks), as determined by the median time to first on-study skeletal-related event (primary endpoint) at the time of the primary analysis (â??34 or 41 months).Denosumab treatment was superior to zoledronic acid in terms of the primary endpoint in two trials in patients with breast cancer or prostate cancer, based on secondary superiority analyses. In a third trial in patients with solid tumours excluding breast or prostate cancer, superiority of denosumab treatment versus zoledronic acid treatment was not demonstrated.The tolerability profile of denosumab was manageable in patients with bone metastases from solid tumours. Osteonecrosis of the jaw occurred in 1.8 and 1.3 of patients in the denosumab and zoledronic acid groups during the primary treatment phase; the incidence after approximately 4 additional months of denosumab treatment was 2.2. © 2011 Adis Data Information BV. All rights reserved. |
0 | Predictors of revision, prosthetic joint infection and mortality following total hip or total knee arthroplasty in patients with rheumatoid arthritis: a nationwide cohort study using Danish healthcare registers | OAK 3 - Non-arthroplasty tx of OAK | OBJECTIVES: To investigate predictors of 10-year risk of revision and 1-year risk of prosthetic joint infection (PJI) and death following total hip/total knee arthroplasty (THA/TKA) in (1) patients with rheumatoid arthritis (RA) compared with patients with osteoarthritis (OA); and (2) patients with RA treated with biological disease-modifying antirheumatic drugs (bDMARD) within 90 days preceding surgery compared with non-treated.
METHODS: Register-based cohort study using the Danish National Patient Register, the DANBIO rheumatology register (RA-specific confounders and treatment episodes) and the Danish Hip and Knee Arthroplasty Registers. Survival analyses were used to calculate confounder-adjusted sub-HRs (SHR) and HRs.
RESULTS: In total, 3913 patients with RA with THA/TKA were compared with 120 499 patients with OA. Patients with RA had decreased risk of revision (SHR 0.71 (0.57-0.89)), but increased risk of PJI (SHR=1.46 (1.13-1.88)) and death (HR=1.25 (1.01-1.55)). In DANBIO, 345 of 1946 patients with RA with THA/TKA had received bDMARD treatment within 90 days preceding surgery. bDMARD-treated patients did not have a statistically significant increased risk of revision (SHR=1.49 (0.65-3.40)), PJI (SHR=1.61 (0.70-3.69)) nor death (HR=0.75 (0.24-2.33)) compared with non-treated. Glucocorticoid exposure (HR=2.87 (1.12-7.34)) and increasing DAS28 (HR=1.49 (1.01-2.20)) were risk factors for mortality.
CONCLUSION: Patients with RA had a decreased 10-year risk of revision while the risk of death and PJI was increased compared with patients with OA following THA/TKA. bDMARD exposure was not associated with statistically significant increased risk of neither PJI nor death in this study. Glucocorticoid exposure and increased disease activity were associated with an increased risk of death. |
0 | Anthropometric measures as screening test for carpal tunnel syndrome: Roc curves and accuracy | Diagnosis and Treatment of Carpal Tunnel Syndrome CPG | Some anthropometric measures, such as high body mass index (BMI) and characteristic hand shape, were reported to be associated with carpal tunnel syndrome (CTS). The aim of this study was to check optimal cutoff values of body, wrist and hand measures to identify CTS patients using receiver-operating characteristic (ROC) curves. We decided in advance to enroll one CTS case for two controls regardless of age and gender. Case and controls were consecutively recruited among all patients referred to 3 outpatient EMG clinics because of upper limb complaints. CTS diagnosis was made according to clinical findings and distal conduction delay of median nerve. Case and controls with diabetes, connective and thyroid diseases, renal failure, polyneuropathy, wrist trauma were excluded, as well as women in pregnancy or lactation. The following anthropometric measures were collected: weight, height, waist and hip circumferences, wrist depth and width, hand length, palm length and width. These ratios were calculated: BMI, waist-to-hip-ratio, wrist area, wristratio= wrist depth/wrist width, hand-ratio=hand length/palm width, shape-index=palm width x100/hand length, wristpalm- ratio=wrist depth/length palm. ROC curves and areas delimited by ROC curves, sensitivity, specificity and likelihood ratio of all anthropometricmeasures (considered as continuous values) were calculated. We considered optimal cut-offs the values for which sensitivity and specificity were crossing. To evaluate possible differences among areas under the ROC curves, Chi-squared test was used, with a significance level of 0.05. The analysis was performed separately for males and females. 1,117 patients were included. Female cases and controls were 250 and 474; male cases and controls were 120 and 273. Shapeindex, wrist/palm-ratio and hand-ratio demonstrated to be sufficiently accurate as screening test for CTS, in males. The largest areas under ROC curves were 0.75, 0.75 and 0.25, respectively. Shape-index and wrist-palm-ratio cut-offs (46.07 and 0.395) provided the same sensitivity (69.2%) and a specificity of 69.2% and 71.1%, respectively. Among females, no area delimited by ROC curves was over 0.7 (or below 0.3 if under the reference), the relatively largest areas (about 0.63) were obtained by BMI, waist circumference, wrist-palm-ratio. Using ROC analysis, the discriminative ability of many anthropometric measures to detect patients with CTS is low, especially in females. The only measure common to both genders sufficiently accurate is wrist-palmratio, the cut-off of 0.39 has sensitivity and specificity of approximately 70% in males and 60% in females. The accuracy of the well-known cut-off of 0.7 of wrist-ratio and of all body measures is disappointing |
0 | MOC-PS(SM) CME article: abdominoplasty | Panniculectomy & Abdominoplasty CPG | LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Understand the reasoning behind obtaining a thorough medical history from abdominoplasty patients and determine how that information (e.g., history of massive weight loss, prior operations with abdominal scars) may affect the surgical plan. 2. Understand the thromboembolic risks associated with abdominoplasty patients, especially when abdominoplasty is performed in conjunction with other surgical procedures, and appropriate and currently accepted prophylaxis. 3. Describe the indications and potential risks of performing liposuction as an adjunct to abdominoplasty. 4. Evaluate a patient's abdomen, taking into consideration all the aesthetic subunits of the trunk and lower body, and determine the appropriate type of abdominoplasty indicated. 5. Identify and understand the treatment of early and late complications associated with abdominoplasty. SUMMARY: In this article, the authors review the preoperative assessment, surgical treatment plan, and outcomes of abdominoplasty. Preoperative assessment emphasizes obtaining an accurate and detailed medical history, conducting a thorough physical examination, and determining suitable and safe anesthetic options in appropriate surgical facilities. Preoperative planning stresses measures taken to minimize perioperative complications, and intraoperative planning reviews the various surgical techniques. Postoperative complications and their treatments are discussed, as well as the safety of combining abdominoplasty with other procedures. Current procedural terminology is also reported, since there have been recent changes to those codes commonly used in abdominoplasty. |
0 | Antibiotic prophylaxis for medical-risk patients | Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures | The three current regimens for the prevention of infective endocarditis are discussed and compared along, with at-risk patients and dentally-induced bacteremias. The principles of antibiotic prophylaxis, and other medical conditions where antibiotic prophylaxis is controversial or inadequately documented is critically analyzed |
0 | Miller-Galante total knee arthroplasty: the importance of material and design on the revision rate | Surgical Management of Osteoarthritis of the Knee CPG | We have reviewed 142 Miller-Galante I (MG I) total knee arthroplasties (TKAs) with a follow-up of 56 months, and compared these with the outcome of 219 Miller-Galante II (MG II) TKAs with a follow-up of 36 months. In the MG II TKAs we found markedly lower revision rates, higher postoperative Hospital for Special Surgery (HSS) scores, less retropatellar pain and better patellar centring without patellar resurfacing. The higher revision rate in MG I TKAs was mainly due to the need to revise the metal-backed patellae |
0 | Floppy eyelid syndrome: quantifying the effect of horizontal tightening on upper eyelid position | Upper Eyelid and Brow Surgery | PURPOSE: To evaluate the change in upper eyelid position after horizontal surgical tightening in patients with floppy eyelid syndrome. DESIGN: Prospective, noncomparative, interventional case series. PARTICIPANTS: Eighteen patients with a clinical diagnosis of floppy eyelid syndrome. METHODS: Horizontal surgical tightening of the upper eyelid was performed by full-thickness wedge resection in 24 eyelids of 18 patients with floppy eyelid syndrome. Preoperative and postoperative upper eyelid position as measured by the margin reflex distance (MRD) was assessed. Student's paired t test then was used to analyze the change in upper eyelid position after horizontal tightening alone of floppy upper eyelids. MAIN OUTCOME MEASURES: Change in upper eyelid MRD after surgery. RESULTS: Preoperative MRD ranged from -0.5 to 4.0 mm, with a mean of 1.9 mm (+/-1.3 mm, standard deviation [SD]). Postoperative MRD ranged from 0.5 to 6.0 mm, with a mean of 3.2 mm (+/-1.4 mm, SD). The change in MRD ranged from -0.5 to 2.5 mm, with a mean of 1.3 mm (+/-0.7 mm, SD; P<0.001). CONCLUSIONS: Horizontal upper eyelid tightening alone generally results in secondary improvement of the ptosis associated with floppy eyelid syndrome. |
0 | Comparison of percutaneous compression plating and short reconstruction nail for treatment of intertrochanteric fracture | Management of Hip Fractures in the Elderly | To compare percutaneous compression plating (PCCP) with Trigen short reconstruction nail (Trigen SRN) for the treatment of intertrochanteric hip fracture. Eighty-four patients with intertrochanteric hip fracture admitted to our hospital from January 2007 to June 2008 were included in this retrospective study. Thirty-six patients were treated with PCCP and 48 with Trigen SRN. Information regarding age, surgical time, blood loss, length of follow-up, mortality, fracture impaction, time to union, complications, Harris score and visual analog scale (VAS) were all recorded. The mean follow-up time was 16.3 (plus or minus) 3.2 months (13-19 months). The mean time to achieve radiological fracture healing was 3.6 (plus or minus) 0.8 and 4.1 (plus or minus) 1.0 months for the PCCP and Trigen SRN groups, respectively (P= 0.020); the mean Harris hip scores were 78.1 (plus or minus) 4.8 and 74.1 (plus or minus) 5.2 (P= 0.001); and the mean fracture impaction was 3.6 (plus or minus) 2.3 and 3.3 (plus or minus) 2.6 mm (P= 0.023). There were no statistical differences between the two groups in duration of surgery (P= 0.131) and blood loss (P= 0.268). The amount of nail in the inferior-central quadrants was greater in the PCCP group than in the Trigen SRN group. PCCP achieves earlier pain release and better fracture reduction than Trigen SRN. (copyright) 2011 Tianjin Hospital and Blackwell Publishing Asia Pty Ltd |
0 | [Mini-Subvastus approach for total knee replacement] | Surgical Management of Osteoarthritis of the Knee CPG | Objective: Total knee replacement in minimally invasive technique without any trauma to the extensor apparatus and with soft-tissue-referenced bone resections. Only the subvastus approach preserves the integrity of the extensor apparatus and has therefore been modified to become a minimally invasive technique with a shorter skin incision and lateralization instead of eversion of the patella. Soft-tissue balancing is done through this direct anterior approach. Indications: Mild to moderate varus osteoarthritis of the knee up to 15degrees of malalignment, mild and passively correctable valgus osteoarthritis of the knee up to 10degrees of malalignment. Contraindications: Severe, contract varus osteoarthritis of the knee, severe and moderate, contract valgus osteoarthritis of the knee, severe obesity, exceptionally muscular patients, decreased skin perfusion. Surgical Technique: Central skin incision from the superior pole of the patella to the tibial tubercle. Exposure of the medial retinaculum and mobilization of the vastus medialis muscle subcutaneously. Incision of the medial retinaculum and blunt separation of the vastus medialis muscle from the intermuscular septum. Lateralization of the patella and flexion of the knee joint. Resection of the tibia perpendicular to the diaphysis. Adjustment of the anteroposterior (AP) resection block at the level of the anterior femoral cortex and of rotation by applying equal tension to the collateral ligaments. Balancing of soft-tissue tension in flexion gap by release, if necessary. After AP resection fixation of distal resection block in planned valgus angle. Balancing of soft-tissue tension in extension gap by release, if necessary. After distal femur resection facet resection, adaptation of posterior femoral condyles, and implantation of prosthesis. Check on stability and range of motion. Wound closure. Postoperative Management: Full weight bearing from the 1st postoperative day, CPM (continuous passive motion) with up to 90degrees flexion with peridural anesthesia as tolerated, stair climbing starting on the 7th postoperative day. Results: 100 patients were randomized to total knee replacement via a parapatellar or subvastus approach. Radiologically, there were no differences in operative precision or leg alignment. Patients treated minimally invasively suffered less pain and achieved a higher flexion of 110degrees versus 95degrees 6 weeks postoperatively. However, there were two cases of delayed wound healing in this group. The surgical technique is demanding and the operating time is longer. Long-term results are still missing. copyright Urban & Vogel. Copyright © 2011 Elsevier B. V., Amsterdam. All Rights Reserved |
0 | The national clinical audit of falls and bone health: the clinical management of hip fracture patients | Management of Hip Fractures in the Elderly | BACKGROUND: The standards of care for older people who present with a fractured neck of femur (#NOF) have been defined by previously published national guidelines. To assess compliance with these standards the Healthcare Commission commissioned the Clinical Effectiveness and Evaluation Unit (CEEU) for the Royal College of Physicians to deliver 'The National Clinical Audit of Falls and Bone Health for Older People'. METHODS: The audit was developed by a multi-disciplinary team using available best evidence to set audit standards. All acute hospital trusts admitting orthopaedic trauma cases and all primary care trusts (PCTs) in England were recruited. Patients >65 years old presenting with a proven #NOF were included in the audit with a target of 20 cases per participating site. RESULTS: Data was entered for 3184 #NOF patients. 80% (2555/3184) were female with a median age of 83 years admitted from their own home (68% 2152/3184). Over 97% (3172/3184) presented to the A&E department on the same day as the fall (88% 2813/3184). The time in the A&E department was less than 2h in only 20% (640/3133) of cases with 23% (716/3133) having a stay of >240min. 35% (1080/3088) of #NOF patients were operated on within 24h of admission. Causes of delay to theatre included awaiting medical review (59% 566/956) or organisational reasons (29% 278/956). 48% (1480/2998) of patients were sat out of bed within 24h. Only 35% (1115/3184) of patients were cared for in an orthogeriatric setting. The median length of stay for the #NOF patients was 16 days with an interquartile range of 10-27 days. CONCLUSIONS: There are currently unacceptable wide variations in the delivery of clinical care to older people presenting with a #NOF. Of concern were the long lengths of time in A&E for many patients and the low level of routine access to pre-operative medical assessment. It is hoped that the launch of joint initiatives between the British Orthopaedic Association and the British Geriatric Society aimed at delivering service improvements in this area should lead to improved outcomes |
0 | Subcapital fractures complicating pertrochanteric fractures treated by internal fixation. Review of the literature and 3 case reports | Management of Hip Fractures in the Elderly | Three female patients over 70 years of age were treated surgically for a pertrochanteric fracture of the hip. In 2 of them internal fixation was achieved by way of a dynamic screw-plate assembly while intramedullary Ender nails were used in the 3rd patient. All 3 patients were readmitted a couple of months after discharge from hospital due to a new subcapital fracture that occurred ipsilaterally through the tip of the fixation device after the primary pertrochanteric fracture had already reached a solid union. None of these cases resulted from inadequate placement of the fixation device: 1. The neck-shaft angle had been correctly restored. 2. The metals were centrally positioned in the femoral head and neck as documented in both the AP and axial views. 3. The distance between the subchondral bone and the tip of the device was consistently less than 10 mm. Neither X-rays nor histology showed any evidence of AVN or other pathologic processes (other than osteoporosis). This rare complication which requires immediate reoperation with removal of the metals and some form of arthroplasty of the hip joint has been reported 27 times following different types of internal fixation methods. The etiology of these interesting cases is still unclear and multiple theories have been proposed to explain this phenomenon. Among these the most popular is that of a technical error consisting of inserting the nail not deeply enough into the subchondral bone thus exposing the cancellous femoral neck to strong forces that tend to deform the femoral head into a varus position, with the metallic tip acting as a stress riser. Our own observations hereby presented challenge this theory as we have found no evidence to support it. The fact that perfect positioning of the device is not enough to guarantee a successful outcome raises the issue of whether it is justified to consider a second operative intervention for early removal of the metals as a preventive measure |
1 | Antimicrobial prophylaxis for surgery: An advisory statement from the National Surgical Infection Prevention Project | Diagnosis of Periprosthetic Joint Infections of the Hip and Knee CPG | In January 2003, leadership of the Medicare National Surgical Infection Prevention Project hosted the Surgical Infection Prevention Guideline Writers Workgroup meeting. The objectives were to review areas of agreement among the published guidelines for surgical antimicrobial prophylaxis, to address inconsistencies, and to discuss issues not currently addressed. The participants included authors from most of the published North American guidelines for antimicrobial prophylaxis and several specialty colleges. The workgroup reviewed currently published guidelines for antimicrobial prophylaxis. Nominal group process was used to draft a consensus paper that was widely circulated for comment. The consensus positions of the workgroup include that infusion of the first antimicrobial dose should begin within 60 minutes before surgical incision and that prophylactic antimicrobial agents should be discontinued within 24 hours of the end of surgery. This advisory statement provides an overview of other issues related to antimicrobial prophylaxis including specific suggestions regarding antimicrobial selection |
0 | Bone impairment assessed by HR-pQCT in juvenile-onset systemic lupus erythematosus | Distal Radius Fractures | Summary: High-resolution peripheral quantitative computed tomography (HR-pQCT) analysis of female juvenile-onset systemic lupus erythematosus (JoSLE) patients revealed trabecular/cortical bone damage and reduced bone strength primarily at the distal radius compared to healthy controls. We demonstrated for the first time that JoSLE patients with vertebral fracture (VF) present trabecular impairment at the distal radius. Introduction: This study investigated the volumetric bone mineral density (vBMD), microarchitecture, and biomechanical features at the distal radius and tibia using HR-pQCT and laboratory bone markers in JoSLE patients compared to controls to determine whether this method discriminates JoSLE patients with or without VF. Methods: We compared 56 female JoSLE patients to age- and Tanner-matched healthy controls. HR-pQCT was performed at the distal radius and tibia. Serum levels of the amino-terminal pro-peptide of type I collagen, the C-terminal telopeptide of type I collagen, intact parathormone, sclerostin, and 25-hydroxyvitamin D (25OHD) were evaluated. VFs were analyzed using VFA-dual-energy X-ray absorptiometry (DXA) (Genantâ??s method). Results: Reduced density and strength parameters and microarchitecture alterations of cortical and trabecular bones were observed in JoSLE patients compared to controls, primarily at the distal radius (p < 0.05). Patients with VF exhibited a significant decrease in trabecular bone parameters solely at the distal radius (Total.BMD, p = 0.034; Trabecular.BMD [Tb.BMD], p = 0.034; bone volume (BV)/trabecular volume (TV), p = 0.034; apparent modulus, p = 0.039) and higher scores for disease damage (Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index (SLICC/ACR-DI), p = 0.002). Bone metabolism markers were similar in all groups. Logistic regression analysis of parameters that were significant in univariate analysis revealed that Tb.BMD (OR 0.98, 95Â % CI 0.95â??0.99, p = 0.039) and SLICC/ACR-DI (OR 7.37, 95Â % CI 1.75â??30.97, p = 0.006) were independent risk factors for VF. Conclusion: In conclusion, this study is the first demonstration of bone microstructure and strength deficits in JoSLE patients, particularly at the distal radius. Our results demonstrated that VF was associated with trabecular radius alteration and emphasized the potential detrimental effect of disease damage on this condition. |
0 | Feasibility of the Atlas Unicompartmental Knee System Load Absorber in Improving Pain Relief and Function in Patients Needing Unloading of the Medial Compartment of the Knee: 1-Year Follow-Up of a Prospective, Multicenter, Single-Arm Pilot Study (PHANTOM High Flex Trial) | OAK 3 - Non-arthroplasty tx of OAK | In young patients with medial knee osteoarthritis (OA), surgical intervention may not be desirable due to preferences to avoid bone cutting procedures, return to high activity levels, and prolong implant survival. The Atlas Knee System was designed to fill the gap between ineffective conservative treatments and invasive surgery. This single-arm study included 26 patients, aged 25 to 65 years, who completed 12 months of follow-up. All dimensions of the Knee injury and Osteoarthritis Outcome Score (KOOS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and Knee Society Score significantly improved from baseline to 12 months. About 96.2% and 92.3% of patients experienced a ⩾20% improvement in their KOOS pain and WOMAC pain scores, respectively, at 12 months. This study highlights the potential benefit of a joint unloading device in the management of young patients with medial knee OA. The trial is still ongoing and another analysis is planned at 24 months. |
0 | Medial and Lateral Meniscus Allograft Transplantation Showed No Difference With Respect to Graft Survivorship and Clinical Outcomes: A Comparative Analysis With a Minimum 2-Year Follow-Up | AMP (Acute Meniscal Pathology) | PURPOSE: To compare the differences with respect to clinical and graft survivorship and patient-reported outcomes (PROs) between lateral (LMAT) and medial (MMAT) meniscus allograft transplantation.
METHODS: Patients having a primary MAT between 1998 and 2016 were enrolled. The inclusion criteria were (1) patients who had a minimum 2-year follow-up and (2) patients who had magnetic resonance imaging (MRI) >2 years after surgery. Knees with localized grade 4 articular cartilage lesions >3 cm<sup>2</sup> at the time of MAT were excluded. Clinical failure was defined as follows: modified Lysholm score <65, meniscectomy >50% of the graft, meniscectomy to the meniscocapsular junction zone, conversion to revision MAT, or realignment osteotomy or arthroplasty. Graft failure was defined as follows: tears involving >50% of the graft or unhealed peripheral rim observed on MRI. Kaplan-Meier survival analysis with log-rank test was used to compare survivorship between LMAT and MMAT. Patient-reported outcomes were compared based on the Hospital for Special Surgery, modified Lysholm, and International Knee Documentation Committee subjective scores collected preoperatively and at the final follow-up.
RESULTS: A total of 299 knees (249 LMAT, 50 MMAT, mean age 33.0 +/- 9.8 years) were included. Twenty clinical [2 MMAT (4.0%), 18 LMAT (7.2%)] and 24 graft [2 MMAT (4.0%), 22 LMAT (8.8%)] failures were identified. The mean clinical follow-up period was 63.1 +/- 43.1 months (range 2 to 248), and MRI follow-up period was 62.6 +/- 43.8 months (range 2 to 248). No significant differences in clinical and graft survivorship were found between the LMAT and MMAT groups (P = .481, P = .271, respectively). PROs preoperatively and at last follow-up also showed no significant difference between the groups.
CONCLUSION: No significant differences in clinical survivorship, graft survivorship, and PROs were found between the LMAT and MMAT groups.
LEVEL OF EVIDENCE: Level III, retrospective comparative study. |
0 | Treatment with thalidomide and cyclophosphamide (TCID) is superior to vincristine (VID) and to vinorelbine (VRID) regimens in patients with refractory or recurrent multiple myeloma | MSTS 2018 - Femur Mets and MM | Treatment of relapsed or refractory multiple myeloma remains a challenge and novel treatment regimen are required. Here, a matched pair analysis was performed comparing TCID (thalidomide, cyclophosphamide, idarubicin, dexamethasone) treatment to the treatment of patients with VID (vincristine, idarubicin, dexamethasone) or with VRID (vinorelbine, idarubicin, dexamethasone) for relapsed or refractory multiple myeloma. In total, 197 patients were enrolled in multicenter trials. After matching for important prognostic variables 46 matched-pairs (total of 138 patients) could be analysed with regard to survival, toxicity and efficacy. Interestingly, a significant improvement of overall response rate (ORR) for TCID treatment compared to VID and VRID was found. In addition, TCID treatment also led to a significantly higher overall survival (OS) as well as progression- free survival (PFS) compared to VID and VRID. In conclusion, TCID treatment appears to be superior to VRID and VID treatment in patients with progressive or refractory myeloma. © Indian Society of Haematology & Transfusion Medicine 2011. |
0 | Intrathecal morphine provides better postoperative analgesia than psoas compartment block after primary hip arthroplasty | AAHKS (8) Anesthetic Infiltration | PURPOSE: Intrathecal morphine and psoas compartment block represent two accepted techniques to provide postoperative analgesia after hip arthroplasty. We designed a prospective, randomized, single-blinded study to compare these two techniques.
METHODS: Patients scheduled for primary hip arthroplasty under general anesthesia were randomized to receive either an intrathecal administration of 0.1 mg morphine (Group I, n = 27) or a psoas compartment block with ropivacaine 0.475% 25 mL (Group II, n = 26). Pain scores, morphine consumption, associated side-effects were assessed for 48 hr postoperatively. In addition, patient's acceptance and satisfaction of the postoperative analgesic technique were also recorded.
RESULTS: During the first 24 hr, pain scores (3.3 +/- 9.6 mm vs 22.8 +/- 27.1 at H+6, 3.3 +/- 8.3 mm vs 25 +/- 26.7 mm at H+12, 7 +/- 14.9 mm vs 21.9 +/- 29 mm at H+18) and morphine consumption (0.56 +/- 2.12 mg vs 9.42 +/- 10.13 mg) were lower in Group I than in Group II. Urinary retention was the more frequent side-effect occurring in 37% of cases in Group I vs 11.5% in Group II (P < 0.05). No major complication occurred. Despite better analgesia provided by the use of intrathecal morphine, there was no difference in the satisfaction scores between groups.
CONCLUSION: 0.1 mg intrathecal morphine administration provides better postoperative analgesia than single-shot psoas compartment block after primary hip arthroplasty. |
0 | Cartilage Disease of the Patellofemoral Joint: Realignment, Restoration, Replacement | Osteochondritis Dissecans 2020 Review | Chondral lesions of the patellofemoral joint are common, and when symptomatic they can be difficult to manage. Not only are there various degrees of injury with multiple etiologies, but patellofemoral anatomy is complex and the patient's lower extremity alignment may contribute to the pathology. Treatment depends on the location, size, and depth of the lesion and may require realignment or concomitant stabilizing procedures. Tibial tubercle osteotomy can be performed in isolation or combined with various cartilage-based treatments, including marrow stimulation techniques, autologous chondrocyte implantation, osteochondral autograft, and osteochondral allograft. End-stage lesions, failed primary patellofemoral cartilage restoration with diffuse involvement, or isolated primary patellofemoral arthritis may be amenable to treatment with patellofemoral arthroplasty. Recent investigations in properly indicated patients using advanced techniques have shown that management of patellofemoral cartilage disease is now more effective and predictable than in the past. |
0 | Visual concerns that interfere with daily activities in patients on rehabilitation units: a descriptive study | Upper Eyelid and Brow Surgery | The purpose of this study was to estimate the prevalence of patients with visual concerns that interfere with their activities of daily living (ADL) performance in physical rehabilitation units through occupational therapy assessment. Over the two-month study period, 215 adult inpatients from a physical rehabilitation hospital were evaluated using the Brief Vision Screen (BVS) through ADL. The BVS assessed four areas of visual concerns, namely left visual field, focusing, and near- and low-contrast acuity, while patients engaged in ADL. The occupational therapists identified 33% of patients who had at least one area of visual concern, with the largest proportion diagnosed with stroke (55%), followed by pulmonary disease (40%) and joint replacement (35%). When comparing the four areas of visual concerns in the BVS between the two major diagnostic groups (acquired brain injury, ABI and non-acquired brain injury, non-ABI), a significantly higher proportion of patients with ABI were identified as having left hemianopsia concerns compared to patients with non-ABI. No significant difference was observed in other areas of visual concern between the two groups. Findings indicated that visual concerns that interfere with ADL performance among older patients in rehabilitation units are common. The high proportion of patients with pulmonary disease identified as having visual concerns warranted further confirmation and investigation. Preliminary evidence to support the psychometric properties of the BVS for identifying visual concerns in patients on rehabilitation units was established. |
0 | New technique of soft tissue reconstruction for proximal tibiofibular joint instability using iliotibial band and biceps femoris longhead autograft | AMP (Acute Meniscal Pathology) | Instability of the proximal tibiofibular joint is an uncommon problem, which may occur in multiple directions and because of multiple etiologies. Proximal tibiofibular joint instability can be divided into 3 types: acute traumatic dislocations, chronic or recurrent dislocation, and atraumatic subluxations. Instability of this joint may be in the anterolateral, posteromedial, or superior directions. Chronic instability results in lateral knee pain and instability with snapping or catching often leading to a misdiagnosis of lateral meniscal injury. Subluxation may be treated nonsurgically with activity modification, supportive straps, and knee strengthening therapy. Chronic pain or instability is an indication for surgical treatment including arthrodesis, fibular head resection, or soft tissue ligamentous reconstruction. The article describes the use of a new technique for reconstruction using the iliotibial band and a biceps femoris longhead autograft. |
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