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NexGen LPS rotating platform total knee arthroplasty: medium-term results of a prospective study

Surgical Management of Osteoarthritis of the Knee CPG

The purpose of this study is to present midterm results of NexGen LPS (Zimmer, Warsaw) rotating platform total knee arthroplasty. A prospective consecutive series of 50 primary rotating platform total knee replacements in 43 patients were clinically and radiographically evaluated at a mean follow-up of 46.4 (range 30-78) months. There were 12 men (30%) and 31 women (70%) with an average age of 72.3 years (range 55-85). All implants were cruciate-substituting and cemented. Patients were assessed using the Knee Society Clinical Rating System and the Knee Society Total Knee Arthroplasty Roentgenographic Evaluation and Scoring System. Pre-operatively, the mean knee score was 50.7 points (SD 15.1) and the mean function score was 40.5 points (SD 22.7). Post-operatively the mean knee score was 91.6 (SD 6.5) and the mean function score was 85.9 (SD 17.4). No sign of component loosening or osteolysis could be identified. The NexGen LPS rotating platform total knee replacement design provided excellent mid-term clinical and radiographical results

Identifying crash involvement among older drivers: agreement between self-report and state records

Upper Eyelid and Brow Surgery

Older drivers have a high crash rate per vehicle mile of travel. Coupled with the growth of the number of older drivers on the road, this has generated interest in the identification of factors which place older drivers at increased risk. However, much of the existing research on medical and functional risk factors for crash involvement has generally been inconsistent. Methodological differences between studies have been hypothesized as being partly responsible for such inconsistencies. The source of information used to identify crash-involved drivers has been identified as one such difference. This paper reports on the agreement between self-report and state record for identifying crash involved-older drivers. We also sought to determine whether the prevalence of visual and cognitive impairment differs across crash-involved drivers identified by either or both sources. Finally, we assessed whether risk factors for crash involvement differed when crash-involved drivers were identified by either self-report or state records. Results indicated that there was a moderate level of agreement between self-reported and state-recorded crash involvement (kappa = 0.45). However, we did find significant differences between crash-involved drivers identified via state records and/or self-report with respect to demographic (age, race), driving (annual mileage, days per week driven), and vision impairment (acuity, contrast sensitivity, peripheral visual field sensitivity, useful field of view). We also found that the possibility for biased measures of association is real. Useful field of view impairment was associated with both self-reported and state-recorded crash involvement; however, the magnitude of the associations was disparate. Moreover, glaucoma was identified as a significant risk factor when considering state-recorded crashes but not self-reported crashes. While validation of these findings is required, research designed to identify risk factors for crash involvement among older drivers should carefully consider the issue of case definition, particularly if self-report is used to identify crash-involved older drivers.

Osteoporosis

Management of Hip Fractures in the Elderly

Osteoporosis, as defined by the National Osteoporosis Foundation, is a disease that is characterized by low bone mass and structural deterioration of bone tissue, which leads to bone fragility and an increased susceptibility to fractures. Aging is only one factor that contributes to the development of osteoporosis. Genetics, suboptimal nutrition, deficiency of calcium and vitamin D, lifestyle, smoking, decrease in sex hormone production, and medications also contribute to skeletal fragility. Osteoporotic fractures are a frequent and important cause of disability and medical costs worldwide. Fortunately, osteoporotic fractures are preventable. Several guidelines for the prevention, screening, diagnosis, and management for osteoporosis have been established. Although some are consistent and similar, others are not

Bisphosphonate-related osteonecrosis of the maxilla and sinusitis maxillaris

MSTS 2018 - Femur Mets and MM

Bisphosphonates (BPs) are widely used as bone-stabilizers, but side effects of BP therapy include bisphosphonate-related osteonecrosis of the jaw (BRONJ), which is resistant to therapy. The aim of this study was to evaluate the outcome of maxillary BRONJ involving sinusitis maxillaris. 21 patients presenting with maxillary BRONJ, from 2005 to 2008, were included in the study. In 18 cases BP had been administered for carcinoma and in 3 cases for osteoporosis, with an average exposure time of 47.4 months. 12 patients spontaneously developed BRONJ. The 10 patients diagnosed with stage III BRONJ presented with concomitant sinusitis maxillaris. Despite treatment, there were six recurrences of BRONJ, four of them with additional sinusitis maxillaris. Whether BRONJ occurred spontaneously or after extraction there was no difference in the outcome. Patients with advanced maxillary BRONJ often suffer from sinusitis maxillaris, both of which are frequently resistant to therapy. © 2010 International Association of Oral and Maxillofacial Surgeons.

Neuro-ophthalmological symptoms in vertigo and dizziness

Upper Eyelid and Brow Surgery

The vestibular and visual systems are closely linked in the genesis of vertigo and dizziness. An examination of these two systems is helpful in the search for an aetiological diagnosis. In ENT, this double approach can also help to avoid certain ophthalmological pitfalls such as the mistaken idea that a squint cannot be of vestibular origin, that the absence of diplopia symptoms is enough to exclude any recent oculomotor paresis, or even that eyelid asymmetry is not relevant to diagnosing dizziness. This paper is intended to help in understanding the neuro-ophthalmological aspects of the guidelines. It is sometimes limited to defining certain terms. However, on the whole, it covers diagnostic procedures.

Undiagnosed phaeochromocytoma in the perioperative period. Case reports

Management of Hip Fractures in the Elderly

Phaeochromocytomas appear as frequently as one in 1000-2000 patients. Release of catecholamines may be triggered by events in the perioperative period. Patients whose phaeochromocytomas are diagnosed in this period, have a mortality of about 80%. Three patients with perioperative debut of symptoms of a phaeochromocytoma are presented. A possible drug-induced release of catecholamines from the tumour is suggested for two of the patients. The first symptoms of a phaeochromocytoma may be arrhythmias and shock, which favours the use of adrenergic blockade prior to elective removal of phaeochromocytomas. Therapeutic approaches to the treatment of catecholamine-induced heart failure may be potassium and magnesium supplements and possibly drugs reducing circulating angiotensin II activities. Caution is advised in the use of digitalis

Low bone mineral density in Indian patients with fragility fractures

Management of Hip Fractures in the Elderly

Objective Low bone mineral density (BMD) is a major risk factor for fragility fractures in osteoporosis. In recent studies, its use with clinical risk factors has been shown to enhance prediction of fragility fractures. The present study was done to assess BMD in Indian patients with fragility fractures using digital X-ray radiogrammetry (DXR-BMD). Methods A total of 228 patients (64 male and 164 female) admitted to an Orthopedic Hospital for management of fragility fracture were recruited. For each patient, DXR-BMD was obtained from an anteroposterior radiograph of the non-dominant hand. Results The number of subjects with hip fracture was 104 (40 male, 64 female). Vertebral fractures were seen in 67 patients (11 male, 56 female) and distal radial fracture in 57 patients (13 male, 44 female). The DXR-BMD (g/cm(2)) was significantly lower in subjects with any fragility fracture (0.51 vs. 0.58 in men and 0.41 vs. 0.54 in women). When compared to the age-matched normative reference data by decade, all subjects with fragility fracture had significantly lower DXR-BMD except male subjects in the age decade of 4049 years. Conclusion This study confirms lower DXR-BMD in Indian subjects with fragility fractures. This may have a potential role in fracture prediction when used with clinical risk factors in the Indian population. (copyright) 2012 International Menopause Society

Comparative study on the wrist positions during raise maneuver and their effect on hand function in individuals with paraplegia

Diagnosis and Treatment of Carpal Tunnel Syndrome CPG

OBJECTIVE: To determine the appropriate wrist position in individuals with high-level paraplegia during the RAISE (relief of anatomical ischial skin embarrassment) maneuver. METHOD: Thirty individuals with high-level paraplegia were randomly selected; 15 individuals performed RAISE maneuver with extended wrist and 15 with neutral wrist. All the subjects who were at least 1 year post spinal cord injury were screened for positive carpal tunnel syndrome symptoms. All the subjects were allowed to participate in a trial of the Jebsen-Taylor Test of Hand Function to familiarize them with the test. Hand function was measured using the Jebsen-Taylor test. RESULTS: During the RAISE maneuver, individuals with paraplegia weight bearing on their hands with wrists in the neutral position showed better hand function (P < .001) when compared to those weight bearing with their wrists in extension. CONCLUSION: Weight bearing with the wrist in neutral position is advisable for paraplegics to prevent the deterioration in hand function due to carpal tunnel syndrome

Topical capsaicin (low concentration) for chronic neuropathic pain in adults

SR for PM on OA of All Extremities

Background: Topical creams with capsaicin are used to treat pain from a wide range of chronic conditions including neuropathic pain. Following application to the skin capsaicin causes enhanced sensitivity to noxious stimuli, followed by a period with reduced sensitivity and, after repeated applications, persistent desensitisation. There is uncertainty about the efficacy and tolerability of capsaicin for treating painful chronic neuropathies. This is an update of an earlier review of topical capsaicin for chronic neuropathic pain in adults that looked at all doses and formulations of capsaicin. The original review has now been split: here we consider only formulations using a low concentration of capsaicin (< 1%) applied several times daily over several weeks, while another review will consider a single application of capsaicin at a high concentration.Objectives: To review the evidence from controlled trials on the efficacy and tolerability of topically applied low-concentration (< 1%) capsaicin in chronic neuropathic pain in adults.Search methods: Cochrane CENTRAL, MEDLINE, EMBASE and Oxford Pain Relief Database, searched to July 2012.Selection criteria: Randomised, double-blind, placebo-controlled studies of at least six weeks' duration, using low-concentration (< 1%) topical capsaicin to treat neuropathic pain.Data collection and analysis: Two review authors independently assessed study quality and validity, and extracted data. Information was extracted on numbers of participants with pain relief (clinical improvement) after at least six weeks, and with local skin reactions, and used to calculate relative risk (or risk ratio, RR) and numbers needed to treat to benefit (NNT) and harm (NNH). Details of definition of pain relief and specific adverse events were sought.Main results: No additional studies were identified for this update of low concentration capsaicin. Included studies were published before 1996. Six studies (389 participants in total) compared regular application of low dose (0.075%) capsaicin cream with placebo cream. There was substantial heterogeneity in results, probably as a result of the small number of studies each with small numbers of participants, as well as the different pain conditions studied and different definitions of "clinical success" reported. Only two studies reported data for the preferred primary outcome of at least 50% pain relief, and there were too few data for pooled analysis. Local skin reactions were more common with capsaicin, usually tolerable, and attenuated with time; the NNH for repeated low-dose application was 2.5 (95% confidence interval (CI) 2.1 to 3.1). All studies satisfied minimum criteria for quality and validity, but maintenance of blinding remains a potential problem.Authors' conclusions: There were insufficient data to draw any conclusions about the efficacy of low-concentration capsaicin cream in the treatment of neuropathic pain. The information we have suggests that low-concentration topical capsaicin is without meaningful effect beyond that found in placebo creams; given the potential for bias from small study size, this makes it unlikely that low-concentration topical capsaicin has any meaningful use in clinical practice. Local skin irritation, which was often mild and transient but may lead to withdrawal, was common. Systemic adverse effects were rare

Extended osteotomy for periprosthetic femoral fractures in total hip arthroplasty

DoD SSI (Surgical Site Infections)

Total hip arthroplasty periprosthetic fractures that involve a loose prosthesis and are located at or beyond the tip of the prosthesis are difficult to manage and have higher complication and nonunion rates. In this case report, I describe a fracture-site exposure that allows simple insertion of a long, distally fixed revision prosthesis. In an extended femoral osteotomy, the entire proximal fragment opens the upper segment in "clamshell" fashion. The proximal segment is repaired with or without femoral strut allografts and multiple cerclage wires. With this method, 7 periprosthetic fractures united successfully, and none has required further reconstruction.

CircSPI1_005 ameliorates osteoarthritis by sponging miR-370-3p to regulate the expression of MAP3K9

AMP (Acute Meniscal Pathology)

BACKGROUND: Osteoarthritis (OA), caused by the destruction of joint cartilage, is the most prevalent form of arthritis, causing pain and stiffness in joints among millions of patients worldwide. Increasing evidence suggests that non-coding RNAs, including circular RNAs, play important roles in the pathogenesis of OA, but the precise signaling pathway is still unclear. METHODS: To study OA, we established a mouse model by the destabilized medial meniscus (DMM) surgery and used IL-1beta stimulated human cell line C28/I2 as an in vitro study. To further study the role of circSPI1_005 in regulating cell proliferation and apoptosis, EdU staining and FACS-based (fluorescence-activated cell sorting) apoptosis examination were performed after the manipulation of the expression of circSPI1_005. Also, bioinformatics predictions were conducted to analyze the downstream microRNAs of circSPI1_005 and the protein regulated by circSPI1_005. The luciferase assay and the RNA immunoprecipitation (RIP) assay were used to confirm the binding between circSPI1_005 and the predicted microRNA. To verify the role of circSPI1_005 in regulating OA in vivo, we also over-expressed circSPI1_005 by injecting AAV into previously injured knees to improve the OA symptoms. RESULTS: In this study, we found that circSPI1_005 was significantly down-regulated in IL-1beta treated chondrocyte cell lines and cartilage tissues of the OA mouse model. Overexpression of circSPI1_005 ameliorated OA by increasing proliferation and inhibiting apoptosis, and knockdown of circSPI1_005 in chondrocytes mimicked OA phenotypes. Bioinformatics study showed circSPI1_005 could sponge to miR-370-3p, and mechanistic studies confirmed the functional binding between circSPI1_005 and miR-370-3p. Furthermore, we conducted a TargetScan analysis and found that MAP3K9 (mitogen-activated protein kinase kinase kinase 9) could be the downstream protein effector. The expression level of MAP3K9 was regulated by miR-370-3p and overexpression of MAP3K9 could efficiently ameliorate OA. Also, we over-expressed circSPI1_005 in vivo and found that the cartilage surface in the OA mouse model was improved with overexpression of circSPI1_005. CONCLUSIONS: Collectively, circSPI1_005 could sponge to miR-370-3p to regulate the expression of MAP3K9, ameliorating the progression of osteoarthritis.

High social desirability and prefrontal cortical activity in cancer patients: A preliminary study

DoD PRF (Psychosocial RF)

Background: Social desirability is sometimes associated with poor prognosis in cancer patients. Psychoneuro-immune interaction has been hypothesized as an underlying mechanism of the negative clinical outcome. Purpose of this study was to examine possible effects of high social desirability on the regional brain activity in patients with malignant diseases. Material/Methods: Brain metabolism of 16 patients with various malignant diseases was measured by PET with 18-fluorodeoxyglucose (FDG). Patients were divided into 2 groups using median split on Marlowe & Crown's Social Desirability Scale (MC), controlling for age, gender, and for severity of depression and anxiety, the possible two major influential factors. A group comparison of the regional cerebral activity was calculated on a voxel-by-voxel basis using statistical parametric mapping (SPM). Results: The subgroup comparison showed that the high social desirability was associated with relatively increased metabolism in the cortical regions in the prefrontal, temporal and occipital lobes as well as in the anterior cingulate gyrus. Conclusion: High social desirability seems to be associated with increased activity in the prefrontal and other cortical areas. The finding is in an accordance with previous studies that demonstrated an association between prefrontal damage and anti-social behavior. Functional neuroimaging seems to be useful not only for psychiatric evaluation of major factors such as depression and anxiety but also for further psychosocial factors in cancer patients.

Ultrasound- or nerve stimulation-guided wrist blocks for carpal tunnel release: a randomized prospective comparative study

Diagnosis and Treatment of Carpal Tunnel Syndrome CPG

BACKGROUND AND OBJECTIVES: We hypothesized that ultrasound-guided wrist blocks may be faster to perform, and may increase success rate, compared with nerve stimulation-guided wrist blocks. METHODS: Sixty patients undergoing ambulatory endoscopic carpal tunnel release were randomly allocated to receive median and ulnar nerve blocks using either sensory-motor nerve stimulation (n = 30) or ultrasound guidance (n = 30). Four mL of mepivacaine 1.5% was injected around each nerve. Performance time and onset time of complete sensory block were assessed. RESULTS: Median time to perform both median (ultrasound, 55 [48-60] vs. nerve stimulation, 100 [65-150] seconds, P = .002) and ulnar (ultrasound, 57 [50-70] vs. nerve stimulation, 80 [60-105] seconds, P = .02) nerve blocks were significantly shorter in the ultrasound group. Onset time of complete sensory block in the median (ultrasound, 370 [278-459] vs. nerve stimulation, 254 [230-300] seconds, P = .02) and ulnar (ultrasound, 367 [296-420] vs. nerve stimulation, 241 [210-300] seconds, P = .01) nerve areas were shorter in the nerve stimulation group. The success rate was 93% in both groups. CONCLUSIONS: This randomized prospective study demonstrates that ultrasound-guided wrist nerve blocks are as efficient as those performed with nerve stimulation

Outcomes of Endoprosthetic Replacement for Salvage of Failed Fixation of Malignant Pathologic Proximal Femur Fractures

MSTS 2018 - Femur Mets and MM

Background: Internal fixation is often used to treat pathologic proximal femur fractures. However, nonunion and/or tumor progression may lead to hardware failure. In such cases, endoprosthetic replacement may be considered. The purpose of this study is to analyze the outcome of patients undergoing conversion to an endoprosthetic replacement following failed fixation of a pathological proximal femur fracture. Methods: We identified 26 patients who underwent conversion hip arthroplasty for salvage of failed fixation of a pathologic proximal femur fracture between 2000 and 2016. Previous surgical hardware included femoral nail (n = 18), dynamic hip screw (n = 5), proximal femoral locking plate (n = 1), blade plate (n = 1), and cannulated screws (n = 1). Twenty-one patients had metastatic disease, 4 myeloma, and 1 lymphoma. All received adjuvant or neoadjuvant radiotherapy at a mean dose of 30 Gy. Results: There were 15 males and 11 females with mean age 63 ± 11 years. Patients underwent conversion arthroplasty at a mean of 13 ± 12 months after initial fixation. At final follow-up, 19 patients had died, with 5-year overall survival of 35%. Conversion to arthroplasty was performed due to disease progression (n = 12), hardware failure (n = 8), and nonunion (n = 6). Eight hips required reoperation, most commonly for infection (n = 4). At last follow-up, the Harris Hip Scores (P <.001) and Musculoskeletal Tumor Society Scores (P <.001) significantly improved from a mean of 24 and 14 preoperatively to 68 and 59 postoperatively, respectively. Conclusion: Conversion hip arthroplasty reliably provides improved quality of life and immediate weight bearing, making it an effective treatment for salvage of failed fixation of pathologic proximal femur fractures.

Infected dermoid cyst of the tongue with a sinus tract to the submental skin

Patrick’s pharmacoepidemiology project

Objectives: We report a case of a teratoid type dermoid cyst of the tongue with a sinus tract to the submental skin. Study design: Case report. Methods: We present a 3-month-old infant with a dermoid cyst of the tongue with a sinus tract to the submental skin and review of the literature on dermoid cysts of the tongue. Results: This rare case presented as an enlarging tongue mass and difficulty feeding. A midline submental skin pinpoint discharge revealed to be a sinus tract connecting the cyst to the skin. Complete excision of the cyst and sinus tract through midline ventral tongue and submental incisions was performed. Conclusion: Although dermoid cysts of the tongue are rare they should be part of the differential diagnosis of tongue masses and presence of a sinus tract should be considered in such cases. �© 2007 Elsevier Ireland Ltd. All rights reserved

Effect of arthroscopic debridement for osteoarthritis of the knee on health-related quality of life

AMP (Acute Meniscal Pathology)

BACKGROUND: The available evidence supporting the use of arthroscopic debridement for the treatment of symptomatic osteoarthritis of the knee is largely retrospective and lacks validated health-related quality-of-life measures. The goal of the study was to prospectively assess a cohort of patients with osteoarthritis of the knee who were selected for arthroscopic debridement and determine which clinical criteria favor a sustained improvement in health-related quality of life after two years of follow-up. METHODS: One hundred and twenty-six patients with symptomatic primary osteoarthritis of the knee underwent arthroscopic debridement of the knee after failure of medical management. Two groups of surgeons (postgraduate fellows and attending staff) independently evaluated the patients preoperatively with use of a standardized assessment of clinical symptoms and signs and plain radiography. The intervention was arthroscopic debridement, which included resection of unstable chondral flaps and meniscal tears. Abrasion was not performed. Outcome measures included the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), a disease-specific scale, and the Short Form-36 (SF-36), a generic outcome measure. RESULTS: Sixty-seven (53%) of the 126 patients were female, and the mean age (and standard deviation) was 61.7 +/- 8.6 years (range, forty-three to seventy-five years). The medial compartment was more frequently and severely involved, with 57% showing Grade-III or IV involvement, according to the system of Dougados et al. Seventy-nine patients (63%) had an unstable meniscal tear. Fifty-six patients (44%) were rated as having had a clinically important reduction in pain, as determined with the WOMAC pain scale, at two years after the arthroscopic debridement. Physicians were poor at predicting which patients would have improvement. The rate of accuracy of the fellows and staff was 54% and 59%, respectively, and their agreement was only slightly better than chance, with a kappa of 0.27 (95% confidence interval, 0.09 to 0.45). Only three variables were significantly associated with improvement: the presence of medial joint-line tenderness (p = 0.04), a positive Steinman test (p = 0.01), and the presence of an unstable meniscal tear at arthroscopy (p = 0.01). CONCLUSIONS: The prospectively evaluated quality-of-life benefit from arthroscopic debridement of the osteoarthritic knee is less than that reported in previous retrospective surveys on satisfaction. These results may serve as a baseline for comparison against more sophisticated procedures for resurfacing of the articular cartilage. Clinical variables were only partially helpful for predicting a successful result after arthroscopic debridement, and a search for other biologic markers (such as synovial fluid) may be of benefit. LEVEL OF EVIDENCE: Therapeutic study, Level IV (case series [no, or historical, control group]). See p. 2 for complete description of levels of evidence.

[A case of locally advanced breast cancer successfully treated with wide resection and reconstruction of chest wall with A-O metallic plates]

Acellular Dermal Matrix

A 63-year-old female with locally advanced breast cancer was treated with preoperative chemotherapy using docetaxel. The therapeutic regimen was comprised of four cycles at 3-week intervals. One cycle consisted of 80 mg of docetaxel which was administered on day 1. A remarkable response was confirmed. The side effects such as leukopenia, general fatigue and alopecia were moderate and had no influence on the patient's QOL. After preoperative chemotherapy, a full thickness chest wall resection was performed. Chest wall defect was reconstructed with orthopedic A-O metallic plates, Marlex mesh and rectus abdominis myocutaneous flap. These metal plates were very useful because it was easy to bend and twist them manually to fit the defect at the time of operation. Moreover, the curved metal plates preserved the cone form of the chest cage. The postoperative course was favourable without frail chest or wound infection.

What Is the Price and Claimed Efficacy of Platelet-Rich Plasma Injections for the Treatment of Knee Osteoarthritis in the United States?

PRP (Platelet-Rich Plasma)

Platelet-rich plasma (PRP) injections are often used for the treatment of knee osteoarthritis (OA), despite clinical value and cost-effectiveness not being definitely established. PRP injections are considered as a potential means of reducing pain and improving function in patients with knee OA, in the hope of delaying or avoiding the need for surgical intervention. Centers that offer PRP injections usually charge patients out of pocket and directly market services. Therefore, the purpose of this study was to quantify the current (1) prices and (2) marketed clinical efficacy of autologous PRP injections for knee OA. A prospective cross-sectional study was performed based on 286 centers identified in the United States offering PRP injections for knee OA. A total of 179 (73.4%) centers were successfully contacted via e-mail or phone, using a simulated 52-year-old male patient with knee OA. Scripted questions were asked by the simulated patient to determine the current marketed prices and clinical efficacy, either reported as "good results" or "symptomatic improvement," claimed by each treating center. The mean price for a single unilateral knee same-day PRP injection was $714 with a standard deviation of $144 (95% confidence interval [CI]: $691-737, n = 153). The mean claim of clinical efficacy was 76% with a standard deviation of 11% (95% CI: 73.5-78.3%, n = 84). Out of the 84 clinics, 10 claimed "90 to 100% efficacy," 27 claimed "80 to 90%," 29 claimed "70 to 80%," 9 claimed "60 to 70%," 8 claimed "50 to 60%," and 1 claimed "40 to 60%." These findings provide a unique perspective on the PRP market for the treatment of knee OA that is valuable to physicians and health care providers in providing better education to patients on the associated costs and purported clinical benefits of PRP injections.

New oral anticoagulants after total knee arthroplasty: Clinical considerations for orthopaedic surgeons

AAHKS (9/10) Regional Nerve Blocks

Patients who undergo total knee arthroplasty are at risk of developing venous thromboembolism. Thromboprophylaxis is widely accepted as standard of care in patients receiving total knee arthroplasty, but implementation of clinical practice guidelines is hampered by several barriers, including limitations of current agents. New anticoagulants in clinical development offer equivalent or superior efficacy and safety to existing anticoagulants and the added convenience of oral administration. To date, rivaroxaban is the only new oral anticoagulant with regulatory approval for total knee arthroplasty in the United States, although dabigatran and apixaban are approved in other countries. For total knee arthroplasty, neuraxial blockade offers advantages over general anesthesia and narcotic-based systemic analgesia, but it carries a risk of spinal hematoma if used in conjunction with antithrombotics. Clinical practice guidelines already exist for the use of neuraxial blockade with traditional antithrombotics, and similar evidence-based recommendations are required for the new oral anticoagulants. © 2013 Wolters Kluwer Health.

Effects of computer-assisted navigation versus conventional total knee arthroplasty on the levels of inflammation markers: A prospective study

OAK 3 - Non-arthroplasty tx of OAK

Total knee arthroplasty (TKA) is a well-established modality for the treatment of advanced knee osteoarthritis (OA). However, the detrimental effects of intramedullary reaming used in conventional TKA for distal femur cutting are of concern. Avoiding intramedullary reaming with the use of computer-assisted navigation TKA can not only provide superior prosthetic alignment, but also mitigate perioperative blood loss and the dissipation of marrow emboli. We quantified local and systemic concentrations of inflammation markers for both techniques. Forty-four participants undergoing computer-assisted navigation and 53 receiving conventional TKA for advanced knee OA were recruited between 2013/02/08 and 2015/12/09. Blood samples were collected from all participants at baseline then again at 24 and 72 hours postoperatively and analyzed by ELISA for interleukin 6 (IL-6), IL-10, tumor necrosis factor alpha (TNF-alpha) and transforming growth factor beta 1 (TGF-beta1); these markers were also measured in Hemovac drain fluid collected at 24 and 72 hours. Serum levels of IL-6, IL-10, TNF-alpha and TGF-beta1(unit for all markers: pg/mL) were increased from baseline by smaller increments in the navigation TKA cohort compared with the conventional TKA group at 24 hours (17.06 vs 29.39, p = 0.02; 0.51 vs 0.83, p = 0.16; -0.04 vs 0.36, p < 0.01 and -48.18 vs 63.24, p< 0.01, respectively) and at 72 hours (12.27 vs 16.87, p = 0.01; -0.40 vs 0.48, p < 0.01; 0.58 vs 0.98, p = 0.07 and -55.16 vs 63.71, p < 0.01, respectively). IL-10 levels in drainage fluids collected 24 hours after TKA were also significantly lower in the navigation group versus the conventional TKA group (8.55 vs 12.32, p < 0.01). According to our evidence, the merits of computer-assisted navigation TKA are augmented by low levels of inflammation markers.

Increased capsaicin receptor TRPV1 in skin nerve fibres and related vanilloid receptors TRPV3 and TRPV4 in keratinocytes in human breast pain

Reduction Mammoplasty for Female Breast Hypertrophy

BACKGROUND: Breast pain and tenderness affects 70% of women at some time. These symptoms have been attributed to stretching of the nerves with increase in breast size, but tissue mechanisms are poorly understood. METHODS: Eighteen patients (n = 12 breast reduction and n = 6 breast reconstruction) were recruited and assessed for breast pain by clinical questionnaire. Breast skin biopsies from each patient were examined using immunohistological methods with specific antibodies to the capsaicin receptor TRPV1, related vanilloid thermoreceptors TRPV3 and TRPV4, and nerve growth factor (NGF). RESULTS: TRPV1-positive intra-epidermal nerve fibres were significantly increased in patients with breast pain and tenderness (TRPV1 fibres / mm epidermis, median [range] - no pain group, n = 8, 0.69 [0-1.27]; pain group, n = 10, 2.15 [0.77-4.38]; p = 0.0009). Nerve Growth Factor, which up-regulates TRPV1 and induces nerve sprouting, was present basal keratinocytes: some breast pain specimens also showed NGF staining in supra-basal keratinocytes. TRPV4-immunoreactive fibres were present in sub-epidermis but not significantly changed in painful breast tissue. Both TRPV3 and TRPV4 were significantly increased in keratinocytes in breast pain tissues; TRPV3, median [range] - no pain group, n = 6, 0.75 [0-2]; pain group, n = 11, 2 123, p = 0.008; TRPV4, median [range] - no pain group, n = 6, [0-1]; pain group, n = 11, 1 [0.5-2], p = 0.014). CONCLUSION: Increased TRPV1 intra-epidermal nerve fibres could represent collateral sprouts, or re-innervation following nerve stretch and damage by polymodal nociceptors. Selective TRPV1-blockers may provide new therapy in breast pain. The role of TRPV3 and TRPV4 changes in keratinocytes deserve further study.

Conversion of hip fusion to total hip arthroplasty: clinical, radiological outcomes and complications in 40 hips

OAK 3 - Non-arthroplasty tx of OAK

Objective: The purpose of this retrospective study is to report the clinical and radiological outcome of total hip arthroplasty in patients with previous hip arthrodesis. Patients and methods: We retrospectively reviewed 28 (40 hips) prospectively followed patients in whom ankylosed hips were converted to total hip arthroplasty (THA) between 2010 and 2014 in our institution. The average age at the time of the conversion operation was 40.8 ± 9.8 years (range 24â??62). The ankylosis had lasted 20.4 ± 13.0 years (range 3â??56) before conversion surgery. The etiology of the ankylosis was septic arthritis in 10 (25%), post-traumatic hip osteoarthritis in 8 (20%), developmental hip dysplasia in 6 (15%), rheumatoid arthritis in 6 (15%), primary osteoarthritis in 5 (12.5%) and ankylosing spondylitis in 5 (12.5%) hips. The indications for arthroplasty were intractable low back pain in 14 (50%), hip pain in 24 (85.7%), and ipsilateral knee pain in 19 (67.8%) patients. Harris Hip Score (HHS) was used to rate the clinical results before and after the surgery. Radiographic evaluations included component malposition and loosening. All complications during the study period were recorded. Results: The mean follow-up period was 39.9 ± 10.6 months (range 24â??60). The mean preoperative HHS was 33.3 ± 8.6 (range 18â??50) and the mean HHS at the final follow-up was 74.9 ± 8.6 (range 52â??97). There was a statistically significant increase in HHS (p = 0.0001). HHS was excellent in 1, good in 6, fair in 14 and poor in 7 patients. Increase in HHS was lower than 20 points in one patient (18 points), and one patient required two-staged exchange procedure due to deep infection. Thus, according to our success criteria (increase in HHS more than 20 points, radiographically stable implant, and no further surgical reconstruction), 92.8% (26/28) of patients had benefit from the surgery. Trendelenburg sign was positive in 12 hips. There was limb length inequality in 11 patients (mean 0.5 cm, range 1â??3 cm). No patients had heterotopic ossification, sciatic nerve palsy or dislocation. There were five intra-operative fractures of the greater trochanter that were treated with cable wiring. One patient had trochanteric avulsion injury and was treated with trochanteric grip and cables. One patient (2.5%) had deep infection one year after the conversion THA and was treated with two-staged exchange procedure. Conclusion: Conversion hip arthroplasty is an effective treatment method which provides functional recovery and patient satisfaction. However, a proper surgical technique and planning is necessary to minimize the complications.