Datasets:

Eitanli

/

abstracts_cleaned

like 1

Scintimetric evaluation of complications after femoral neck fractures

Management of Hip Fractures in the Elderly

The primary surgical approach to the femoral neck fracture should be one with the lowest mortality and morbidity. Internal fixation appears to be the safe and logical approach for most of the reducible intracapsular fractures. Careful follow-up of these patients then is important. 85Sr scintimetry is a simple and accurate method in the early detection and evaluation of secondary complications in these patients. The 85Sr scintimetric pattern in the normal healing process was defined in relation to time interval after the fracture. At any time after 4 months following fracture, those hips destined for osteonecrosis, with or without non-union, showed significantly more radionuclide uptake over the femoral head than those hips which healed normally. In non-union there was a trend toward increased counts over the fracture site during 6 to 18 months after fracture, but no such tendency was noted in other periods

Acquired melanocytic nevi in Egyptian patients: a clinicopathological study

Reconstruction After Skin Cancer

INTRODUCTION: Melanocytic nevi (MN) are the most important simulants of melanoma. Although acquired nevi are usually clinically stable, they may show abnormal clinical behavior. This study assessed the histological changes and prognosis of acquired MN with changing clinical behavior in Egyptian patients.METHODS: The study included 236 patients that were classified into two groups; Group A included nevi with abnormal clinical presentation and Group B included clinically typical nevi.RESULTS: Each group included 118 patients with a predominance of female patients. Abnormal clinical presentation in Group A included altered pigmentation (35.6%), rapid enlargement (30.5%), keratotic changes (16.9%), inflammation (7.6%), ulceration (5.1%), and hemorrhage (4.2%). Typical histological features were significantly higher (p = 0.008) in Group B (99.2%) compared with Group A (87.3%). Atypical histological features were significantly higher (p = 0.002) in Group A, with higher numbers of ulcerative and altered pigmented nevi. Malignant changes showed no significant difference (p = 0.47) between the two groups. No relapse was recorded after excision of any lesion.DISCUSSION: Among Egyptians, changing clinical behavior of MN may show histological atypia but low risk of malignant transformation. Early excision and follow-up of ulcerative and altered pigmented nevi are recommended.

Spinal anaesthesia in young patients using a 29-gauge needle: technical considerations and an evaluation of postoperative complaints compared with general anaesthesia

Surgical Management of Osteoarthritis of the Knee CPG

One hundred patients aged 18-49 yr, undergoing elective arthroscopy of the knee joint, were allocated randomly to either spinal anaesthesia using a 29-gauge spinal needle or general anaesthesia. Dural puncture was considered difficult in 18% of the patients receiving spinal anaesthesia. In three patients (6%) it was necessary to supplement the spinal anaesthetic with general anaesthesia. Spinal and general anaesthesia were otherwise uneventful in all patients. The incidence of postoperative headache was similar in the two groups. One patient developed post dural puncture headache following spinal anaesthesia. This headache was of short duration and disappeared without treatment. Spinal anaesthesia caused more backache than general anaesthesia, otherwise the frequency of postoperative complaints was the same or lower. Ninety-six percent of the patients receiving spinal anaesthesia would prefer the same anaesthetic for a similar procedure in the future

Radiostereometric analysis in measurements of migration and inducible micromotion in intra-articular distal radius fractures treated with a volar plate

Distal Radius Fractures

OBJECTIVES: This study examined the use of radiostereometric analysis (RSA) in the assessment of fixation stability and healing characteristics in intra-articular fractures of the distal radius treated with a volar locking plate. DESIGN: Prospective cohort study. SETTING: University hospital. PATIENTS: Fifteen patients between 39 and 67 years of age with OTA type C distal radius fractures. INTERVENTION: All fractures were treated with a locked volar plate, and tantalum markers were inserted into fracture fragments. RSA was performed at 2, 6, 12, 18, and 52 weeks postoperatively. RSA measurements were also performed using maximal voluntary grip to create inducible micromotion at the fracture site at 6, 12, 18, and 52 weeks. MAIN OUTCOME MEASUREMENTS: Interfragmentary migration and inducible micromotion in terms of translation and rotation in 3 orthogonal axes were determined. The total translation and rotation were also calculated. RESULTS: Precision of measurements along individual axes was between 0.08 and 0.17 mm and 0.70-0.94 degrees for migration and between 0.04 and 0.07 mm and 0.29 and 0.86 degrees for inducible micromotion. Fractures underwent significant translational and rotational migration (P = 0.004 for both) during the first 2 weeks after surgery. This permanent migration was not detectable on conventional radiographs. Inducible fracture micromotion, measured during maximal grip, was detectable up to 18 weeks, even after achievement of radiographic union. CONCLUSIONS: RSA seems to have the potential to be a unique tool in redefining the biologic progress of fracture union. In plated fractures of the distal radius, the method is technically challenging due to difficulties in achieving a good scatter and visibility of tantalum RSA markers. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Limited clinical utility of a self-evaluating risk assessment scale for postmenopausal osteoporosis: lack of predictive value of lifestyle-related factors

Management of Hip Fractures in the Elderly

The aim of this study was to assess the efficiency of a self-administered questionnaire to identify subjects with postmenopausal osteoporosis in the setting of first line medical care. A sample of 300 postmenopausal women completed the questionnaire based on 18 items. Bone mineral density at the lumbar spine (BMD-L), total hip (BMD-H), and femoral neck (BMD-N) was used as objective criterion for evaluation. The mean risk score was 8.2 +/- 3.21. BMD was correlated with total risk score: r = -0.32 for BMD-L, -0.36 for BMD-N, and -0.43 for BMD-H. Cutoff points for the risk score (equal likelihood points) according to a T-score threshold of -2.5 were 8.6 for BMD-L and BMD-N and 9.3 for BMD-H; specificity and sensitivity was 62% and 62%, respectively, for BMD-L, 65% and 62% for BMD-N, and 75% and 63% for BMD-H. Stepwise multiple regression analysis of the questionnaire items in relation to BMD showed higher correlation coefficients for models including individual items rather than the overall risk score. Items concerning low weight, older age, and wrist fracture after 50 years of age were always selected as significant determinants of BMD (R = 0.43-0.55). Hormonal replacement therapy was also an important determinant. Lifestyle-related items did not contribute significantly. In conclusion, the diagnostic performance of the 18-item self-administered questionnaire was poorer than a shortened questionnaire omitting lifestyle factors. The clinical utility of a questionnaire should ultimately be evaluated in the specific optic of a chosen global strategy for prevention of osteoporotic fractures

Minimally invasive sliding hip screw insertion technique

Management of Hip Fractures in the Elderly

Sliding hip screws (SHS) are commonly used for fixation of extra-capsular hip fractures, and there is increasing use of minimally invasive methods of insertion of such devices. We describe a case series of 579 consecutive patients operated on by the senior author using such a technique. Data were collected prospectively and analysed retrospectively. The technique involves a 5cm incision, retraction of vastus lateralis superiorly by a chain retractor, and use of a SHS clamp to stabilise the plate on the femur. The patients had a mean age of 81 years, surgery time of 43 minutes and hospital stay of 17 days. 77% were female and 35% required a blood transfusion post-operatively. Everyone was mobilised fully weight-bearing post-operatively. Follow-up was at six weeks for radiographic review and then subsequently at one year. The commonest complications were superficial wound infection (1.7%), detachment of the plate (0.9%) and cut-out of the lag screw (0.5%)

Articular fractures of the distal part of the humerus

The Treatment of Pediatric Supracondylar Humerus Fractures AUC

BACKGROUND: The purpose of this retrospective study was to identify the patterns of distal humeral articular fractures and to analyze the results of open reduction and internal fixation of these injuries. METHODS: The cases of twenty-one patients with an articular fracture of the distal part of the humerus were reviewed at an average of forty months after the injury. Five components of the injury were identified: (1) the capitellum and the lateral aspect of the trochlea, (2) the lateral epicondyle, (3) the posterior aspect of the lateral column, (4) the posterior aspect of the trochlea, and (5) the medial epicondyle. All fractures were reduced and were stabilized with implants buried beneath the articular surface. RESULTS: All fractures healed, and no patient had residual ulnohumeral instability or weakness. Ten patients required a second operation: six, for release of an elbow contracture; two, for treatment of ulnar neuropathy; one, for removal of hardware causing symptoms; and one, because of early loss of fixation. The average arc of ulnohumeral motion was 96 degrees (range, 55 degrees to 140 degrees ). The results according to the Mayo Elbow Performance Index were excellent in four patients, good in twelve, and fair in five. CONCLUSIONS: Apparent fractures of the capitellum are often more complex fractures of the articular surface of the distal part of the humerus. Treatment of these injuries with operative reduction and fixation with buried implants can result in satisfactory restoration of elbow function

Surgical versus conservative interventions for treating fractures of the middle third of the clavicle

DoD SSI (Surgical Site Infections)

BACKGROUND: Clavicle fractures are common, accounting for 2.6% to 4% of all fractures. Eighty per cent of clavicle fractures are located in the middle third of the clavicle. Although treatment of these fractures is usually non-surgical, displaced clavicle fractures may be considered for surgical treatment because of their greater risk of non-union. This is an update of a Cochrane Review first published in 2013. OBJECTIVES: To assess the effects (benefits and harms) of surgical versus conservative interventions for treating middle third clavicle fractures. SEARCH METHODS: We searched the Cochrane Bone, Joint and Muscle Trauma Specialised Register, CENTRAL, MEDLINE, Embase, LILACS, trials registries and reference lists updated to December 2017. We did not apply any language or publication restrictions. SELECTION CRITERIA: We considered randomised and quasi-randomised controlled trials evaluating surgical versus conservative interventions for treating fractures in the middle third of the clavicle. The primary outcomes were shoulder function or disability, pain and treatment failure, defined as the number of participants who had been given a non-routine secondary surgical intervention (excluding hardware removal), for symptomatic non-union, malunion or other complications. DATA COLLECTION AND ANALYSIS: At least two review authors selected eligible studies, independently assessed risk of bias and cross-checked data. Where appropriate, we pooled results of comparable studies. MAIN RESULTS: We included 14 studies involving 1469 participants with acute middle third clavicle fractures. All studies included adults, with the overall range from 17 to 70 years. Of the studies that reported gender, men were over-represented. Ten studies compared plate fixation with sling or figure-of-eight bandage, or both, and four studies compared intramedullary fixation with wearing either a sling or a figure-of-eight bandage. Almost all studies had design features that carry a high risk of bias, thus limiting the strength of their findings.Low-quality evidence from 10 studies (838 participants), showed that, compared with conservative treatment, surgical treatment of acute middle third clavicle fractures may not improve upper arm function at follow-up of one year or longer: standardised mean difference (SMD) 0.33, 95% confidence interval (CI) -0.02 to 0.67. We downgraded the quality of the evidence because of risk of bias and high statistical heterogeneity (I² = 83%). This corresponds to a mean improvement of 2.3 points in favour of surgery (0.14 points worse to 4.69 points better), on the 100-point Constant score; this does not represent a clinically important difference. There may be no difference in pain measured using a visual analogue scale (0 to 100 mm; higher scores mean worse pain) between treatments (mean difference (MD) -0.60 mm, 95% CI -3.51 to 2.31; 277 participants, 3 studies; low-quality evidence reflecting risk of bias and imprecision). Surgery may reduce the risk of treatment failure, that is, number of participants who had non-routine secondary surgical intervention (excluding hardware removal), for symptomatic non-union, malunion or other complication (risk ratio (RR) 0.32, 95% CI 0.20 to 0.50; 1197 participants, 12 studies; low-quality evidence, downgraded for risk of bias and imprecision). The main source of treatment failure was mechanical failure (3.4%) in the surgery group and symptomatic non-union (11.6%) in the conservative-treatment group. We are uncertain whether surgery results in fewer people having one or more cosmetic problems, such as deformities, which were more common after conservative treatment, or hardware prominence or scarring, which only occurred in the surgery group (RR 0.55, 95% CI 0.31 to 0.98; 1130 participants, 11 studies; I² = 63%; very low-quality evidence downgraded for risk of bias, imprecision and inconsistency). We are uncertain whether there is any difference between surgery and conservative treatment in the risk of incurring an adverse outcome that includes local infection, dehiscence, symptomatic malunion, discomfort leading to implant removal, skin and nerve problems: RR 1.34, 95% CI 0.68 to 2.64; 1317 participants, 14 studies; I² = 72%; very low-quality evidence, downgraded for risk of bias, imprecision and inconsistency). Hardware removal for discomfort was a common adverse outcome in the surgery group (10.2%) while symptomatic malunion was more common in the conservative-treatment group (11.3% versus 1.2% in the surgery group). Infection occurred only in the surgery group (3.2%). There may be no between-group difference in quality of life at one year (SF-12 or SF-36 physical component scores: 0 to 100 scale, where 100 is the best score): MD 0.30 (95% CI -1.95 to 2.56, 321 participants, 2 studies; low-quality evidence downgraded for risk of bias and imprecision). AUTHORS' CONCLUSIONS: There is low-quality evidence that surgical treatment has no additional benefits in terms of function, pain and quality of life compared with conservative treatment, but may result in fewer treatment failures overall. Very low-quality evidence means that we are very uncertain of the findings of a slightly better cosmetic result after surgery and of no difference between surgical and conservative treatment in the risk of adverse events. For both composite outcomes, there is a need to consider the balance of risks between the individual outcomes; for example, surgical adverse events, including wound infection or dehiscence and hardware irritation, against risk of adverse events that may be more commonly associated with conservative treatment such as symptomatic malunion and shoulder stiffness.Treatment options must be chosen on an individual patient basis, after careful consideration of the relative benefits and harms of each intervention and of patient preferences.

Alzheimer's disease and risk of hip fracture: a meta-analysis study

Management of Hip Fractures in the Elderly

BACKGROUND: Alzheimer's disease (AD) is the most common cause of dementia in the elderly population. Growing evidence supports that AD patients are at high risk for hip fracture, but the issue remains questionable. The purpose of the present study is to perform a meta-analysis to explore the association between AD and risk of hip fracture. Considering that bone mineral density (BMD) acts as a strong predictor of bone fracture, we also studied the hip BMD in AD patients. METHODS: We searched all publications in Medline, SciVerse Scopus, and Cochrane Library published up to January 2012 about the association between AD and hip fracture or hip BMD. RESULTS: There are 9 studies included in the meta-analysis. The results indicate that AD patients are at higher risk for hip fracture (OR and 95% CI fixed: ES = 2.58, 95% CI = [2.03, 3.14]; dichotomous data: summary OR = 1.80, 95% CI = [1.54, 2.11]) than healthy controls. Further meta-analysis showed that AD patients have a lower hip BMD (summary SMD = -1.12, 95% CI = [-1.34, -0.90]) than healthy controls. CONCLUSIONS: It was found that in comparison with healthy controls AD patients are at higher risk for hip fracture and have lower hip BMD

A survey of antibiotic use in dentistry

Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures

BACKGROUND: Antibiotics are important in the management and prophylaxis of infection in patients at risk of experiencing microbial disease. As a result of the increase in antimicrobial resistance, the authors conducted a survey to assess current antibiotic use in dental practice. METHODS: The authors mailed a two-page, pretested survey to all licensed dental practitioners in British Columbia, Canada. A total of 2,542 surveys were mailed; 19.9 percent were returned by fax or mail. The authors examined an association between factors analyzed using a chi 2 test. RESULTS: Respondents were demographically consistent with all registered dentists in British Columbia. They reported writing an average of 4.45 prescriptions per week. Antibiotics prescribed after treatment primarily were penicillin and its derivatives. Recommended adult doses of penicillin were prescribed by 59.2 percent of respondents; recommended daily doses of amoxicillin were prescribed by 72.2 percent of respondents. The average prescription duration was 6.92 days. Respondents prescribed prophylactic antibiotics an average of 1.15 times per week for prophylaxis of bacterial endocarditis; 17.5 percent reported postoperative dosing for prophylaxis, ranging from a one- to seven-day prescription with an average of 6.91 postoperative doses. Preoperative antibiotics were prescribed for patients with a history of rheumatic fever or any heart murmur or prosthetic hip. Antibiotics were prescribed more frequently for surgical procedures and patients with acquired immunodeficiency syndrome than for other circumstances. CONCLUSIONS: More than 80 percent of respondents reported that they followed current American Heart Association prophylaxis guidelines. The authors, however, noted discrepancies in prophylactic use of antibiotics for bacterial endocarditis and for patients with large joint prostheses, as well as in prescribing antibiotics in the presence of clinical infection. In therapeutic use, approximately 85 percent of respondents followed appropriate prescription guidelines for dosing and duration of therapy. CLINICAL IMPLICATIONS: Appropriate and correct use of antibiotics is essential to ensure that effective and safe treatment is available and that practices that may enhance microbial resistance are avoided. To improve standards of care, dentists need up-to-date pharmacology in dental education, as well as continuing education, further outcome studies and continuous assessment of dental practices

Cemented all polyethylene tibial insert unicompartimental knee arthroplasty: a long term follow-up study

Surgical Management of Osteoarthritis of the Knee CPG

Unicompartimental knee arthroplasty outcome is sometimes compared to total knee arthroplasty but various implant parameters might greatly influence this outcome. The objectives of this study were to report the results of a consecutive series of 172 all-polyethylene unicompartmental knee arthroplasties (UKAs) and to detail possible factors of success and failure. HYPOTHESIS: It is possible to outline implant and technique factors determining success or failure in unicompartimental knee arthroplasty. MATERIALS AND METHODS: One hundred seventy-two HLS-type cemented resurfacing UKAs, with the femoral implant made of chrome-cobalt and the tibial implant tibial entirely in polyethylene (without anchorage studs) were consecutively implanted between 1988 and 2004 in 134 patients (111 females and 23 males) in our center according to the indications established in 1988, using the same technique for each surgery. The patients' mean age was 72.2 years (range, 25-90 years). The review rate was 83.7% (144 UKAs), with a mean follow-up of 62.3 months (range, 24-160 months). The series included 84 medial UKAs and 60 lateral UKAs. The clinical data were analyzed using the IKS criteria and the patients had a complete radiological evaluation before surgery and at the last follow-up. RESULTS: The rate of satisfied or very satisfied patients was 97.2%. No pain or slight pain was found in 81% of the cases. The mean flexion was 133 degrees (range, 85-150 degrees). The mean knee score varied from 63.6 before surgery to 91.5 (90.4 for medial UKAs and 92.9 for lateral UKAs) and the function score from 63.6 to 83.8 (84.7 for medial UKAs and 82.6 for lateral UKAs). The mean range of motion was 133 degrees (range, 85-150 degrees), better than the medial UKAs for osteonecrosis. The mean residual deformity was 4 degrees varus for the medial UKAs and 2 degrees valgus for the lateral UKAs. A radiolucency was found in 23% of the cases (20% tibial and 3% femoral), nonprogressive in all cases. In 87.2% of the cases, the opposite femorotibial compartment remained radiologically normal. No progression to osteoarthritis in the femoropatellar joint required additional surgery. Sixteen patients required revision surgery: in six cases, the implant was removed and a total prosthesis implanted (one late infection, one case of involvement of the opposite compartment, and four cases of tibial component loosening). In the other cases, one tibial baseplate was changed, five arthroscopies were done, and four unicompartmental knee replacements were done on the opposite compartment. The Kaplan-Meier survival rate (taking into account the revisions with implant change) was 95.6. The results of this series were very satisfactory and were similar to recent series in the world literature that showed survival rates between 90 and 98% at 10 years, rates that are equivalent to those found for total knee replacements. The mean flexion range of motion found was higher than the majority of other recent series, probably because of the precise patient selection in the present study, a minimally invasive approach, and the femoral implant design with an ascending condylar posterior cut. The deterioration of the contralateral compartment is frequently reported, but was perhaps prevented by the absence of overcorrection and patient selection. In this series, none of the UKAs was revised for wear. We explain this by the systematic preservation of a moderate undercorrection, particularly for medial UKAs, the quality of the polyethylene, and a selection based on patient weight and age. CONCLUSIONS: The option of an all-polyethylene tibial implant, with minimal bone cuts (femoral resurfacing), makes excellent long-term results possible

Lower-extremity kinetic response to activity program dosing in older adults

Management of Hip Fractures in the Elderly

The purpose of this investigation was to determine the effects of two doses of a weighted vest on acute lower-extremity gait kinetics in older adults. Peak ankle, knee, and hip net joint moments were quantified in 56 men and women volunteers (73.8 +/- 6.9 years old) enrolled in a 6-month physical activity study. At the initial study visit, participants underwent 6 walking trials (3 with vest, 3 without vest) at their normal pace. During the vest-wearing trials, participants wore a vest loaded with either 0% of body weight (BW) (n = 19), 3% of BW (n = 16), or 5% of BW (n = 21). With acute application of the vests, maximum peak plantarflexion moments increased by 5.7% in the 5% BW group compared to the 0% BW group, p < 0.01. Compared to the 0% vest-weight group, knee extension moments increased by 13.8% when 5% BW was applied,p < 0.01; a marginally significant treatment effect was evident in the 3% BW group, p = 0.04. Despite these acute alterations, knee strength and physical performance did not improve when subjects wore the vests 2 hours a day, 4 days a week for 27 weeks, without additional exercise prescription. These findings suggest that: (a) the acute changes in vest-mediated lower-extremity kinetics are not systemic but joint specific and load dependent, and (b) weighted vest prescription should be greater than 5% BW without prescribed exercise, or should include prescribed exercises, to invoke long-term strength and physical performance gains in older adults. Number of References 22. Copyright © 2011 Elsevier B. V., Amsterdam. All Rights Reserved

Femoral fractures in adolescents: a comparison of four methods of fixation

DoD SSI (Surgical Site Infections)

BACKGROUND: The optimal management of femoral fractures in adolescents is controversial. This study was performed to compare the results and complications of four methods of fixation and to determine the factors related to those complications. METHODS: We conducted a retrospective cohort study of 194 diaphyseal femoral fractures in 189 children and adolescents treated with elastic stable intramedullary nail fixation, external fixation, rigid intramedullary nail fixation, or plate fixation. After adjustment for age, weight, energy of the injury, polytrauma, fracture level and pattern, and extent of comminution, treatment outcomes were compared in terms of the length of the hospital stay, time to union, and complication rates, including loss of reduction requiring a reoperation, malunion, nonunion, refracture, infection, and the need for a reoperation other than routine hardware removal. RESULTS: The mean age of the patients was 13.2 years, and their mean weight was 49.5 kg. There was a loss of reduction of two of 105 fractures treated with elastic nail fixation and ten of thirty-three treated with external fixation (p < 0.001). At the time of final follow-up, five patients (two treated with external fixation and one in each of the other groups) had >or=2.0 cm of shortening. Eight of the 104 patients (105 fractures) treated with elastic nail fixation underwent a reoperation (two each because of loss of reduction, refracture, the need for trimming or advancement of the nail, and delayed union or nonunion). Sixteen patients treated with external fixation required a reoperation (ten because of loss of reduction, one for replacement of a pin complicated by infection, one for debridement of the site of a deep infection, three because of refracture, and one for lengthening). One patient treated with a rigid intramedullary nail required debridement at the site of a deep infection, and one underwent removal of a prominent distal interlocking screw. One fracture treated with plate fixation required refixation following refractures. A multivariate analysis with adjustment for baseline differences showed external fixation to be associated with a 12.41-times (95% confidence interval = 2.26 to 68.31) greater risk of loss of reduction and/or malunion than elastic stable intramedullary nail fixation. CONCLUSIONS: External fixation was associated with the highest rate of complications in our series of adolescents treated for a femoral fracture. Although the other three methods yielded comparable outcomes, we cannot currently recommend one method of fixation for all adolescents with a femoral fracture. The choice of fixation will remain influenced by surgeon preference based on expertise and experience, patient and fracture characteristics, and patient and family preferences.

The influence of patellofemoral degenerative changes on the outcome of the unicompartmental knee replacement

Surgical Management of Osteoarthritis of the Knee CPG

Introduction: Unicompartmental knee arthroplasty (UKA) is a recognized procedure for treatment of medial compartment osteoarthritis. Patellofemoral (PF) joint degeneration is widely considered to be a contraindication to medial unicompartmental knee replacement. We examined the validity of this preconception using information gathered prospectively on consecutive patients who underwent UKA using the Repicci II(registered trademark) UKA prosthesis for medial compartment osteoarthritis. Methods: We prospectively collected data on 147 consecutive patients who underwent the Repicci II(registered trademark) UKA for medial compartment osteoarthritis. All operations were performed between July 1999 and September 2000 by the same surgeon. The status of the PF joint was assessed intra-operatively in all patients, and accordingly patients were divided into two groups, one group with a normal PF joint, and the second group with degenerative changes of the PF joint. Variables measured for outcome included the International Knee Society (IKS) score, limb alignment, and range of motion. Radiographs were assessed for progression of disease or failure of implant. The mean follow-up was 9.4 years (range 5-10.7 years). Patients were reviewed initially at 2 weeks, and then at 6 months post-operatively. They were subsequently reviewed on an annual basis. All patients completed an IKS score preoperatively and at last follow-up. Age, gender, BMI, length of hospital stay, perioperative complications, all subsequent surgery, including revision of the prosthesis, and survivorship at 10 years was recorded, and results of the 2 groups compared. Results: A total of 147 patients were included in the study. None were lost to follow-up. 69 had associated PF osteoarthritis (group A) while 78 patients had a normal PF compartment when assessed intraoperatively (group B). Post-operative outcomes of the two groups were compared using the ANCOVA analysis with adjustment for pre-operation values firstly, and adjusting also for gender, age, BMI and follow-up secondly. There were no significant differences in terms of IKS, alignment, and flexion between the two groups. However, patients in group B had significantly better extension post-operatively than patients in group A (p<0.05). Conclusion: We concluded that damage to the articular cartilage of the patellofemoral joint to the extent of full-thickness cartilage loss is not a contraindication to the Repicci II(registered trademark) unicondylar knee arthroplasty for medial compartment osteoarthritis. However, extension is significantly improved post-operatively in those patients with minimal or no PF joint degenerative disease. (Table Presented)

The Barrel Vault Tibial Osteotomy of Maquet for Medial Compartment Arthritis of the Knee

OAK 3 - Non-arthroplasty tx of OAK

The barrel vault tibial osteotomy performed for knee varus osteoarthritis avoids the complications of the opening wedge osteotomy and minimizes the potential complications of the lateral closing wedge osteotomy. It allows correction of large varus deformities in knee medial compartment osteoarthritis.

Nonsteroid antiinflammatory drugs and tamoxifen for desmoid tumors and carcinoma of the stomach

MSTS 2018 - Femur Mets and MM

The results of treatment of desmoid tumor patients with nonsteroid antiinflammatory drugs alone or in combination with tamoxifen are described. Tumor growth was inhibited in six of seven patients. Nonsteroid antiinflammatory drugs administered along with 5-fluorouracil and cyclophosphamide and other inhibitors of T-suppressor cells were used to treat nine patients with metastatic carcinoma of the stomach. Survival of these patients was extended so that after 12 months minimal follow-up the majority are well. A prospective controlled clinical trial is indicated.

Lateral trochanteric pain following total hip arthroplasty: radiographic assessment of altered biomechanics as a potential aetiology

AAHKS (2) Corticosteroids

INTRODUCTION: Lateral trochanteric pain (LTP) complicates up to 17% of cases of total hip arthroplasty (THA). Studies have refuted underlying trochanteric bursitis. Restoration of the femoral offset and reproduction of the natural femoral centre of rotation are important in successful arthroplasty. LTP is believed to be associated with their alteration. AIM: The aim of our study was to evaluate the effect of femoral offset and centre of rotation on the incidence of LTP post-THA. METHODS: A retrospective case control study was developed from 158 patients who underwent a THA over a two-year period to form two patient cohorts. Twenty-nine patients diagnosed with LTP were matched with 110 control subjects. The direct lateral approach was used in all cases. Anterior-posterior pelvic radiographs before and after surgery were compared to assess the femoral, cup and global offsets and limb length discrepancies between the two groups. Statistical analyses were performed using the Mann-Whitney U test and independent samples t test. RESULTS: Twenty-nine diagnosed with post-operative LTP. Sixty-two percent of symptomatic patients were female (p = 0.13). The median ages were 74.33 (symptomatic) and 70.71 (control) (p = 0.11). The differences (pre-post) of the femoral (p = 0.17), cup (p = 0.5) and global offsets (p = 0.99) and mean of limb length discrepancy (LLD) (p = 0.83) were not significant between the two groups. CONCLUSION: No relationship was found between LTP and femoral offset or femoral centre of rotation. Disruption of the soft tissues during a lateral approach with resultant abductor tear, tendon defects and tendinitis might play a role in LTP and explain the apparent efficacy of corticosteroid injections.

Flexion space configuration in total knee arthroplasty

Surgical Management of Osteoarthritis of the Knee CPG

Equal resection of the posterior femoral condyles combined with a 90(degrees) tibial resection results in a trapezoidal flexion space. Two groups of patients were studied; in one group, the flexion space was allowed to remain trapezoidal, whereas in the other group, the anteroposterior femoral resections were externally rotated to allow rectangularization of the flexion space. In the second group, the range of flexion was increased and the incidence of medial tibial pain and zone I radiolucencies decreased. Other than for knees in a hypervalgus position before surgery, the mean amount of rotation required was 3(degrees) (plus or minus) 0.2(degrees)

Recovery time and patient satisfaction in ambulatory knee arthroscopy: Prospective study comparing three anaesthetic methods

Surgical Management of Osteoarthritis of the Knee CPG

The aim of this study was to compare recovery time and satisfaction of patients operated under two anaesthetic techniques. A randomised-controlled trial that enrolled ASA I-II patients submitted to ambulatory knee arthroscopy was designed. Patients included were randomly assigned to one of the three study groups: general intravenous anaesthesia (TIVA), spinal anaesthesia with lidocaine (LIDO), and spinal anaesthesia with prilocaine (PRILO). Spinal groups did not receive supplementary sedation. Major outcome measures considered were both the time to discharge from the post-anaesthesia care unit (PACU) and from the day-case surgical unit (DSU), the incidence of adverse events, postoperative need for analgesics and patients satisfaction. One hundred and twenty patients were enrolled. Mean time from the patients comes into operating room to discharge from

Osteoporotic Fracture: 2015 Position Statement of the Korean Society for Bone and Mineral Research

Pediatric Supracondylar Humerus Fracture 2020 Review

Osteoporotic fractures are one of the most common causes of disability and a major contributor to medical care costs worldwide. Prior osteoporotic fracture at any site is one of the strongest risk factors for a new fracture, which occurs very soon after the first fracture. Bone mineral density (BMD) scan, a conventional diagnostic tool for osteoporosis, has clear limitations in diagnosing osteoporotic fractures and identifying the risk of subsequent fractures. Therefore, early and accurate diagnosis of osteoporotic fractures using the clinical definition which is applicable practically and independent of BMD, is essential for preventing subsequent fractures and reducing the socioeconomic burden of these fractures. Fractures caused by low-level trauma equivalent to a fall from a standing height or less at major (hip, spine, distal radius, and proximal humerus) or minor (pelvis, sacrum, ribs, distal femur and humerus, and ankle) sites in adults over age 50, should be first regarded as osteoporotic. In addition, if osteoporotic fractures are strongly suspected on history and physical examination even though there are no positive findings on conventional X-rays, more advanced imaging techniques such as computed tomography, bone scan, and magnetic resonance imaging are necessary as soon as possible.

Ibandronate for the treatment of hypercalcemia or nephrocalcinosis in patients with multiple myeloma and acute renal failure: Case reports

MSTS 2018 - Femur Mets and MM

Multiple myeloma disrupts calcium homeostasis by a variety of mechanisms, including bone destruction and resorption. This causes hypercalcemia. When left untreated, hypercalcemia leads to nephrocalcinosis, impairment of kidney function, and eventually renal failure. Some degree of renal dysfunction is common in myeloma patients. Here, we report case studies showing the efficacy and renal safety of the single-nitrogen bisphosphonate, ibandronate, for the treatment of hypercalcemia and/or nephrocalcinosis in multiple myeloma patients hospitalized with acute renal failure. Patients (n = 7) received either one or two intravenous infusions of ibandronate (2-6 mg). Ibandronate was well tolerated in all patients and returned elevated blood calcium levels to normal. Renal function improved for all patients and normalized in 3/7 patients. We conclude that ibandronate is involved in rapidly improving or restoring acute renal function and calcium levels to within the normal range in this patient population. To clarify the exact value of ibandronate, further investigation is warranted in randomized prospective trials. Copyright © 2006 S. Karger AG.

Gene-environment interaction between body mass index and transforming growth factor beta 1 (TGFbeta1) gene in knee and hip osteoarthritis

OAK 3 - Non-arthroplasty tx of OAK

INTRODUCTION: The objective was to investigate potential gene-environment interaction between body mass index (BMI) and each of eight TGFbeta1 polymorphisms in knee and hip osteoarthritis (OA). METHODS: We conducted a case-control study of Caucasian men and women aged 45 to 86 years from Nottingham, United Kingdom (Genetics of OA and Lifestyle (GOAL) study). Cases had clinically severe symptoms and radiographic knee or hip OA; controls had no symptoms and no radiographic knee/hip OA. We used logistic regression to investigate the association of TGFbeta1 polymorphisms and OA when stratifying by BMI. Knee and hip OA were analyzed separately with adjustment for potential confounders. Additive and multiplicative interactions were examined. RESULTS: 2,048 cases (1,042 knee OA, 1,006 hip OA) and 967 controls were studied. For hip OA, the highest risk was in overweight (BMI >= 25 kg/m2) individuals with the variant allele of single-nucleotide polymorphism (SNP) rs1800468 (odds ratio (OR) 2.21, 95% confidence interval (CI) 1.55, 3.15). Evaluation of gene-environment interaction indicated significant synergetic interaction (relative excess risk due to interaction (RERI) = 0.93, synergy index (SI) = 4.33) with an attributable proportion due to interaction (AP) of 42% (AP = 0.42; 95% CI 0.16, 0.68). Multiplicative interaction was also significant (OR for interaction (ORINT) = 2.27, P = 0.015). For knee OA, the highest risk was in overweight individuals with homozygous genotype 11 of SNP rs2278422 (OR = 6.95, P <0.001). In contrast, the variant allele indicated slightly lower risks (OR = 4.72, P <0.001), a significant antagonistic interaction (RERI = -2.66, SI = 0.59), AP = -0.56 (95%CI -0.94, -0.17) and a significant multiplicative interaction (ORINT = 0.47, P = 0.013). CONCLUSION: TGFbeta1 gene polymorphisms interact with being overweight to influence the risk of large joint OA.

Posterior-stabilized versus cruciate-retaining total knee arthroplasty: Balancing the gap

Surgical Management of Osteoarthritis of the Knee CPG

A prospective, randomized, double-blind trial was carried out to compare cruciate-retaining (CR) and posterior-stabilized (PS) total knee arthroplasties (TKAs). A total of 40 knees were randomized to receive either a NexGen CR (Zimmer, Warsaw, IN) or a Legacy PS (Zimmer, Warsaw, IN) TKA. All knees were implanted with identical surgical technique, making sure to balance precisely the flexion-extension gaps before implantation of the components. At 2-year follow-up, there was no difference between the CR and the PS TKAs with respect to their Knee Society clinical, functional, and radiographic scores. These findings suggest that with careful attention to surgical technique and balancing the knee, orthopaedic surgeons should expect similar results whether they use a CR or PS TKA. Copyright 2002, Elsevier Science (USA). All rights reserved

Revision of infected hip replacement. Two-stage procedure with a temporary gentamicin spacer

Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures

We revised 5 infected totally-replaced hips in 2 stages. At the first operation a gentamicin-loaded modelled cement spacer was inserted, and the definitive prosthesis was inserted 3-8 weeks later. 9-24 months after the last operation, there was a recurrent infection in 1 case. 2 of the patients could walk in the interval

Pain threshold correlates with functional scores in osteoarthritis patients

Surgical Management of Osteoarthritis of the Knee CPG

Background and purpose - Pain sensitization may be one of the reasons for persistent pain after technically successful joint replacement. We analyzed how pain sensitization, as measured by quantitative sensory testing, relates preoperatively to joint function in patients with osteoarthritis (OA) scheduled for joint replacement. Patients and methods - We included 50 patients with knee OA and 49 with hip OA who were scheduled for joint replacement, and 15 control participants. Hip/knee scores, thermal and pressure detection, and pain thresholds were examined. Results - Median pressure pain thresholds were lower in patients than in control subjects: 4.0 (range: 0-10) vs. 7.8 (4-10) (p = 0.003) for the affected knee; 4.5 (2-10) vs. 6.8 (4-10) (p = 0.03) for the affected hip. Lower pressure pain threshold values were found at the affected joint in 26 of the 50 patients with knee OA and in 17 of the 49 patients with hip OA. The American Knee Society score 1 and 2, the Oxford knee score, and functional questionnaire of Hannover for osteoarthritis score correlated with the pressure pain thresholds in patients with knee OA. Also, Harris hip score and the functional questionnaire of Hannover for osteoarthritis score correlated with the cold detection threshold in patients with hip OA. Interpretation - Quantitative sensory testing appeared to identify patients with sensory changes indicative of mechanisms of central sensitization. These patients may require additional pain treatment in order to profit fully from surgery. There were correlations between the clinical scores and the level of sensitization

Foreseeable pharmaceutical repair of age-related extracellular damage

Panniculectomy & Abdominoplasty CPG

Various molecular and cellular alterations to our tissues accumulate throughout life as intrinsic side-effects of metabolism. These alterations are initially harmless, but some, which we may term "damage", are pathogenic when sufficiently abundant. The slowness of their accumulation explains why decline of tissue and organismal function generally does not appear until the age of 40 or older. Aging is thus best viewed as a two-part process in which metabolism causes accumulating damage and sufficiently abundant damage causes pathology. Hence, a promising approach to avoiding age-related pathology is periodically to repair the various types of damage and so maintain them at a sub-pathogenic level. Some examples of such types of damage are intracellular and others extracellular. Several types of intracellular damage are highly challenging - sophisticated cellular and genetic therapies will be needed to combat them, which are surely at least 20 years away and maybe much more. Extracellular damage, by contrast, generally appears more amenable to pharmaceutical repair which may be feasible in a shorter timeframe. In this article, the major types of age-related extracellular damage and promising avenues for their repair are reviewed. © 2006 Bentham Science Publishers Ltd.

Body mass index and risk of adverse cardiac events in elderly patients with hip fracture: a population-based study

Management of Hip Fractures in the Elderly

OBJECTIVES: To determine whether obesity affects cardiac complications after hip fracture repair. DESIGN: A population-based historical study using data from the Rochester Epidemiology Project. SETTING: Olmsted County, Minnesota. PARTICIPANTS: All urgent hip fracture repairs between 1988 and 2002. MEASUREMENTS: Body mass index (BMI) was categorized as underweight (<18.5 kg/m(2)), normal-weight (18.5-24.9 kg/m(2)), overweight (25.0-29.9 kg/m(2)), and obese (>or=30 kg/m(2)). Postoperative cardiac complications were defined as myocardial infarction, angina pectoris, congestive heart failure, or new-onset arrhythmias within 1-year of surgery. Incidence rates were estimated for each outcome, and overall cardiac complications were assessed using Cox proportional hazards models adjusted for age, sex, year of surgery, use of beta-blockers, and the Revised Cardiac Risk Index. RESULTS: Hip fracture repairs were performed in 184 (15.6%) underweight, 640 (54.2%) normal-weight, 251 (21.3%) overweight, and 105 (8.9%) obese subjects (mean age 84.2 +/- 7.5; 80% female). Baseline American Society of Anesthesiologists (ASA) status was similar in all groups (ASA I/II vs III-V, P=.14). Underweight patients had a significantly higher risk of developing myocardial infarction (odds ratio (OR) 1.44, 95% confidence interval (CI)=1.0-2.1; P=.05) and arrhythmias (OR=1.59, 95% CI=1.0-2.4; P=.04) than normal-weight patients. Multivariate analysis demonstrated that underweight patients had a higher risk of developing an adverse cardiac event of any type (OR=1.56, 95% CI=1.22-1.98; P<.001). Overweight and obese patients with hip fracture had no excess risk of any cardiac complication. CONCLUSION: The obesity paradox and low functional reserve in underweight patients may influence the development of postoperative cardiac events in elderly people with hip fracture

Recurrent hemarthrosis following a total knee arthroplasty

Surgical Management of Osteoarthritis of the Knee CPG

The case of a recurrent hemarthrosis of a total knee arthroplasty after the sixth postoperative month is described. Because of disabling pain, the patient underwent an explorative arthrotomy 18 months after implantation of the total knee arthroplasty. A hypertrophied vascular mass of synovium was discovered in the lateral gutter and excised with an associated synovectomy. Since the arthrotomy, the hemarthrosis has not recurred. Therefore, in cases of recurrent hemarthrosis of a total knee arthroplasty that becomes disabling, exploration by arthrotomy should be considered

The use of a closed expandable prosthesis for pediatric sarcomas

DoD SSI (Surgical Site Infections)

PURPOSE: The purpose of this paper is to review our experience with a non-invasive expandable prosthesis for skeletally immature patients following limb-salvage for malignant tumors about the knee. MATERIALS & METHODS: Between 1998 and 2002, Repiphysis prostheses (Wright Medical Technology, Memphis, Tenn.) were implanted in 18 patients. 16 patients had at least 12 months follow-up. There were 10 males and 8 females. The diagnosis was Stage IIB osteosarcoma in all patients. Sites included femur 14, and 4 proximal tibias. The average age was 10.7 years (range 8-16); the average age for males was 12 years and females, 9 years. Fifteen of the prostheses were implanted at the time of surgical resection and the remainder was conversions of previous surgery. RESULTS: Follow-up averaged 24.8 months (range 12-47). Fourteen patients have undergone a total of 58 lengthening procedures. Average expansion 38 mm per patient (range, 10-76 mm). An average of 8.5 mm per lengthening procedure. There was only one failure to lengthen. ISOLS functional scores averaged 83.5%. For those with a current functional prosthesis, the ISOLS score averaged 94%. Three patients have reached maximal expansion and converted to a conventional prosthesis. There were complications in 7 patients: 2 expandable component fractures, 1 femoral component fracture, 2 stem fractures, 1 stem loosening and 1 deep infection. Of the two expandable component fractures, 1 patient reached full expansion and was converted to an endoprosthesis. The femoral component fracture and 2 stem fractures were revised to a new prosthesis 13 months post-op and are functioning well. The 1 loose stem was revised to an APC. CONCLUSIONS: The Repiphysis prosthesis utilizes energy stored in a spring that is held compressed by a locking mechanism. Controlled release of the locking mechanism via an external electromagnetic field allows for lengthening of the device. In our early experience, the functional results were excellent similar to conventional modular devices. Complications should be anticipated but are salvageable. This device allows limb salvage in pediatric patients when amputation would be otherwise chosen.

Alterations in nitric oxide synthase isoforms in acute lower limb ischemia and reperfusion

Surgical Management of Osteoarthritis of the Knee CPG

Alterations in nitric oxide synthase (NOS) are implicated in ischemia and ischemia-reperfusion injury. Changes in the 3 NOS isoforms in human skeletal muscle subjected to acute ischemia and reperfusion were studied. Muscle biopsies were taken from patients undergoing total knee replacement. Distribution of the specific NOS isoforms within muscle sections was studied using immunohistochemistry. NOS mRNA levels were measured using real-time reverse transcription-polymerase chain reaction and protein levels studied using Western blotting. NOS activity was also assessed using the citrulline assay. All 3 NOS isoforms were found in muscle sections associated with muscle fibers and microvessels. In muscle subjected to acute ischemia and reperfusion, NOS I/neuronal NOS mRNA and protein were elevated during reperfusion. NOS III/endothelial NOS was also upregulated at the protein level during reperfusion. No changes in NOS II/inducible NOS expression or NOS activity occurred. In conclusion, alterations in NOS I and III (neuronal NOS and endothelial NOS) at different levels occurred after acute ischemia and reperfusion in human skeletal muscle; however, this did not result in increased NOS activity. In the development of therapeutic agents based on manipulation of the NO pathway, targeting the appropriate NOS isoenzymes may be important

Condylar total knee arthroplasty after failed proximal tibial osteotomy

Surgical Management of Osteoarthritis of the Knee CPG

Data were collected retrospectively on thirty-five patients who had a failed osteotomy of the proximal part of the tibia for unicompartmental osteoarthrosis of the knee that was treated with a cruciate condylar, total condylar, kinematic condylar, or cemented porous-coated anatomical total knee prosthesis. The patients were evaluated clinically and roentgenographically before and after the arthroplasty. The minimum period of follow-up was twenty-nine months (mean, forty-four months). On the basis of the knee-rating scale of The Hospital for Special Surgery, 89 per cent of the patients had either an excellent or a good result after the arthroplasty. No result was a failure. One patient had loosening of the patellar component, but no other loosening was identified. The results of total knee arthroplasty after osteotomy of the proximal part of the tibia were found to be comparable with the results after arthroplasty in knees that had not had a prior osteotomy. The intraoperative and postoperative rates of complications were not higher, and no untoward technical difficulties were encountered at surgery. These data support the clinical impression that an osteotomy of the proximal part of the tibia does not "burn any bridges" insofar as a future successful arthroplasty is concerned

Use of aromatase inhibitors in breast carcinoma

MSTS 2018 - Femur Mets and MM

Aromatase, a cytochrome P-450 enzyme that catalyzes the conversion of androgens to estrogens, is the major mechanism of estrogen synthesis in the post-menopausal woman. We review some of the recent scientific advances which shed light on the biologic significance, physiology, expression and regulation of aromatase in breast tissue. Inhibition of aromatase, the terminal step in estrogen biosynthesis, provides a way of treating hormone-dependent breast cancer in older patients. Aminoglutethimide was the first widely used aromatase inhibitor but had several clinical drawbacks. Newer agents are considerably more selective, more potent, less toxic and easier to use in the clinical setting. This article reviews the clinical data supporting the use of the potent, oral competitive aromatase inhibitors anastrozole, letrozole and vorozole and the irreversible inhibitors 4-OH androstenedione and exemestane. The more potent compounds inhibit both peripheral and intra-tumoral aromatase. We discuss the evidence supporting the notion that aromatase inhibitors lack cross-resistance with antiestrogens and suggest that the newer, more potent compounds may have a particular application in breast cancer treatment in a setting of adaptive hypersensitivity to estrogens. Currently available aromatase inhibitors are safe and effective in the management of hormone-dependent breast cancer in post-menopausal women failing antiestrogen therapy and should now be used before progestational agents. There is abundant evidence to support testing these compounds as first-line hormonal therapy for metastatic breast cancer as well as part of adjuvant regimens in older patients and quite possibly in chemoprevention trials of breast cancer. [References: 70]

The pattern of bone marrow oedema on MRI in osteonecrosis of the femoral head

Management of Hip Fractures in the Elderly

It has been suggested that transient osteoporosis or the bone marrow oedema syndrome (BMOS) may be the initial phase of osteonecrosis of the femoral head (ONFH) and that there may be a common pathophysiology. In this study, we have assessed the MR images of 200 consecutive patients with ONFH in respect of the BMO pattern in order to test this hypothesis. This pattern was not observed in the early stage of ONFH. The initial abnormal finding detected on the MR images was an abnormal band of intensity at the junction between the necrotic area and the normal bone. Structural damage of the head seems to result in the appearance of the BMO pattern and the development of pain in ONFH. There was no finding to support the existence of a continuum between BMOS and ONFH

Surgical treatment of subtrochanteric fractures of the femur: biomechanical aspects

Management of Hip Fractures in the Elderly

The internal fixation of subtrochanteric fractures of the femur must meet precise mechanical requirements in order to be capable of resisting the considerable bending stresses acting on this part of the body. On the basis of the results obtained in ninety two fractures treated surgically with various fixation devices, the authors analyse the biomechanical characteristics of the various implants in relation to the different types of fractures

Treatment of excessive anticoagulation with phytonadione (vitamin K): a meta-analysis

Management of Hip Fractures in the Elderly

BACKGROUND: Patients taking oral anticoagulants with an international normalized ratio (INR) greater than 4.0 are at increased risk for bleeding. We performed a meta-analysis to determine the effectiveness of phytonadione (vitamin K) in treating excessive anticoagulation. METHODS: The MEDLINE, EMBASE, and Cochrane Library databases were searched (without language restrictions) for articles published between January 1985 and September 2004. Randomized controlled trials or prospective, nonrandomized trials that used vitamin K to treat patients without major hemorrhage with an INR greater than 4.0 due to oral anticoagulant use were included. The primary outcome was achievement of the target INR (1.8-4.0) at 24 hours after vitamin K administration. Summary estimates were calculated using a random effects model. RESULTS: Twenty-one studies (10 randomized and 11 prospective trials) were included. Among oral vitamin K treatment arms (4, n = 75), the proportion with a target INR at 24 hours was 82% (95% confidence interval [CI], 70%-93%), which was similar to intravenous vitamin K treatment arms (6, n = 69; target INR, 77%; 95% CI, 60%-95%). Treatment arms of subcutaneous vitamin K (3, n = 58; 31%; 95% CI, 7%-55%) and placebo/observation (2, n = 27; 20%; 95% CI, 0%-47%) were less likely to achieve target INR at 24 hours. Only 1 of 21 trials appropriately assessed for adverse events, so a summary estimate for bleeding risk could not be generated. CONCLUSIONS: Limited evidence suggests that oral and intravenous vitamin K are equivalent and more effective for excessive anticoagulation than simply withholding warfarin sodium. Subcutaneous vitamin K, however, is inferior to oral and intravenous vitamin K for this indication and is similar to placebo. Whether treatment with vitamin K decreases hemorrhagic events cannot be determined from the published literature

The outcome of failed knee arthrodesis following total knee arthroplasty

Surgical Management of Osteoarthritis of the Knee CPG

After failure of total knee arthroplasty, arthrodesis was attempted in 120 cases, and unsuccessful in 25 (21%). Failure of arthrodesis was defined as nonunion persisting one year after arthrodesis or reoperation to obtain union. The number of attempts at arthrodesis ranged from one to four. The most frequent reasons for reoperation were persistent pain and instability. Most failures were caused by poor apposition owing to bone loss. Union was obtained in ten knees (average follow-up period, 44.5 months), but not in 11 (average, 35.3 months)

Multimodal analgesia for hip arthroplasty

AAHKS (2) Corticosteroids

Multimodal analgesia incorporates the use of analgesic adjuncts with different mechanisms of action to enhance postoperative pain management. Acetaminophen, anti-inflammatories, and gabapentinoids provide effective analgesia while reducing opioid requirements and opioid-related side effects. Intrathecal morphine and periarticular local anesthetic infiltration further enhance dynamic analgesia and improve postoperative mobilization. Epidural analgesia, peripheral nerve blocks, tramadol, ketamine, and/or clonidine can be added for improved benefit in opioid-tolerant individuals. [References: 92]

Impact of patellar height on unicompartment knee arthroplasty: Does patella baja lead to an inferior outcome?

Surgical Management of Osteoarthritis of the Knee CPG

Background Though a number of series with long-term results have been published, there is still a paucity of literature on the role of patellar height after unicompartment knee arthroplasty (UKA). The present study was conducted with a hypothesis that patella baja may lead to a poor outcome at follow-up.Materials and methods A retrospective review of 134 knees was performed and patellar height calculated before and after UKA by Blackburne-Peel index (BPI) and the Insall-Salvati ratio (ISR) on true lateral radiographs of the patients in 30(degrees) of flexion taken pre-operatively and at 1 year, 2 years and final follow-up (minimum 5 years). Statistical analysis was performed to evaluate the outcomes.Results There was a decrease in ISR in 14.18% and in BPI in 19.4% at final follow-up. There was a significant decrease in BPI values while the decrease was not significant for ISR. After eliminating the pre-operative patella baja, 7.3% developed post-operative patella baja, according to ISR, while 11.5% developed patella baja as per BPI. At final follow-up there was a statistically significant decrease in stair climbing scores in patients with patella baja when compared to patients with normal ISR.Conclusion Patients with a decrease in patellar height as per ISR have a decrease in stair climbing score at mid-term follow-up while the overall KSS, and pain scores are not affected by a change in patellar height and neither is there a significant progress in patellofemoral osteoarthritis among patients with patella baja compared to normal patella

Humeral shaft fractures secondary to hand grenade throwing

Pediatric Supracondylar Humerus Fracture 2020 Review

A series of five cases were presented in which similar fractures of the shaft of the humerus occurred during the hand grenade throwing activity during the military education. All the fractures were in the 1/3 distal humeral shaft, and butterfly fragments were accompanying in two soldiers. All the fractures healed without any clinical complications with conservative treatment. The mechanism of the fracture is discussed with reference to the recent literature.

Pelvic trauma: What are the predictors of mortality and cardiac, venous thrombo-embolic and infectious complications following injury?

DoD SSI (Surgical Site Infections)

INTRODUCTION: This study sought to determine risk factors that influence mortality, cardiac events, venous thrombo-embolic disease (VTED), and infection following fractures of the pelvis and/or acetabulum. METHODS: The 2008 National Sample Program (NSP) of the National Trauma Databank was queried to identify all patients who sustained pelvic and acetabular fractures. Demographic data, injury-specific and surgical characteristics, and medical co-morbidities were abstracted. The occurrence of in-hospital mortality, cardiac events, VTED and infections were documented. Univariate testing, weighted logistic regression, and sensitivity analyses were performed to identify significant independent predictors of mortality and the complications under study. RESULTS: The NSP contained 41,297 cases of pelvic trauma. In-hospital mortality was documented in 3055 (7%) and one or more complications occurred in 6932 (17%). Cardiac events transpired in 2% of patients, VTED in 4% and infections in 3%. Increasing age, shock, time to procedure, ISS, and GCS were predictive of mortality. Cardiac events were found to be influenced by obesity, diabetes, ISS, GCS, age, and trauma mechanism. VTED was impacted by obesity, history of respiratory disease, male sex, ISS, GCS, medical co-morbidities, and time to procedure. Injuries caused by mechanisms other than blunt trauma, shock, age, ISS, GCS, medical co-morbidities, and time to procedure were associated with infection. CONCLUSIONS: Several important predictors were identified for specific complications and mortality following pelvic trauma. The design of this study may render it more generalisable to American patients with pelvic injuries. LEVEL OF EVIDENCE: II - Prognostic retrospective study of a prospective dataset.

5-Year experience of highly cross-linked polyethylene in cemented and uncemented sockets: Two randomized studies using radiostereometric analysis

Management of Hip Fractures in the Elderly

Background: Laboratory tests and early clinical studies have shown that highly cross-linked polyethylene (PE) markedly improves wear resistance compared to conventional PE. We evaluated this type of PE in two randomized clinical studies using radiostereometric analysis (RSA). The 2- and 3-year follow-up of these studies have already been reported. We found a lower penetration rate for the highly cross-linked PE than for conventional PE. We now report the outcome after 5 years. Patients and methods: 60 patients (61 hips) with a median age of 55 years were randomized to receive either highly cross-linked PE (Durasul) or conventional cemented all-polyethylene sockets of the same design. 55 patients (56 hips) were followed for 5 years. In the second study, 32 patients (64 hips) with a median age of 48 years and with bilateral primary or secondary osteoarthritis of the hip had hybrid total hip arthroplasty with liners made of highly cross-linked PE (Longevity) on one side and conventional PE on the other. 23 patients in this study have passed the 5-year follow-up. Results: Bedding-in and creep for the Durasul all-PE was reached by 2 years, and by 1 year for the Longevity liners. In both control groups with conventional PE, this was reached by 6 months. The steady-state wear rate was close to zero in the two study groups and 0.06 mm/ year for the conventional PE in the two control groups. Interpretation: We found that use of highly crosslinked PE instead of conventional PE reduced the wear by more than 95%, which supports continued use of this type of PE in young, active patients. Copyright(copyright) Taylor & Francis 2007. all rights reserved

Liposomal nanomedicines in the treatment of prostate cancer

MSTS 2018 - Femur Mets and MM

Prostate cancer is the most common cancer type and the second leading cause of death from cancer in males. In most cases, no curative treatment options are available for metastatic castration-resistant prostate cancer as these tumors are highly resistant to chemotherapy. Targeted drug delivery, using liposomal drug delivery systems, is an attractive approach to enhance the efficacy of anticancer drugs and prevent side effects, thereby potentially increasing the therapeutic index. In most preclinical prostate cancer studies, passive liposomal targeting of anticancer drugs (caused by enhanced permeability and retention of the therapeutic compound) leads to an increased antitumor efficacy and decreased side effects compared to non-targeted drugs. As a result, the total effective dose of anticancer drugs can be substantially decreased. Active (ligand-mediated) liposomal targeting of tumor cells and/or tumor-associated stromal cells display beneficial effects, but only limited preclinical studies were reported. To date, clinical studies in prostate carcinoma have been performed with liposomal doxorubicin only. These studies showed that long-circulating, PEGylated, liposomal doxorubicin generally outperforms conventional short-circulating liposomal doxorubicin, stressing the importance of passive tumor targeting for this drug in prostate carcinoma. In this review, we provide an overview of the (pre)clinical studies that focus on liposomal drug delivery in prostate carcinoma. © 2013 Elsevier Ltd.

Clinical imaging diagnosis of implant materials for breast augmentation

Panniculectomy & Abdominoplasty CPG

BACKGROUND: The ingredients of substances implanted for breast augmentation sometimes remain unknown due to lack of information from patients. Significant clinical problems sometimes necessitate removal and reconstruction. Thus, preoperative diagnostic imaging to identify the ingredients of implants may improve the treatment decision-making process. In this report, we created a clinical imaging index. PURPOSE: Here, we summarize computed tomography (CT) and magnetic resonance imaging (MRI) imaging of implant materials to predict the ingredients of implant substances preoperatively. METHODS: A total of 104 patients with late complications after receiving breast augmentations between 1971 and 2002 were examined using CT and MRI. In addition, further examinations were conducted, including postoperative chemical analysis using Nuclear magnetic resonance (NMR) spectroscopy and MRI imaging of various implanted substances using an experimental magnetic resonance system. RESULTS: We identified the ingredients of implant materials used for breast augmentation by imaging diagnostics as follows: silicone: radiopaque-low/high (CT-MRI T1/T2); hydrogel: radiolucent-low�iso/high; hydrocarbon: radiolucent-high�iso/low�iso; saline: radiolucent-low/high. CONCLUSION: We have identified by imaging diagnosis the ingredients of implant materials. Copyright © 2006 by Lippincott Williams & Wilkins.

Hyaluronans: is clinical effectiveness dependent on molecular weight?

Surgical Management of Osteoarthritis of the Knee CPG

The original rationale for viscosupplementation with hyaluronans was fluid replacement, suggesting that the most viscous materials (eg, those of highest molecular weight [MW]) would provide the most clinical benefits. However, it has become clear that mechanisms of action for osteoarthritis pain management are not only mechanical but also biological. After intra-articular injection, hyaluronans exert a range of biological actions within the joint. Although high- and low- to mid-MW hyaluronans (but not hyaluronans <500 kDa MW) are more or less active (depending on the specific effect examined), it is not known which actions are clinically meaningful. There is no evidence for a difference between hyaluronan products in clinical efficacy measured as pain relief, but investigators in several preclinical studies evaluating joint-structure modification in osteoarthritis models have reported advantages to using low- to mid-MW hyaluronans

Abnormal preoperative MRI does not correlate with failure of UKA

Surgical Management of Osteoarthritis of the Knee CPG

Modern indications for medial mobile-bearing unicompartmental knee arthroplasty (UKA) include a normal lateral compartment, minimal patellofemoral disease, and a ligamentously stable knee. Radiographs and intraoperative inspection can determine the appropriateness of UKA. Magnetic resonance imaging (MRI) interpretations can over-estimate the degree of knee pathology. This study reports the outcomes of UKA performed despite an abnormal MRI of the lateral compartment, patellofemoral compartment, and/or cruciate ligaments. One thousand consecutive medial UKAs were reviewed, and 33 patients had pre-operative MRI with interpretations of osteoarthritic changes in the lateral compartment, patellofemoral compartment, and/or deficiency of the anterior cruciate ligament (ACL). We compared the postoperative Knee Society pain score, total score, and functional score between the abnormal MRI group (n=33) and the remaining patients (n=967). Average follow-up was 43.4months and 38.3months for the two groups, respectively. Knee Society pain, total, and functional scores for the abnormal MRI group were 40.8, 88.7, and 78.5 respectively compared with 43.4, 90.6, and 80.0 respectively for the remaining patients. The failure rate was 3% (1/33) in the abnormal MRI group and 4% (39/967) in the remaining patients. Based on the numbers available, there were no differences between the two groups in terms of survival and clinical results. The results of this study suggest abnormal preoperative MRI findings do not have an influence on the outcome of UKA when modern radiographic and clinical criteria are met

The Mark Coventry Award: in vivo knee forces during recreation and exercise after knee arthroplasty

Surgical Management of Osteoarthritis of the Knee CPG

Knee forces directly affect arthroplasty component survivorship, wear of articular bearing surfaces, and integrity of the bone-implant interface. It is not known which activities generate forces within a range that is physiologically desirable but not high enough to jeopardize the survivorship of the prosthetic components. We implanted three patients with an instrumented tibial prosthesis and measured knee forces and moments in vivo during exercise and recreational activities. As expected, stationary bicycling generated low tibial forces, whereas jogging and tennis generated high peak forces. On the other hand, the golf swing generated unexpectedly high forces, especially in the leading knee. Exercise on the elliptical trainer generated lower forces than jogging but not lower than treadmill walking. These novel data allow for a more scientific approach to recommending activities after TKA. In addition, these data can be used to develop clinically relevant structural and tribologic testing, which may result in activity-specific knee designs such as a knee design more tolerant of golfing by optimizing the conflicting needs of increased rotational laxity and conformity

Effects of long-term intravenous ibandronate therapy on skeletal-related events, survival, and bone resorption markers in patients with advanced multiple myeloma

MSTS 2018 - Femur Mets and MM

PURPOSE: Bisphosphonates have been found to reduce the incidence of skeletal-related events (SREs) in patients with multiple myeloma. This is the first double-blind, randomized, placebo-controlled study to assess the efficacy of ibandronate, a third-generation amino-bisphosphonate, in preventing SREs in advanced-stage multiple myeloma patients. PATIENTS AND METHODS: Patients with multiple myeloma stage II or III were randomly assigned to receive either ibandronate 2 mg or placebo as a monthly intravenous (IV) bolus injection for 12 to 24 months in addition to conventional chemotherapy. SREs such as peripheral pathologic or vertebral fractures, hypercalcemia, severe bone pain, and bone radiotherapy or surgery were analyzed. Bone-turnover markers were also studied. Finally, post hoc analyses of bone morbidity and survival were performed. RESULTS: Ninety-nine patients per treatment group were assessable for efficacy analysis. The occurrence of SRE per patient year and the time to first SRE were not significantly different between the two treatment groups. In overall evaluation, no differences were found between the treatment groups regarding bone pain, analgesic drug use, quality of life, and median survival (33.1 v 28.2 months, respectively). Explorative post hoc analyses revealed that ibandronate patients with strongly suppressed bone-turnover markers (> or = 30% and > or = 50% mean reduction of serum osteocalcin and urinary C-terminal telopeptides) developed significantly less bone morbidity. Ibandronate was tolerated well during as many as 25 therapy cycles. CONCLUSION: Monthly injections of ibandronate 2 mg IV neither reduced bone morbidity nor prolonged survival in the overall population of stage II/III multiple myeloma patients.

Anti-inflammatory and anti-arthritic effects of the ethanolic extract of Aralia continentalis Kitag. in IL-1beta-stimulated human fibroblast-like synoviocytes and rodent models of polyarthritis and nociception

OAK 3 - Non-arthroplasty tx of OAK

BACKGROUND: Blocking the formation and invasive growth of pannus and its secretion of inflammatory cytokines and MMPs is important for treating rheumatoid arthritis. HYPOTHESIS/PURPOSE: Anti-arthritic activity of Aralia continentalis Kitag., an oriental herbal medicine, and the underlying mechanisms involved were investigated. STUDY DESIGN: Anti-inflammatory and anti-nocicpetive activities of the ethanolic extract (50% v/v) of Aralia continentalis Kitag. harvested from Imsil, Korea (ACI) were investigated in IL-1beta-stimulated human fibroblast-like synoviocyte (FLS) cells and rodent models of collagen-induced polyarthritis and carrageenan-induced acute paw pain. METHODS: In IL-1beta-stimulated FLS cells derived from rheumatoid arthritis patients, the anti-inflammatory activity of ACI was examined by analyzing the expression levels of inflammatory mediators such as TNF-alpha, IL-6, IL-8, MMP-1, MMP-3, MMP-13, PGE2, and COX-2 using ELISA and RT-PCR analysis. The anti-arthritic activity of ACI was investigated by measuring body weight, squeaking score, paw volume, and arthritis index in collagen-induced polyarthritis mice. The anti-nociceptive activity of ACI was examined in the paw-pressure test and Tail-flick latency test in rats. RESULTS: The ethanolic extract (50% v/v) of ACI reduced the levels of TNF-alpha, IL-6, IL-8, MMP-1, and MMP-13 secreted by IL-1beta-stimulated FLS cells, whereas MMP-3, COX-2, and PGE2 were not significantly affected. ACI inhibited the migration of NF-kappaB into the nucleus through the inhibition of ERK- and JNK-dependent MAP kinase pathways in IL-1beta-stimulated FLS cells. In collagen-induced polyarthritis mice, oral administration of ACI extract (200mg/kg) significantly alleviated arthritic behaviors. Histological observations of arthritic mouse knees were consistent with their behaviors. The anti-arthritic and anti-inflammatory activities of 200mg/kg ACI extract were comparable to those of 10mg/kg prednisolone when administered to mice. However, ACI administration did not significantly affect carrageenan-induced hyperalgesia or thermal nociception in rats. CONCLUSION: These results suggest that the ethanolic extract of ACI have significant anti-inflammatory and anti-arthritic effects in a rodent arthritis model and in IL-1beta-stimulated FLS cells. Thus, ACI may be a useful candidate for developing pharmaceuticals or dietary supplements for the treatment of inflammatory arthritis.

Hip and knee replacement after longstanding hip arthrodesis

Surgical Management of Osteoarthritis of the Knee CPG

This study determined whether patients with severe knee disease below a hip arthrodesis can be treated successfully with total knee replacement alone or whether such patients require total hip arthroplasty followed by knee replacement. Eighteen patients who had hip arthrodesis for a mean of 33 years underwent total hip replacement alone, total knee replacement alone, or a combination of both. The Harris hip score improved from a mean of 55.3 to a mean of 86.9 points at 45 months after total hip arthroplasty. The Hospital for Special Surgery knee score improved from a mean of 33 to a mean of 78 points in patients who had total knee replacement after total hip arthroplasty. The Hospital for Special Surgery knee score improved from a mean of 35 to a mean of 44 points in patients having total knee replacement alone below a hip arthrodesis. The followup after total knee replacement averaged 53 months. These data suggest that a knee replacement alone in a patient with a fused hip is unlikely to provide a satisfactory result. Patients with severe knee disease below hip arthrodesis require total hip arthroplasty followed by knee replacement. This applies even when severe osteoarthritis of the knee is the primary complaint

Single stage correction of gynecomastia: Liposuction & glandular excision

Panniculectomy & Abdominoplasty CPG

Objective: To determine the frequency of complications after single stage correction of gynecomastia, along with level of satisfaction in patients and surgeon 4 weeks post operatively Study Design: Prospective cohort study. Place and Duration of Study: This study was conducted at the Department of Plastic Surgery, Liaquat National Hospital, Karachi from April 2014 to March 2017. Material and Methods: Informed consent was taken from all patients enrolled. The surgical technique consisted of liposuction and excision of the glandular tissue by minimal Periareolar incision. Skin excision was done where needed. Post operatively, patients were followed for complication rate and 4 weeks postoperatively both patient and surgeon were asked to grade their level of satisfaction. Results: 26 patients were enrolled and analyzed. Over all, complication rate was 15% (4/26). One developed hematoma for which he required re-operation, one had irregularities and two had flattening of chest. Patient Satisfaction was 85% & Surgeons Satisfaction was 87%. Conclusion: Liposuction along with glandular & skin excision decreases post-op nipple projection and have aesthetically pleasing results with a low rate of complications and excellent patient & surgeon's satisfaction.

Comparison of "hematoma block" versus "wrist block" anesthesia in the treatment of fifth metacarpal fracture

Distal Radius Fractures

INTERVENTION: Group A (hematoma block anesthesia): barbotage injection of the lidocaine 2% (3�5 ml) without epinephrine in hematoma site. Group B (wrist block anesthesia): after detecting landmarks with the help of a nerve locator, following shots will be injected respectively: 5�7 ml of lidocaine 2% without epinephrine in radial and median nerve, 4�5 ml of lidocaine 2% without epinephrine in ulnar nerve. Intervention 1: Group A (hematoma block anesthesia): barbotage injection of the lidocaine 2% (3�5 ml) without epinephrine in hematoma site. Intervention 2: Group B (wrist block anesthesia): after detecting landmarks with the help of a nerve locator, following shots will be injected respectively: 5�7 ml of lidocaine 2% without epinephrine in radial and median nerve, 4�5 ml of lidocaine 2% without epinephrine in ulnar nerve. Treatment � Other CONDITION: Fracture of fifth metacarpal bone. ; Fracture of other metacarpal bone Fracture of other metacarpal bone PRIMARY OUTCOME: Pain intensiy. Timepoint: pre� intra� and 5 minute post�reduction. Method of measurement: Visual analogue scale. Patient satisfaction. Timepoint: during the reduction. Method of measurement: Visual analogue scale. SECONDARY OUTCOME: Angle correction of the fracture. Timepoint: 2 month post treatment. Method of measurement: Goniometer. Grip strength of the fifth figer (compared to contra�lateral finger). Timepoint: 2 month post treatment. Method of measurement: Dynamometer. INCLUSION CRITERIA: INCLUSION CRITERIA: all patients with the age between 18�75 years old with type I or II in ASA classification whom are candidate for the reduction of the fifth metacarpal fracture. Exclusion criteria: hyper�sensitivity or allergy to local anesthesia; local active infection in the site of injection; coagulopathy disorders; and drug abuse.

Association between beta-blocker use and fracture risk: the Dubbo Osteoporosis Epidemiology Study

Management of Hip Fractures in the Elderly

INTRODUCTION: In animal model, mice treated with beta-blockers (BB) had increased bone mass. In humans, high bone mass is associated with reduce fracture risk. The present study sought to test the hypothesis that BB use is associated with reduced fracture risk. MATERIALS AND METHODS: Data from 3488 participants (1285 men) aged 50 years and above in the Dubbo Osteoporosis Epidemiology Study (DOES) were analyzed. Baseline characteristics of participants were obtained at the initial visit which had taken place between 1989 and 1993. Bone mineral density (BMD) at the lumbar spine and femoral neck was measured by dual energy X-ray absorptiometry (GE-LUNAR Corp, Madison, WI). Two hundred and sixty two (20%) men and 411 (19%) women had been on BB, as ascertained by direct interview and verification with medication history. The incidence of fragility fractures was ascertained during the follow-up period (1989-2008). RESULTS: In men, BB use was associated with higher BMD at the femoral neck (0.96 versus 0.92 g/cm(2), P < 0.01), higher lumbar spine (1.32 versus 1.25 g/cm(2), P < 0.01), and lower fracture risk than those not on BB (odds ratio [OR]: 0.49; 95% CI: 0.32-0.75). In women, BB users also had higher femoral neck BMD (0.83 versus 0.81 g/cm(2), P < 0.01), higher lumbar spine BMD (1.11 versus 1.06 g/cm(2), P < 0.01), and lower risk of fracture than non-users (OR 0.68, 95% CI: 0.53-0.87). The associations between BB use and fracture risk were independent of age, BMD, and clinical risk factors. Subgroup analysis suggested that the association was mainly found in selective BB, not in non-selective BB. CONCLUSION: Beta-blockers use, particularly selective BB, was associated with reduced fracture risk in both men and women, and the association was independent of BMD

New technique for humerus shaft fracture retrograde intramedullary nailing

Distal Radius Fractures

Humeral shaft fracture intramedullary nailing is less invasive than plates and screws. Antegrade technique has postoperative shoulder pain, increased rehab time, and frequent reoperation for rod removal. Published retrograde technique is not collinear with the shaft, has insertion site fractures (5% to 15%), and radial nerve palsies (5%). Our retrograde technique is collinear with the humerus shaft, simpler, and decreases operative fracture risk. The supine patient's elbow is fully flexed. A guide pin is inserted through the triceps tendon to the olecranon fossa roof, aligned with the humerus shaft, and drilled thought the cortex followed by the 6.5 mm cannulated drill through a small triceps splitting incision. The guide pin is passed along the humerus shaft and across the fracture. A small incision is made to identify and protect the radial nerve during reduction, reaming, and rod insertion. Flexible reamers are used and the nail placed and locked at least distally to prevent distal migration. An institutional review broad approved retrospective review of Louisiana State University Health Sciences Center adult humeral shaft fractures with retrograde technique from 1999 to January of 2009 was carried out. Sixteen patients were treated without perioperative fracture or nerve palsy.

Ipsilateral femoral autograft reconstruction after resection of a pelvic tumor

MSTS 2018 - Femur Mets and MM

Background: Reconstruction of bone afterthe resection of a pelvic tumor is challenging. The purpose of the present study was to evaluate the use of the ipsilateral femur as the graft material for reconstruction. Methods: We performed a retrospective review of thirteen patients with a malignant pelvic lesion who underwent resection followed by reconstruction with an ipsilateral femoral autograft and insertion of a total hip replacement. The study group included nine men and four women with a median age of fifty-one years at the time of the reconstruction. The diagnosis was chondrosarcoma in eight patients, metastasis in three, and myeloma and radiation-induced malignant disease in one each. The surviving patients were assessed functionally and radiographically; the cumulative probability of revision was estimated while taking into account competing risks. Results: The median duration of follow-up was forty-nine months. At the time of the latest follow-up, seven patients were alive and disease-free and six had died from metastatic disease. Four patients had had revision of the reconstruction, two for the treatment of mechanical complications and two forthe treatment of infection. Three other patients had mechanical complications but had not had a revision. The cumulative probability of revision of the reconstruction for mechanical failure was8%(95%confidence interval, 0%to23%), 8%(95%confidence interval, 0%to 23%), and 16%(95%confidence interval, 0%to 39%) at one, two, and four years, respectively. Conclusions: Although it has attendant complications consistent with pelvic tumor surgery, an ipsilateral femoral autograft reconstruction may be an option for reconstruction of pelvic discontinuity in a subgroup of patients following tumor resection. This innovative procedure requires longer-term follow-up studies. Level of Evidence: Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence. Copyright © 2009 by The Journal of Bone and Joint Surgery, Incorporated.

Shear-enhanced oral microbial adhesion

Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures

Shear-enhanced adhesion, although not observed for fimbria-mediated adhesion of oral Actinomyces spp., was noted for Hsa-mediated adhesion of Streptococcus gordonii to sialic acid-containing receptors, an interaction implicated in the pathogenesis of infective endocarditis

The role of regional anesthesia in patient outcome: orthopedic surgery

Surgical Management of Osteoarthritis of the Knee CPG

Outcome is defined as "a change in a patient's health status that can be attributed to antecedent health care." Postoperative pain is a major concern after orthopedic limb surgery. Indeed, pain is exacerbated with motion, particularly after shoulder and knee surgery. From moderate at rest, pain becomes most severe during mobilization. Several studies have shown that regional anesthesia is associated with superior analgesia compared with patient-controlled analgesia morphine. The better postoperative pain control has led to the application of early mobilization, a new trend in modern orthopedics. Other benefits of regional anesthesia techniques in this setting are lower incidence of nausea and vomiting, higher patient satisfaction, and probably less postoperative cognitive dysfunction. (copyright) 2008 Elsevier Inc. All rights reserved

Percutaneous fixation of adult Humerus with Titanium elastic nails

MSTS 2022 - Metastatic Disease of the Humerus

Objective: To study the results of treatment of fractures of shaft of Humerus using percutaneous Titanium Nails. Methodology: This is a quasi-experimental, prospective, interventional, study of 30 clinical cases that were operated with retrograde, per cutaneous elastic Titanium nails for treatment of diaphyseal fractures of adult Humerus. Cases close to either ends of the bone, those presenting with Grade II open fractures and neurovascular injury were excluded along with pathological fractures. All complications were noted. All cases were followed up for one year postoperatively. Results: The age range of the 30 patients included in the study was 33.50 + 11.08 (18-65) years with a follow up period of one year. There were 21(70%) male patients and 9(30%) female patients in the study. We observed clinical and radiological union in 23 patients, delayed union in 5(bone grafting done later), non union in 2 patients. Both these nonunion cases were treated later with internal fixation with plating. All united fractures were in acceptable range of angulation and rotation. On an average radiological union occurred between 3 to 4 months. We observed average 10 degree of limitation in shoulder abduction and extension lag of 10 degree at elbow joint. Two cases reported with deep infection. Conclusion: The use of Titanium Elastic Nails in the treatment of diaphyseal Humerus fractures seems to be a safe option with minimal morbidity. Percutaneous fixation of adult Humerus fracture is a less time consuming procedure with minimal blood loss, minimal soft tissue disruption and facilitates natural healing at fracture site.

Magnetic resonance imaging: a cost-effective alternative to bone scintigraphy in the evaluation of patients with suspected hip fractures

HipFx Supplemental Cost Analysis

OBJECTIVE: To evaluate the cost-effectiveness of magnetic resonance imaging (MRI) compared with radionuclide bone scan in the evaluation of patients with clinically suspected hip fractures. DESIGN: The medical records of all patients who had been seen in the emergency room over a 4 1/2 year period with a clinically suspected hip fracture, negative or equivocal plain films, and either a subsequent bone scan or MRI examination were retrospectively reviewed. The time to diagnosis, admission rate, and time to surgery were determined. A two-sample t-test was used to assess the statistical significance of the results. A theoretical cost analysis was performed using current charges to estimate all expenses. PATIENTS: Forty patients (11 male, 29 female; age 28-99 years) satisfied our inclusion criteria. RESULTS AND CONCLUSIONS: Twenty-one patients had bone scans (six with fractures), and 19 had MRI (four with fractures). The time to diagnosis was 2.24 +/- 1.30 days for bone scanning and 0.368 +/- 0.597 days for MRI (P < 0.0001). Twenty patients in the bone scan group were admitted compared with 13 in the MRI group. The time to surgery was at least 1 day longer in patients undergoing bone scanning. Bone scanning resulted in higher patient costs compared with MRI because of the delay in diagnosis. In the evaluation of patients with suspected hip fractures, early MRI is more cost-effective than delayed bone scanning. Further prospective studies comparing the cost-effectiveness of early MRI with early bone scanning are needed

Single-institution outcome experience using AlloDerm(R) as temporary coverage or definitive reconstruction for cutaneous and soft tissue malignancy defects

Reconstruction After Skin Cancer

Definitive reconstruction after excision of cutaneous and soft tissue malignancies is sometimes limited as a result of lack of native tissue coverage options, patient comorbidities, or pending permanent margin analysis. Acellular dermis (AlloDerm(R)) reconstruction offers an excellent coverage alternative in these situations. We describe our experience using AlloDerm for coverage of skin and soft tissue defects. An Institutional Review Board approved review of patients undergoing skin/soft tissue coverage with AlloDerm from 2006 to 2012 was performed. Clinicopathologic variables, early postoperative findings, and subjective final cosmetic outcome were analyzed. Sixty-seven patients underwent AlloDerm reconstruction. Melanoma (67%) was the most frequent diagnosis. The median defect size was 42 cm(2) (range, 2 to 340 cm(2)), involving predominantly the lower extremity (45%) or head and neck (32%). AlloDerm was intended for use as a temporary dressing in 64 per cent (43 of 67) and permanent coverage in 24 (36%). Ten patients required reexcision for positive margins. Twenty-five (37%) underwent split-thickness skin graft or flap coverage after AlloDerm placement. Radiation was administered to 16 patients (24%) after AlloDerm reconstruction within a median of 53 days after surgery (range, 18 to 118 days). At first postoperative examination (median, 11 days after surgery), 85 per cent had evidence of healthy AlloDerm incorporation. Cellulitis was the most frequent complication (13%), all resolving with oral antibiotics. AlloDerm reconstruction after skin and soft tissue resection offers a suitable coverage alternative and may serve as a bridge to permanent reconstruction or as a permanent biologic dressing of complex surgical defects. In situations in which adjuvant radiation is needed, AlloDerm can be used without major complications.

Exercise and NSAIDs: effect on muscle protein synthesis in patients with knee osteoarthritis

OAK 3 - Non-arthroplasty tx of OAK

PURPOSE: The purpose of this study was to determine muscle and tendon protein fractional synthesis rates (FSR) at rest and after a one�legged kicking exercise in patients with knee osteoarthritis (OA) receiving either placebo or nonsteroidal anti�inflammatory drugs (NSAIDs). METHODS: Twenty patients with knee OA (50�70 yr) were enrolled. For each of the 3 days before the exercise intervention, 9 patients were administered NSAIDs (1200 mg), and 11 patients were administered placebo in a double�blinded manner. Each patient performed 60 min of one�legged kicking at 55% of workload maximum while the contralateral leg remained rested. Twenty�four hours after exercise, we determined circulating concentrations of inflammatory parameters and measured FSR of myofibrillar and sarcoplasmic protein fractions of vastus lateralis muscle and patellar tendon collagen protein by the direct incorporation method using a flooding dose of 13C/12C�proline. RESULTS: Circulating levels of prostaglandin F2α were lower in the NSAID group compared with the placebo group (P < 0.05). There was an overall significant effect of exercise on FSR in muscle myofibrillar (P = 0.003) and sarcoplasmic protein (P = 0.026) but not in tendon collagen protein (P = 0.52). No overall significant effect of the drug was seen on either of the tissue protein fractions (P > 0.05) or on the interaction between the drug and exercise on FSR in tendon collagen (P = 0.21), muscle myofibrillar (P = 0.68), or sarcoplasmic protein, FSR (P = 0.16). CONCLUSION: In elderly patients with knee OA, an acute bout of moderate exercise significantly increases FSR of muscle myofibrillar and sarcoplasmic protein, but not tendon collagen, 24 h after exercise. NSAID administration in patients with knee OA reduced the level of circulating prostaglandin F2α but did not diminish the exercise�induced response of muscle contractile protein FSR. However, we cannot exclude that a minor inhibition of muscle sarcoplasmic proteins may have been present with NSAID treatment. This study suggests that muscle hypertrophy after long�term training is not influenced by NSAIDs.

Hyperbaric oxygen therapy as an adjuvant to standard therapy in the treatment of diabetic foot ulcers

DoD SSI (Surgical Site Infections)

Background and Aims: Chronic diabetic foot ulcers pose a major problem because of associated limb threatening complications. The aim of the present study was to evaluate the efficacy of hyperbaric oxygen therapy (HBOT) as an adjuvant to standard therapy for treatment of diabetic foot ulcers. Material and Methods: A total of 54 patients with diabetic foot ulcer of Wagner grade II-IV were recruited in this prospective, randomized, double blind study. Patients were randomized to receive HBOT along with standard therapy (group H; n = 28) or standard therapy alone (group S; n = 26). Patients were given 6 sessions per week for 6 weeks and followed up for 1 year. Outcomes were measured in terms of healing, and need for amputation, grafting or debridement. Parametric continuous variables were analyzed using Student unpaired t-test and categorical variables were analyzed using Chi square test. Results: The diabetic ulcers in 78% patients in Group H completely healed without any surgical intervention while no patient in group S healed without surgical intervention (P = 0.001). 2 patients in group H required distal amputation while in Group S, three patients underwent proximal amputation. Conclusion: The present study shows that hyperbaric oxygen therapy is a useful adjuvant to standard therapy and is a better treatment modality if combined with standard treatment rather than standard treatment alone for management of diabetic foot ulcers.

Treatment of trochanteric fractures with Ender rods

Management of Hip Fractures in the Elderly

The technical aspects of Ender's method in the treatment of trochanteric fractures are described. Problems and complications encountered with this method and their prevention and treatment are discussed. Intraoperative and postoperative problems are subdivided into those in the hip area and around the knee joint, such as: varus deformity, protrusion of the rod medially or laterally or into the hip joint, cracking the distal femur, incorrectly placing the window on the anteromedial side of the femoral condyle, backing out of the rods, and supracondylar fractures

Radiographic Predictors of DRUJ Instability with Distal Radius Fractures

Distal Radius Fractures

Because the distal radioulnar joint (DRUJ) is an inherently unstable joint, the diagnosis and treatment of DRUJ instability is often difficult in a clinical hand surgery practice. Several soft tissue stabilizers are recognized, of which the deep limbs of the radioulnar ligament are primary stabilizers. This article discusses the predictors of DRUJ instability in distal radius fractures based on our clinical and biomechanical analyses.

Viscosupplementation in haemophilic arthropathy: a long-term follow-up study

OAK 3 - Non-arthroplasty tx of OAK

Haemophilic arthropathy is the most common clinical manifestation of haemophilia, secondary to recurrent haemarthroses and chronic synovitis. Modern bleeding-preventing drugs have limited significantly the incidence of severe arthropathy, and primary approach is usually conservative. Use of intra-articular injections of hyaluronan acid is considered one of the most efficient treatments for early stages of articular degenerative diseases. Assessment of long-term effectiveness of intra-articular administration of hyaluronic acid (HA) in knees, ankles and elbows of patients affected by haemophilic arthropathy was done for 46 patients (10 elbows, 24 knees and 25 ankles) affected by haemophilic arthropathy. They received injections of HA and were evaluated with Visual Analogue Scale, Short Form-36, World Federation of Haemophilia score and Petterson score with a 6-year mean follow-up. Most of the patients showed improvement in pain relief and functional recovery without any complications: only a limited number of patients (8.6%) found poor results, undergoing surgery or other further treatments in the follow-up period for persistent pain or limitation. Viscosupplementation is an effective therapeutic strategy in early stages of haemophilic arthropathy, with no complications and long-term good clinical results.

Subdural empyema after tooth extraction in which Capnocytophaga species was isolated

Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures

We describe a patient with meningitis and a subdural empyema arising from an infection after teeth extraction in which Capnocytophaga species was detected. The patient was a 54-y-old man without any underlying diseases. A computerized tomography scan showed a subdural empyema 21 d after the extraction

Nutritional assessment of residents in long-term care facilities (LTCFs): recommendations of the task force on nutrition and ageing of the IAGG European region and the IANA

HipFx Supplemental Cost Analysis

Unintentional weight loss and Undernutrition are major problems among older people living in Long-Term Care Facilities (LTCF). Undernutrition manifests in LTCF particularly as weight loss and low Body Mass Index (BMI) and is associated with increased morbidity and mortality as well as with functional decline. There are many factors associated with poor nutritional status and affecting protein-energy intake and/or energy expenditure. These include age of 85 years or older, low nutrient intake, loss of ability to eat independently, swallowing and chewing difficulties, becoming bed-ridden, pressure ulcers, history of hip fracture, dementia, depressive symptoms and suffering from two or more chronic illnesses. Nutritional evaluation is an essential part of the Comprehensive Geriatric Assessment (CGA). This evaluation ranges from methods such as BMI to several validated tools such as Mini-Nutritional Assessment (MNA). After diagnosis, the management of undernutrition in LTCF requires a multidisciplinary approach which may involve dietary and environmental improvements and managing multiple co-morbidities, while avoiding polypharmacy as far as possible. Finally, the need for supplementation or artificial (tube) feeding may be considered taking into account the CGA and individual needs. This document presents a succinct review and recommendations of evaluation and treatment of undernutrition

Arthroscopic management of osteoarthritis of the knee

Surgical Management of Osteoarthritis of the Knee CPG

Recent advances in instrumentation and a growing understanding of the pathophysiology of osteoarthritis have led to increased use of arthroscopy for the management of degenerative arthritis of the knee. Techniques include lavage and debridement, abrasion arthroplasty, subchondral penetration procedures (drilling and microfracture), and laser/thermal chondroplasty. In most patients, short-term symptomatic relief can be expected with arthroscopic lavage and debridement. Greater symptomatic relief and more persistent pain relief can be achieved in patients who have acute onset of pain, mechanical disturbances from cartilage or meniscal fragments, normal lower extremity alignment, and minimal radiographic evidence of degenerative disease. Arthroscopic chondroplasty techniques provide unpredictable results. Concerns include the durability of the fibrocartilage repair tissue in subchondral penetration procedures and thermal damage to subchondral bone and adjacent normal articular cartilage in laser/thermal chondroplasty. Although recent prospective, randomized, double-blinded studies have demonstrated that outcomes after arthroscopic lavage or debridement were no better than placebo procedure for knee osteoarthritis, controversy still exists. With proper selection, patients with early degenerative arthritis and mechanical symptoms of locking or catching can benefit from arthroscopic surgery

Carpal wedge osteotomy for the arthrogrypotic wrist

DOD - Acute Comp Syndrome CPG

The upper limbs of the child with the amyoplasia form of arthrogryposis are typically internally rotated at the shoulders, extended at the elbows, and flexed and deviated ulnarly at the wrists. This position results in an obligatory crossed-limb pattern of bimanual use, as neither hand is sufficiently strong or agile to function independently. A change in the position of deformity to one that allows the palms to come together without crossing the arms, and also allows access to desktops and keyboards, is a reasonable goal for children with this condition. A severe internal rotation deformity at the shoulder can be corrected with external rotation osteotomy, and elbow extension contractures can be released with soft-tissue procedures to increase the passive range of motion. However, most attempts to improve wrist position have been disappointing because they have resulted in the loss of any limited motion that might be present. This paper describes a technique of resection of a portion of the carpus that improves position and retains motion because it spares the radiocarpal joint. © 2004 Lippincott Williams & Wilkins, Philadelphia.

The assessment and management of the stiff elbow

The Treatment of Pediatric Supracondylar Humerus Fractures AUC

Posttraumatic loss of elbow motion can cause substantial disability, limiting the ability to put one's hand in the volume of a sphere in space. Although a number of conditions can lead to loss of motion, a greater understanding of the functional anatomy of the elbow has led to advances in surgical management. Elbow stiffness has been classified in a number of ways, but the consistent feature is capsular contracture. Treatment of the stiff elbow begins with clinical evaluation of elbow stiffness and identification of indications for surgical intervention. Techniques of open and arthroscopic elbow contracture release are evolving. Assessment and management of elbow contracture associated with heterotopic ossification, and treatment of distal humerus nonunion should be done early to restore elbow motion

Radial head fractures--an update

The Treatment of Pediatric Supracondylar Humerus Fractures AUC

Radial head fractures are the most common fractures occurring around the elbow. Although radial head fractures can occur in isolation, associated fractures and ligament injuries are common. Assembling the clinical presentation, physical examination, and imaging into an effective treatment plan can be challenging. The characteristics of the radial head fracture influence the technique used to optimize the outcome. Fragment number, displacement, impaction, and bone quality are considered when deciding between early motion, fragment excision, and radial head excision, repair, or replacement. Isolated, minimally displaced fractures without evidence of mechanical block can be treated nonsurgically with early active range of motion (ROM). Partial, displaced radial head fractures without evidence of mechanical block can be treated either nonsurgically or with open reduction internal fixation (ORIF), as current evidence does not prove superiority of either strategy. For displaced fractures with greater than 3 fragments, radial head replacement is recommended. Radial head arthroplasty may be preferred over tenuous fracture fixation in the setting of associated ligament injuries when maintenance of joint stability could be compromised by ineffective fracture fixation

The treatment of unstable ankle fractures in patients over eighty years of age

DoD SSI (Surgical Site Infections)

BACKGROUND: The current study examined the outcomes of operative treatment of unstable ankle fractures in patients at least 80 years old at the time of injury. METHODS: Of 2,682 patients who presented for treatment of ankle fractures, 17 patients met the study criteria. These patients had open reduction and internal fixation after sustaining 15 closed and two open unstable ankle fractures. There were 11 type B fractures and six type C fractures by the Danis-Weber classification, and 12 supination-external rotation and five pronation-external rotation fractures by the Laugen-Hansen classification systems. RESULTS: When noncompliant patients who developed complications were removed from analysis, the fixation failure and deep infection rates were 0% each. CONCLUSIONS: These results highlight the importance of patient compliance and non-weightbearing status in the treatment of ankle fractures in patients over 80 years.

Novel Pre-Surgery Exercise-Conditioning in Patients Waiting for Total Knee Arthroplasty (TKA)

OAK 3 - Non-arthroplasty tx of OAK

Total knee arthroplasty (TKA) is the treatment of choice for patients suffering from severe pain and functional limitation caused by osteoarthritis (OA) of the knee joint's surfaces (Magee et al. 2009). Within the UK, over 60,000 TKA surgeries are registered yearly (NJR 2015), making TKA one of the most common surgeries of the joint. Rehabilitation following surgery is essential for recovery and with TKA this is crucial in regaining movement, function and control. Current rehabilitation mainly focuses on post�surgery rehabilitation to increase range of motion (ROM) and muscle power, and to aid in achieving a quick return to functional independence for patients. Despite this, research has shown that patients undergoing TKA, still continue to experience reduced capacities in neuromuscular responses which are required for quick knee joint reactions, stability and proprioception, up to months following TKA surgery (Silva et al. 2003). A deficit in an individual's knee joint proprioception (synonymously referred to as a deficit in sensorimotor performance), together with impaired strength, can lead to reduced functional balance capabilities and movement control (Piva et al. 2010; Rätsepsoo et al. 2011), and can also contribute to injury (Lephart et al. 1997) and a greater risk of falls (Swinkels et al. 2009; Bade et al. 2010; Rätsepsoo et al. 2011). In part, the latter may be due to time�constraints within the health�care system, where a necessary preservation of the primary focus, to decrease pain and improve general function in patients following a TKA, has sometimes been to the detriment of other aspects of rehabilitation. Pre�surgery exercise�conditioning: Studies have investigated the effects of pre�surgery exercise' (also known as pre�habilitation exercise) interventions on strength and sensorimotor performance deficits in patients undergoing TKA, through various modes of exercise. Their aim has been to utilise a period of time pre�surgery to improve patients' rehabilitation status (Huber et al. 2015; Topp et al. 2009; Desmueles et al. 2013; Mackay et al. 2012). However, the patterns of patients' adaptations to the generic exercise stimuli used within these studies, has not shown the gains that had been expected by physiological dose�response, and ultimately questioned the efficacy of using pre�habilitation for effective gains in long�term outcomes. Nevertheless, the concept of achieving early gains to conditioning status that might potentiate patients' later rehabilitation processes and status, remains attractive to the latter (Calatayud et al. 2016, Huber et al. 2015) and the NHS (Rooks et al. 2006; Crowe and Henderson, 2003). Conditioning for enhanced sensorimotor performance has been consistently endorsed in the sports�medical and sports�performance (Hubscher et al. 2010; Mandelbaum et al. 2005) and clinical literature (Tsao et al. 2007; Granacher et al. 2006) for its causal relationship to reduced injury likelihood and capability to improve function. While the precise dose of stimuli to achieve gains in sensorimotor performance is less clearly defined, enhancing motor performance by means of exercise that resist the effects of gravity or externally�applied loading to a joint system, has established underpinnings physiologically by improving motor performance and indirectly effecting sensorimotor responses (Vikne et al. 2006; Hakan et al. 2002; Moran et al. 2007). Clinically, the challenge has been to formulate a suitably pragmatic programme of conditioning that will accommodate the time� and cost�pressures associated with contemporary care practice while simultaneously offering efficacy when delivered prior to surgery as a pre�habilitative intervention. Rehabilitative and prophylactic conditioning programmes used in current studies for enhanced neuromuscular and sensorimotor performance, have typically required and been delivered in a duration of 6�8�weeks (Calatayud et al. 2016; Huber et al. 2015; Topp et al. 2009; Desmueles et al. 2013; Mackay et al. 2012). This has ommanded a substantive logistical burden to elicit expected gains. A novel approach to conditioning � Development of the P�SEC protocol: A novel formulation of conditioning that could condense the pattern of delivery of physiologically�effective, dose�related stimuli, while simultaneously maintaining the vast proportion of potential gains in performance, would offer advantages to patients and clinicians for logistical versatility with which a package of conditioning might be delivered. This would be especially important within the relatively short period of time between the patients electing for surgery after clinical consultation and a surgical procedure, if pre�habilitation were to be incorporated effectively within care pathways. Recent studies have shown that with careful periodization and micro�cyclical management of the mode of exercise�conditioning, patterning of exercise intensity and work/recovery ratios, and progression of increasing physiological stimuli for adaptation, it is possible to deliver gains in neuromuscular performance within a programme lasting 2�3�weeks, which match 70% of the effects expected during longer programmes (Peer and Gleeson, in press; Peer et al. under review). Additional adaptations to this intervention model would be needed to counteract arthrogenic and autogenic sources of inhibition associated with long�term disease conditions such as OA (Rice et al. 2010), limiting neuromuscular performance and conditioning gains by the intrusion of nociceptive stimuli such as an increase in intra�articular joint pressure (Palmieri�Smith et al. 2007). The cost�neutrality of the embedding pre�habilitative conditioning for improved motor performance might be feasible if a portion of the end�phase rehabilitation following a surgical procedure, which has been shown recently to offer limited gains in performance within the formal care pathway (Bailey et al. 2014), could be sacrificed in favour of an equivalent time� period of conditioning prior to surgery. Therefore, the purpose of the P�SEC study is to undertake a randomized controlled feasibility trial in order to investigate the effects of this new formulation of exercise�conditioning for motor performance on objectively�measured and patient�perceived sensorimotor, functional and psychophysiological performance capacities in patients waiting for a TKA.

Dichloromethylene-diphosphonate in the treatment of osteolytic metastases

MSTS 2018 - Femur Mets and MM

Dichloromethylene diphosphonate (Clodronate) is very effective against osteoclasts. We studied its effects on calcium balance in patients with malignant osteolytic lesions. Ten normocalcemic patients with advanced metastatic bone disease or myeloma were evaluated in a baseline 20Î?Ã?Ã?day calcium balance and kinetic study. They were then randomized to a clodronate or placebo regimen, treated intravenously for two weeks and orally for a month, and finally reÎ?Ã?Ã? evaluated in another 20Î?Ã?Ã?day balance and kinetic study, conducted while they were still receiving treatment. The results show that both calcium balance and calcium absorption increased from base line in the clodronate group and that these changes were significantly different from those in the placebo group. There was a marginal decrease in bone resorption in the clodronate group and no change in bone accretion. Our results suggest that clodronate may be a useful adjuvant in managing metastatic bone disease. Copyright â?¬â? 2011 Elsevier B. V., Amsterdam. All Rights Reserved.

Results and outcomes after operative treatment of high-energy tibial plafond fractures

DoD SSI (Surgical Site Infections)

BACKGROUND: The purposes of this study were to evaluate the clinical and radiographic results and the functional outcomes after operative treatment of tibial plafond fractures treated with internal or external fixation. METHODS: A retrospective review identified 76 patients with 79 fractures (OTA 43-B or 43-C) of the tibial plafond. Their average age was 45 years. Twenty-one fractures (27%) were open, and 43 (54%) were type 43-C3. Five were type 43-B1, four were 43-B2, two were 43-B3, 15 were 43-C1, and 10 were 43-C2. Patients were treated with open reduction and internal fixation (ORIF) (n = 63) or limited open articular reduction and wire ring external fixation (EF) (n = 16). Tibial fixation was performed at a mean of 7.6 days after injury, with staged reconstruction in 56 fractures (71%). Bone graft was used initially in 32 fractures (41%). Early and late complications, secondary procedures, and radiographic evidence of post-traumatic arthritis were evaluated. Foot Function Index (FFI) and Musculoskeletal Function Assessment (MFA) questionnaires were administered. RESULTS: Seventy-nine fractures were followed clinically and radiographically for a mean of 26 (range 24 to 38) months, and 33 patients completed outcomes questionnaires at a mean of 98 months after surgery. Early complications included two superficial wound problems and three deep infections. Late complications included two nonunions and four malunions. Thirty-one fractures (39%) developed post-traumatic arthritis. Complications occurred after six of 21 open fractures and after 11 of 43 type C3 fractures (p = 0.007). Patients treated with EF more frequently had type C3 fractures (88% versus 46%, p = 0.004) compared with patients treated with ORIF. The EF patients developed more complications (six of 16, p = 0.007) and post-traumatic arthritis (11 of 16, p = 0.01) when compared with ORIF. Patients treated with EF (88% were type C3 fractures) had lower FFI and MFA scores. The greatest impairment in outcome was noted after type C3 fractures, regardless of the method of treatment. CONCLUSIONS: Tibial plafond fractures are difficult to manage and may have serious complications. We identified more complications, more secondary procedures, and worse outcomes in patients with articular and metaphyseal comminution (type C3). ORIF was associated with fewer complications and less post-traumatic arthritis when compared to EF, possibly reflecting a selection bias for open injuries and more severely comminuted fractures to be managed with EF. ORIF with appropriate soft tissue handling resulted in acceptable results in most patients. Severely damaged soft tissues and highly comminuted C3 fractures may be safely treated with EF. Loss of function and progression to post-traumatic arthritis are common after tibial plafond fractures. Assessment of long-term results and the efficacy of additional reconstructive procedures will refine the treatment algorithms for these fractures.

Cathepsin D non-proteolytically induces proliferation and migration in human omental microvascular endothelial cells via activation of the ERK1/2 and PI3K/AKT pathways

MSTS 2018 - Femur Mets and MM

Epithelial ovarian cancer (EOC) frequently metastasises to the omentum, a process that requires pro-angiogenic activation of human omental microvascular endothelial cells (HOMECs) by tumour-secreted factors. We have previously shown that ovarian cancer cells secrete a range of factors that induce pro-angiogenic responses e.g. migration, in HOMECs including the lysosomal protease cathepsin D (CathD). However, the cellular mechanism by which CathD induces these cellular responses is not understood. The aim of this study was to further examine the pro-angiogenic effects of CathD in HOMECs i.e. proliferation and migration, to investigate whether these effects are dependent on CathD catalytic activity and to delineate the intracellular signalling kinases activated by CathD. We report, for the first time, that CathD significantly increases HOMEC proliferation and migration via a non-proteolytic mechanism resulting in activation of ERK1/2 and AKT. These data suggest that EOC cancer secreted CathD acts as an extracellular ligand and may play an important pro-angiogenic, and thus pro-metastatic, role by activating the omental microvasculature during EOC metastasis to the omentum.

Comparison of negative pressure wound therapy (NPWT) &conventional wound dressings in the open fracture wounds

DoD SSI (Surgical Site Infections)

OBJECTIVE: Successful closure is a primary step of treatment in open fracture wounds. Delayed healing or complications can lead to increased treatment duration, costs and disability rates. The aim of this study was to compare Negative Pressure Wound Therapy (NPWT) and conventional wound dressings in patients with open fracture wounds. METHODS: In a prospective randomized clinical trial study, 90 patients with open fractures that were referred for treatment were enrolled between February 2013 to March 2015. Patients were divided into two groups. Group I underwent NPWT and group II underwent conventional wound dressing. Then patients were followed up for one month. Within the one month, the number of dressing change varied based on the extent of the wound. Duration of wound healing, presence of infection and the number of hospitalization days in these patients were recorded and compared at the end of the study between the two groups. Questionnaires and check lists were used to collect data. Analysis was done with SPSS 20, paired sample T-test, and chi-square tests. P<0.05 was considered significant. RESULTS: There was a significant difference between the rate of wound healing in the group one or NPWT group and group II (conventional wound dressings) P<0.05. There was no significant difference between two groups in incidence of infection (P=0.6). CONCLUSION: Using NPWT expedites the healing process of extremity wounds. It is more economical and can be considered as a substitute for the treatment of extremity wounds.

Denosumab: The era of targeted therapies in bone metastatic diseases

MSTS 2018 - Femur Mets and MM

This system constituted of the Receptor Activator of nuclear Factor-kB Ligand (RANKL), the Receptor Activator of Nuclear Factor-kB (RANK) and by the decoy Receptor Osteoprotegerin (OPG) plays a central role in bone resorption. Denosumab (AMG 162) is an investigational fully human monoclonal antibody with a high affinity and specificity for RANKL.This review will critically describe and discuss the recent results of clinical trial investigating denosumab in different settings of medical oncology. In particular, we will report the recently published data of clinical trials investigating denosumab in prevention of cancer treatment induced bone loss (CTIBL), in prevention of skeletal related events (SREs) in bone metastatic patients and the ongoing studies in prevention of disease recurrence in the adjuvant setting of solid tumours. The clinical data that will be reported in this review represent the first step in a path that will conduct us to explore new horizons in the field of bone health care in cancer patients. © 2009 Bentham Science Publishers Ltd.

Reducing fatal opioid overdose: Prevention, treatment and harm reduction strategies

DOD - Acute Comp Syndrome CPG

The opioid overdose epidemic is a major threat to the publicâ??s health, resulting in the development and implementation of a variety of strategies to reduce fatal overdose [1-3]. Many strategies are focused on primary prevention and increased access to effective treatment, although the past decade has seen an exponential increase in harm reduction initiatives. To maximize identification of opportunities for intervention, initiatives focusing on prevention, access to effective treatment, and harm reduction are examined independently, although considerable overlap exists. Particular attention is given to harm reduction approaches, as increased public and political will have facilitated widespread implementation of several initiatives, including increased distribution of naloxone and policy changes designed to increase bystander assistance during a witnessed overdose [4-7].

Osteonecrosis of the jaws in patients treated with intravenous bisphosphonates (BRONJ): A concise update

MSTS 2018 - Femur Mets and MM

Bisphosphonate-related osteonecrosis of the jaws (BRONJ) is a severe complication seen most frequently in patients on intravenous bisphosphonates treatment for malignant diseases. High potency bisphosphonates are generally implicated and risk factors also include dental extractions. Prevention is of paramount importance. Management is controversial but there is little evidence basis and the consensus is to be conservative. Recent advances in this area are summarised in this concise review. [References: 43]

Bisphosphonates and osteonecrosis of the jaw: a retrospective study

MSTS 2018 - Femur Mets and MM

OBJECTIVE: To assess the prevalence of osteonecrosis of the jaw (ONJ) in patients receiving bisphosphonate therapy and in those who were bisphosphonate naive. METHODS: We undertook a retrospective review of medical records of patients at the New York Harbor Health Care System from 1999 through 2004. Charts were selected for review if patients had a Current Procedural Terminology (CPT) code suggestive of ONJ or if they had ever received bisphosphonate therapy. RESULTS: Among 1,951 medical records reviewed, we identified 2 patients with ONJ who had received bisphosphonates and 2 patients with ONJ who were bisphosphonate naive. Both patients treated with bisphosphonates had multiple myeloma and were receiving monthly infusions. They had initially received pamidronate before treatment was changed to zoledronic acid. In each case, ONJ was precipitated by a routine dental extraction. The prevalence of ONJ in our patient population receiving intravenously administered bisphosphonates was 1 in 71.5. Of the 2 cases of ONJ in bisphosphonate-naive patients, osteoradionecrosis was clearly incriminated in 1 patient and potentially the causative factor in the other patient as well. No patients receiving orally administered bisphosphonates had ONJ, nor did this complication occur in any patients receiving parenteral bisphosphonate therapy for disorders such as osteoporosis or Paget's disease of bone. CONCLUSION: Bisphosphonates remain an important option for management of metabolic bone disease and complications of malignant disease. The overall prevalence of ONJ in patients receiving bisphosphonates seems to be very low; however, patients receiving intense parenteral therapy for an underlying malignant condition appear to have a uniquely elevated risk for the development of this complication. A causal relationship between bisphosphonates and ONJ remains to be proved and merits further investigation.

Bone mass and subsequent risk of hip fracture

Management of Hip Fractures in the Elderly

We examined prospectively the associations of bone density and bone dimensions with risk of hip fracture using data from the first National Health and Nutrition Examination Survey and its three follow-up studies. A cohort of 1,489 white women age 45 years or older who received detailed medical examinations in the baseline survey in 1971-1975 were subsequently contacted in 1982-1984, 1986, and 1987. Bone density and hand bone dimensions at several sites were measured at baseline. Fifty incident hip fractures were identified during the follow-up studies. Using Cox regression analyses, we found a relative risk of 11 for women with bone density below the 5th percentile, compared with those above the 75th percentile (95% confidence interval = 2.2-58). Women with smaller external bone dimensions also faced increased risk of hip fracture (relative risk = 4.6 for dimensions below the 5th percentile vs above the 75th percentile; 95% confidence interval = 1.5-14). On the other hand, internal bone dimensions were not associated materially with hip fracture

Multimodal analgesia after total knee arthroplasty

Surgical Management of Osteoarthritis of the Knee CPG

BACKGROUND: Perioperative pain management is the focus in total knee arthroplasty. Looking for a safe and effective analgesic way has become one of the important tasks of the surgeons. OBJECTIVE: To compare the analgesia and rehabilitation effect of the epidural analgesia and the femoral nerve analgesia after total knee arthroplasty, and to explore the relative multimodal analgesia proposal. METHODS: Forty patients undergoing unilateral total knee arthroplasty were randomly selected, and the patients were divided into two groups according to different analgesia proposals: epidural analgesia group and femoral nerve analgesia group, 20 patients in each group. All patients received unilateral total knee arthroplasty and preoperative missionary and celecoxib administration under epidural analgesia. Patients in the epidural analgesia group were given analgesia with 0.2% ropivacaine and 2 ug/mL fentanyl after the replacement. The patients in the femoral nerve analgesia group were given analgesia with 0.2% popivacaine from the femoral nerve block vessel. The visual analog scores of the patients were observed at 6, 12 and 24 hours and 2-7 days after total knee arthroplasty, and the range of motion was recorded at 2-7 days after total knee arthroplasty. RESULTS AND CONCLUSION: At 2-7 days after total knee arthroplasty, the visual analog scores of rest/movement pain were decreased in two groups, and the pain degree in the femoral nerve analgesia group was smaller than that in the epidural analgesia group. At 2-7 days after total knee arthroplasty, the range of motion of the patients in two groups was increased gradually, and the range of motion in the femoral nerve analgesia group was larger than in the epidural analgesia group. The results showed that both the epidural analgesia and the femoral nerve analgesia can relieve pain after total knee arthroplasty, but the femoral nerve analgesia can provide better pain relief than epidural analgesia, and it can lead to a quick functional recovery. Multimodal analgesia proposal can effectively control the pain

The posterior cruciate ligament in total knee surgery: Save, sacrifice, or substitute?

Surgical Management of Osteoarthritis of the Knee CPG

To determine the role of the posterior cruciate ligament in total knee arthroplasty, 242 consecutive primary total knee arthroplasties were included in 1 of 3 sequential groups. Group I included 77 Press Fit Condylar total knee replacements in which the posterior cruciate ligament was completely released from its tibial attachment. In Group II, there were 80 Press Fit Condylar total knee replacements in which the posterior cruciate ligament was retained. Group III consisted of 85 total knee replacements with a posterior cruciate-substituting device (Insall-Burstein II). All patients were observed at least 2 years and evaluated by the Knee Society's Clinical and Functional Scoring System, including a radiographic evaluation. No differences were found between the posterior cruciate ligament sacrificed group and the posterior cruciate ligament preserved group. The 1 significant difference among the 3 groups was in range of motion (ROM). Groups I and II averaged 103(degrees) and 104(degrees) motion respectively, whereas Group III, the posterior cruciate-substituting group, averaged 112(degrees) (p = 0.001). In addition, only in Group III was the lower 95% confidence limit of the mean ROM >90(degrees). These findings suggest that preserving the posterior cruciate ligament does not consistently lead to improved functional ROM. The posterior cruciate ligament-substituting device historically has demonstrated excellent survivorship and appears to offer greater ROM

Evidence for central sensitization in patients with osteoarthritis pain: A systematic literature review

OAK 3 - Non-arthroplasty tx of OAK

Hyperexcitability of the central nervous system (CNS) has been suggested to play an important role in the chronic pain experienced by osteoarthritis (OA) patients. A systematic review following PRISMA guidelines was performed to evaluate the existing evidence from the literature related to the presence of central sensitization (CS) in patients with OA.Electronic databases PubMed and Web of Science were searched to identify relevant articles using pre-defined keywords regarding CS and OA. Full-text clinical reports addressing studies of CS in human adults with chronic complaints due to osteoarthritis were included and screened for methodological quality by two independent reviewers. From the 40 articles that were initially eligible for methodological quality assessment, 36 articles achieved sufficient scores and therefore were discussed. The majority of these studies were case-control studies and addressed OA of the knee joint. Different subjective and objective parameters considered manifestations of CS, which have been previously reported in other chronic pain conditions such as whiplash or rheumatoid arthritis, were established in subjects with OA pain. Overall results suggest that, although peripheral mechanisms are involved in OA pain, hypersensitivity of the CNS plays a significant role in a subgroup of subjects within this population. Although the majority of the literature provides evidence for the presence of CS in chronic OA pain, clinical identification and treatment of CS in OA is still in its infancy, and future studies with good methodological quality are necessary.

Biphasic anti-osteoclastic action of intravenous alendronate therapy in multiple myeloma bone disease

MSTS 2018 - Femur Mets and MM

Multiple myeloma is a malignancy of plasma cells with osteolytic bone destruction. Bisphosphonates inhibit osteoclast activity and are widely used for the treatment of myeloma bone disease. We analyzed the changes in urinary cross-linked N-telopeptides of collagen (u-NTx) and urinary calcium (u-Ca) after bisphosphonate alendronate therapy in ten patients with myeloma bone disease. In all patients, the levels of u-Ca and u-NTx decreased within a week. After the maximum decrease of u-NTx, u-NTx started increasing in half of the patients. However, this further increase in u-NTx decreased again without any additional therapy. Disease severity and pretreatment u-NTx concentrations did not differ between patients with and without the rebound. Patients who did not have rebound had decreased bone marrow monocytes and decreased serum concentrations of interleukin 18, which is produced by monocytes. Our results suggest that impaired activity of monocytes, which are possible osteoclast precursors, is related to reduced bone destruction in multiple myeloma.

Strategies for treating HIV-related lipodystrophy

Panniculectomy & Abdominoplasty CPG

HIV-related lipodystrophy has emerged as one of the most prevalent problems for patients with HIV, since this infection can now be seen as a chronic disease. Despite its growing importance, crucial issues such as aetiopathogenesis, diagnosis, prevention and therapy remain largely unknown and unexplored. Current evidence suggests that aetiology is multifactorial. HIV infection, antiretroviral therapy and patient-related factors probably all contribute to the development of lipodystrophy. The lack of a formal definition and the nature of wasting syndromes that affect HIV-infected patients can hinder the diagnosis and treatment of lipodystrophy. Body fat changes have a major negative impact on the quality of life of patients. Metabolic abnormalities are also well known cardiovascular risk factors that can increase the morbidity and mortality due to cardiovascular disorders in a relatively young population. As yet, we do not know whether lipodystrophy is preventable or reversible. Several therapeutic approaches have been tested with limited success, however potential complications must be considered. These therapeutic approaches include general health measures (diet, exercise and discontinuation of smoking), switching antiretrovirals (from protease inhibitors to non-nucleoside reverse transcriptase inhibitors or abacavir, or from stavudine to other nucleoside reverse transcriptase inhibitors) and use of drugs with metabolic effects (metformin, thiazolidinediones, recombinant growth hormone and anabolic steroids). A judicious use of available data, and opting for an individualised approach seems the best option for management of this problem at present.

[Minimally invasive total knee arthroplasty and navigation - a logical combination?]

Surgical Management of Osteoarthritis of the Knee CPG

The minimally invasive approach has been recommended for total knee arthroplasty by many surgeons and by industry in recent years, and patients now also expect it. The definition of a minimally invasive procedure is still the subject of some controversy. Some authors limit the length of the skin incision to 14 cm, while others propose the"least possible and barely adequate" approach. The main problem of the minimally invasive technique is still the increased risk of component malalignment owing to reduced visibility. As computer-assisted surgery has been shown in many studies to yield better component alignment than is obtained with the conventional technique, it seemed logical to use navigation systems in combination with the minimal invasive approach. The aim of this paper is to highlight and discuss the use of computer assistance with a minimally invasive approach

External fixation and delayed unreamed intramedullary interlocking nailing of open fractures of Tibia. (A protocol)

DoD SSI (Surgical Site Infections)

Between June 2001 and Aug 2003, 27 open fractures of the Tibial shaft were treated with debridement and provisional external fixation, followed by delayed soft closure and subsequent interlocking nailing without reaming. There were 11(39%) grade-I fractures and 17(61%) grade-II fractures. All the fractures were the result of road traffic accident. The average duration of external fixation was 3weeks.The average time between removal of the fixator and intramedullary nailing was about 2 weeks. Mean time to union was 29 weeks for grade 1 fractures and 32 weeks for grade 2 fractures. There were 2 infections(7%) at the site of grade2 fractures. Both infections healed, with retention of nail and without chronic osteomyelitis. There was one Non union and two delayed unions. This sequential protocol for treatment, which involved a short period of external fixation and delayed intramedullary interlocking nailing thus minimized colonization of the pin tracks, is a simple and effective technique with good results and a low rate of infection, in treating these fractures.

New screening system for unruptured cerebral aneurysms--combination of an expert system and DSA examination

Upper Eyelid and Brow Surgery

We have designed a screening system to diagnose unruptured aneurysms, including the use of digital subtraction angiography (DSA). We surveyed 115 patients who had undergone clipping procedures after subarachnoid hemorrhage (SAH) and questioned them with regard to the subjective symptoms. Sixty-eight of 92 patients who returned the questionnaire reported, prior to rupture, headache, eye pain, and neck pain most frequently, and also impairment of extraocular movements, ptosis, visual field defects, and motor and sensory disturbances. Nineteen (47.5%) of 40 patients who had complete pain relief after surgery complained of headache from 1 week to 1 month before SAH. In addition, nine patients (22.5%) complained of headache for several years, and were also pain-free after surgery. For the indication of DSA, we employed an expert system based on fuzzy set theory. Seven groups of parameters are: Group 1, a basic questionnaire concerning age, sex, and past and family histories; Group 2, 15 warning signs selected on the basis of retrospective study; and Groups 3-7, detailed questions concerning each sign. Scoring weights assigned to each condition based on the results of the retrospective study, and threshold values were determined by several neurosurgeons. The certainty factors for intermediate hypotheses were calculated from these weights and threshold values and summed up, from which the conclusion was obtained. Twelve new cases of unruptured cerebral aneurysm were diagnosed using this screening system. This system may improve the ability to diagnose cerebral aneurysms before rupture.

Extra-oral endosseous craniofacial implants: current status and future developments

Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures

The published experience of extra-oral endosseous craniofacial implants (EOECIs) is reviewed. The definition of osseointegration, concept of success, the relative merit of one- or two-stage implant placement, EOECI design and control of peri-abutment skin infection are discussed. A plea is made for more consistent and objective reading of clinical experience of this technique

Treatment of homonymous visual field defects

Upper Eyelid and Brow Surgery

OPINION STATEMENT: A clinical presentation of a retrochiasmal or homonymous visual field defect (HVFD) usually represents a permanent visual impairment. The visual and functional ramifications of HVFD will vary by patient. Comprehensive care-the clinical evaluation and consideration for treatment of HVFD-includes vision rehabilitation provided by optometrists, occupational therapists, or ophthalmologists. On the basis of individual patient needs, the eye care practitioner typically uses one or both of the following approaches to treat the HVFD: (1) field enhancement (also referred to in the literature as "field expansion"), in which optical systems incorporating prism are prescribed to optimize the use of the remaining vision, and (2) rehabilitative techniques including saccadic training ("compensation training") or vision restorative therapy ("restitution training"). Although lacking in strength, the evidence does support benefits from field enhancement and saccadic training for patients with HVFD, but vision restorative therapy has not been shown to be an effective option.

Prevention of bone loss by vitamin D supplementation in elderly women: a randomized double-blind trial

Management of Hip Fractures in the Elderly

The purpose of the study was to determine the effect of vitamin D supplementation on bone turnover and bone loss in elderly women. Three hundred forty-eight women, ages 70 yr and older, were randomized to receive 400 IU vitamin D3 per day (n = 177) or placebo (n = 171), double-blind, for a period of 2 yr. Main outcome measures were bone mineral density of both hips (femoral neck and trochanter) and the distal radius, as well as biochemical markers of bone turnover. The effect of vitamin D supplementation was expressed as the difference in mean (percentage) change between the placebo group and the vitamin D group. The measurements were repeated in 283 women after 1 yr and in 248 women after 2 yr. Vitamin D supplementation significantly increased serum 25-hydroxyvitamin D (250HD) (+35 nmol/L) and 1,25-dehydroxyvitamin D [1,25-(OH)2D] (+7.0 pmol/L) levels and urinary calcium/creatinine ratios (+0.5%) and significantly decreased PTH(1-84) secretion (-0.74 pmol/L) after 1 yr. No effect was found for the parameters of bone turnover. The effect on the bone mineral density of the left femoral neck was +1.8% in the first yr, +0.2% in the second yr, and +1.9% during the whole period (95% confidence interval 0.4, 3.4%). At the right femoral neck the effects were +1.5%, +1.1%, and +2.6% (confidence interval 1.1, 4.0%), respectively. No effect was found at the femoral trochanter and the distal radius. Supplementation with 400 IU vitamin D3 daily in elderly women slightly decreases PTH secretion and increases bone mineral density at the femoral neck

A locked hip screw-intramedullary nail (cephalomedullary nail) for the treatment of fractures of the proximal part of the femur combined with fractures of the femoral shaft

MSTS 2018 - Femur Mets and MM

Twenty-seven patients with complex femoral fractures (combined shaft and proximal femoral fractures) were treated with a modified Grosse-Kempf slotted locking nail (cephalomedullary nail), wherein two screws were inserted in the hip. Four types of complex, multifocal femoral fractures were represented in the series. Eleven of the femoral shaft fractures were secondary to a previous, internally fixed, not yet united hip fracture (type I). Ten comminuted peritrochanteric fractures occurred in normal bone (type II). Three similar fractures were pathologic because of metastasis. Two patients had an ipsilateral fracture of the femoral shaft and the trochanteric area (type III), and one of the shaft and the femoral neck (type IV). Locking was made static in 24 cases. Additional cerclage wiring was used in three type II fractures. Five complications were as follows: one cutting out of a screw in the femoral head, two fractures of the nail, one deep venous thrombosis, and one wound hematoma. Reoperations were two salvage operations using a new nail and one evacuation of hematoma. One patient with multiple injuries and four elderly patients died within 2 months. Eighteen patients with fractures in normal bone were followed for a median of 20 (6 to 37) months. All fractures united. Two nails were removed. The end result was excellent in ten patients, good in seven, and fair in one (2-cm shortening and 20-degree external rotation). We conclude that a locked intramedullary construct with locking screws in femoral neck and distal femur controls a complex fracture situation well.

Chemokine receptors as specific anti-inflammatory targets in peripheral nerves

MSTS 2018 - Femur Mets and MM

Chemokines are the initial mediators of leukocyte migration across concentration gradients in vitro and to sites of inflammation in vivo. Chemokines signal via specific seven-transmembrane spanning G-protein coupled receptors (GPCRs). About 50 chemokine ligands and 18 receptors have been identified to date, and several are involved in leukocyte trafficking in human inflammation. Several chemokines signal via a single receptor, while others signal via multiple receptors. This redundancy may be necessary to mediate essential biological processes in vivo. There is evidence that specific chemokines and their receptors are expressed in the peripheral nerves or cerebrospinal fluid of patients with autoimmune neuropathies such as Guillain-Barré syndrome and Chronic Inflammatory Demyelinating Polyradiculoneuro- pathy and their animal models. Hematogenous leukocyte trafficking and chemokine-mediated signaling have also been implicated in the generation of neuropathic pain following peripheral nerve injury. Chemokine receptors, being GPCRs, provide an attractive drug target for modulating the harmful effects of peripheral nerve inflammation. The efficacy of anti- inflammatory therapies, including treatments that restrict leukocyte migration, has been established in several inflamma- tory disorders such as multiple sclerosis. There are several ongoing clinical trials testing chemokine receptor antagonists as specific anti-inflammatory drugs. This review evaluates the current status of the chemokine biology of peripheral neuropathies, highlighting areas where further studies are needed and discusses potentially selective drug targets for peripheral nerve inflammation and neuropathic pain © 2011 Bentham Science Publishers Ltd.

Liposuction gives complete reduction of chronic large arm lymphedema after breast cancer

Panniculectomy & Abdominoplasty CPG

About one-third of all women treated for breast cancer develop arm lymphedema. In addition to the worry of the cancer itself, the swollen and heavy arm is both a physical and a psychosocial handicap for the patients. Previous surgical and conservative treatments have not always given satisfactory and permanent results, conceivably because lymphedema causes hypertrophy of the subcutaneous adipose tissue. From this point of view, liposuction (LS) combined with Controlled Compression Therapy (CCT) is an interesting approach, as the hypertrophied adipose tissue is effectively removed and the outcome sustained by wearing a compression garment. Pre- and postoperative arm edema volumes were measured using the water displacement technique. Skin blood flow was recorded using Laser Doppler imaging. Lymph transport in the arm was assessed by indirect lymphoscintigraphy. LS + CCT reduced the arm edema volume completely, compared with a 50% decrease following CCT alone. The use of a compression garment after liposuction is necessary in order to maintain the normalized arm volume. LS + CCT did not affect the already impaired lymph transport; it merely increased skin microcirculation. A reduced incidence of cellulitis was noted.

Physiological closure of the physeal plate of the distal radius: An MRI analysis

Distal Radius Fractures

To have knowledge of the physiological closure of a particular physeal plate is necessary to understand fractures close to the end of growth (transitional fractures). Most frequent fractures involve the distal radius in adolescents. However, there are no systematic investigations on the topic of growth plate closure concerning the distal radius plate, so far. Twenty-two healthy female volunteers underwent MRI investigations of their left wrist. Absolute width, percentage and localization of the physeal part, closed at the time of investigation were recorded. Sequential MRI scans were performed. In this series T1-weighted sequences were most useful to distinguish open and closed parts of the physis. Total area was 291-469 mm2 (average, 399 mm2). It did positively correlate with body height (P < 0.01), but not with weight (P = 0.241) or BMI (P = 0.394). Physeal closure took place at 15-18 years. There was no significant correlation between menarche and closure (P = 0.091). Bony bridging of the growth plate begins centroradial and ends with a small limbus dorsoradial. Sequential scans showed that there are only a few months from beginning to end of physeal closure. Physiological closure of the distal radius growth plate takes place in late adolescence, varying individually. There seems to be no influence of the menarche in female individuals. The process happens within a very short time of less than a year. This may be one rationale for the fact, that transitional fractures of the distal radius are rare. © 2011 Wiley Periodicals, Inc.

Cemented versus uncemented hemiarthroplasty for intracapsular hip fractures: A randomised controlled trial in 400 patients

Management of Hip Fractures in the Elderly

We undertook a prospective randomised controlled trial involving 400 patients with a displaced intracapsular fracture of the hip to determine whether there was any difference in outcome between treatment with a cemented Thompson hemiarthroplasty and an uncemented Austin-Moore prosthesis. The surviving patients were followed up for between two and five years by a nurse blinded to the type of prosthesis used. The mean age of the patients was 83 years (61 to 104) and 308 (77%) were women. The degree of residual pain was less in those treated with a cemented prosthesis (p < 0.0001) three months after surgery. Regaining mobility was better in those treated with a cemented implant (p = 0.005) at six months after operation. No statistically significant difference was found between the two groups with regard to mortality, implant-related complications, re-operations or post-operative medical complications. The use of a cemented Thompson hemiarthroplasty resulted in less pain and less deterioration in mobility than an uncemented Austin-Moore prosthesis with no increase in complications

Total ankle arthroplasty: indications, results, and biomechanical rationale

Surgical Management of Osteoarthritis of the Knee CPG

Total ankle replacement was developed in the 1970s after the success of total hip and knee arthroplasty. The goal of total ankle arthroplasty is to decrease pain and improve function in the lower limb. Ideally, to be superior to an arthrodesis, the ankle replacement should provide the patient with good patterns of joint motion and the ability to walk and run and should have low complication rates. Unfortunately, total ankle arthroplasty has not been as successful as replacement of other joints. Published studies of early series with greater follow-up show that ankle arthroplasties did not provide lasting pain relief or improve function, and most ultimately failed. During the 1980s, many authors concluded that a total ankle arthroplasty was not warranted because of the generally poor long-term results and the high rate of complications. However, newer second-generation design techniques, innovative operative procedures, and dissatisfaction with the results of ankle arthrodesis have renewed interest in total ankle arthroplasties. This review describes the numerous types of ankle joint replacements, critically reviews the results, and reports on newer prostheses that incorporate more anatomic designs

Systemic biochemical markers of joint metabolism and inflammation in relation to radiographic parameters and pain of the knee: Data from CHECK, a cohort of early-osteoarthritis subjects

OAK 3 - Non-arthroplasty tx of OAK

Objective: To investigate associations of biochemical markers of joint metabolism and inflammation with minimum joint space width (JSW) and osteophyte area (OP area) of knees showing no or doubtful radiographic osteoarthritis (OA) and to investigate whether these differed between painful and non-painful knees. Design: Serum (s-) and urinary (u-) levels of the cartilage markers uCTX-II, sCOMP, sPIIANP, and sCS846, bone markers uCTX-I, uNTX-I, sPINP, and sOC, synovial markers sPIIINP and sHA, and inflammation markers hsCRP and erythrocyte sedimentation rate (ESR) were assessed in subjects from CHECK (Cohort Hip and Cohort Knee) demonstrating Kellgren and Lawrence grade â?¤1 OA on knee radiographs. Minimum JSW and OP area of these knees were quantified in detail using Knee Images Digital Analysis (KIDA). Results: uCTX-II levels showed negative associations with minimum JSW and positive associations with OP area. sCOMP and sHA levels showed positive associations with OP area, but not with minimum JSW. uCTX-I and uNTX-I levels showed negative associations with minimum JSW and OP area. Associations of biochemical marker levels with minimum JSW were similar between painful and non-painful knees, associations of uCTX-II, sCOMP, and sHA with OP area were only observed in painful knees. Conclusions: In these subjects with no or doubtful radiographic knee OA, uCTX-II might not only reflect articular cartilage degradation but also endochondral ossification in osteophytes. Furthermore, sCOMP and sHA relate to osteophytes, maybe because synovitis drives osteophyte development. High bone turnover may aggravate articular cartilage loss. Metabolic activity in osteophytes and synovial tissue, but not in articular cartilage may be related to knee pain.

Age-related changes in visual pseudoneglect

Upper Eyelid and Brow Surgery

Pseudoneglect is a slight but consistent leftward attentional bias commonly observed in healthy young populations, purportedly explained by right hemispheric dominance. It has been suggested that normal aging might be associated with a decline of the right hemisphere. According to this hypothesis, a few studies have shown that elderly tend to exhibit a rightward attentional bias in line bisection. In the present study, we tested this hypothesis in young and older participants using a perceptual landmark task. Results yield evidence for an age-related shift, from a strong attentional leftward bias in young adults toward a suppressed or even a reversed bias in the elderly. Right hemisphere impairment coupled to a left hemispheric compensation might explain the perceptual shift observed in older adults. However, a decline in corpus callosum function cannot be excluded. Alternatively, these results may be in agreement with the hypothesis of an age-related specific inhibition of return dysfunction, an overt attentional orienting mechanism, and/or a decrease of dopamine.