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Bundled Care for Hip Fractures: A Machine-Learning Approach to an Untenable Patient-Specific Payment Model

Hip Fx in the Elderly 2019

Objectives:With the transition to a value-based model of care delivery, bundled payment models have been implemented with demonstrated success in elective lower extremity joint arthroplasty. Yet, hip fracture outcomes are dependent on patient-level factors that may not be optimized preoperatively due to acuity of care. The objectives of this study are to (1) develop a supervised naive Bayes machine-learning algorithm using preoperative patient data to predict length of stay and cost after hip fracture and (2) propose a patient-specific payment model to project reimbursements based on patient comorbidities.Methods:Using the New York Statewide Planning and Research Cooperative System database, we studied 98,562 Medicare patients who underwent operative management for hip fracture from 2009 to 2016. A naive Bayes machine-learning model was built using age, sex, ethnicity, race, type of admission, risk of mortality, and severity of illness as predictive inputs.Results:Accuracy was demonstrated at 76.5% and 79.0% for length of stay and cost, respectively. Performance was 88% for length of stay and 89% for cost. Model error analysis showed increasing model error with increasing risk of mortality, which thus increased the risk-adjusted payment for each risk of mortality.Conclusions:Our naive Bayes machine-learning algorithm provided excellent accuracy and responsiveness in the prediction of length of stay and cost of an episode of care for hip fracture using preoperative variables. This model demonstrates that the cost of delivery of hip fracture care is dependent on largely nonmodifiable patient-specific factors, likely making bundled care an implausible payment model for hip fractures.

Revision Decompression and Collagen Nerve Wrap for Recurrent and Persistent Compression Neuropathies of the Upper Extremity

Diagnosis and Treatment of Carpal Tunnel Syndrome CPG

BACKGROUND: Recurrent or persistent compression neuropathies of the upper extremity, including carpal and cubital tunnel syndrome, present a difficult treatment challenge to the hand or peripheral nerve surgeon. Collagen conduits have been used successfully for decades in nerve injury repair, but have not been studied in the treatment of compression neuropathy. METHODS: Patients with recurrent or persistent compression neuropathies treated with a repeat decompression and collagen wrap from a 5-year period were retrieved from the Computerized Patient Record System database and 15 patient records were identified. A systematic review was performed for all articles from 1946 to 2012 on secondary carpal and cubital tunnel syndrome. RESULTS: The mean age of the 15 patients treated was 63.3 years and ranged from 35 to 86 years. The patients with revision carpal tunnel decompression had an 89% subjective response rate, whereas those with revision cubital tunnel decompression had an 83% resolution or improvement of symptoms. Visual analog scale decreased from a preoperative mean 2.47 to 0.47 postoperatively and the mean number of opiate medications decreased from 0.67 to 0.40. We identified 32 papers using various treatment strategies for recurrent carpal tunnel syndrome with success rates ranging from 53% to 100%. We identified 18 papers on recurrent cubital tunnel syndrome, with success rates ranging from 33% to 100%, with a weighted success of 78.1% overall but 71.7% in the submuscular transposition group. CONCLUSIONS: Here we report on the novel technique of using a collagen matrix wrap in recurrent compression neuropathies with good success. The collagen wrap allows nerve gliding, protection from perineural scar formation, and a favorable microenvironment. Submuscular transposition seems to be no better than other methods of decompression for recurrent cubital tunnel syndrome in contrary to traditional teaching

Chemokine receptors in epithelial ovarian cancer

MSTS 2018 - Femur Mets and MM

Ovarian carcinoma is the deadliest gynecologic malignancy with very poor rate of survival, and it is characterized by the presence of vast incurable peritoneal metastasis. Studies of the role of chemokine receptors, a family of proteins belonging to the group of G protein-coupled receptors, in ovarian carcinoma strongly placed this family of membrane receptors as major regulators of progression of this malignancy. In this review, we will discuss the roles that chemokine-receptor interactions play to support angiogenesis, cell proliferation, migration, adhesion, invasion, metastasis, and immune evasion in progression of ovarian carcinoma. Data regarding the role that the chemokine receptors play in the disease progression accumulated insofar strongly suggest that this family of proteins could be good therapeutic targets against ovarian carcinoma.

Transosseous suture fixation of proximal humeral fractures. Surgical technique

Glenohumeral Joint OA

BACKGROUND: The optimal treatment of displaced fractures of the proximal part of the humerus remains controversial. We evaluated the long-term functional and radiographic results of transosseous suture fixation in a series of selected displaced fractures of the proximal part of the humerus. METHODS: Over an eleven-year period, a consecutive series of 188 patients with a specifically defined displaced fracture of the proximal part of the humerus underwent open reduction and internal fixation with transosseous sutures. Twenty patients were lost to follow-up and three died before the time of follow-up, leaving a cohort of 165 patients (ninety-four women and seventy-one men; mean age, fifty-four years) available for the study. Forty-five (27%) of the injuries were four-part fractures with valgus impaction; sixty-four (39%) were three-part fractures; and fifty-six (34%) were two-part fractures of the greater tuberosity, thirty-six (64%) of which were associated with anterior dislocation of the shoulder. All fractures were fixed with transosseous, nonabsorbable, number-5 Ethibond sutures. Associated rotator cuff tears detected in fifty-seven patients (35%) were also repaired. Over a mean follow-up period of 5.4 years, functional outcome was assessed with the Constant score. Follow-up radiographs were assessed for fracture consolidation, malunion, nonunion, heterotopic ossification, and signs of impingement, humeral head osteonecrosis, and degenerative osteoarthritis. RESULTS: All fractures, except for two three-part fractures of the greater tuberosity, united within four months. The quality of fracture reduction as seen on the first postoperative radiograph was regarded as excellent/very good in 155 patients (94%), good in seven (4%), and poor in three (2%). Malunion was present in nine patients (5%) at the time of the last follow-up; six of the nine had had good or poor initial reduction and three, excellent/very good reduction. Humeral head osteonecrosis was seen in eleven (7%) of the 165 patients; four demonstrated total and seven, partial collapse. Fifteen patients had heterotopic ossification, but none had functional impairment. Four patients had signs of impingement syndrome, and two had arthritis. At the time of the final evaluation, the mean Constant score was 91 points, and the mean Constant score as a percentage of the score for the unaffected shoulder, unadjusted for age and gender, was 94%. CONCLUSIONS: The clinical and radiographic results of this transosseous suture technique were found to be satisfactory at an average of 5.4 years postoperatively. Advantages of this technique include less surgical soft-tissue dissection, a low rate of humeral head osteonecrosis, fixation sufficient to allow early passive joint motion, and the avoidance of bulky and expensive implants.

Urate-lowering treatment and risk of total joint replacement in patients with gout

AAHKS (2) Corticosteroids

Objectives. To examine whether gout is an independent risk factor for total joint replacement (TJR) and whether urate-lowering treatment (ULT) reduces this risk. Methods. Using the Taiwan National Health Insurance database and the UK Clinical Practice Research Datalink, 74 560 Taiwan patients and 34 505 UK patients with incident gout were identified and age and sex matched to people without gout. Cox proportional hazards models and condition logistic regression were used to examine the risk of TJR in gout patients and the association between cumulative defined daily dose (cDDD) of ULT and TJR. Results. The prevalence rates of TJR in the patients at the time of diagnosis of gout and in people without gout were 1.16% vs 0.82% in Taiwan and 2.61% vs 1.76% in the UK. After a gout diagnosis, the incidence of TJR was higher in the patients with gout compared with those without (3.23 vs 1.91 cases/1000 person-years in Taiwan and 6.87 vs 4.61 cases/1000 person-years in the UK), with adjusted HRs of 1.56 (95% CI 1.45, 1.68) in Taiwan and 1.14 (1.05, 1.22) in the UK. Compared with patients with gout with <28 cDDD ULT, the adjusted ORs for TJR were 0.89 (95% CI 0.77, 1.03) for 2890 cDDD, 1.03 (0.85, 1.24) for 90180 cDDD and 1.12 (0.94, 1.34) for >180 cDDD ULT in Taiwan. In the UK, the respective ORs were 1.09 (0.83, 1.42), 0.93 (0.68, 1.27) and 1.08 (0.94, 1.24). Conclusion. This population-based study provides evidence from two nation populations that gout confers significant TJR risk, which was not reduced by current ULT.

Numerical correlation between nerve conduction velocity and compound nerve action potential of median nerve in patients with carpal tunnel syndrome and normal group

Diagnosis and Treatment of Carpal Tunnel Syndrome CPG

BACKGROUND: Electrodiagnostic studies have a major role in the diagnosis of carpal tunnel syndrome (CTS). The parameters used in this regard include nerve conduction velocity (NCV) and compound nerve action potential (CNAP). In some individuals, recording sensory nerve action potential (SNAP) and as a result NCV is impossible. This study aims at determining the numerical correlation between CNAP and NCV calculated through SNAP METHODS: NCV and CNAP in 100 hands of 50 electrophysiologically and clinically asymptomatic individuals and 100 hands of 70 patients with CTS were surveyed. The correlation between NCV and CNAP was determined using independent t-test and regression model. RESULTS: The results indicated that there is a significant correlation between sex, group, CNAP and NCV statistically (P(value) < 0.05). Pearson correlation coefficient was -0.95. Agreement between NCV and CNAP was proved based on Bland Altman plot. CONCLUSIONS: There is numerical correlation between NCV and CNAP that we can use it when we are not able to calculate NCV through SNAP

Superior medial geniculate artery pseudoaneurysm after primary total knee arthroplasty

Surgical Management of Osteoarthritis of the Knee CPG

Vascular complications after total knee arthroplasty are rare. To date, there are 7 reported cases of pseudoaneurysms affecting the popliteal artery and 6 cases affecting one of the geniculate arteries. We present a case of a geniculate artery pseudoaneurysm that shared symptoms of a deep venous thrombosis on physical examination of a patient who underwent primary total knee arthroplasty. To date, there are no reports in American literature of pseudoaneurysms affecting the superior medial geniculate artery after primary total knee arthroplasty. After a vascular workup including computed tomographic angiography, surgical management included evacuation of the pseudoaneurysm and ligation of the feeding artery. The patient went on to successful recovery

Patient controlled analgesia with fentanyl or sufentanil in the post-operative period of knee ligament reconstruction: Comparative study. [Portuguese, English]

Surgical Management of Osteoarthritis of the Knee CPG

Background and Objectives - Epidural opioids, associated or not to local anesthetics, have been used for postoperative analgesia in continuous infusion and/or patient controlled boluses. The aim of this study was to compare postoperative analgesia provided by epidural fentanyl or sufentanil, in bolus or continuous infusion, in patients submitted to knee ligament reconstruction. Methods - Seventy ASA I - II patients, aged 16 to 47 years, were randomly distributed in two groups. All patients were submitted to epidural anesthesia with 0.5% bupivacaine (100 mg) with epinephrine 1:200,000 associated to fentanyl (100 mg). At the end of the procedure, patients received epidural fentanyl (Group F) or sufentanil (Group S) in continuous infusion plus patient controlled boluses. Group F infusion solution was made of saline (85 ml), 500 mug fentanyl (10 ml) and 0.5% bupivacaine (5 ml). Group S solution was made of saline (92 ml), 150 mug sufentanil (3 ml) and 0.5% plain bupivacaine (5 ml). Infusion pump's flow was initially programmed to 5 ml.h^-1, with 2 ml patient controlled bolus doses every 15 minutes at most, for both groups. The following parameters were compared: pain, number of patient controlled boluses, opioid consumption, motor block, sedation and side-effects. Results - There have been no statistically significant difference in analgesia quality between groups, being in most cases rated good (AVS 0 to 2). There has been a significant difference in the number of patient controlled boluses, with Group F needing more boluses than Group S. There has been no difference in total infused solution volume and total infusion time. There has been no motor block after beginning of patient-controlled analgesia. Vomiting and urine retention incidences were higher in Group S and there have been no significant differences in sedation and pruritus between groups. Conclusions - Epidural fentanyl or sufentanil in continuous epidural infusion and patient-controlled boluses in the doses used in this study have induced excellent postoperative analgesia. However, sufentanil caused more severe side effects than fentanyl

A systematic review and meta-analysis of the sinus tarsi and extended lateral approach in the operative treatment of displaced intra-articular calcaneal fractures

DoD SSI (Surgical Site Infections)

BACKGROUND: The optimal surgical approach for displaced intra-articular calcaneal fractures (DIACF) is subject of debate. The primary aim of this systematic review and meta-analysis was to assess wound-healing complications following the sinus tarsi approach (STA) compared to the extended lateral approach (ELA). Secondary aims were to assess time to surgery, operative time, calcaneal anatomy restoration, functional outcome, implant removal and injury to the peroneal tendons and sural nerve. METHODS: MEDLINE, EMBASE and Cochrane databases were searched for clinical studies comparing the STA and the ELA (until September 2017). RESULTS: Nine studies were included (two randomized controlled trials; seven comparative studies). 326 patients (331 fractures) were treated by the STA and 383 patients (390 fractures) by ELA. Ninety-nine per cent were Sanders type II/III fractures. Wound healing complications in the STA and ELA occurred in 11/331 and 82/390 fractures, respectively. Weighted means were 4.9% and 24.9%, respectively. Meta-analysis showed significantly less wound healing complications in the STA compared to ELA (risk ratio 0.20; 95% CI 0.11-0.36; P<0.00001; I²=0%). In general, time to surgery and operative time were shorter in the STA. Meta-analysis was not possible due to heterogeneity between studies. No differences were found in remaining secondary outcomes. CONCLUSIONS: The STA is associated with significantly less wound healing complications. With similar functional outcome and calcaneal anatomy restoration, the STA may be the preferred approach in the operative treatment of Sanders type II/III DIACF.

The value of fluorine-18 fluorodeoxyglucose PET in patients with medullary thyroid cancer

MSTS 2018 - Femur Mets and MM

The early detection of metastases from medullary thyroid cancer (MTC) is important because the only curative therapy consists in surgical removal of all tumour tissue. There is no single sensitive diagnostic imaging modality for the localization of all metastases in patients with MTC. Therefore, in many cases several imaging modalities (e.g. ultrasonography, magnetic resonance imaging, computerized tomography and scintigraphy using pentavalent technetium-99m dimercaptosuccinic acid, thallium-201 chloride, indium-111 pentetreotide, anti-CEA antibodies or metaiodobenzylguanidine) must be performed consecutively in patients with elevated calcitonin levels until the tumour is localized. In this prospective study, we investigated the value of fluorine-18 fluorodeoxyglucose positron emission tomography ([18F]FDG PET) in the follow-up of patients with MTC. [18F]FDG PET examinations of the neck and the chest were performed in 20 patients with elevated calcitonin levels or sonographic abnormalities in the neck. Positive [18F]FDG findings were validated by histology, computerized tomography or selective venous catheterization. [18F]FDG PET detected tumour in 13/17 patients (nine cases were validated by histology, four by computerized tomography). Five patients showed completely negative PET scans (of these cases, one was true-negative and four false-negative). One patient with [18F]FDG accumulation in pulmonary lesions from silicosis and one patient with a neck lesion that was not subjected to histological validation had to be excluded. Considering all validated localizations, [18F]FDG PET detected 12/14 tumour manifestations in the neck, 6/7 mediastinal metastases, 2/2 pulmonary metastases and 2/2 bone metastases. In two patients with elevated calcitonin levels, no diagnostic modality was able to localize a tumour. The sensitivity of [18F]FDG PET in the follow-up of MTC was 76% (95% confidence interval 53%-94%); this is encouraging. [18F]FDG PET promises to be a valuable diagnostic method, especially for the detection of lymph node metastases, surgical resection of which can result in complete remission.

Validation of an extracted tooth model of endodontic irrigation

Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures

An extracted tooth model of endodontic irrigation, incorporating reproducible inoculation and irrigation procedures, was tested against Enterococcus faecalis using a variety of different irrigants in a Latin square methodology. ANOVA revealed no significant variations between the twelve teeth or experiments undertaken on different occasions; however, variation between irrigants was significant

[Retrograde intramedullary interlocking nailing in fractures of the distal femur]

DoD SSI (Surgical Site Infections)

OBJECTIVES: We evaluated retrograde locked intramedullary nail applications in patients with distal femur fractures. METHODS: Distal femur fractures of 16 patients (11 males, 5 females; mean age 45 years; range 25 to 69 years) were treated with retrograde locked intramedullary nailing. One patient had bilateral fractures. According to the AO classification, the fractures were A1 (n=8), A2 (n=4), A3 (n=4), and C1 (n=1). There were 13 closed (76.5%), and four open (23.5%) fractures. The mean time to surgery was 10 days (range 2 to 20 days). Open technique was used for nine fractures, and percutaneous technique for eight fractures. Preoperatively, three patients with a floating knee were evaluated with magnetic resonance imaging and were found to have a ruptured cruciate ligament. All patients underwent intraoperative knee examination, which showed a ruptured cruciate ligament in five patients. Functional results were assessed using the modified HSS (Hospital for Special Surgery) knee rating scale at the end of a mean follow-up period of 32.6 months (range (12 to 68 months). RESULTS: The mean time to union was 25 weeks (range 14 to 42 weeks). One patient had delayed union (42 weeks). Joint range of motion was normal in three knees (17.7%), was 100 to 110 degrees in nine knees (52.9%), 80 degrees in four knees (23.5%), and below 80 degrees in one knee (5.9%). According to the modified HSS knee scale, the results were excellent in five femurs (29.4%), good in six femurs (35.3%), moderate in five femurs, and poor in one femur (5.9%). Postoperative radiographic examination showed varus angulation (10 degrees ) in four patients (23.5%), and posterior angulation (10-20 degrees ) in four patients. In one patient, healing occurred with extreme deformation (30 degrees posterior angulation). None of the patients experienced wound site problems or infections. One patient developed deep vein thrombosis in the early postoperative period. CONCLUSION: Treatment of distal femur fractures with retrograde locked intramedullary nailing yields satisfactory results in adults.

Clinical results of treatment using a clavicular hook plate versus a T-plate in neer type II distal clavicle fractures

Distal Radius Fractures

AO clavicular hook plate fixation provides more rigid fixation and good bony union rates for Neer type II distal clavicular fractures. However, the hook may cause rotator cuff tears and subacromial impingement, which adversely affect the clinical results. T-plate fixation is another surgical method of treatment for unstable clavicle fractures, and its clinical efficacy has been demonstrated. The purpose of this study was to compare the clinical outcomes of AO clavicular hook plate and T-plate fixation for Neer type II distal clavicular fractures. Forty-two patients with Neer type II fractures were divided into 2 groups. The hook plate group comprised 23 patients who underwent hook plate fixation, and the T-plate group comprised 19 patients who underwent distal radius volar locking T-plate fixation. Hook plates were removed 3 to 14 months postoperatively in 15 patients because of shoulder function limitations. All patients were evaluated postoperatively for shoulder pain, activities of daily living, range of motion, strength, and satisfaction according to the University of California, Los Angeles (UCLA) Shoulder rating scale. All fractures in the 2 groups achieved stable fixation and bony union. Both groups yielded similar outcomes with regard to shoulder strength and patient satisfaction (P=.207 and P=.398, respectively). Significant differences existed between the 2 groups in the mean scores of shoulder pain, activities of daily living, range of motion, and total UCLA score (P=.001, P=.011, P=.038, and P=.001, respectively). More patients (74%) in the hook plate group had mild to severe shoulder pain than in the T-plate group (16%). However, shoulder pain was relieved and function improved significantly after removal of the hook plate (P=.001).

Risk factors for hip fracture among elderly patients with Parkinson's disease

Management of Hip Fractures in the Elderly

Incidence of hip fracture among patients with Parkinson's disease (PD) is high, especially in elderly women. To determine effects of various factors on hip fracture risk, we prospectively studied fractures in a cohort of 115 elderly patients of both genders with PD (46 men, 69 women; mean age, 71.9 years) for 1 year. At baseline, we recorded body mass index (BMI), Hoehn and Yahr stage, and postmenopausal interval, and also measured bone mineral density (BMD) and serum concentrations of ionized calcium, intact parathyroid hormone (PTH), pyridinoline cross-linked carboxyterminal telopeptide of type I collagen (ICTP; a bone resorption marker), and 25-hydroxyvitamin (25-OHD). During the year hip fractures occurred in 18 patients (2 male and 16 female). We compared baseline variables between patients with and without hip fracture. PD patients with decreased BMI, lower BMD, and low concentrations of serum ionized calcium, and 25-OHD (mean 4.0 ng/ml) with compensatory hyperparathyroidsim had increased risk of hip fracture. Female PD patients with long postmenopausal intervals also had increased hip fracture risk. BMI, illness duration, postmenopausal intervals, Hoehn and Yahr stage, 25-OHD, PTH, calcium, and ICTP were determinants of BMD in patients with fracture. Elderly PD patients with low BMI, low BMD, and serum 25-OHD concentrations < or =5 ng/ml with secondary hyperparathyroidism have increased risk of hip fracture, as do female PD patients with long postmenopausal intervals

Intraarticular fractures of the distal radius in young adults--a review of the outcome of treatment

Distal Radius Fractures

A retrospective review of 30 intraarticular fractures of the distal radius in 27 patients was done. Only young adults aged between 18 and 40 were included. Road traffic accidents accounted for 25 of the cases (23 motorcyclists). Fourteen fractures were treated by closed reduction and a plaster cast. Sixteen fractures were treated by open reduction with internal fixation using a buttress plate or multiple Kirschner wires. At a mean follow-up of 17 months, 63% of the wrists had a satisfactory result and 37% unsatisfactory result. The main adverse factor was intraarticular congruity. The grip strength on the injured side averaged 56% of that of the uninjured side and the pinch strength averaged 73%. Most of the patients were able to return to their former occupation in an average of four months. [References: 10]

Internet-based outpatient telerehabilitation for patients following total knee arthroplasty: a randomized controlled trial

Surgical Management of Osteoarthritis of the Knee CPG

BACKGROUND: total knee arthroplasty is an effective means for relieving the symptoms associated with degenerative arthritis of the knee. Rehabilitation is a necessary adjunct to surgery and is important in regaining optimum function. Access to high-quality rehabilitation services is not always possible, especially for those who live in rural or remote areas. The aim of this study was to evaluate the equivalence of an Internet-based telerehabilitation program compared with conventional outpatient physical therapy for patients who have had a total knee arthroplasty. METHODS: this investigation was a single-blinded, prospective, randomized, controlled noninferiority trial. Sixty-five participants were randomized to receive a six-week program of outpatient physical therapy either in the conventional manner or by means of an Internet-based telerehabilitation program. The primary outcome measure was the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) measured at baseline and six weeks by a blinded independent assessor. Secondary outcomes included the Patient-Specific Functional Scale, the timed up-and-go test, pain intensity, knee flexion and extension, quadriceps muscle strength, limb girth measurements, and an assessment of gait. Noninferiority was assessed through the comparison of group differences with a noninferiority margin and with linear mixed model statistics. RESULTS: baseline characteristics between groups were similar, and all participants had significant improvement on all outcome measures with the intervention (p < 0.01 for all). After the six-week intervention, participants in the telerehabilitation group achieved outcomes comparable to those of the conventional rehabilitation group with regard to flexion and extension range of motion, muscle strength, limb girth, pain, timed up-and-go test, quality of life, and clinical gait and WOMAC scores. Better outcomes for the Patient-Specific Functional Scale and the stiffness subscale of the WOMAC were found in the telerehabilitation group (p < 0.05). The telerehabilitation intervention was well received by participants, who reported a high level of satisfaction with this novel technology. CONCLUSIONS: the outcomes achieved via telerehabilitation at six weeks following total knee arthroplasty were comparable with those after conventional rehabilitation. LEVEL OF EVIDENCE: therapeutic Level I. See Instructions to Authors for a complete description of levels of evidence

The conservative treatment of the fractures and dislocations of the extremities in children

The Treatment of Pediatric Supracondylar Humerus Fractures AUC

Both authors have dedicated most of their time since 1948 to the treatment of fractures in children. On the basis of their experience they are therefore submitting to the medical public those methods and results of the conservative treatment of fractures and dislocations in children which stood the test of time. The experiences of both authors as well as successful therapeutic methods of other surgeons are discussed in this book. Differences are stated between fractures in adults and in children which may be attributed to the growth factor of children's bones and their enormous biological drive. These factors will play their part in correcting certain displaced fractures by re-moulding, fractures which in an adult would have to be perfectly reduced unless a permanent deformity should ensue associated with subsequent impairment of function to the injured limb. The authors are stating which displaced angulations and side to side displacements in a fracture may be left and which must be repaired under all circumstances and why, if conservative treatment fails, surgery has to be performed. Sideways and longitudinally displaced fractures, especially metaphysial ones do not warrant a perfect reduction. Rotational displacements must be corrected every time even in very small infants e.g. in newborn babies. Age plays an important part in the healing of fractures. Moulding and union of a fracture will be most rapid in newborn babies and infants while in fractures of adolescents a similar procedure has to be adopted as in fractures of adults. Special problems of epiphysiolyses and epiphysial fractures are discussed emphasizing that conservative treatment may be unsuccessful in epiphysiolyses Salter-Harris type III and IV and surgical intervention may be indicated. Fractures of upper and lower limbs are dealt with in detail while paying special attention to obstetrical fractures. Fractures round the elbow are treated in a similar manner, they will frequently heal in angulation of the upper limb and may cause nerve injuries and ischaemic changes of the forearm. Special attention is being paid to the longitudinal overgrowth of fractures of the femoral diaphysis associated with the sequelae of the treatment of these very serious injuries to newborn babies and infants as well as to toddlers and older children

Femoral neck fractures after metal-on-metal total hip resurfacing: a prospective cohort study

Management of Hip Fractures in the Elderly

There has been a renewed interest in metal-on-metal resurfacing total hip arthroplasty. Recent studies have reported high success rates at short to midterm follow-up. Despite these excellent early outcomes, femoral neck fractures have been reported as a major complication after this procedure. The purpose of this study was to identify the incidence of this complication in a prospective cohort of patients. In addition, various demographic and radiographic factors such as surgeon experience, age, sex, body mass index, femoral neck notching, and cysts were assessed as potential risk factors. Between November 2000 and August 2006, 550 metal-on-metal total hip resurfacings were performed by a single surgeon. The absolute risk for femoral neck fracture in this cohort was 2.5%. Of the 14 fractures, 12 occurred in the first 69 resurfacings performed. After this time, the incidence of fracture was 0.4%. Women and obese patients were shown to have higher cumulative incidences of fractures. These findings suggest the need for careful patient selection and surgical technique, especially for surgeons during the early learning curve for this technically difficult surgery

Distal tibial osteotomies for the treatment of foot and ankle disorders

Diagnosis and Treatment of Osteochondritis Dissecans AUC

Distal tibial osteotomy is an effective treatment for a variety of pediatric and adult foot and ankle disorders. Exposure osteotomies provide access to the tibiotalar joint for such problems as talar body fractures and osteochondral lesions of the talus. The channel osteotomy provides improved access to posterior talar dome lesions, especially for the use of osteochondral autograft. Although technically demanding, the supramalleolar osteotomy can benefit many patients, including patients with residual clubfoot deformity, primary and secondary osteoarthritis, malunion, and physeal arrest

Effect of preoperative exercise on measures of functional status in men and women undergoing total hip and knee arthroplasty

OAK 3 - Non-arthroplasty tx of OAK

OBJECTIVE: To evaluate the effect of a short preoperative exercise intervention on the functional status, pain, and muscle strength of patients before and after total joint arthroplasty. METHODS: A total of 108 men and women scheduled for total hip arthroplasty (THA) or total knee arthroplasty (TKA) were randomized to a 6�week exercise or education (control) intervention immediately prior to surgery. We assessed outcomes through questionnaires and performance measures. Analyses examined differences between groups over the preoperative and immediate postoperative periods and at 8 and 26 weeks postsurgery. RESULTS: Among THA patients, the exercise intervention was associated with improvements in preoperative Western Ontario and McMaster Universities Osteoarthritis Index function score (improvement of 2.2 in exercisers versus decline of 3.9 in controls; P = 0.02) and Short Form 36 physical function score (decline of 0.4 in exercisers versus decline of 14.3 in controls; P = 0.003). No significant differences were seen in TKA patients. Exercise participation increased muscle strength preoperatively (18% in THA patients and 20% in TKA patients), whereas the control patients had essentially no change in strength (P > 0.05 for exercise versus education in both THA and TKA groups). Exercise participation prior to total joint arthroplasty substantially reduced the risk of discharge to a rehabilitation facility in THA and TKA patients (adjusted odds ratio 0.27, 95% confidence interval 0.074�0.998). The intervention had no effects on outcomes 8 and 26 weeks postoperatively. CONCLUSION: A 6�week presurgical exercise program can safely improve preoperative functional status and muscle strength levels in persons undergoing THA. Additionally, exercise participation prior to total joint arthroplasty dramatically reduces the odds of inpatient rehabilitation.

MRI features of the anterolateral ligament of the knee

AMP (Acute Meniscal Pathology)

OBJECTIVE: Evaluate the visibility and describe the anatomical features of the anterolateral ligament of the knee using MRI. MATERIALS AND METHODS: Magnetic resonance imaging examinations of the knee were independently reviewed by two musculoskeletal radiologists and assessed for the visibility of the anterolateral ligament under direct cross-referencing of axial and coronal images as complete, partial, or non-visible. Distal insertion site (tibial, meniscal), distance to lateral tibial plateau, measurements (length, width, thickness), and associated imaging findings were also tabulated. Clinical and surgical records were also reviewed. RESULTS: Seventy MRI scans from 60 consecutive subjects were included in the study. Mean age was 40 years, body mass 74.9 kg, and height 1.72 m. The subject population was 53% male, most of the knees were from the left side (51%), and chronic pain was the main clinical symptom (40%). Nine knees (13 %) had undergone previous surgery. The anterolateral ligament was identified in 51% of the knees: completely visible in 11% and partially visible in 40%. In all visible cases, the distal insertion site was identified on the tibia, with a mean distance of 5.7 mm to the plateau. A completely visible ligament had a mean length of 33.2 mm, width of 5.6 mm, and thickness of 1.9 mm [corrected]. Inter-observer agreement for ligament presence was significant (kappa = 0.7). Statistical analyses showed a trend to be more visible in men, with a longer length compared with women. CONCLUSIONS: Magnetic resonance imaging clearly identifies the anterolateral ligament of the knee in slightly more than half of cases, being partially visible in most of them. In all cases, a tibial insertion is characterized.

Dystrophic Epidermolysis Bullosa: Pathogenesis and Clinical Features

Reconstruction After Skin Cancer

Dystrophic epidermolysis bullosa (DEB) is relatively well understood. Potential therapies are in development. This article describes the pathogenesis and clinical features of DEB. It also describes therapeutic options and the future of molecular therapies. © 2010 Elsevier Inc. All rights reserved.

Oncoplastic reduction mammaplasty, an effective and safe method of breast conservation

Reduction Mammoplasty for Female Breast Hypertrophy

INTRODUCTION: Oncoplastic breast conserving surgery (BCS) can enhance both cosmetic and oncologic breast cancer outcomes. This study evaluates the outcomes and complications associated with oncoplastic reduction mammaplasty performed by surgical breast oncologists. METHODS: A single institution retrospective chart review of patients undergoing oncoplastic reduction mammaplasty by a surgical breast oncologist for the treatment of breast cancer. RESULTS: Seventy-one patients were identified. The average patient age was 59.6 years (range 37-77 years). Average lesion span was 31.4mm (range 3-166mm). Six (8.5%) patients required additional surgery to obtain adequate margins. One (1.4%) patient developed recurrent disease during the follow-up interval. No major surgical complications were observed. CONCLUSION: Oncoplastic reduction mammaplasty is associated with low rates of re-excision and complications and can be safely and effectively performed by appropriately trained surgical breast oncologists.

Breast implant-associated anaplastic large cell lymphoma: sensitivity, specificity, and findings of imaging studies in 44 patients

Example Literature Review

Breast implant-associated anaplastic large cell lymphoma (BIA ALCL) is a newly described clinicopathologic entity. The purpose of this study is to describe the imaging findings of patients with BIA ALCL and determine their sensitivity and specificity in the detection of the presence of an effusion or a mass related to BIA ALCL. A retrospective search was performed of our files as well as of the world literature for patients with pathologically proven BIA ALCL who had been assessed by any imaging study including ultrasound (US), computerized tomography (CT), magnetic resonance imaging (MRI), or positron emission tomography (PET)-CT, as well as mammography. The sensitivity and specificity of each imaging modality in the detection of an effusion or a mass around breast implants was determined. We identified 44 patients who had BIA ALCL and imaging studies performed between 1997 and 2013. The sensitivity for detecting an effusion was 84, 55, 82, and 38 %, and for detecting a mass was 46, 50, 50, and 64 %, by US, CT, MRI, and PET, respectively. The sensitivity of mammography in the detection of an abnormality without distinction of effusion or mass was 73 %, and specificity 50 %. Progression-free survival was worse in patients with an implant-associated mass (p = 0.001). CONCLUSIONS: Current imaging with US, CT, MR, and PET appears suboptimal in the detection of an imaging abnormality associated with BIA ALCL. This under diagnosis may reflect a lack of awareness of this rare entity suggesting the need for better understanding of the spectrum of imaging findings associated with BIA ALCL by breast imagers

The impact of social isolation on delayed hospital discharges of older hip fracture patients and associated costs

DoD PRF (Psychosocial RF)

Summary: Delayed discharges represent an inefficient use of acute hospital beds. Social isolation and referral to a public-funded rehabilitation unit were significant predictors of delayed discharges while admission from an institution was a protective factor for older hip fracture patients. Preventing delays could save between 11.2 and 30.7 % of total hospital costs for this patient group. Introduction: Delayed discharges of older patients from acute care hospitals are a major challenge for administrative, humanitarian, and economic reasons. At the same time, older people are particularly vulnerable to social isolation which has a detrimental effect on their health and well-being with cost implications for health and social care services. The purpose of the present study was to determine the impact and costs of social isolation on delayed hospital discharge. Methods: A prospective study of 278 consecutive patients aged 75 or older with hip fracture admitted, as an emergency, to the Orthopaedics Department of Hospital Universitário de Santa Maria, Portugal, was conducted. A logistic regression model was used to examine the impact of relevant covariates on delayed discharges, and a negative binomial regression model was used to examine the main drivers of days of delayed discharges. Costs of delayed discharges were estimated using unit costs from national databases. Results: Mean age at admission was 85.5 years and mean length of stay was 13.1 days per patient. Sixty-two (22.3 %) patients had delayed discharges, resulting in 419 bed days lost (11.5 % of the total length of stay). Being isolated or at a high risk of social isolation, measured with the Lubben social network scale, was significantly associated with delayed discharges (odds ratio (OR) 3.5) as was being referred to a public-funded rehabilitation unit (OR 7.6). These two variables also increased the number of days of delayed discharges (2.6 and 4.9 extra days, respectively, holding all else constant). Patients who were admitted from an institution were less likely to have delayed discharges (OR 0.2) with 5.5 fewer days of delay. Total costs of delayed discharges were between 11.2 and 30.7 % of total costs (â?¬2352 and â?¬9317 per patient with delayed discharge) conditional on whether waiting costs for placement in public-funded rehabilitation unit were included. Conclusion: High risk of social isolation, social isolation and referral to public-funded rehabilitation units increase delays in patientsâ?? discharges from acute care hospitals.

Reoperations of cervical hip fractures: Increase risk of wound infection?

Management of Hip Fractures in the Elderly

A total of 445 cervical hip fractures were operated and followed for 1-5 years. Internal fixation was used in 224 fractures, a total hip replacement was used in 98 fractures and hemiarthroplasty was used in 123 fractures. The failure rate for internal fixation was 63/224 = 28%. The most common complication following total hip replacement and hemiarthroplasty was luxation. A total of 28 of these patients had a total of 55 luxations. Closed reduction was sufficient in 12 patients but 16 patients needed further surgery. The must common operation was a total hip replacement used in 56 cases out of 83 reoperations. A total of 32 (7%) patients had a postoperative superficial or deep infection following either the primary operation or an eventual reoperation. Cultures identified Staphylococcus aureus as the cause in 59% and E. coli in 9.4% of these infections. The total wound infection rate was 5.6% following primary operation in contrast to 8.4% following reoperation (P < 0.05). However the difference was not significant for deep infection alone (2.0% and 2.4%)

Care of the transgender patient: The role of the gynecologist

Panniculectomy & Abdominoplasty CPG

Gender dysphoria refers to distress that is caused by a sense of incongruity between an individual's self-identified gender and natal sex. Diagnosis is made in accordance with the Diagnostic and Statistical Manual of Mental Disorders and treatment first involves psychiatric therapy, which can help determine a patient's true goals in regards to achieving gender identity. Patients who wish to transition to the opposite sex must undergo a supervised real-life test and often are treated with hormonal therapy to develop physical characteristics consistent with their gender identity. Sex reassignment surgery is an option for patients who wish to transition completely. Transpatients face many barriers when it comes to basic health needs including education, housing, and health care. This is a result of long-standing marginalization and discrimination against this community. Because of these barriers, many patients do not receive the proper health care that they need. Additionally, because of certain high-risk behaviors as well as long-term hormonal therapy, transpatients have different routine health care needs that should be addressed in the primary care setting. Gynecologists play an important role in caring for transgender patients and should be knowledgeable about the general principles of transgender health. © 2014 Mosby, Inc. All rights reserved.

The good and the bad of chemokines/chemokine receptors in melanoma

MSTS 2018 - Femur Mets and MM

Summary Chemokine ligand/receptor interactions affect melanoma cell growth, stimulate or inhibit angiogenesis, recruit leukocytes, promote metastasis, and alter the gene expression profile of the melanoma associated fibroblasts. Chemokine/chemokine receptor interactions can protect against tumor development/growth or can stimulate melanoma tumor progression, tumor growth and metastasis. Metastatic melanoma cells express chemokine receptors that play a major role in the specifying the organ site for metastasis, based upon receptor detection of the chemokine gradient elaborated by a specific organ/tissue. A therapeutic approach that utilizes the protective benefit of chemokines involves delivery of angiostatic chemokines or chemokines that stimulate the infiltration of cytotoxic T cells and natural killer T cells into the tumor microenvironment. An alternative approach that tackles the tumorigenic property of chemokines uses chemokine antibodies or chemokine receptor antagonists to target the growth and metastatic properties of these interactions. Based upon our current understanding of the role of chemokine-mediated inflammation in cancer, it is important that we learn to appropriately regulate the chemokine contribution to the tumorigenic 'cytokine/chemokine storm', and to metastasis.

Direct Anterior Approach for Total Hip Arthroplasty in the Lateral Decubitus Position: Our Experiences and Early Results

PJI DX Updated Search

BACKGROUND: The direct anterior approach (DAA) for total hip arthroplasty (THA) is typically performed in the supine position using a specially designed operating room table, which makes this approach more accessible to orthopedic surgeons. We attempted to perform this procedure in the lateral decubitus position on an ordinary operation table to avoid dependence on a special operating room table. There is an obvious absence of literature regarding this subject. METHODS: A total of 248 patients (295 hips) were recruited for primary THAs from July 1, 2014 to December 31, 2014. In total, 126 hips (42.7%) underwent THAs using the DAA in the lateral decubitus position. The technical feasibility and early results were evaluated. RESULTS: The orientation of the acetabular component was 16.5 degrees +/- 4.9 degrees anteversion and 43.3 degrees +/- 3.5 degrees abduction. Intraoperative proximal femoral fracture occurred in one hip. The superficial wound complications occurred in 2 hips and the hematoma in one hip while in hospital. The lateral femoral cutaneous nerve injury was noted in 43 hips. The early dislocation occurred in 2 hips. Heterotopic ossification was Brooker class I in 5 hips and class II in 1 hip. No aseptic loosening, postoperative periprosthetic fracture, and deep infection occurred in our series. CONCLUSION: The DAA for THA in the lateral decubitus position may be a valuable alternative if the DAA in the supine position is difficult to implement owing to absence of a special operating room table. This technique also seems to provide satisfactory clinical and radiographic outcomes with an acceptable complication in our early follow-up

Lateral Epicondylitis/Extensor Tendon Injury

PRPs for Lateral Epicondylitis/Elbow Tendinopathies

Pain over the lateral aspect of the elbow without nerve injury or elbow instability often is diagnosed as lateral epicondylitis or, colloquially, tennis elbow. It is a common complaint, seen most frequently in women between ages 40 and 60, although it is common in men too. Typical presenting symptoms include pain with prolonged wrist extension activities, pain with resisted wrist or elbow extension, and pain at rest radiating from the elbow along the dorsum of the forearm.

Evaluation of the potential use of trabecular bone score to complement bone mineral density in the diagnosis of osteoporosis: a preliminary spine BMD-matched, case-control study

Management of Hip Fractures in the Elderly

The trabecular bone score (TBS) is a new parameter that is determined from gray-level analysis of dual-energy X-ray absorptiometry (DXA) images. It relies on the mean thickness and volume fraction of trabecular bone microarchitecture. This was a preliminary case-control study to evaluate the potential diagnostic value of TBS as a complement to bone mineral density (BMD), by comparing postmenopausal women with and without fractures. The sample consisted of 45 women with osteoporotic fractures (5 hip fractures, 20 vertebral fractures, and 20 other types of fracture) and 155 women without a fracture. Stratification was performed, taking into account each type of fracture (except hip), and women with and without fractures were matched for age and spine BMD. BMD and TBS were measured at the total spine. TBS measured at the total spine revealed a significant difference between the fracture and age- and spine BMD-matched nonfracture group, when considering all types of fractures and vertebral fractures. In these cases, the diagnostic value of the combination of BMD and TBS likely will be higher compared with that of BMD alone. TBS, as evaluated from standard DXA scans directly, potentially complements BMD in the detection of osteoporotic fractures. Prospective studies are necessary to fully evaluate the potential role of TBS as a complementary risk factor for fracture

ORIF vs. arthroplasty in femoral neck fractures: A review of a national database

Management of Hip Fractures in the Elderly

Introduction: Hip fractures represent the second leading cause of hospitalization for elderly patients. Total hip arthroplasty (THA), hemiarthroplasty (HA), and open reduction internal fixation (ORIF) are treatment options for hip fractures. Optimal surgical treatment for displaced femoral neck fractures remains unclear. the aim of this study is to compare 30-day post-operative outcomes of THA, HA, and ORIF among elderly patients with displaced femoral neck fractures within a national surgical database. Methods: A retrospective analysis of the American College of Surgeons National Quality Improvement Program for the periods January 2005 through December 2009 was conducted. Included were patients 65 years or older who underwent THA, HA, and ORIF, for displaced femoral neck femoral fractures. Patient demographics, co-morbidities, and complication rates were compared across the three treatment options. Logistic regression model was used to assess variation in overall morbidity and mortality following surgery, adjusting for age, gender, ethnicity, co-morbidities, functional status prior to surgery, behavioral risk factor, and time from admission to surgery. Results: A total of 3,172 patients met the inclusion criteria. of these patients, 534 underwent ORIF, 358 HA, and 2,271 THA, respectively. Most patients were White (87.5%, n=2,642), female (63.6%, n=2,017), and had an overall mean age of 76. Regarding pre-operative co-morbidities, patients who underwent HA had the highest rate of co-morbidities (91.4%, n=62), followed by ORIF (86.6%, n=96), and THA (23%, n=561). in bivariate analysis, patients who underwent HA had the lowest rate of post-operative complications. on adjusted multivariate analysis, patients who underwent THA had a lower likelihood of developing any complication, including infection, respiratory, sepsis, cardiovascular, and death when compared to ORIF (Table 1). Conclusions: Our study demonstrates that THA had less 30-day post-operative complications and a lower mortality rate than HA and ORIF in elderly patients with displaced femoral neck fractures. (Table presented)

A randomised, controlled trial of circumpatellar electrocautery in total knee replacement without patellar resurfacing: a concise follow-up at a mean of 3.7 years

OAK 3 - Non-arthroplasty tx of OAK

In the absence of patellar resurfacing, we have previously shown that the use of electrocautery around the margin of the patella improved the one-year clinical outcome of total knee replacement (TKR). In this prospective randomised study we compared the mean 3.7 year (1.1 to 4.2) clinical outcomes of 300 TKRs performed with and without electrocautery of the patellar rim: this is an update of a previous report. The overall prevalence of anterior knee pain was 32% (95% confidence intervals [CI] 26 to 39), and 26% (95% CI 18 to 35) in the intervention group compared with 38% (95% CI 29 to 48) in the control group (chi-squared test; p = 0.06). The overall prevalence of anterior knee pain remained unchanged between the one-year and 3.7 year follow-up (chi-squared test; p = 0.12). The mean total Western Ontario McMasters Universities Osteoarthritis Indices and the American Knee Society knee and function scores at 3.7 years' follow-up were similar in the intervention and control groups (repeated measures analysis of variance p = 0.43, p = 0.09 and p = 0.59, respectively). There were no complications. A total of ten patients (intervention group three, control group seven) required secondary patellar resurfacing after the first year. Our study suggests that the improved clinical outcome with electrocautery denervation compared with no electrocautery is not maintained at a mean of 3.7 years' follow-up.

Post-NICE 2008: Antibiotic prophylaxis prior to dental procedures for patients with pulmonary arteriovenous malformations (PAVMs) and hereditary haemorrhagic telangiectasia

Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures

Recently published guidance from NICE highlights that antibiotic prophylaxis is no longer required for patients with structural heart disease at risk of infective endocarditis. The American Heart Association has published similarly less interventive guidance. Individuals with pulmonary arteriovenous malformations and hereditary haemorrhagic telangiectasia are at risk of brain abscess from dental bacteraemias. In this article we explore why these patients do not fall into the groups considered by NICE and provide recommendations to reduce their risks of dental bacteraemias, including optimising dental hygiene and use of antibiotic prophylaxis prior to dental procedures

Femoroacetabular impingement

PJI DX Updated Search

Femoroacetabular impingement has been proposed as one of the causes leading to osteoarthritis of the hip. Features are mostly seen in young active individuals. Two morphological types, cam and pincer have been identified. Prompt clinical and radiological examination with appropriate surgical intervention can alleviate the symptoms and delay the degenerative changes associated with this condition

Review article: Risk factors of infection following total knee arthroplasty

PJI DX Updated Search

22 PubMed articles in English were identified using the key words: 'risk factors', 'infection', and 'primary total knee arthroplasty (TKA)'. The 10 most relevant articles were reviewed. In one study, obesity and diabetes were considered risk factors for infection following TKA. In another study, postoperative infection correlated with a history of open reduction and internal fixation, male gender, remnants of previous internal fixation material, and body mass index. In yet another study, the risk factors were (in decreasing order of significance): congestive heart failure, chronic pulmonary disease, preoperative anaemia, diabetes, depression, renal disease, pulmonary circulation disorders, obesity, rheumatologic disease, psychoses, metastatic tumour, peripheral vascular disease, and valvular disease

Acute knee trauma: value of a short dedicated extremity MR imaging examination for prediction of subsequent treatment

AMP (Acute Meniscal Pathology)

PURPOSE: To assess the predictive value of a short magnetic resonance (MR) imaging examination, in addition to or instead of radiography, performed in patients with acute knee trauma to identify those who require additional treatment versus those who do not and can be discharged without further follow-up. MATERIALS AND METHODS: The randomized controlled trial and use of collected data for prediction modeling were approved by the institutional review board; informed consent was obtained. Patients with recent knee injury were included in the trial if radiography was ordered. They were randomized into a group undergoing only radiography and a group undergoing radiography plus immediate MR imaging. A 0.2-T dedicated extremity MR imager and four short pulse sequences were used. Univariable and multivariable logistic regression analysis was used to evaluate patient characteristics, trauma mechanism, and findings at radiography and MR imaging for their value in prediction of need for subsequent treatment within the 6-month follow-up. RESULTS: Data in 189 patients (123 male patients, 66 female patients; mean age, 33.4 years), 109 of whom underwent treatment after their initial visit, were analyzed. Age of 30 years or older, indirect trauma mechanism, radiographic results, and MR imaging results were significant predictors of need for treatment in univariable and multivariable analyses (P < .05). In the multivariable analysis, only abnormal MR imaging results were significantly predictive of need for treatment, and only when MR imaging replaced radiography (odds ratio, 2.61; 95% confidence interval: 1.12, 6.06). CONCLUSION: Implementation of a dedicated extremity MR imaging examination, in addition to or instead of radiography, performed in patients with traumatic knee injury improves prediction of the need for additional treatment but does not significantly aid in identification of patients who can be discharged without further follow-up. Value of a short MR imaging examination in the initial stage after knee trauma is limited.

Clinical manifestations of AB-amyloidosis: effects of biocompatibility and flux

Diagnosis and Treatment of Carpal Tunnel Syndrome CPG

BACKGROUND: Highly permeable biocompatible dialysis membranes may postpone the development of AB-amyloidosis, but the relative contribution of enhanced flux or reduced inflammation by highly biocompatible membranes and sterile dialysis fluid remains unknown. METHODS: In this retrospective investigation, 89 patients with end-stage renal disease maintained on regular haemodialysis for at least 10 years and treated with one type of dialysis membrane exclusively were selected for analysis. They were divided into three groups: low-flux, bioincompatible cellulose (I), low-flux, intermediately biocompatible polysulphone or PMMA (II), or high-flux, highly biocompatible polysulphone or AN69 (III). In addition, the patients were analysed according to the microbiological quality of the dialysis fluid, which had been tested regularly and was classified either as standard or as intermittently contaminated. The clinical manifestations indicative of AB-amyloidosis, namely, carpal tunnel syndrome, arthropathy and bone cysts, were diagnosed after recruitment. RESULTS: Clinical symptoms were most pronounced in group I, intermediate in group II, and lowest in group III. Patients treated with intermittently contaminated dialysis fluid showed a higher prevalence of AB-amyloidosis than patients with less contaminated dialysis fluid. Logistic regression analysis demonstrated that the flux characteristics of the dialyser and the microbiological quality of the dialysis fluid as well as the biocompatibility of the dialyser were independent determinants of AB-amyloidosis. CONCLUSION: It would be prudent clinical practice to employ high-flux biocompatible membranes in conjunction with ultrapure dialysis fluid for the treatment of end-stage renal disease patients who need to remain on long-term haemodialysis

GPs' attitudes, beliefs and behaviours regarding exercise for chronic knee pain: a questionnaire survey

OAK 3 - Non-arthroplasty tx of OAK

OBJECTIVES: The aim of this study was to investigate general practitioners' (GPs) attitudes, beliefs and behaviours regarding the use of exercise for patients with chronic knee pain (CKP) attributable to osteoarthritis. SETTING: Primary care GPs in the UK. PARTICIPANTS: 5000 GPs, randomly selected from Binley's database, were mailed a cross-sectional questionnaire survey. OUTCOME MEASURES: GPs' attitudes and beliefs were investigated using attitude statements, and reported behaviours were identified using vignette-based questions. GPs were invited to report barriers experienced when initiating exercise with patients with CKP RESULTS: 835 (17%) GPs responded. Overall, GPs were positive about general exercise for CKP. 729 (87%) reported using exercise, of which, 538 (74%) reported that they would use both general and local (lower limb) exercises. However, only 92 (11% of all responding) GPs reported initiating exercise in ways aligning with best-evidence recommendations. 815 (98%) GPs reported barriers in using exercise for patients with CKP, most commonly, insufficient time in consultations (n=419; 51%) and insufficient expertise (n=337; 41%). CONCLUSIONS: While GPs' attitudes and beliefs regarding exercise for CKP were generally positive, initiation of exercise was often poorly aligned with current recommendations, and barriers and uncertainties were reported. GPs' use of exercise may be improved by addressing the key barriers of time and expertise, by developing a pragmatic approach that supports GPs to initiate individualised exercise, and/or by other professionals taking on this role.

A Prospective Clinical and Radiological Evaluation at 5 Years After Arthroscopic Matrix-Induced Autologous Chondrocyte Implantation

OAK 3 - Non-arthroplasty tx of OAK

BACKGROUND: While midterm outcomes after matrix-induced autologous chondrocyte implantation (MACI) are encouraging, the procedure permits an arthroscopic approach that may reduce the morbidity of arthrotomy and permit accelerated rehabilitation. HYPOTHESIS: A significant improvement in clinical and radiological outcomes after arthroscopic MACI will exist through to 5 years after surgery. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: We prospectively evaluated the first 31 patients (15 male, 16 female) who underwent MACI via arthroscopic surgery to address symptomatic tibiofemoral chondral lesions. MACI was followed by a structured rehabilitation program in all patients. Clinical scores were administered preoperatively and at 3 and 6 months as well as 1, 2, and 5 years after surgery. These included the Knee injury and Osteoarthritis Outcome Score (KOOS), Lysholm knee scale (LKS), Tegner activity scale (TAS), visual analog scale for pain, Short Form-36 Health Survey (SF-36), active knee motion, and 6-minute walk test. Isokinetic dynamometry was used to assess peak knee extension and flexion strength and limb symmetry indices (LSIs) between the operated and nonoperated limbs. High-resolution magnetic resonance imaging (MRI) was performed at 3 months and at 1, 2, and 5 years postoperatively to evaluate graft repair as well as calculate the MRI composite score. RESULTS: There was a significant improvement ( P < .05) in all KOOS subscale scores, LKS and TAS scores, the SF-36 physical component score, pain frequency and severity, active knee flexion and extension, and 6-minute walk distance. Isokinetic knee extension strength significantly improved, and all knee extension and flexion LSIs were above 90% (apart from peak knee extension strength at 1 year). At 5 years, 93% of patients were satisfied with MACI to relieve their pain, 90% were satisfied with improving their ability to undertake daily activities, and 80% were satisfied with the improvement in participating in sport. Graft infill ( P = .033) and the MRI composite score ( P = .028) significantly improved over time, with 90% of patients demonstrating good to excellent tissue infill at 5 years. There were 2 graft failures at 5 years after surgery. CONCLUSION: The arthroscopically performed MACI technique demonstrated good clinical and radiological outcomes up to 5 years, with high levels of patient satisfaction.

The quality of reporting in randomized controlled trials of acupuncture for knee osteoarthritis: A cross-sectional survey

OAK 3 - Non-arthroplasty tx of OAK

OBJECTIVE: To assess the reporting quality of acupuncture trials for knee osteoarthritis (KOA), and explore the factors associated with the reporting. METHOD: Three English and four Chinese databases were searched from inception to December 2016 for randomized control trials testing effects of acupuncture for knee osteoarthritis. We used the standard CONSORT (2010 version), CONSORT Extension for Non-Pharmacological Treatments, and STRICTA for measuring the quality of reporting. Using pre-specified study characteristics, we undertook regression analyses to examine factors associated with the reporting quality. RESULTS: A total of 318 RCT reports were included. For the standard CONSORT, ten items were substantially under-reported (reported in less than 5% of RCTs), including specification of important changes to methods after trial commencement (0.6%), description of any changes to trial outcomes (0.0%), implementation of interim analyses and stopping guidelines (0.6%), statement about why the trial ended or was stopped (1.6%), statement about the registration status (4.4%), accessibility of full trial protocol (4.7%), implementation of randomization (4.7%), description of the similarity of interventions (3.5%), conduct of ancillary analyses (3.8%) and presentation of methods for additional analyses (4.4%). Four of the STRICTA items were under-reported (reported in less than 10% of RCTs), including description of acupuncture style (8.5%), presentation of extent to which treatment varied (1.3%), statement of practitioner background (7.2%) and rationale for the control (9.1%). For CONSORT Extension, the reporting was poor across all items (reported in less than 10% of trials). Trials including authors with expertise in epidemiology or statistics, published in English, or enrolling patients from multiple centers were more likely to have better reporting. CONCLUSIONS: The reporting in RCTs of acupuncture for KOA was generally poor. To improve the reporting quality, journals should encourage strict adherence to the reporting guidelines.

Shoulder resurfacing with Durom Cup: Clinical and radiological re-assessment

Glenohumeral Joint OA

Background: The purpose of this study was to analyze and report functional and radiological results obtained with the Durom� Shoulder Cup. Methods: From 2004 to 2009, 42 consecutive shoulder resurfacing prostheses were implanted in a cohort of forty patients with morphologically and functionally healthy rotator cuff. Those cases were evaluated preoperatively and postoperatively after an average of 33.5 months on the basis of Constant score, ASES score, and X-rays. Results: The Constant score increased from 29.88 points preoperatively to 82.34 after a mean follow-up period of 33.5 months. The ASES score went from 30.55 points preoperatively to 76.61. Radiologically we noticed neither radiolucent lines nor any aseptic loosening of the prosthetic cup. In the post-operative X-rays evaluation we found no significant central migration of the humeral head from the first postoperative X-ray. Conclusions: The good functional results observed with a mean follow-up of approximately 3 years doubtless resulted from the reduction in implant-placement error, as a result of the resurfacing procedure, and from the normal rotator cuff function. This technique facilitates surgical reconstruction of the anatomical and biomechanical conditions required for physiological function of the shoulder. © The Japanese Orthopaedic Association 2012.

Challenges and solutions for total hip arthroplasty in treatment of patients with symptomatic sequelae of developmental dysplasia of the hip

PJI DX Updated Search

Conditions that adversely affect a child's hip alignment, joint congruity, or articular surfaces often result in joint destruction associated with pain and motion limitation later in life. The usual culprits are developmental dysplasia of the hip (DDH), slipped capital femoral epiphysis, Legg-Calve-Perthes disease, juvenile rheumatoid arthritis, infection, trauma, and neoplasm. In this review, we address DDH, the most common cause of secondary osteoarthritis of the hip. Symptomatic sequelae of DDH present challenges for total hip arthroplasty, including excessive proximal femoral anteversion, narrowing of the medullary canal, acetabular anteversion, verticality, hypoplasia and incongruity, pseudoacetabulum, and neurovascular shortening. Presiding corrective femoral and/or acetabular osteotomies, as well as retained hardware, further complicate total hip arthroplasty. This review emphasizes evaluation of hip morphology while considering reconstructive techniques and implants

Quantitatively evaluated magnetic resonance tomography as a therapeutic follow-up of the nonsteroidal antirheumatic ademetionin: a pilot study in patients with gonarthrosis

OAK 3 - Non-arthroplasty tx of OAK

The report deals with a double�blind study of nine patients treated over a period of three months with either ademetionin (five patients) or with a placebo (four patients). Prior to treatment, and after three months, clinical and biochemical studies were carried out as well as radiological examinations and MRT. The latter had been standardised previously in order to obtain a cartilage signal which could be quantified. Of the five patients treated with ademetionin, none were improved clinically, two were worse and three were unchanged, but on MRT, three were improved, one was worse and one was unchanged. Amongst the placebo patients, the clinical results were: three improved, none worse and one unchanged, with similar findings on MRT. MRT appears to be useful for complementing the information for treatment planning with chondroprotective drugs.

Serum undercarboxylated osteocalcin is a marker of the risk of hip fracture in elderly women

Management of Hip Fractures in the Elderly

It has been previously shown that the level of circulating undercarboxylated osteocalcin (ucOC) is elevated in elderly women in comparison with young, healthy, premenopausal ones. To understand the mechanism of the increase in the ucOC in the elderly and to assess its potential consequences on bone fragility, we have measured ucOC in the sera of 195 elderly institutionalized women 70-101 yr of age. In 45 women (23%) serum ucOC was above the upper limit of the normal range for young women. The level of ucOC was negatively correlated with 25OHD (r = -0.32, P < 0.001) even after excluding the effect of age, parathyroid hormone (PTH), and creatinine by partial correlation (r = -0.24, P < 0.002). During an 18-mo follow-up, 15 women sustained a hip fracture and their baseline ucOC level was higher (P < 0.01) in women who subsequently sustained hip fracture than in the nonfracture group contrasting with no significant differences for serum calcium, phosphate, alkaline phosphatase, creatinine, PTH, 250HD, and total and carboxylated OC. The risk of hip fracture was increased in women with elevated ucOC (relative ratio 5.9, 99.9% Cl 1.5-22.7, P < 0.001). During 1 yr of calcium/vitamin D2 treatment, ucOC decreased (P < 0.05), especially in those with the initially increased values (from 2.22 +/- 0.35 to 1.41 +/- 0.29 ng/ml, P <0.005) contrasting with an increase in the placebo group (P < 0.05). In conclusion, the increase in ucOC in the elderly reflects not only some degree of vitamin K deficiency but also their poor vitamin D status, suggesting that vitamin D may be important, either directly or indirectly through its effect on bone turnover, for achieving a normal gamma-carboxylation of OC. The ucOC, but not conventional calcium metabolism parameters, predicts the subsequent risk of hip fracture, suggesting that serum ucOC reflects some changes in bone matrix associated with increased fragility

Innovations in total knee replacement: new trends in operative treatment and changes in peri-operative management

Surgical Management of Osteoarthritis of the Knee CPG

The human knee joint can sustain damage due to injury, or more usually osteoarthritis, to one, two or all three of the knee compartments: the medial femorotibial, the lateral femorotibial and the patellofemoral compartments. When pain associated with this damage is unmanageable using nonsurgical techniques, knee replacement surgery might be the most appropriate course of action. This procedure aims to restore a pain-free, fully functional and durable knee joint. Total knee replacement is a well-established treatment modality, and more recently, partial knee replacement-more commonly known as bi- or unicompartmental knee replacement-has seen resurgence in interest and popularity. Combined with the use of minimally invasive surgery (MIS) techniques, gender-specific prosthetics and computer-assisted navigation systems, orthopaedic surgeons are now able to offer patients knee replacement procedures that are associated with (1) minimal risks during and after surgery by avoiding fat embolism, reducing blood loss and minimising soft tissue disruption; (2) smaller incisions; (3) faster and less painful rehabilitation; (4) reduced hospital stay and faster return to normal activities of daily living; (5) an improved range of motion; (6) less requirement for analgesics; and (7) a durable, well-aligned, highly functional knee. With the ongoing advancements in surgical technique, medical technology and prosthesis design, knee replacement surgery is constantly evolving. This review provides a personal account of the recent innovations that have been made, with a particular emphasis on the potential use of MIS techniques combined with computer-assisted navigation systems to treat younger, more physically active patients with resurfacing partial/total implant knee arthroplasty

Automatic scan planning for magnetic resonance imaging of the knee joint

AMP (Acute Meniscal Pathology)

Automatic scan planning for magnetic resonance imaging of the knee aims at defining an oriented bounding box around the knee joint from sparse scout images in order to choose the optimal field of view for the diagnostic images and limit acquisition time. We propose a fast and fully automatic method to perform this task based on the standard clinical scout imaging protocol. The method is based on sequential Chamfer matching of 2D scout feature images with a three-dimensional mean model of femur and tibia. Subsequently, the joint plane separating femur and tibia, which contains both menisci, can be automatically detected using an information-augmented active shape model on the diagnostic images. This can assist the clinicians in quickly defining slices with standardized and reproducible orientation, thus increasing diagnostic accuracy and also comparability of serial examinations. The method has been evaluated on 42 knee MR images. It has the potential to be incorporated into existing systems because it does not change the current acquisition protocol.

Diastasis recti: clinical anatomy

Panniculectomy & Abdominoplasty CPG

BACKGROUND: Enduring diastasis repair is one of the yardsticks by which a successful abdominoplasty is measured, because the presence and size of diastasis recti are thought to be reliable indicators of abdominal wall laxity and protrusion. The author's study of the "normal" anatomy of diastasis challenges these concepts about diastasis recti. METHODS: Ninety-two consecutive abdominoplasty patients, in whom intraoperative measurements of the linea alba were taken, were included in this study. The degree of abdominal wall protrusion was quantified by estimating the intra-abdominal fat volume in the upright patient as large, medium, or small. RESULTS: The most striking anatomical finding was that the linea alba has a limited range of stretch, most commonly between 1 and 2 inches, regardless of the extent of the abdominal girth. Moreover, eight patients with diastasis did not manifest abdominal protrusion, and in five patients, diastasis was absent, although a significant protrusion was present. Also, the site of the widest diastasis (supraumbilical/infraumbilical) frequently did not correspond to the site of the protrusion. CONCLUSIONS: Contrary to current thought, abdominal wall protrusions are caused by the stretching of the entire abdominal wall and not only the linea alba. Thus, significant abdominal wall protrusions may occur without diastasis and flat abdomens may exhibit a diastasis. Abdominal protrusion should replace diastasis as the prime indicator of abdominal wall laxity; stretching and the decision to perform diastasis repair should be influenced primarily by the evaluation of the protrusion rather than the diastasis.

Transconjunctival orbital fat repositioning: transposition of orbital fat pedicles into a subperiosteal pocket

Upper Eyelid and Brow Surgery

Rejuvenation of the lower eyelid complex is based on the principle that the contour changes characterizing aging involve not only prolapse of orbital fat but also descent of the cheek tissues, resulting in accentuation of the orbital rim and tear trough groove. When a deep groove is present along the orbital rim in the area of the tear trough deformity, it is advantageous, rather than removing orbital fat, to reposition the fat over the orbital rim through the opened arcus marginalis onto the superior face of the maxilla. Orbital fat repositioning can be accomplished through a transconjunctival approach. The arcus marginalis is exposed and incised, and a subperiosteal pocket is created over the superior face of the maxilla. The subperiosteal pocket shape and location are customized based on the desired location of the orbital fat pedicle; often the origins of the levator superioris labialis and the levator alae nasi muscles are partially dissected. Medial and central fat pedicles are created and rotated over the orbital rim into the subperiosteal pocket. A 6-0 polypropylene externalized sutured is used to fixate the fat pedicle in position. The suture can be removed after 3 to 5 days. Twenty-four patients were followed clinically after orbital fat repositioning, with follow-up ranging from 6 to 30 months. Although the fat pedicle undergoes some variable resorption, the viability of the graft, the texture and contour of the repositioned fat after a healing period of 1 to 2 months, and the excellent patient acceptance are indicative of the viability of orbital fat repositioning.

Molecular analysis of bacteria in asymptomatic and symptomatic endodontic infections

Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures

The purpose of the present study was to use terminal restriction fragment length polymorphism analysis and the 16S rRNA gene clone library to investigate the diversity of the microbiota associated with asymptomatic and symptomatic endodontic infections and to compare the bacterial community structure in these two clinical conditions. Samples were taken from asymptomatic endodontic infections associated with chronic periradicular lesions and from symptomatic infections clinically diagnosed as acute abscesses. 16S rRNA genes from DNA isolated from clinical samples were used to construct clone libraries or were subjected to terminal restriction fragment length polymorphism analysis. Sequence analysis of 186 clones revealed 42 taxa; 23 (55%) were uncultivated phylotypes, of which seven were unique to endodontic infections. Clone sequencing and terminal restriction fragment length polymorphism analysis revealed that the most commonly detected taxa were Fusobacterium nucleatum (including terminal restriction fragment types 1 and 2), Peptostreptococcus micros/Peptostreptococcus sp. oral clone AJ062/BS044/FG014, Prevotella species, Dialister species, Mogibacterium species, Lachnospiraceae oral clone 55A-34, Filifactor alocis, Megasphaera sp. oral clone CS025/BS073, and Veillonella sp. oral clone BP1-85/Veillonella dispar/V. parvula. Bacteroides-like sp. oral clone X083/Bacteroidales oral clone MCE7_20 and Dialister sp. oral clone BS016/MCE7_134 were detected only in asymptomatic teeth. On the other hand, F. nucleatum terminal restriction fragment type 2, Prevotella intermedia, Dialister pneumosintes, and some phylotypes were exclusively detected in symptomatic samples. Bacterial profiles of symptomatic endodontic infections generated by terminal restriction fragment length polymorphism analysis were clearly different from those of asymptomatic infections. Overall, the average number of terminal restriction fragments in symptomatic samples was significantly larger than in asymptomatic samples. Molecular analysis of the microbiota associated with symptomatic or asymptomatic endodontic infections indicates that the endodontic bacterial diversity is greater than previously described by culture methods and that the structure of the microbiota differ significantly between asymptomatic and symptomatic infections

Biomechanical assessment of unicompartmental knee arthroplasty, total condylar arthroplasty and tibial osteotomy

Surgical Management of Osteoarthritis of the Knee CPG

A prospective biomechanical study of unicompartmental arthroplasty using the Oxford Meniscal Knee, total condylar arthroplasty, and tibial osteotomy is described. The 50 patients all had degenerative osteoarthrosis of the knee associated with a varus or valgus deformity. The decision as to which operation a patient would undergo was made on clinical grounds alone; 20 patients underwent unicompartmental arthroplasty, 10 patients total condylar arthroplasty, and 20 patients tibial osteotomy. Dynamic assessments of functional knee joint biomechanics were performed both before and after the surgery. Cadence, velocity and stride length improved in all three groups. Changes in sagittal plane knee parameters were generally small. In the coronal plane, all groups showed correction of varus or valgus deformity, with corresponding decreases in the adduction/abduction moment. In the unicompartmental group the postoperative coronal plane angulation was predictable from its preoperative value. Some overcorrection of the varus deformity was observed after tibial osteotomy, and the total condylar arthroplasty group showed a small degreee of residual deformity

Osteoarthritis year in review 2016: clinical

PRP (Platelet-Rich Plasma)

Both epidemiologic and clinical research continues to be performed in osteoarthritis (OA). While epidemiologic studies identify risk factors for incident and progressive disease, clinical studies explore the role of both non-pharmacologic and pharmacologic treatments, including oral and intra-articular therapies. We performed a systematic review of the literature using PubMed for the time period between April 1, 2015 to February 22, 2016. Selected publications in the areas of both epidemiology and treatment are reviewed in this article.

Mesomelic dysplasia with periosteal thickening, radio-humeral dislocation, osteoporosis and multiple fractures

The Treatment of Pediatric Supracondylar Humerus Fractures AUC

We report a boy with a new form of mesomelic dysplasia characterised by short stature, multifocal periosteal thickening, radio-humeral dislocation, osteoporosis and multiple fractures with minimal trauma. Electrophoresis of fibroblast collagens detected defects in type III and type V collagen. CONCLUSION: Bone dysplasias presenting with osteopenia, abnormal trabecular pattern, bone fragility, and periosteal thickening suggest a collagenopathy. A possible collagen defect requires biochemical investigations

Association Between Life's Simple 7 and Noncardiovascular Disease: The Multi-Ethnic Study of Atherosclerosis

Hip Fx in the Elderly 2019

BACKGROUND: The American Heart Association introduced the Life's Simple 7 (LS7) metrics to assess and promote cardiovascular health. We examined the association between the LS7 metrics and noncardiovascular disease. METHODS AND RESULTS: We studied 6506 men and women aged between 45 and 84 years, enrolled in the Multi-Ethnic Study of Atherosclerosis. Median follow-up time was 10.2 years. Each component of the LS7 metrics (smoking, body mass index, physical activity, diet, total cholesterol, blood pressure, and blood glucose) was assigned points, 0 indicates "poor" category; 1, "intermediate," and 2, "ideal." The LS7 score, ranged from 0 to 14, was created from the points and categorized as optimal (11-14), average (9-10), and inadequate (0-8). Hazard ratios and event rates per 1000 person-years were calculated for outcomes based on self-reported hospitalizations with the International Classification of Diseases, 9th Revision, diagnoses of cancer, chronic kidney disease, pneumonia, deep venous thromboembolism/pulmonary embolism, chronic obstructive pulmonary disease, dementia, and hip fracture. Analyses were adjusted for age, sex, race/ethnicity, income, and education. Overall, noncardiovascular disease event rates were lower with increasing LS7 scores. With the inadequate LS7 score as reference, an optimal score was associated with a decreased risk for noncardiovascular disease events. The hazard ratio for cancer was, 0.80 (0.64-0.98); chronic kidney disease, 0.38 (0.27-0.54); pneumonia, 0.57 (0.40-0.80); deep venous thromboembolism/pulmonary embolism, 0.52 (0.33-0.82), and chronic obstructive pulmonary disease, 0.51 (0.31-0.83). CONCLUSIONS: The American Heart Association's LS7 score identified individuals who were vulnerable to multiple chronic nonvascular conditions. These results suggest that improving cardiovascular health will also reduce the burden of cancer and other chronic diseases.

Repurposing Human Osteoarthritic Cartilage as a Bone Graft Substitute in an Athymic Rat Posterolateral Spinal Fusion Model

OAK 3 - Non-arthroplasty tx of OAK

Background: Spinal fusion involves both endochondral and intramembranous bone formation. We previously demonstrated that endochondral cartilage grafts that were derived from human osteoarthritic (OA) articular cartilage can be used as a bone graft in mouse models. We hypothesized that OA cartilage could also be recycled and repurposed as a bone graft substitute in a posterolateral lumbar spinal fusion model in athymic rats. Methods: OA articular cartilage was obtained from the femoral resection of a healthy 60-year-old man undergoing elective total knee arthroplasty. The chondrocytes recovered from this tissue were dedifferentiated in monolayer tissue culture and then transitioned to culture conditions that promote chondrocyte hypertrophy. The resultant cell pellets were then used as bone graft substitute for single-level posterolateral spinal fusion in 5 athymic rats. Decortication alone was used as the control group. Spinal fusion was assessed with manual palpation, micro-computed tomography, and histologic analysis. Results: In the experimental group, micro-computed tomography at 4 and 8 weeks demonstrated bilateral fusion in 4 of 5 animals and unilateral fusion in 1 animal. At 8 weeks, manual palpation and histologic analysis showed direct correlation with the radiographic findings. Animals undergoing decortication alone failed to generate any spinal fusion. The difference in the fusion rate between groups was statistically significant with respect to both unilateral fusion (P = .047) and bilateral fusion (P = .007). Conclusions: In the absence of additional surgically implanted bone graft, hypertrophic chondrocyte grafts are sufficient for generating single-level posterolateral lumbar fusion in athymic rats. Clinical Relevance: This animal study demonstrates that cartilage harvested from OA knees can be used as a bone graft substitute. Commercially available cell-based bone grafts have previously only used mesenchymal stem cells or osteoblast precursor cells.

Peripheral neuropathy masquerading as an epidural complication

Surgical Management of Osteoarthritis of the Knee CPG

BACKGROUND: Epidural anaesthesia generally provides safe postoperative pain control, but does carry a small risk of nerve damage. CASE DESCRIPTION: A 30-year-old woman with long standing rheumatoid arthritis underwent a primary total knee replacement under general anaesthetic. Postoperatively, a continuous epidural infusion was used for pain relief. On discontinuation of the epidural, she was confirmed to have a foot drop. Her subsequent investigation and management for neuropathic pain was coordinated by the acute pain service. Magnetic resonance imaging excluded a central lesion. Nerve conduction studies 6 weeks later confirmed peripheral nerve lesions. The patient's neurological deficit was not due to her epidural, but rather her intraoperative tourniquet. DISCUSSION: The episode raises a number of discussion points for our pain service around the use of epidurals for knee replacement surgery, the management of nerve injury and the ease at which the epidural can be blamed for coincident injuries. International evidence would suggest that neurological complications following knee replacement are more likely to be related to surgery can epidural analgesia

An evaluation of resource utilisation of single stage porcine acellular dermal matrix assisted breast reconstruction: A comparative study

Acellular Dermal Matrix

OBJECTIVES: To evaluate resource utilization of single stage porcine acellular dermal matrix (ADM) assisted breast reconstruction compared with tissue expander (TE), latissimus dorsi flap and implant (LD/I) and latissimus dorsi flap and TE (LD/TE) reconstructive techniques. MATERIALS AND METHODS: Clinical data was collected for length of stay, operative time, additional hospitalisations and operative procedures, and outpatient appointments for 101 patients undergoing unilateral implant based breast reconstruction. Resources utilised by ADM (Strattice Reconstructive Tissue Matrix™) patients were analysed and compared to the resource usage of traditional techniques. RESULTS: 25 patients undergoing single stage ADM (ADM/I) were compared with 27 having TE, 32 having LD/I and 17 having LD/TE reconstructions. Follow up was 24 months. Compared to TE, ADM/I had similar length of stay and operative time, lower rate and number of additional procedures, fewer, shorter re-admissions (p < 0.05) and fewer appointments (p < 0.05). Compared to LD/TE, ADM/I had shorter length of stay and operative time (p < 0.05), lower rate and number of additional procedures, fewer, shorter re-admissions (p < 0.05) and fewer appointments (p < 0.05). Compared to LD/I, ADM/I had shorter length of stay (p < 0.05) and operative time (p < 0.05), fewer appointments, similar rate and number of additional procedures but required more and longer re-admissions. CONCLUSION: In our experience, unilateral single stage ADM/I was associated with fewer resources utilised in comparison with two staged TE and LD/TE reconstructions in both complication-free and complicated settings over a 24-month period, despite requiring aesthetic revision in 60.9% of patients. Compared to LD/I, resource utilisation was commensurate in complication-free and complicated settings.

Volkmann's ischemic contracture

DOD - Acute Comp Syndrome CPG

Volkmann's ischemic contracture is a complex process that often results in a significant functional disability. Destruction of the forearm musculature can, in certain situations, be reconstructed utilizing muscle transplantation. Proper patient selection, attention to detail at the time of the surgical procedures, and patient compliance during rehabilitation are key factors in a successful outcome. Functional results have been very rewarding, although certain problem areas await resolution. [References: 4]

Effects of an educational audiovisual videodisc on patients' pre-operative expectations with total knee arthroplasty: a prospective randomized comparative study

Surgical Management of Osteoarthritis of the Knee CPG

PURPOSE: To investigate the effectiveness of an educational videodisc in modifying pre-operative patients' expectations with total knee arthroplasty (TKA) and to find a biophysical profile of subjects in whom this videodisc could be most effective. It was hypothesized that patients receiving standard information plus additional medical information through audiovisual videodiscs would modify their pre-operative expectations more than those only receiving the standard information through medical interviews. METHODS: Ninety-two patients (age, 50-90 years) with knee osteoarthritis waiting for TKA were randomized into two groups. All patients received general verbal information about this procedure. Forty-two patients (study group) additionally viewed an educational videodisc related to the whole process of TKA, whereas 50 patients did not view it (control group). Patients completed baseline and post-videodisc questionnaires regarding their expected results after TKA. RESULTS: Expectations with TKA were not modified by the audiovisual videodisc, except for knee range of motion and use of stairs. There were no differences in change of expectations between groups depending on demographic, functional, health, emotional, and cognitive variables, except for body mass index. The overall pre-operative, pre-intervention expectations were not modified by the audiovisual videodisc. CONCLUSIONS: Based on these results, the use of this complementary tool may not be systematically recommended. In addition, it was not possible to identify a biophysical profile of patients in whom the intervention could be most effective

Lower limb injuries caused by improvised explosive devices: proposed 'Bastion classification' and prospective validation

DoD LSA (Limb Salvage vs Amputation)

BACKGROUND: Complex lower limb injury caused by improvised explosive devices (IEDs) has become the signature wounding pattern of the conflict in Afghanistan. Current classifications neither describe this injury pattern well, nor correlate with management. There is need for a new classification, to aid communication between clinicians, and help evaluate interventions and outcomes. We propose such a classification, and present the results of an initial prospective evaluation. PATIENTS AND METHODS: The classification was developed by a panel of military surgeons whilst deployed to Camp Bastion, Afghanistan. Injuries were divided into five classes, by anatomic level. Segmental injuries were recognised as a distinct entity. Associated injuries to the intraperitoneal abdomen, genitalia and perineum, pelvic ring, and upper limbs, which impact on clinical management and resources, were also accounted for. RESULTS: Between 1 November 2010 and 20 February 2011, 179 IED-related lower limb injuries in 103 consecutive casualties were classified, and their subsequent vascular and musculoskeletal treatment recorded. 69% of the injuries were traumatic amputations, and the remainder segmental injuries. 49% of casualties suffered bilateral lower limb amputation. The most common injury was class 3 (involving proximal lower leg or thigh, permitting effective above-knee tourniquet application, 49%), but more proximal patterns (class 4 or 5, preventing effective tourniquet application) accounted for 18% of injuries. Eleven casualties had associated intraperitoneal abdominal injuries, 41 suffered genital or perineal injuries, 9 had pelvic ring fractures, and 66 had upper limb injuries. The classification was easy to apply and correlated with management. CONCLUSIONS: The 'Bastion classification' is a pragmatic yet clinically relevant injury categorisation, which describes current injury patterns well, and should facilitate communication between clinicians, and the evaluation of interventions and outcomes. The validation cohort confirms that the injury burden from IEDs in the Helmand Province of Afghanistan remains high, with most casualties sustaining amputation through or above the knee. The rates of associated injury to the abdomen, perineum, pelvis and upper limbs are high. These findings have important implications for the training of military surgeons, staffing and resourcing of medical treatment facilities, to ensure an adequate skill mix to manage these complex and challenging injuries.

Diagnostic and prognostic nomograms for bone metastasis in small cell lung cancer

MSTS 2022 - Metastatic Disease of the Humerus

Objective: Patients with bone metastasis (BM) of small cell lung cancer (SCLC) have a poor prognosis. We aimed to identify predictors and prognostic factors in patients with BM of SCLC and construct nomograms to predict BM. Methods: We retrospectively analyzed 18,187 cases from the Surveillance, Epidemiology, and End Results database reported between 2010 and 2016. Differences in overall survival (OS) and cancer-specific survival (CSS) were evaluated after propensity score matching. Independent predictors for BM and prognostic factors for patients with BM of SCLC were determined using univariate and multivariate regression analyses. Two nomograms were constructed and evaluated using C-statistics. Results: BM was observed in 4014 (22.07%) patients. Kaplan–Meier survival analysis revealed significant differences between BM and non-BM groups. The median OS for patients with and without BM was 6 and 7 months, respectively. The median CSS for patients with and without BM was 9 and 13 months, respectively. Age, sex, tumor size, N stage, chemotherapy, surgery, radiotherapy, and liver/brain/lung metastases were related to BM and independent prognostic factors for OS and CSS. Diagnostic and prognostic nomograms were generated. Conclusion: Our nomograms predicted the incidence of BM and the 5-month survival rate of patients with SCLC and BM.

Osteoporosis case manager for patients with hip fractures: results of a cost-effectiveness analysis conducted alongside a randomized trial

HipFx Supplemental Cost Analysis

BACKGROUND: In a randomized trial of patients with hip fractures, we previously demonstrated that a hospital-based case manager could increase rates of appropriate osteoporosis treatment to 51% compared with 22% for usual care (P < .001). Alongside that trial, we conducted an economic analysis. METHODS: Patients with hip fractures were randomized to usual care (n = 110) or a case manager (n = 110) and followed up for 1 year. Time-motion studies were used to determine intervention costs. From a third-party health care payer perspective and over the patient's remaining lifetime, a Markov decision-analytic model was constructed to determine cost-effectiveness of the intervention compared with usual care. Costs and benefits were discounted at 3% and expressed in 2006 Canadian dollars. RESULTS: The intervention cost CaD $56 per patient. Compared with usual care, the intervention strategy was dominant: for every 100 patients case managed, 6 fractures (4 hip fractures) were prevented, 4 quality-adjusted life-years were gained, and CaD $260 000 was saved by the health care system. Irrespective of the number of patients case managed, the intervention reached a break-even threshold within 2 years. The intervention dominated usual care over the entire spectrum of 1-way sensitivity analyses and was cost-saving in 82% of probabilistic model simulations. CONCLUSIONS: Compared with usual care, we found that using a case manager for patients with hip fractures increased rates of appropriate osteoporosis treatment. The intervention dominated usual care, and the analysis suggests that systems implementing an intervention similar to ours should expect to see a reduction in fractures, gains in life expectancy, and substantial cost savings. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00175175

Evaluation of the long-term stability of sheath plication using absorbable sutures in 51 patients with diastasis of the recti muscles: an ultrasonographic study

Panniculectomy & Abdominoplasty CPG

BACKGROUND: Rectus sheath plication within abdominoplasty is a standard treatment for diastasis of the recti muscles. There are questions regarding the efficacy and long-term stability of the correction of rectus diastasis and whether absorbable sutures work as well as nonabsorbable sutures. METHODS: The authors conducted a case-control study to assess the outcomes of recti muscle diastasis correction with absorbable suture. The authors assessed the outcomes by physical and ultrasonographic examinations and a patient questionnaire, which asked about the number of pregnancies and the types of deliveries, other abdominal operations before or after the abdominoplasty, and the interval of time required to return to full activity. During the examination, the interrecti distances were measured at three levels: halfway between the xiphoid and umbilicus, just above the umbilicus, and halfway between the umbilicus and the pubis. The same examination was performed on a control group of nulliparous women. RESULTS: The authors examined a group of 51 patients aged 25 to 64 years (mean, 41 years). The time interval between the operation and the ultrasonographic examination was 12 to 41 months (mean, 20.8 months). There was no statistically significant difference between the studied group and the control group with respect to their interrecti distances. CONCLUSION: Rectus sheath plication using absorbable sutures in patients with diastasis of the recti muscles is a reliable method that maintains the long-term stability of the abdominal wall. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

Hypoxia, Snail and incomplete epithelial-mesenchymal transition in breast cancer

MSTS 2018 - Femur Mets and MM

BACKGROUND: Hypoxia is an element of the tumour microenvironment that impacts upon numerous cellular factors linked to clinical aggressiveness in cancer. One such factor, Snail, a master regulator of the epithelial-mesenchymal transition (EMT), has been implicated in key tumour biological processes such as invasion and metastasis. In this study we set out to investigate regulation of EMT in hypoxia, and the importance of Snail in cell migration and clinical outcome in breast cancer. METHODS: Four breast cancer cell lines were exposed to 0.1% oxygen and expression of EMT markers was monitored. The migratory ability was analysed following Snail overexpression and silencing. Snail expression was assessed in 500 tumour samples from premenopausal breast cancer patients, randomised to either 2 years of tamoxifen or no adjuvant treatment. RESULTS: Exposure to 0.1% oxygen resulted in elevated levels of Snail protein, along with changes in vimentin and E-cadherin expression, and in addition increased migration of MDA-MB-468 cells. Overexpression of Snail increased the motility of MCF-7, T-47D and MDA-MB-231 cells, whereas silencing of the protein resulted in decreased migratory propensity of MCF-7, MDA-MB-468 and MDA-MB-231 cells. Moreover, nuclear Snail expression was associated with tumours of higher grade and proliferation rate, but not with disease recurrence. Interestingly, Snail negativity was associated with impaired tamoxifen response (P=0.048). CONCLUSIONS: Our results demonstrate that hypoxia induces Snail expression but generally not a migratory phenotype, suggesting that hypoxic cells are only partially pushed towards EMT. Furthermore, our study supports the link between Snail and clinically relevant features and treatment response.

Skeletal metastases and impact of anticancer and bone-targeted agents in patients with castration-resistant prostate cancer

MSTS 2018 - Femur Mets and MM

Incidence of bone metastases is very high in advanced prostate cancer patients. Bone metastases likely have a significant impact on functional status and quality of life, not only related to pain, but also to the relevant risk of skeletal-related events. A better understanding of mechanisms associated with bone metastatic disease secondary to prostate cancer and more specifically to the cross-talk between tumor cells and bone microenvironment in metastatic progression represented the background for the development of new effective bone-targeted therapies. Furthermore, a better knowledge of biological mechanisms driving disease progression led to significant advances in the treatment of castration-resistant prostate cancer, with the development and approval of new effective drugs. Aim of this review is to outline the physiopathology of bone metastases in prostate cancer and summarize the main results of clinical trials conducted with different drugs to control morbidity induced by skeletal metastases and bone disease progression. For each agent, therapeutic effect on bone metastases has been measured in terms of pain control and/or incidence of skeletal-related events, usually defined as a composite endpoint, including the need for local treatment (radiation therapy or surgery), spinal cord compression, pathological bone fractures. In details, data obtained with chemotherapy (mitoxantrone, docetaxel, cabazitaxel), new generation hormonal agents (abiraterone, enzalutamide), radium-223, bone-targeted agents (zoledronic acid, denosumab) and with several experimental agents (cabozantinib, dasatinib, anti-endothelin and other agents) in patients with castration-resistant prostate cancer are reviewed.

Racial and ethnic disparities in functional, psychosocial, and neurobehavioral outcomes after brain injury

DoD PRF (Psychosocial RF)

Because of the growing minority population in the past 3 decades in the United States and the increasing numbers of individuals who sustain a traumatic brain injury (TBI), researchers and clinicians have started to pay more attention to the role of race and ethnicity in outcomes after TBI, with the goal of better serving this population. The aim of this article is to review the literature on the influence of race/ethnicity on functional, psychosocial, and neurobehavioral outcomes after TBI. Specifically, the following 8 areas of outcomes will be examined: (1) treatment outcomes, (2) neuropsychological outcomes, (3) employment/productivity, (4) functional outcomes, (5) community integration, (6) marital status, (7) quality of life/life satisfaction, and (8) emotional/neurobehavioral outcomes. To conclude this review, suggestions for improvements in professional competency, research, systems of care, and training are proposed. [References: 55]

Exome sequencing identifies a dominant tnnt3 mutation in a large family with distal arthrogryposis

Developmental Dysplasia of the Hip 2020 Review

Distal arthrogryposis (DA) is a group of rare, clinically and genetically heterogeneous disorders primarily characterized by congenital contractures of the distal limb joints without a neuromuscular disease. Mutations in at least 8 different genes have been shown to cause DA. Here, we report a 4-generation Indian family with 18 affected members presenting variable features of camptodactyly, brachydactyly, syndactyly, decreased flexion palmar creases, ulnar deviation of the hands, sandal gaps and club feet. We undertook exome sequencing of 3 distantly related affected individuals. Bioinformatics filtering revealed a known pathogenic missense mutation c.188G>A (p.Arg63His) in TNNT3 in all 3 affected individuals that segregated with the phenotype. The affected individuals exhibit significant phenotypic variability. This study demonstrates the value of exome sequencing helping to define the causative variant in genetically heterogeneous disorders. © 2014 S. Karger AG, Basel.

The Role of Prophylactic Antibiotics in Elective Hand Surgery

Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures

The current literature has poorly defined the role of antibiotic agents in elective hand surgery. The reason for this may be due to a small number of well-designed studies specifically addressing the efficacy of antibiotics in hand surgery. Our purpose is to critically review the current literature in an attempt to more precisely define the role of prophylactic antibiotics in elective hand surgery. (copyright) 2008 American Society for Surgery of the Hand

Pediatric hand and wrist injuries

Distal Radius Fractures

In the last 40 years, childhood hand and wrist injuries have become progressively more common as children have become heavier and more active in high impact sports. The majority of children with such injuries do well, but treatment is not always straightforward. Distal radius fractures, scaphoid fractures, metacarpal and phalangeal fractures, nailbed injuries, and amputations are among the pediatric hand and wrist injuries most often seen by orthopedists. These are all discussed, with a focus on the most recent literature and areas of evolving controversy. © 2012 Springer Science+Business Media New York.

C-reactive protein is an independent predictor for 1-year mortality in elderly patients undergoing hip fracture surgery: A retrospective analysis

Hip Fx in the Elderly 2019

Numerous factors are associated with mortality after hip fracture surgery in elderly patients. The aim of this study was to investigate whether preoperative C-reactive protein (CRP) was an independent risk factor for 1-year mortality after hip fracture surgery in the elderly. The electronic medical records of 772 elderly patients (age >= 65 years) undergoing hip fracture surgery from May 2003 to November 2011 were reviewed retrospectively. The patients comprised a high CRP group (>10.0 mg/dL) and low CRP group (<=10.0 mg/dL), based upon preoperative CRP levels. The overall 1-year mortality was 14.1%; the value was significantly higher in the high CRP group than in the low CRP group (31.8% vs 12.5%; P < 0.001). On binary logistic regression, body mass index (odds ratio [OR], 0.93; 95% confidence interval [CI], 0.88-0.99; P = 0.025), history of malignancy (OR, 2.59; 95% CI, 1.47-4.57; P = 0.001), American Society of Anesthesiologists physical status (ASA PS) class 3-4 (OR, 1.96; 95% CI, 1.25-3.07; P = 0.003), preoperative albumin (OR, 0.39; 95% CI, 0.25-0.61; P < 0.001), preoperative CRP > 10.0 mg/dL (OR, 2.04; 95% CI, 1.09-3.80; P = 0.025), postoperative intensive care unit (ICU) admission (OR, 2.29; 95% CI, 1.15-4.59; P = 0.019), and creatinine on the second postoperative day (OR, 1.20; 95% CI, 1.00-1.45; P = 0.048) were independent predictors of 1-year mortality after hip surgery. Male gender and low preoperative hemoglobin were associated with in-hospital mortality, whereas delayed surgery and femoral neck fracture were related to the 6-month mortality. Low preoperative albumin and low body mass index predicted the 6-month and 1-year mortality. An increased preoperative CRP level, particularly >10.0 mg/dL, was associated with the 1-year mortality after hip fracture surgery in the elderly. In addition, a history of malignancy, high ASA PS score, and postoperative ICU admission were related to mortality after hip fracture.

Magnetic resonance imaging evaluation of congenital dislocation of the hips

Developmental Dysplasia of the Hip CPG

Magnetic resonance (MR) images were obtained preoperatively and postoperatively for 12 pediatric patients with congenital dislocation of the hip (CDH). The images were compared with arthrograms and computed tomography scans. The MR images were more accurate in defining soft-tissue anatomy, hip position, and obstructive factors to relocation. MR imaging is an efficient diagnostic tool in CDH

Common peroneal nerve dysfunction after high tibial osteotomy

DOD - Acute Comp Syndrome CPG

We assessed 16 patients before and after high tibial osteotomy by electrophysiological recordings, creatine phosphokinase levels, radiographs and intracompartmental pressure monitoring. We found mild electrophysiological abnormalities pre-operatively in 12 of the 16 patients, but postoperatively these had deteriorated in 11 of the 14 patients studied. Creatine phosphokinase levels, compartment pressure and radiological deformity were not predictive of the development of postoperative common peroneal nerve palsy. Patients who also had a proximal fibular osteotomy had greater electrical abnormalities postoperatively and two of them developed common peroneal palsies. Proximal fibular osteotomy appears to be a causative factor in the development of common peroneal nerve palsy; more work is needed on the blood supply of the nerve.

Examination of determinants of patient preferences for total knee replacement (TKR) among men and women

Surgical Management of Osteoarthritis of the Knee CPG

Background Elective TKR is an effective treatment option for end-stage knee osteoarthritis (OA) that is rapidly growing. Although women have as much or greater prevalence of knee OA than men, men undergo TKR more often than women. Patient preference is emerging as an important consideration in TKR gender disparities. However, few studies have examined the determinants of patients' preference in a racially diverse sample of men and women. Objectives We sought to identify whether determinants of patients' preference for TKR differ by gender. Methods Our sample consisted of 509 women (59% white) and 290 men (73% white) with chronic, frequent knee pain and radiographic evidence of knee OA. We used logistic regression models, stratified by gender, to identify clinical and socio-cultural determinants of patients' preference for TKR. Clinical and socio-cultural factors were entered simultaneously into the stratified models. Stepwise selection methods were used to select socio-cultural items to be included in the final models, using a criterion of p<0.20. All models were adjusted for age, income level, disease severity (using the WOMAC), and study site. Results White women had lower preference for TKR compared to white men (adjusted OR=0.56, 95%CI 0.34 to 0.94), whereas African-American (AA) women had higher preference for TKR compared to AA men (adjusted OR=1.24, 95%CI 0.70 to 2.18). Among women, items related to knowledge (p<0.001) and expectations (p=0.007) regarding surgical outcomes, and religiosity (p=0.045) were selected for inclusion in the multivariate model. Among men, items related to knowledge (p=0.46) and expectations regarding surgical outcomes (p=0.027) were selected for inclusion in the multivariate model (see Table 1). Conclusions Expectations regarding surgical outcomes are important for both men and women with regard to their preferences for TKR, but the genders differ with regard to which other socio-cultural determinants impact these preferences. Interventions to reduce or eliminate gender disparities in the utilization of TKR should consider and target these factors. (Table Presented)

Longitudinal preclinical magnetic resonance imaging of diffuse tumor burden in intramedullary myeloma following bortezomib therapy

MSTS 2018 - Femur Mets and MM

Multiple myeloma (MM) is a largely incurable, debilitating hematologic malignancy of terminally differentiated plasma cells in the bone marrow (BM). Identification of therapeutic response is critical for improving outcomes and minimizing costs and off-target toxicities. To assess changes in BM environmental factors and therapy efficacy, there is a need for noninvasive, nonionizing, longitudinal, preclinical methods. Here, we demonstrate the feasibility of preclinical magnetic resonance imaging (MRI) for longitudinal imaging of diffuse tumor burden in a syngeneic, immunocompetent model of intramedullary MM. C57Bl/KaLwRij mice were implanted intravenously with 5TGM1-GFP tumors and treated with a proteasome inhibitor, bortezomib, or vehicle control. MRI was performed weekly with a Helmholtz radiofrequency coil placed on the hind leg. Mean normalized T1-weighted signal intensities and T2 relaxation times were quantified for each animal following manual delineation of BM regions in the femur and tibia. Finally, tumor burden was quantified for each tissue using hematoxylin and eosin staining. Changes in T2 relaxation times correlated strongly to cell density and overall tumor burden in the BM. Median T2 relaxation times and regional T1-weighted contrast uptake were shown to be most relevant in identifying posttherapy disease stage in this model of intramedullary MM. In summary, our results highlighted potential preclinical MRI markers for assessing tumor burden and BM heterogeneity following bortezomib therapy, and demonstrated the application of longitudinal imaging with preclinical MRI in an immunocompetent, intramedullary setting.

Coculture of meniscus cells and mesenchymal stem cells in simulated microgravity

AMP (Acute Meniscal Pathology)

Simulated microgravity has been shown to enhance cartilaginous matrix formation by chondrocytes and chondrogenesis of mesenchymal stem cells (MSCs). Similarly, coculture of primary chondrocytes with MSCs has been shown as a strategy to simultaneously retain the differentiated phenotype of chondrocytes and enhance cartilaginous matrix formation. In this study, we investigated the effect of simulated microgravity on cocultures of primary human meniscus cells and adipose-derived MSCs. We used biochemical, qPCR, and immunofluorescence assays to conduct our investigation. Simulated microgravity significantly enhanced cartilaginous matrix formation in cocultures of primary meniscus cells and adipose-derived MSCs. The enhancement was accompanied by increased hypertrophic differentiation markers, COL10A1 and MMP-13, and suppression of hypertrophic differentiation inhibitor, gremlin 1 (GREM1).

Patient-reported outcome measurement in upper blepharoplasty: How to measure what the patient sees

Upper Eyelid and Brow Surgery

Background: Blepharochalasis is very common and affects not only appearance but also visual function. Upper blepharoplasty is therefore the most frequently performed facial cosmetic procedure worldwide. It is generally seen as a small procedure with good patient acceptance and postoperative satisfaction. Research concerning the outcome of this procedure in terms of satisfaction and quality of life is lacking, as well as a recommendation on which assessment tools to use in this patient group. Method: A prospective study was performed on patients who underwent blepharoplasty. They were requested to complete a questionnaire preoperatively and at 3â??6 months postoperatively. The Blepharoplasty Outcome Evaluation (BOE) and the Derriford Appearance Scale (DAS59) were used preoperatively and postoperatively. Visual analog scales (VAS) were also used preoperatively and postoperatively to measure visual impairment and aesthetic aspects of the eyelids. The Glasgow Benefit Inventory (GBI) was used postoperatively. Subjects: Thirty-six patients completed all questionnaires. They had a mean age of 55 years (range 25â??73 years) and 31 were female. Main findings: Reliability of all questionnaires was moderate to good. Both satisfaction with the eyes and self-esteem improved significantly. Patients reported significant benefits afterwards. All scales showed significant correlations with the exception of several DAS59 subscales. Conclusions: Upper blepharoplasty can result in great improvement in patient satisfaction, self-consciousness of appearance and benefit in daily life. Only the general subscale of the DAS59 seems relevant to use in this patient group. The BOE and GBI are brief but excellent tools to use in patients who underwent blepharoplasty to measure satisfaction and benefit in daily life.

Atraumatic avulsion of the distal iliopsoas tendon: an unusual cause of hip pain

Management of Hip Fractures in the Elderly

While uncommon, isolated avulsion fractures of the lesser trochanter occur in children and adolescents prior to the fusion of this apophysis as a result of athletic activities. In the elderly, isolated fractures of the lesser trochanter are rare but can occur as a result of trauma. They have been identified in patients with primary or secondary bone malignancies, which were previously considered pathognomonic for metastatic disease. In the absence of trauma, weakening of the bone due to systemic disorders such as osteoporosis or osteomalacia chronica renal failure may also be responsible. Diagnosis may be difficult with physical examination and radiographs alone. This case report details this rare fracture in 2 patients suffering from debilitating chronic disease. Patient 1 was a 30-year-old woman with an 18-year history of type 1 diabetes mellitus, a 6-year history of end-stage renal disease, hypertension, hypothyroidism, peripheral vascular disease, and a 3-year history of systemic lupus erythematosus with antiphospholipid syndrome treated with warfarin. Patient 2 was a 66-year-old woman with a history of type 2 diabetes mellitus, peripheral neuropathy, obesity, chronic obstructive pulmonary disease, gout, hypertension, and chronic neck and low back pain. Both were assessed with magnetic resonance imaging following physical examination, which revealed atraumatic avulsion of the distal iliopsoas tendon from the lesser trochanter. Following retraction of the iliopsoas tendon, the patients were treated with conservative therapy and anti-inflammatory medication. These 2 cases broaden the range of patients for whom spontaneous avulsion of the distal iliopsoas tendon should be considered in the differential diagnosis

Autosomal dominant type I osteopetrosis is related with iatrogenic fractures in arthroplasty

PJI DX Updated Search

Autosomal dominant osteopetrosis (ADO) is a sclerotic bone disorder due to failure of osteoclasts. ADO poses difficulties during arthroplasty because of the increased chance for iatrogenic fractures due to sclerotic bone. ADO is divided into two types based on radiological findings, fracture risk, and osteoclast activity. These differences suggest less brittle bone in patients with ADO I compared to that of patients with ADO II, which suggests a smaller chance of preoperative fractures during cementless arthroplasty in ADO I compared with that in ADO II. A case of cementless total knee arthroplasty in a patient with ADO I is presented. Total hip arthroplasty was performed during follow-up, and known major problems related to ADO II were experienced. Therefore, the differences between ADO I and ADO II may not be clinically relevant for an iatrogenic fracture during arthroplasty in patients with ADO

A multicenter, randomized, triple-masked, placebo-controlled trial of the effect of ambulatory continuous femoral nerve blocks on discharge-readiness following total knee arthroplasty in patients on general orthopaedic wards

AAHKS (9/10) Regional Nerve Blocks

A continuous femoral nerve block (cFNB) involves the percutaneous insertion of a catheter adjacent to the femoral nerve, followed by a local anesthetic infusion, improving analgesia following total knee arthroplasty (TKA). Portable infusion pumps allow infusion continuation following hospital discharge, raising the possibility of decreasing hospitalization duration. We therefore used a multicenter, randomized, triple-masked, placebo-controlled study design to test the primary hypothesis that a 4-day ambulatory cFNB decreases the time until each of three predefined readiness-for-discharge criteria (adequate analgesia, independence from intravenous opioids, and ambulation 30m) are met following TKA compared with an overnight inpatient-only cFNB. Preoperatively, all patients received a cFNB with perineural ropivacaine 0.2% from surgery until the following morning, at which time they were randomized to either continue perineural ropivacaine (n=39) or switch to normal saline (n=38). Patients were discharged with their cFNB and portable infusion pump as early as postoperative day 3. Patients who were given 4 days of perineural ropivacaine attained all three criteria in a median (25th-75th percentiles) of 47 (29-69)h, compared with 62 (45-79)h for those of the control group (Estimated ratio=0.80, 95% confidence interval: 0.66-1.00; p=0.028). Compared with controls, patients randomized to ropivacaine met the discharge criterion for analgesia in 20 (0-38) versus 38 (15-64)h (p=0.009), and intravenous opioid independence in 21 (0-37) versus 33 (11-50)h (p=0.061). We conclude that a 4-day ambulatory cFNB decreases the time to reach three important discharge criteria by an estimated 20% following TKA compared with an overnight cFNB, primarily by improving analgesia.

Analgesics in postoperative care in hip fracture patients with dementia - reported by nurses

Hip Fx in the Elderly 2019

AIMS AND OBJECTIVES: To describe the analgesic use in hip fracture patients with dementia during the first two postoperative days as reported by nurses. BACKGROUND: Nurses play a pivotal role in treating postoperative pain in patients with dementia and monitoring the effects of administered analgesics. DESIGN: Cross-sectional descriptive questionnaire study in seven university hospitals and 10 central hospitals in Finland. METHODS: The study was conducted from March until May in 2011 in Finland. For this analysis, the focus was on the sample of nurses (n = 269) who were working in orthopaedic units. Analgesics were classified according to the Anatomical Therapeutic Chemical Classification System. Nonparametric tests were applied to find out the significant differences between analgesic use and different hospitals. RESULTS: Paracetamol and strong opioids administered orally or parenterally seemed to be the most typical of postoperatively used types of analgesics in patients with dementia. Nonsteroidal anti-inflammatory analgesics and weak opioids were also commonly reported to be in use. There were no statistically significant differences between hospitals in typical daily doses. The majority of the nurses reported that the primary aim of postoperative pain management in hip fracture patients with dementia was 'slight pain, which does not prevent normal functioning' (72%). CONCLUSION: The pharmacological postoperative pain treatment in acute care was commonly based on the use of strong opioids and paracetamol in hip fracture patients with dementia. The reported use of transdermal opioids and codeine combination warrants further examination. Further studies are also needed to find out whether the pain is appropriately and adequately treated. RELEVANCE TO CLINICAL PRACTICE: Transdermal opioids and codeine combination may not be relevant analgesics for acute pain management in older adults. It is important to create a balance between sufficient pain relief and adverse effects of analgesics to allow early mobilisation and functional recovery.

Prosthetic and extremity survivorship after limb salvage for sarcoma. How long do the reconstructions last?

Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures

Ninety-three consecutive prosthetic reconstructions performed for limb salvage after the resection of sarcomas of the lower extremity were reviewed to determine how long the reconstructions lasted, how successful they were in avoiding amputation in the long term, how significant a problem was aseptic loosening, and what was the associated patient survival. Reconstruction was of the proximal femur in 16, distal femur in 61 and proximal tibia in 16 patients. Minimum follow-up time was 24 months, with a median of 66 months and mean of 80 months. If any event leading to the removal of the prosthesis is considered a reason for failure, the event-free prosthetic survival at five years for the proximal femur was 88%, distal femur 59%, and proximal tibia 54%. Limb survival at five years was significantly better, with the proximal femur at 88%, distal femur at 88%, and proximal tibia at 78% intact. Aseptic loosening survival was better than the event free prosthetic survival, which demonstrates the influence of factors such as sepsis (hematogenous) or wound necrosis that lead to prosthetic removal. Aseptic loosening survivorship of the proximal femur at five years was 100%; distal femur, 78%; and the proximal tibia, 73%. At five years, patient survival was low for the proximal femur (62%) and distal femur (75%) but notably better for the proximal tibia (93%). Prosthetic, extremity, and patient survival differed depending on the site. Wound necrosis was a significant cause of prosthetic removal and loss of limb early in this series, but the more aggressive use of soft tissue procedures has improved this.(ABSTRACT TRUNCATED AT 250 WORDS)

Polymorphism at an Sp1 binding site of COL1A1 and bone mineral density in premenopausal female twins and elderly fracture patients

Management of Hip Fractures in the Elderly

Polymorphism at an Sp1 binding site in the COL1A1 gene has been reported to be associated with bone mineral density (BMD) and osteoporotic vertebral fracture. We therefore examined for associations and linkage of the Sp1 polymorphism in the COL1A1 gene and BMD at the lumbar spine and femoral neck in 38 monozygotic (MZ) and 40 dizygotic (DZ) twin pairs of white adult women. All twins were premenopausal with an age range of 21-49 years. Sp1 genotypes of 56 patients with idiopathic osteoporotic vertebral fracture were examined for a preponderance of either genotype relative to our normal healthy twin subjects. In the twin sample no significant association was found between Sp1 genotypes and BMD at the spine and femoral neck. No linkage of Sp1 genotype and BMD at the spine or femoral neck was observed in DZ twins discordant for genotype. Frequencies of Sp1 genotypes were similar in our healthy (twin) and fracture population samples. In conclusion, in our American sample of premenopausal twins we found no association or linkage of the Sp1 polymorphism at the COL1A1 gene and BMD at the lumbar spine and femoral neck, and no over-representation of any Sp1 genotype was observed in our sample of patients with osteoporotic vertebral fracture. Taken together these results indicate that the Sp1 polymorphism is not related to BMD in our American sample, and contrasts with the findings in a British population

Use of prophylactic antibiotics in surgical practice

Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures

During the last decade great inroads have been made concerning the appropriate use of antibiotic prophylaxis in the surgical patient. Well-controlled, prospective, blinded studies have outlined many of the areas in which antibiotic prophylaxis is of benefit, as well as those clinical situations in which the risks of antibiotic prophylaxis outweighed the expected value. Historically, the most common errors in usage include the widespread use of antibiotic prophylaxis in clean surgery and the faulty timing of administration. The most common error today (in the use of prophylactic antibiotics in surgical practice) is continuation of the agents beyond the time necessary for maximal benefit. In order to appropriately administer prophylactic antibiotics in the various clinical settings on the surgical service, in which this practice has been of proved value, one must be aware of the following nuances including (1) choice of the antibiotic agent based on the type of organisms usually causing infection, (2) route of its administration, (3) the dosage necessary to attain efficacious tissue or serum levels, and (4) the timing of administration which offers the maximum benefits without risking the adverse effects

Bisphosphonates in the management of prostate carcinoma metastatic to the skeleton

MSTS 2018 - Femur Mets and MM

BACKGROUND: Prostate carcinoma metastasizes frequently to the skeleton, causing significant morbidity, particularly severe bone pain. Metastatic lesions typically are osteosclerotic, but there is experimental, histologic, and biochemical evidence of increased bone resorption. Furthermore, bone resorption rates appear to correlate with bone pain. These observations provide the rationale for the use of bisphosphonates in the management of patients with prostate carcinoma and skeletal metastases. METHODS: The authors reviewed the literature and current findings on the use of biphosphonates in the management of patients with prostate carcinoma metastatic to the skeleton. RESULTS: Compared with the large number of studies with bisphosphonates in predominantly osteolytic bone disease, there have been relatively few (mostly uncontrolled) studies in patients with prostate carcinoma. Apart from the lack of appropriate experimental models, the osteoblastic nature of the metastases and the low incidence of objectively assessed endpoints of treatment (e.g., hypercalcemia, pathologic fractures) have delayed developments. Available data, however, strongly suggest that potent bisphosphonates are efficacious in reducing skeletal morbidity in patients with prostate carcinoma. CONCLUSIONS: For the optimal management of patients with skeletal metastases from prostate carcinoma with bisphosphonates their mode of administration, the dose and duration of treatment need to be evaluated. Better understanding of the cellular and molecular mechanisms underlying bone metastases can lead to the design of improved treatment protocols with potent bisphosphonates. [References: 41]

A systematic review of studies identifying predictors of poor return to work outcomes following workplace injury

DoD PRF (Psychosocial RF)

Background: Injuries occurring in the workplace can have serious implications for the health of the individual, the productivity of the employer and the overall economic community. Objective: The objective of this paper is to increase the current state of understanding of individual demographic and psychosocial characteristics associated with extended absenteeism from the workforce due to a workplace injury. Methods: Studies included in this systematic literature review tracked participantsâ?? return to work status over a minimum of three months, identified either demographic, psychosocial or general injury predictors of poor return to work outcomes and included a heterogeneous sample of workplace injuries. Results: Identified predictors of poor return to work outcomes included older age, female gender, divorced marital status, two or more dependent family members, lower education levels, employment variables associated with reduced labour market desirability, severity or sensitive injury locations, negative attitudes and outcome perceptions of the participant. Conclusions: There is a need for clear and consistent definition and measurement of return to work outcomes and a holistic theoretical model integrating injury, psychosocial and demographic predictors of return to work. Through greater understanding of the nature of factors affecting return to work, improved outcomes could be achieved. (PsycINFO Database Record (c) 2016 APA, all rights reserved)

Intramedullary fixation of distal radius fractures

Distal Radius Fractures

Intramedullary fixation has recently received increased enthusiasm as an option for distal radius fracture fixation. Indications for this fracture fixation technique should be limited to predominately displaced extra-articular or simple intra-articular distal radius fractures. Intramedullary fixation permits limited soft tissue dissection and insertion of a low-profile implant that acts as an internal splint. Purported benefits include a familiar fracture fixation technique, less soft tissue irritation, and locked fixed-angle technology. Thorough understanding of the radial and dorsal approaches to the distal radius is a prerequisite. Important aspects of intramedullary fixation of distal radius fractures include proper fracture selection, good fracture reduction, protection of sensory nerves, and avoidance of inadvertent intra-articular screw placement. Relevant surgical anatomy, technique, postoperative care, and a review of complications are presented.

The effectiveness and safety of two prophylactic antibiotic regimes in hip-fracture surgery

DoD SSI (Surgical Site Infections)

Antibiotic prophylaxis with cefuroxime can reduce the incidence of deep wound infection (DWI) in hip-fracture surgery, but may increase the risk of C. difficile infection (CDI). An alternative is gentamicin with beta-lactam for which a question exists around clinical effectiveness and safety, given the gentamicin-associated nephrotoxicity particularly in the elderly and narrower sensitivity spectrum. We compared 744 consecutive patients (group I-cefuroxime) with 756 in group II (gentamicin + flucloxacillin) who were well matched. There were 4 cases of CDI in the cefuroxime prophylaxis, whereas none in flucloxacillin plus gentamicin (group II). There was a statistically significant (p = 0.036) increased DWI rate in group II (2.5 %) as compared to group I (1.1 %). However, after controlling for age, gender, ASA grade, surgeon grade, implant type and type of anaesthesia, there was no statistically significant difference between the two groups (p = 0.146). 8.5 % of group I and 16.5 % of group II developed AKI post-operatively (p = 0.023); however, 79 % of group I and 80 % of in group II had complete resolution of AKI prior to their discharge. Further, a significant increase in inpatient deaths (p = 0.057) in group II was observed, but not at 30 days (p = 0.378).

Project VALOR: design and methods of a longitudinal registry of post-traumatic stress disorder (PTSD) in combat-exposed veterans in the Afghanistan and Iraqi military theaters of operations

DoD PRF (Psychosocial RF)

Few studies have investigated the natural history of post-traumatic stress disorder (PTSD). Project VALOR (Veterans' After-discharge Longitudinal Registry) was designed as a longitudinal patient registry assessing the course of combat-related PTSD among 1600 male and female Veterans who served in Operation Enduring Freedom (OEF) in Afghanistan or Operation Iraqi Freedom (OIF). Aims of the study include investigating patterns and predictors of progression or remission of PTSD and treatment utilization. The study design was based on recommendations from the Agency for Healthcare Quality and Research for longitudinal disease registries and used a pre-specified theoretical model to select the measurement domains for data collection and interpretation of forthcoming results. The registry will include 1200 male and female Veterans with a recent diagnosis of PTSD in the Department of Veteran Affairs (VA) electronic medical record and a comparison group of 400 Veterans without a medical record-based PTSD diagnosis, to also allow for case-control analyses. Data are collected from administrative databases, electronic medical records, a self-administered questionnaire, and a semi-structured diagnostic telephone interview. Project VALOR is a unique and timely registry study that will evaluate the clinical course of PTSD, psychosocial correlates, and health outcomes in a carefully selected cohort of returning OEF/OIF Veterans.

Expression of hormonal receptors in osteosarcomas of the jaw bones: Clinico-pathological analysis of 21 cases

MSTS 2022 - Metastatic Disease of the Humerus

Background: Sexual hormones have an important role in many hormone-dependant tumors like breast and prostate carcinomas, and also a relationship has been found with bone metabolism and bone tumors. Some studies have demonstrated that the expression of hormonal receptors (HR) in osteosarcomas (OS) of long bones is associated with gender, histological grade, histological type, and possibly may be connection with pathogenesis and evolution. However, to our knowledge there are no studies of HR in osteosarcomas of craniofacial bones (OS-CF). Objectives: To assess the expression of hormonal receptors in OS-CF. Material and Methods: Twenty one cases of OS-CF were included in this study. Clinical outcome was obtained from clinical charts. Histological sections were reviewed, and immunohistochemistry studies for estrogen, progesterone and androgen receptors were performed. Results: A striking female predominance was found (2:1), with a median age of 35 years. The predominant type of OS was osteoblastic (52.4%), and histological grade was high in 86%. Follow-up was obtained in 13 cases and ranged from 6 to 118 months (median 29 months). There were 8 patients (61.5%) dead or alive with progressive disease in the last follow up. Negative expression of HR was found in 19/21 cases; one showed weak nuclear expression for estrogen receptor, and another for androgen receptor. Progesterone receptor was negative in all cases. Conclusions: OS-CF mostly affected females, most of them were of the osteoblastic type and of high grade. Hormonal expression was practically negative in osteosarcoma of craniofacial bones. © Medicina Oral S. L.

A triplanar osteotomy technique in arthroscopy-assisted ankle mosaicplasty

Osteochondritis Dissecans 2020 Review

PURPOSE: Osteochondral lesions of the talus are lesions that are seen particularly in the young age group and are often related to sports injuries and trauma. These lesions, which show late symptoms radiologically, can be determined in the early stages with magnetic resonance imaging. The aim of this study was to present a new osteotomy technique to reduce the complications of mosaicplasty surgery to a minimum and provide an early return to work. METHODS: A total of 11 patients who had cartilage lesions due to osteochondritis dissecans in the medial aspect of the talus underwent mosaicplasty after a triplanar osteotomy. The dimensions of the lesion and the depth of the triplanar osteotomy were determined preoperatively. Coronal, sagittal and transverse cuts were made at the depth defined arthroscopically. Following the osteotomy, an osteochondral graft taken from the ipsilateral knee was placed in the prepared area. Osteotomy side was fixed with one or two cannulated screws following mosaicplasty. RESULTS: With this technique, weight-bearing can be immediate in cases with no need for osteotomy in the joint surface. In cases including the joint surface, partial weight-bearing is permitted after 4 weeks and can be increased as tolerated. In the 11 cases treated with this technique, full weight-bearing was achieved at mean 5 weeks (range, 5-8 weeks). No shift (upward displacement of osteotomized fragment) or non-union was seen in any patient. CONCLUSION: With the triplanar osteotomy technique described here, potential shift complications can be reduced to a minimum. As only the lesion region is targeted, the osteochondral surface formed by the fracture is much less. STUDY DESIGN: Case Series; Level of Evidence, 4.

Oculoplastic surgery practice during the COVID-19 novel coronavirus pandemic: experience sharing from Hong Kong

Coronavirus Disease 2019 (COVID-19)

At present, all parts of the world are hit hard by COVID-19. The first confirmed case of COVID-19 in the territory of Hong Kong was announced on January 23, 2020. Since then, oculoplastic surgeons in Hong Kong have been taking every measure to protect all healthcare workers and patients from contracting the disease. This paper aims to share the experiences of and measures taken by local oculoplastic surgeons in combating COVID-19. Three main aspects are discussed, namely clinical, administrative, and training and educational. We hope our experiences would provide reference to fellow oculoplastic colleagues in other parts of the world in fighting this COVID-19 pandemic.

Intraoral one-stage curved osteotomy for the prominent mandibular angle: A clinical study of 407 cases

Panniculectomy & Abdominoplasty CPG

Background: Many Oriental people have a square face with a prominent mandibular angle. This article presents a good osteotomy method for the prominent mandibular angle (PMA). Methods: Two modifications of the conventional procedures have been made. The first is a one-stage curved osteotomy for the mandibular angle. The second is nonresection of the masse ter muscle. The surgical procedure has been performed using an intraoral approach with a direct field of vision. Results: From October 1996 to December 2002, a total of 407 patients with PMA underwent surgery using this method with satisfactory results. The PMA osteotomy procedure was performed for only 248 patients. In addition, 29 patients received concurrent zygomatic reduction osteotomy, 38 patients underwent concurrent genioplasty, 41 patients had concurrent chin augmentation with excised PMA bone fragment, 2 patients received concurrent submental liposuction, and 39 patients underwent concurrent buccal fat pad resection. Conclusion: The described method is a very simple procedure with fewer complications for the surgical treatment of PMA. © 2005 Springer Science+Business Media, Inc.

Antibiotic prophylaxis in dentistry: a review and practice recommendations

Dental Implant Infection

BACKGROUND: The American Heart Association, or AHA, and the American Dental Association recently changed their recommended protocols for antibiotic prophylaxis against bacterial endocarditis. A new recommendation also has been issued by the ADA and the American Academy of Orthopaedic Surgeons, or AAOS, against routine antibiotic prophylaxis in patients with prosthetic joint replacements. These changes reflect increasing scientific evidence and professional experience in opposition to widespread use of antibiotic prophylaxis in these specific situations and others faced in dentistry., METHODS: The authors reviewed the medical and dental literature for scientific evidence regarding the use of antibiotics to prevent local and systemic infections associated with dental treatment. Situations commonly considered by dentists for potential use of prophylactic antibiotics were reviewed to determine current evidence with regard to use of antimicrobial agents. This included prevention of distant spread of oral organisms to susceptible sites elsewhere in the body and the reduction of local infections associated with oral procedures., RESULTS: There are relatively few situations in which antibiotic prophylaxis is indicated. Aside from the clearly defined instances of endocarditis and late prosthetic joint infections, there is no consensus among experts on the need for prophylaxis. There is wide variation in recommended protocols, but little scientific basis for the recommendations. The emerging trend seems to be to avoid the prophylactic use of antibiotics in conjunction with dental treatment unless there is a clear indication., CONCLUSIONS: Aside from the specific situations described, there is little or no scientific basis for the use of antibiotic prophylaxis in dentistry. The risk of inappropriate used of antibiotics and widespread antibiotic resistance appear to be far more important than any possible perceived benefit., CLINICAL IMPLICATIONS: Dentists are wise to use antibiotic prophylaxis in only those specific situations in which there is a valid scientific basis for it. Whenever possible, dentists should follow the standard protocols recommended by the ADA, AHA or AAOS.

Epidural abscess caused by Streptococcus milleri in a pregnant woman

Patrick’s pharmacoepidemiology project

BACKGROUND: Bacteria in the Streptococcus milleri group (S. anginosus, S. constellatus, and S. intermedius) are associated with bacteremia and abscess formation. While most reports of Streptococcus milleri group (SMG) infection occur in patients with underlying medical conditions, SMG infections during pregnancy have been documented. However, SMG infections in pregnant women are associated with either neonatal or maternal puerperal sepsis. Albeit rare, S. milleri spinal-epidural abscess in pregnancy has been reported, always as a complication of spinal-epidural anesthesia. We report a case of spinal-epidural abscess caused by SMG in a young, pregnant woman without an antecedent history of spinal epidural anesthesia and without any underlying risk factors for invasive streptococcal disease. CASE PRESENTATION: A 25 year old pregnant woman developed neurological symptoms consistent with spinal cord compression at 20 weeks gestation. She underwent emergency laminectomy for decompression and was treated with ceftriaxone 2 gm IV daily for 28 days. She was ambulatory at the time of discharge from the inpatient rehabilitation unit with residual lower extremity weakness. CONCLUSION: To our knowledge, this is the first reported case of a Streptococcus milleri epidural abscess in a healthy, pregnant woman with no history of epidural anesthesia or invasive procedures. This report adds to the body of literature on SMG invasive infections. Treatment of SMG spinal-epidural abscess with neurologic manifestations should include prompt and aggressive surgical decompression coupled with targeted anti-infective therapy

Navigation-assisted minimal invasive total knee arthroplasty in patients with extra-articular femoral deformity

Surgical Management of Osteoarthritis of the Knee CPG

In the presence of extra-articular femoral deformity, total knee arthroplasty (TKA) is difficult to perform because of altered anatomical axis and distorted landmarks. Although minimal invasive surgery (MIS) has known advantage of earlier rehabilitation, MIS with this deformity may have higher incidence of component malposition due to inadequate exposure. Navigation has been shown to increase the accuracy of alignment and may compensate possible complication of MIS. We report 4 cases with extra-articular femoral deformity that underwent MIS-TKA using an image-free navigation system in which preoperatively planned mechanical alignment was surgically achieved with proper positioning of the implants as well as soft tissue balance. Navigation-assisted MIS-TKA may become a valuable mean especially for a patient with a deformed femur in which conventional instruments are difficult to use correctly

Orthobiologics for Focal Articular Cartilage Defects

OAK 3 - Non-arthroplasty tx of OAK

Focal chondral defects of the knee are extremely common and often result in pain, dysfunction, joint deterioration, and, ultimately, the development of osteoarthritis. Due to the limitations of conventional treatments for focal chondral defects of the knee, orthobiologics have recently become an area of interest. Orthobiologics used for cartilage defects include (but are not limited to) bone marrow aspirate concentrate, adipose-derived mesenchymal stem cells, platelet-rich plasma, and micronized allogeneic cartilage. Each of these products can be applied in the clinical setting, as an isolated surgical procedure, or as an augment to cartilage restoration surgery.

Nonoperative care for hip fracture in the elderly: the influence of race, income, and comorbidities

Management of Hip Fractures in the Elderly

CONTEXT: Hip fracture occurs in 340,000 older adults each year. Operative repair is the standard of care, maximizing the chances of functional recovery. Not receiving operative care may condemn patients to a lifetime of pain and potential immobility. OBJECTIVE: To measure the incidence of nonoperative treatment for first-time hip fracture in a population-based cohort and to measure the odds of nonoperative treatment of hip fracture among patients of differing race and income. DESIGN, SETTING, AND PARTICIPANTS: Retrospective cohort study of 165,861 Medicare beneficiaries admitted for hip fracture between March 31, 2002 and December 31, 2006 to hospitals in New York, Illinois, and Texas. MAIN OUTCOME MEASURES: Odds of nonoperative management of hip fracture, adjusted for fracture characteristics, comorbidities, source of admission, age, sex, race, income, and individual hospital effects. RESULTS: Nonoperative management occurred in 6.2% of patients (N = 10,283). After adjustment, black patients had a 79% increase in the odds of nonoperative management as compared with whites (OR 1.79, 95% CI 1.64-1.95). Low income itself was not associated with a change in the odds of nonoperative care. Among patients not receiving operative repair, blacks demonstrated lower mortality than whites at 7 days (7.96% vs. 20.17%, P < 0.0001) and 30 days (24.14% vs. 38.22%, P < 0.0001). CONCLUSIONS: Black race predicts an increased odds of nonoperative care for hip fracture. Among patients receiving nonoperative care, black patients demonstrated increased survival compared with whites. These results are consistent with differential selection of operative candidates by patient race

Prevention and therapy of acute and chronic wounds using NPWT devices during the COVID-19 pandemic, recommendation from The NPWT Working Group

Coronavirus Disease 2019 (COVID-19)

<jats:p>Recent SARS-CoV-2 pandemic leading to a rapidly increasing number of hospitalizations enforced reevaluation of wound management strategies.&#x0D; The optimal treatment strategy for patients with chronic wounds and those recovering from emergency and urgent oncological surgery should aim to minimize the number of hospital admissions, as well as the number of surgical procedures and decrease the length of stay to disburden the hospital staff and to minimize viral infection risk.&#x0D; One of the potential solutions that could help to achieve these goals may be the extensive and early use of NPWT devices in the prevention of wound healing complications.&#x0D; Single-use NPWT devices are helpful in outpatient wound treatment and SSI prevention (ciNPWT) allowing to minimize in-person visits to the health care center while still providing the best possible wound-care. Stationary NPWT should be used in deep SSI and perioperative wound healing disorders as soon as possible. Patientâ??s education and telemedical support with visual wound healing monitoring and video conversations have the potential to minimize the number of unnecessary in-person visits in patients with wounds and therefore substantially increase the level of care.</jats:p>

PCR-based identification of selected pathogens associated with endodontic infections in deciduous and permanent teeth

Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures

OBJECTIVE: The aim of the present study was to evaluate the presence of the selected pathogens in samples from deciduous and permanent tooth root canals by using PCR method and to determine the association of these organisms with clinical symptoms. STUDY DESIGN: A total of 145 children, 5 to 13 years old, were involved in this study. The presence of selected pathogens (Actinomyces israelii, Candida albicans, Enterococcus faecalis, Fusobacterium nucleatum, Porphyromonas endodontalis, Porphyromonas gingivalis, Prevotella intermedia, Streptococcus intermedius, Treponema denticola, Parvimonas micra, Tannerella forsythensis, Enterococcus faecium, Prevotella melaninogenica) in infected root canals was studied using PCR. RESULTS: T. denticola (P = .012, .02) and E. faecalis (P = .012, .04) were highly associated with periapical radiolucency and previous pain, while P. gingivalis was associated with tenderness to percussion in both deciduous and permanent teeth (P = .01, .015). CONCLUSION: The results of the present study confirm that certain species of microorganisms are associated with clinical signs and symptoms of endodontic disease in both deciduous and permanent teeth

Periarthropathies: Clinical spectrum and patterns

Diagnosis and Treatment of Carpal Tunnel Syndrome CPG

Objective: The aim of this study is to review the spectrum of primary periarthropathies. Setting: Rheumatology clinic, Ibn Sina teaching hospital, Mosul, Iraq. Design: Prospective non-experimental clinical study. Method: Two hundred patients having primary periarthropathy were included in the study. Secondary cases of periarthropathy were excluded. Patients with multiple periarthropathy were recorded. Result: Two hundred patients were studied, 114 were females and 33 were males who had one type of periarthropathy; the remaining had combinations of periarthropathies. The mean age for periarthropathy was more than 40, except for tendinitis (36.8 (plus or minus) 10.5). The most common periarthropathies is the shoulder 93 (46.5%), followed by Carpal tunnel syndrome 57 (28.5%) and planter fasciitis 34 (17%), history was significantly high in these three conditions. Various combinations of periarthropathies were seen in the study group. Conclusion: Shoulder periarthropathies and CTS were the most common, 46.5% and 28.5% respectively. The concept of oligoarthropathy and possibly poly-periarthropathy needs further research. Constitutional factors, for example, gender and pro-inflammatory mechanisms need further studies