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Cementless total hip arthroplasty in the treatment of severe hip dysplasia or dislocated hips

Management of Hip Fractures in the Elderly

We present our experience over 6 years with the use of uncemented total hip arthroplasty (THA) for developmental dysplasia of the hip (DDH) with a mean follow-up of 3 years. In a 6-year period, 26 THAs were performed in 19 patients with Hartofilakidis grades 2 and 3 dislocation of the hips. Out of 19 patients, seven had bilateral dislocations. Uncemented acetabular and femoral components were used in all patients. Patients with a minimum follow-up of 1 year were included in the study. The average age at the time of surgery was 38 (range 20-69) years. Approaches used include trochanteric osteotomy in 14 (54%) patients and a lateral approach in 12 (46%) patients. In addition, subtrochanteric osteotomy was performed in four (15%) patients. A Mallory-head femoral stem was used in 15 (58%) patients; a DDH femoral stem was in nine (35%), and the S-ROM femoral prosthesis in two (8%). A Mallory head acetabular shell was used in all cases, a 22.2-mm chrome cobalt head was used in 18 (69%), and a 28-mm chrome cobalt head was used in eight (31%). The average follow-up was 3 (range 1-6) years. The Harris hip score (HHS) improved in the cohort from a mean preoperative score of 51 to a mean postoperative score of 86 (p <0.05). The mean preoperative SF36v2 score was 42 compared to postoperatively of 67(p <0.05). The complication rate was 11% with non-union of a subtrochanteric osteotomy in one patient, dislocation in one, and trochanteric bursitis due to fracture of Dall-Miles cables in one. THA for DDH is a technically demanding procedure. This short-term follow-up of THA for DDH using uncemented implants is encouraging for arthrosis secondary to DDH. It provides better function compared to arthrodesis or excision arthroplasty, especially in young individuals. A long-term follow-up is required in order to establish the role of this management strategy. (copyright) Springer-Verlag 2004

Fracture Risk in Ulnohumeral Arthroplasty-A Biomechanical Study

Pediatric Supracondylar Humerus Fracture 2020 Review

PURPOSE: Ulnohumeral arthroplasty, also known as the Outerbridge-Kashiwagi procedure, was popularized after reports of successful results in 1978, and has long been a means of management for ulnohumeral arthritis. However, there are concerns over the loss of integrity of the distal humerus as a result of fenestration. The purpose of this study was to examine the relationship between the size of fenestration and fracture risk. METHODS: Using a validated fourth-generation sawbones model, load to failure and site of fracture were investigated following incrementally increasing distal humeral fenestration sizes. Each sample was subjected to a uniform extension stress on a materials testing system, with 5 samples run for each group. The experimental groups began with a fenestration size of 10 mm and increased by 3 mm increments up to 31 mm. Load at failure and site of fracture were recorded for each sample. RESULTS: Forty-five fourth-generation sawbones samples were tested. Average load at sample failure was equivalent for each fenestration group up to 25 mm. At 28 mm, average load to failure began to decrease, and was statistically significant beginning between 28 mm and 31 mm. At 28 mm, 4 of 5 samples fractured through the fenestration, and at 31 mm, all 5 samples fractured through the fenestration. This change in fracture site became statistically significant between 25 mm and 28 mm. CONCLUSIONS: Distal humeral fenestration does compromise its structural integrity; however, for resection in the range of 10-25 mm, there is no increased risk of fracture. CLINICAL RELEVANCE: On the basis of this biomechanical model, the authors do not recommend any activity limitations after initial surgical recovery, but do recommend against distal humeral fenestrations larger than 25 mm when performing this procedure.

Calcium and vitamin D supplements and health outcomes: a reanalysis of the Women's Health Initiative (WHI) limited-access data set

Management of Hip Fractures in the Elderly

BACKGROUND: Frequent use of personal, nonprotocol calcium supplements obscured an adverse effect of coadministered calcium and vitamin D (CaD) on cardiovascular risk in the Women's Health Initiative (WHI). OBJECTIVE: We investigated the effects of the use of personal calcium or vitamin D supplements on other outcomes in the WHI CaD Study (WHI CaD) by using the WHI limited-access clinical trials data set. DESIGN: The WHI CaD was a 7-y, randomized, placebo-controlled trial of CaD (1 g Ca/400 IU vitamin D daily) in 36,282 community-dwelling, postmenopausal women. The incidence of total cancer (excluding nonmelanoma skin cancers), breast and colorectal cancers, hip and total fracture, and mortality was assessed by using Cox proportional hazards models. RESULTS: In the WHI CaD, interactions between the use of either personal calcium or vitamin D supplements and CaD were found for total, breast, and colorectal cancers but not for fracture or mortality. In 15,646 women (43%) who were not taking personal calcium or vitamin D supplements at randomization, CaD significantly decreased the risk of total, breast, and invasive breast cancers by 14-20% and nonsignificantly reduced the risk of colorectal cancer by 17%. In women taking personal calcium or vitamin D supplements, CaD did not alter cancer risk (HR: 1.06-1.26). CONCLUSIONS: For women in the WHI CaD who were not taking personal calcium or vitamin D supplements at randomization, CaD decreased the risk of total, breast, and colorectal cancers and did not change the risk of fractures or total mortality. The nonskeletal effects of CaD may be more important than the skeletal effects and should be considered when evaluating these supplements. The WHI CaD trial is registered at clinicaltrials.gov as NCT00000611

Anterior approach white line advancement: technique and long-term outcomes in the correction of blepharoptosis

Upper Eyelid and Brow Surgery

PurposeAnterior approach white line advancement presents a novel surgical option for correction of blepharoptosis. The technique draws on several advantages of other approaches. The aim of this study was to present outcomes using this technique at a minimum follow-up of 18 months.Patients and methodsParticipants having undergone anterior approach white line advancement ptosis correction at a single institution were retrospectively recruited at a minimum of 18 months' follow-up. A total of 18 independent eyelid measurements were recorded at final review. Outcomes included long-term rate of surgical success, upper eyelid margin-reflex distance (MRD1) at both early and late post-operative follow-up, inter-eyelid asymmetry, complications, re-operation rate, patient satisfaction, and quality-of-life improvement using the Glasgow Benefit Inventory (GBI). Pre- and post-operative MRD1, as well as inter-eyelid asymmetry, were compared using a two-tailed t-test.ResultsIn total, 82 eyelids of 47 participants were included with a mean follow-up of 2.3 years (range 1.5-3.7). Surgical success was achieved in 91.5%, with a final mean MRD1 of 3.5 mm (95% confidence 3.2-3.7). An increase of 2.4 mm (2.1-2.8) in eyelid height was observed between baseline and long-term follow-up (P<0.0001). No significant change was observed between early and late post-operative follow-up. Pre-operative asymmetry was reduced from 1.0 mm (0.7-1.3) to 0.4 mm (0.3-0.5; P<0.0001). Patient satisfaction was 95.7% with a mean GBI score of +21.8 (13.2-30.3).ConclusionsAnterior approach white line advancement presents an excellent option for patients undergoing ptosis correction with favourable long-term results. Comparisons are made with other techniques with respect to anatomical, functional, and surgical factors.

Is the prevalence of the medication-related osteonecrosis of the jaws underestimated, evaluation in oncological and non-oncological disease

MSTS 2018 - Femur Mets and MM

OBJECTIVES: The purpose of this study was to evaluate the prevalence of medication-related osteonecrosis of the jaw in Slovak population and compare the literature findings, whether the prevalence of MRONJ is underestimated. BACKGROUND: Antiresorptive drugs significantly increase quality of life, although during therapy, or in post-treatment period, osteonecrosis of the jaws might occur as a severe adverse effect. Medication-related osteonecrosis of the jaws (MRONJ) is a severe problem that has been observed in the past few years. METHODS: This multi-centric study evaluates the prevalence in Slovak population, assesses the values from 4 largest centres of maxillofacial surgery in Slovakia (1166 patients with MRONJ) and provides the comparison of literature review. RESULTS: Between 2010-2015, there was increasing number of newly diagnosed patients with MRONJ (1166 overall MRONJ patients) annually, except 2012 (mean growth of 123.88 %). This finding was supported by a statistical analysis of the rising tendency of prevalence in literature, where there was a significant difference in prevalence of non-oncologic patients before and after 2010 t(15) = 2.725, p = 0.016. The 6-year prevalence was 1.34 % in population with antiresorptive drugs intake, for osteoporosis 0.47 %, for breast cancer 4.10 %, prostate cancer 3.99 % and multiple myeloma 21.26 %. CONCLUSION: This study considers that there is a significant rising tendency of MRONJ in non-oncological patients, what could be caused by underestimation of the risk for development MRONJ in these patients. There should be a better cooperation and information among dentists and doctors indicating the antiresorptive treatment and strong emphasis on primary prevention before the initial treatment even in non-oncological patients (Tab. 5, Fig. 7, Ref. 69).

The Efficacy of Electronic Health-Supported Home Exercise Interventions for Patients With Osteoarthritis of the Knee: Systematic Review

OAK 3 - Non-arthroplasty tx of OAK

BACKGROUND: Osteoarthritis of the knee is the most common cause for disability and limited mobility in the elderly, with considerable individual suffering and high direct and indirect disease-related costs. Nonsurgical interventions such as exercise, enhanced physical activity, and self-management have shown beneficial effects for pain reduction, physical function, and quality of life (QoL), but access to these treatments may be limited. Therefore, home therapy is strongly recommended. However, adherence to these programs is low. Patients report lack of motivation, feedback, and personal interaction as the main barriers to home therapy adherence. To overcome these barriers, electronic health (eHealth) is seen as a promising opportunity. Although beneficial effects have been shown in the literature for other chronic diseases such as chronic pain, cardiovascular disease, and diabetes, a systematic literature review on the efficacy of eHealth interventions for patients with osteoarthritis of knee is missing so far. OBJECTIVE: The aim of this study was to compare the efficacy of eHealth-supported home exercise interventions with no or other interventions regarding pain, physical function, and health-related QoL in patients with osteoarthritis of the knee. METHODS: MEDLINE, CENTRAL, CINAHL, and PEDro were systematically searched using the keywords osteoarthritis knee, eHealth, and exercise. An inverse variance random-effects meta-analysis was carried out pooling standardized mean differences (SMDs) of individual studies. The Cochrane tool was used to assess risk of bias in individual studies, and the quality of evidence across studies was evaluated following the Grading of Recommendations, Assessment, Development, and Evaluation approach. RESULTS: The literature search yielded a total of 648 results. After screening of titles, abstracts, and full-texts, seven randomized controlled trials were included. Pooling the data of individual studies demonstrated beneficial short-term (pain SMD=-0.31, 95% CI -0.58 to -0.04, low quality; QoL SMD=0.24, 95% CI 0.05-0.43, moderate quality) and long-term effects (pain -0.30, 95% CI -0.07 to -0.53, moderate quality; physical function 0.41, 95% CI 0.17-0.64, high quality; and QoL SMD=0.27, 95% CI 0.06-0.47, high quality). CONCLUSIONS: eHealth-supported exercise interventions resulted in less pain, improved physical function, and health-related QoL compared with no or other interventions; however, these improvements were small (SMD<0.5) and may not make a meaningful difference for individual patients. Low adherence is seen as one limiting factor of eHealth interventions. Future research should focus on participatory development of eHealth technology integrating evidence-based principles of exercise science and ways of increasing patient motivation and adherence.

Testing the validity of preventing chronic regional pain syndrome with vitamin C after distal radius fracture

Distal Radius Fractures

Purpose The American Academy of Orthopaedic Surgeons recommends the use of vitamin C to prevent complex regional pain syndrome (CRPS) for patients with distal radius fractures (DRFs). We hypothesized that the evidence for supporting this recommendation is weak, based on epidemiological principles of association and causality. The specific aim of this project was to test the validity of this recommendation. Methods We conducted a literature review to retrieve articles reporting on the use of vitamin C to prevent CRPS. Data collected included sample size, study design type, dose of vitamin C used, and outcome measures of association expressed as relative risk (RR) and odds ratio. We then applied Hill criteria to evaluate the relationship between vitamin C and CRPS. Results We obtained 225 articles from the database search. After the exclusion of duplicates, unrelated articles, editorial letters, and commentaries, we found 4 articles and 1 systematic review relevant to our topic. Six of the 9 Hill criteria were met, and an earlier meta-analysis showed a quantified reduction in CRPS risk. However, criteria like biological plausibility, specificity, and coherence were not met. Conclusions The number of causal/association criteria met was adequate to support the scientific premise of the effect of vitamin C in preventing CRPS after DRF. Furthermore, vitamin C administration is of relatively low cost and has few complications unless administered in large doses. Owing to sufficient epidemiological evidence availability, the American Academy of Orthopaedic Surgeons recommendation of vitamin C to prevent CRPS has practical merit. Type of study/level of evidence Therapeutic II.

Altered expression of chondroitin sulfate structure modifying sulfotransferases in the articular cartilage from adult osteoarthritis and Kashin-Beck disease

OAK 3 - Non-arthroplasty tx of OAK

OBJECTIVE: To investigate the expression of enzymes involved in chondroitin sulfate (CS) sulfation in the articular cartilage isolated from adult patients with osteoarthritis (OA) and Kashin-Beck disease (KBD), using normal adults as controls. METHODS: Articular cartilage samples were collected from normal, OA and KBD adults aged 38-60 years old, and divided into three groups with six individual subjects in each group. The morphology and pathology grading of knee joint cartilage was examined by Safranin O staining. The localization and expression of enzymes involved in CS sulfation (CHST-3, CHST-11, CHST-12, CHST-13, carbohydrate (N-acetylgalactosamine 4-sulfate 6-O) sulfotransferase 15 - CHST-15, and uronyl 2-O-sulfotransferase - UST) were examined by immunohistochemical (IHC) staining and semi-quantitative analysis. RESULTS: Positive staining rates for anabolic enzymes CHST-3, CHST-12, CHST-15, and UST were lower in the KBD and OA groups than those in the control group. Meanwhile, reduced levels of CHST-11, and CHST-13 in KBD group were observed, in contrast to those in OA and control groups. The expressions of all six CS sulfation enzymes were less detected in the superficial and deep zones of KBD cartilage compared with control and OA cartilage. CONCLUSION: The reduced expression of the CS structure modifying sulfotransferases in the chondrocytes of both KBD and OA adult patients may provide explanations for their cartilage damages, and therapeutic targets for their treatment.

Outcomes after ARDS: A distinct group in the spectrum of disability after complex and protracted critical illness

DOD - Acute Comp Syndrome CPG

ARDS represents an important public health problem for patients, family caregivers and society. The last decade has seen a burgeoning literature focussed on the outcomes of this patient group and has informed important new knowledge about the devastating and often irreversible morbidity related to nerve, muscle and brain injury More recent studies have reinforced these robust themes of physical and neuropsychological morbidity in other patient groups and have shown that outcomes after ARDS are one segment of a spectrum of disability and may not be widely generalizable across older patients with multiple comorbidities and protracted length of stay in the critical care unit. Our literature has reached theme saturation in terms of morbidity and needs to identify and begin to address the research agenda for the next decade. Several of these themes will be addressed here and include the following: 1) to generate large diverse datasets to understand different outcome trajectories over time to facilitate risk stratification and inform development of rehabilitation programs; 2) to embrace mixed methodology as a new longitudinal study standard to facilitate detailed qualitative observations to augment insights from quantitative data; 3) to educate patients, families, colleagues and decision-makers about outcomes after critical illness to inform policy and decision-making; 4) to embrace family caregivers and provide intervention when needed and ongoing support across transitions of care; 5) prioritize functional outcome measures over those targeted at health-related quality of life for construction of more focussed rehabilitation interventions; 6) embrace translational research programs to elucidate the relationship between functional outcome and molecular mechanism to gain further insight into the pathophysiology of critical illness, muscle and brain injury and potential insights into novel therapeutic strategies.

Two-stage bone and meniscus allograft and autologous chondrocytes implant for unicompartmental osteoarthritis: midterm results

Osteochondritis Dissecans 2020 Review

BACKGROUND: We analyzed the clinical and radiographic evolution of patients with knee unicompartmental osteoarthritis and axis alteration and osteochondral lesions in the femoral condyle, treated with tibial plateau and meniscus allograft and cultured autologous chondrocyte implantation in the femur in two steps. PURPOSE: To analyze the clinical results with the first patients treated with this two-stage technique to avoid knee prosthesis in patients with unicompartmental osteoarthritis. MATERIAL AND METHODOLOGY: Sixteen patients, average age 56 years, were included in a cohort study. We performed an osteotomy with tibia plateau allograft, including the meniscus. In a second surgery, the chondrocyte fibrin scaffold was placed in the femur. Clinical symptoms and function were measured using KSSR and KOOS scores. Wilcoxon's test was performed to compare the results over the 2-year follow-up period. RESULTS: Mean KSSR before surgery was 35.69 (SD: 3.75) points, rising to 67 (SD: 15.42) at 3 months, 95.88 at 12 months (SD: 2.68) and 96.31 at 24 months (SD: 2.24). The KOOS before surgery was 65.14 (SD: 16.34), rising to 72.68 after 3 months (SD: 19.15), 76.68 at 12 months (SD: 18.92) and 64.28 at 24 months (SD: 11.79). Four of 5 patients returned to engaging in the activity that they had stopped practicing. Three patients experienced collapse of the tibia allograft, and they needed later a prosthesis. CONCLUSIONS: Simultaneous tibia plateau allograft and autologous chondrocyte implantation in the femur, after correction of the angular deformity, were performed, restoring the anatomy of the medial compartment and knee function in 82% of the patients 2 years after the operation. LEVEL OF EVIDENCE: IV.

The prognostic value of the fracture level in the treatment of Gartland type III supracondylar humeral fracture in children

Pediatric Supracondylar Humerus Fracture 2020 Review

A small proportion of children with Gartland type III supracondylar humeral fracture (SCHF) experience troubling limited or delayed recovery after operative treatment. We hypothesised that the fracture level relative to the isthmus of the humerus would affect the outcome. We retrospectively reviewed 230 children who underwent closed reduction and percutaneous pinning (CRPP) for their Gartland type III SCHFs between March 2003 and December 2012. There were 144 boys and 86 girls, with the mean age of six years (1.1 to 15.2). The clinico-radiological characteristics and surgical outcomes (recovery of the elbow range of movement, post-operative angulation, and the final Flynn grade) were recorded. Multivariate analysis was employed to identify prognostic factors that influenced outcome, including fracture level. Multivariate analysis revealed that a fracture below the humeral isthmus was significantly associated with poor prognosis in terms of the range of elbow movement (p < 0.001), angulation (p = 0.001) and Flynn grade (p = 0.003). Age over ten years was also a poor prognostic factor for recovery of the range of elbow movement (p = 0.027). This is the first study demonstrating a subclassification system of Gartland III fractures with prognostic significance. This will guide surgeons in peri-operative planning and counselling as well as directing future research aimed at improving outcomes.

Vitamin K supplementation for cystic fibrosis

Management of Hip Fractures in the Elderly

BACKGROUND: Cystic fibrosis is a genetic disorder which can lead to multiorgan dysfunction. Malabsorption of fat and fat-soluble vitamins (A, D, E, K) may occur and can cause subclinical deficiencies of some of these vitamins. Vitamin K is known to play an important role in both blood coagulation and bone formation. Supplementation with vitamin K appears to be one way of addressing the deficiency, but there is very limited agreement on the appropriate dose and frequency of use of these supplements. OBJECTIVES: To assess the effects of vitamin K supplementation in people with cystic fibrosis and to determine the optimal dose and route of administration of vitamin K for both routine and therapeutic use. SEARCH STRATEGY: We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group's Trials Register comprising references identified from comprehensive electronic database searches and handsearches of relevant journals and abstract books of conference proceedings.Most recent search: 15 April 2010. SELECTION CRITERIA: Randomised and quasi-randomised controlled trials of all preparations of vitamin K used as a supplement compared to either no supplementation (or placebo) at any dose or route and for any duration, in children or adults diagnosed with cystic fibrosis (by sweat test or genetic testing). DATA COLLECTION AND ANALYSIS: Two authors independently screened papers, extracted trial details and assessed their risk of bias. MAIN RESULTS: Two trials (total of 32 participants) were included in the review and were assessed as having a moderate risk of bias. One was a dose-ranging parallel group trial; and the other had a cross-over design, but no separate data were reported for the first intervention period. Neither of the trials addressed any of the primary outcomes (coagulation, bone formation and quality of life). Both trials reported the restoration of serum vitamin K and undercarboxylated osteocalcin levels to the normal range after one month of daily supplementation with 1 mg of vitamin K. AUTHORS' CONCLUSIONS: Evidence from randomised controlled trials on the benefits of routine vitamin K supplementation for people with CF is currently weak and limited to two small trials of short duration. However, no harm was found and until further evidence is available, the present recommendations should be adhered to. VITAMIN K SUPPLEMENTATION FOR CYSTIC FIBROSIS: Cystic fibrosis is an inherited condition causing disease most noticeably in the lungs, digestive tract and pancreas. People with cystic fibrosis often have pancreatic insufficiency which may be linked to deficiencies of fat-soluble vitamins like vitamin K. Vitamin K is needed for adequate blood clotting, bone formation and some metabolic functions.This review looked at giving vitamin K supplements to address the effects of deficiency on blood clotting, bone strength and quality of life in people with cystic fibrosis. We tried to determine the optimal dosage required to prevent this deficiency.Data from two small trials did not clearly indicate whether giving vitamin K supplements will improve blood clotting, bone strength or quality of life in people with cystic fibrosis. We were not able to draw firm conclusions from this review and advise that the current recommendations from the Cystic Fibrosis Foundation and the European Cystic Fibrosis Society should be followed until further evidence becomes available

Ocular Manifestations of Noonan Syndrome: A Prospective Clinical and Genetic Study of 25 Patients

Upper Eyelid and Brow Surgery

PURPOSE: To determine the full spectrum of ocular manifestations in patients with Noonan syndrome (NS). DESIGN: Prospective cross-sectional clinical and genetic study in a tertiary referral center. PARTICIPANTS: Twenty-five patients with NS (mean age, 14 years; range, 8 months-25 years) clinically diagnosed by validated criteria. METHODS: All patients were examined by the same team following a detailed study protocol. Genetic analyses were performed in 23 patients. MAIN OUTCOME MEASURES: Ocular abnormalities of vision and refraction, external ocular features, ocular position and motility, anterior segment, posterior segment, and intraocular pressure. RESULTS: Ocular features of vision and refraction were amblyopia (32%), myopia (40%), and astigmatism (52%). External ocular features were epicanthic folds (84%), hypertelorism (68%), ptosis (56%), high upper eyelid crease (64%), lower eyelid retraction (60%), abnormal upward slanting palpebral fissures (36%), downward slanting palpebral fissures (32%), and lagophthalmos (28%). Orthoptic abnormalities included strabismus (40%), abnormal stereopsis (44%), and limited ocular motility (40%). Anterior segment abnormalities included prominent corneal nerves (72%) and posterior embryotoxon (32%). Additional ocular features were found, including nonglaucomatous optic disc excavation (20%), relatively low (<10 mmHg) intraocular pressure (22%), and optic nerve hypoplasia (4%). Mutations were established in 22 patients: 19 PTPN11 mutations (76%), 1 SOS1 mutation, 1 BRAF mutation, and 1 KRAS mutation. The patient with the highest number of prominent corneal nerves had an SOS1 mutation. The patient with the lowest visual acuity, associated with bilateral optic nerve hypoplasia, had a BRAF mutation. Patients with severe ptosis and nearly total absence of levator muscle function had PTPN11 mutations. All patients showed at least 3 ocular features (range, 3-13; mean, 7), including at least 1 external ocular feature in more than 95% of the patients. CONCLUSIONS: Noonan syndrome is a clinical diagnosis with multiple genetic bases associated with an extensive variety of congenital ocular abnormalities. Ocular features of NS are characterized by 1 or more developmental anomalies of the eyelids (involving the position, opening, and closure) associated with various other ocular abnormalities in childhood, including amblyopia, myopia, astigmatism, strabismus, limited ocular motility, prominent corneal nerves, and posterior embryotoxon.

Pediatric oral ranula: Clinical follow-up study of 57 cases

Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures

Objective: To present 57 cases of oral ranula in children, analyzing the clinical characteristics, treatment and outcome of these lesions. Methods: The clinical histories of patients diagnosed with oral ranula, seen between 1998 and 2008 at the Oral and Maxillofacial Surgery Unit of a reference Children's Hospital (0-14 years) were reviewed. All patients with clinical diagnosis of oral ranula were included. Results: Fifty-seven patients, 21 boys and 36 girls, with a mean age of 5.1 years were included in the study. Thirtytwo cases were located on the left side of the floor of the mouth. The lesion diameter varied between 1 and 3 cm in 27 cases, 22 were less than 1 cm, and 8 were larger than 3 cm. Fifty-four cases were asymptomatic and 3 ranulas had pain on swallowing. Twenty-two cases were resolved by opening with a tract dilator and 35 by marsupialization. Seven cases recurred at a mean of 12 months after treatment, three of these from the marsupialization group. Conclusion: The majority of the oral ranulas occurred in females, asymptomatic, on the left side of the floor of the mouth, with a mean size of 1 to 3 cm; all lesions were treated by surgery, of which 7 recurred. (copyright) Medicina Oral S. L

Surgical treatment for metastatic disease of the pelvis and the proximal end of the femur

MSTS 2018 - Femur Mets and MM

Advances in the treatment of invasive cancers continue to improve the longevity of patients who have these diseases; thus, the care of patients who have bone metastases is an issue of the utmost importance to the orthopaedic surgeon. In terms of maintaining the ability to walk, no site of potential metastatic involvement is more crucial than the proximal end of the femur and the acetabulum. Advances in femoral and acetabular implants, imaging modalities, and operative techniques now allow reconstruction of even the most complex acetabular and proximal femoral defects. However, the orthopaedic surgeon must recognize the need to approach management of these patients from a multidisciplinary perspective. The oncologist, radiotherapist, rehabilitation medicine specialist, radiologist, and pathologist each have a role to play. Only through cooperation among all members of the team will a patient who has metastatic disease or a myeloma be given the best possible care.

Measurement of intra-abdominal pressure in intensive care units in the United Kingdom: a national postal questionnaire study

DOD - Acute Comp Syndrome CPG

BACKGROUND: To explore the attitudes of intensivists in the UK to intra-abdominal pressure (IAP) measurement and abdominal compartment syndrome (ACS) and to determine current practice. METHODS: A postal questionnaire study addressed to the lead clinician in the intensive care unit was sent to hospitals in the UK with a general surgical service. RESULTS: Completed questionnaires were received from 137 of the 207 hospitals surveyed (66.2% response rate). Only 1.5% of the respondents (n=2) had no prior knowledge of intra-abdominal hypertension and ACS. IAP had been measured on some occasion by 75.9% (n=104) of the respondents, always by the intravesical route. Among those intensive care units that measured IAP, in 93.2% (n=97) it was only measured when there was a suspicion of the development of ACS; 3.8% of units (n=4) measured IAP on all patients who had undergone an emergency laparotomy, and 2.9% (n=3) measured IAP only in those who had undergone emergency laparotomy associated with massive fluid resuscitation. There was major disparity in the frequency of IAP measurement and when to recommend abdominal decompression. CONCLUSIONS: Despite widespread awareness of IAH and the ACS, many intensive care units never measure the IAP. When it is measured, the intravesical route is used exclusively. No consensus exists on optimal timing of measurement or when decompressive laparotomy should be performed.

Triangular mattress suture in abdominal diastasis to prevent epigastric bulging

Panniculectomy & Abdominoplasty CPG

In the classic abdominoplasty, the treatment of large diastasis recti with simple or vertical mattress sutures may result in a nonaesthetic bulge. The surgeon may produce a craniocaudal bulge deformity by treating the flaccidity in the horizontal plane only, although it occurs in all directions. The authors describe the triangular mattress suture for the treatment of large diastasis recti, and demonstrate the mechanism involved in producing an epigastric bulge. Also presented is their clinical experience with 56 patients, with a 3-year follow-up, using this new plication method. The triangular mattress suture is a simple, quick, and effective way to correct abdominal diastasis and to avoid the epigastric bulge deformity with no added morbidity.

Comparison of femoral component rotational axes in computer-assisted total knee arthroplasty using the gap technique: A retrospective study

OAK 3 - Non-arthroplasty tx of OAK

Objective: To compare the deviation of three femoral rotational axes in computer assisted surgery [CAS] total knee arthroplasty [TKA] using the gap technique. Materials and Methods: A retrospective cross-sectional study was conducted between 2004 and 2013 at the Department of Orthopaedics, Ramathibodi Hospital of patients who had undergone computer-assisted total knee arthroplasty. All patients were included with the exception of those who had had post-traumatic knee osteoarthritis, valgus knee, or trapezoidal medial-lateral gap. Baseline characteristics and femoral rotational axes (Whiteside, posterior condyle, and transepicondyle) were recorded. Comparison among the three axes was performed using analysis of variance. Results: The study included 140 patients (114 women and 26 men) with an average age of 71.6±8.4 years, representing 140 total knee arthroplasties. The deviation of femoral component rotation axes were: Whitesideâ??s line 0.42±4.49 degrees, posterior condylar line -1.43±4.82 degrees and transepicondylar line -3.93±5.00 (p<0.001). Conclusion: Whitesideâ??s line showed the smallest deviation in femoral component rotation compared to the gap technique in CAS TKA.

Bilateral trochanteric fractures of the femur in a patient with chronic renal failure

Management of Hip Fractures in the Elderly

We report a spontaneous intertrochanteric fracture with bilateral avulsion of the greater trochanter in a patient with chronic renal failure

ORIF versus MIPO for humeral shaft fractures: a meta-analysis and systematic review of randomized clinical trials and observational studies

Pediatric Supracondylar Humerus Fracture 2020 Review

Background: There is no consensus on the optimal operative technique for humeral shaft fractures. This meta-analysis aims to compare minimal-invasive plate osteosynthesis (MIPO) with open reduction internal fixation (ORIF) for humeral shaft fractures regarding non-union, re-intervention, radial nerve palsy, time to union, operation duration and functional outcomes. Methods: PubMed/Medline/Embase/CENTRAL/CINAHL were searched for both randomized clinical trials (RCT) and observational studies comparing MIPO with ORIF for humeral shaft fractures. Effect estimates were pooled across studies using random effects models and presented as weighted odds ratio (OR), risk difference (RD), mean difference (MD) and standardized mean difference (SMD) with corresponding 95% confidence interval (95%CI). Subgroup analysis was performed stratified by study design (RCTs and observational studies). Results: A total of two RCT's (98 patients) and seven observational studies (263 patients) were included. The effect estimates obtained from observational studies and RCT's were similar in direction and magnitude. MIPO carries a lower risk for non-union (RD: 5%; OR 0.3, 95% CI 0.1-0.9) and secondary radial nerve palsy (RD 5%; OR 0.3, 95%CI 0.1- 0.9). Nerve function eventually restored spontaneously in all patients in both groups. Results were inconclusive regarding re-intervention (RD 7%; OR: 0.7, 95%CI 0.2-1.9), infection (RD 4%; OR 0.4, 95%CI 0.1-1.5), time to union (MD -1 week, 95%CI -3 – 1) and operation duration (MD -13 minutes, 95%CI -38.9 – 11.9). Functional shoulder scores (SMD 0.01, 95%CI -0.3 – 0.3) and elbow scores (SMD 0.01, 95%CI -0.3 – 0.3) were similar for the different operative techniques. Conclusion: MIPO has a lower risk for non-union than ORIF for the treatment of humeral shaft fractures. Radial nerve palsy secondary to operation is a temporary issue resolving in all patients in both treatment groups. Although both treatment options are viable, the general balance leans towards MIPO having more favorable outcomes.

Acetabular Coverage May Affect Radiographic and Clinical Outcomes of Osteochondral Allograft Transplantation of Focal Femoral Head Lesions: A Case Series From a Single Institution

Osteochondritis Dissecans 2020 Review

Osteochondral lesions of the femoral head in young people are rare and present unique management challenges. Optimal treatment for these lesions is unclear. From 2009 to 2016, clinical and radiographic outcomes were prospectively collected within a series of symptomatic focal osteochondral lesions of the femoral head with a minimum follow-up of 2 years. A surgical hip dislocation followed by implantation of a size-matched fresh osteochondral femoral head allograft was performed. Nine hips in eight patients (6 female patients) underwent surgery at an average of 17 years (11 to 21 years). Individual allograft sizes ranged from 10 to 35 mm in diameter; with 2 of 9 hips receiving two allografts in a stacked or mosaicplasty technique at the time of treatment. The average graft implantation was 3536.5 mm2. Modified Harris hip scores improved by 13.4 (P = 0.018) from preoperative to final follow-up for all patients. Significant improvements in internal rotation (12° versus 23°, P = 0.011), external rotation (32° versus 50°, P = 0.041), and abduction (28° versus 40°, P = 0.042) were also achieved. Three patients (four hips) demonstrated poor radiographic healing (<50% incorporation at 2 years), which correlated with worse clinical outcomes and was associated with a lower preoperative lateral center edge angle (21.5° versus 30.4°, P = 0.049). Fresh osteochondral allograft treatment is a good option for focal osteochondral lesions of the femoral head with improved outcomes and motion; however, higher failure rates may be seen in those with a lower center edge angle.

Incidence of chronic kidney disease in patients undergoing arthroplasty: A systematic review of the literature

OAK 3 - Non-arthroplasty tx of OAK

Patients undergoing arthroplasty are exposed to different interventions that can lead to renal dysfunction. There is abundant evidence of the incidence and factors associated with acute kidney injury (AKI); however, the incidence and the factors associated with chronic kidney disease (CKD) are not clear. The objective of this study is to determine the incidence and associated factors in arthroplasty patients. A systematic review of the literature was carried out following the recommendations of PRISMA and the Cochrane Collaboration (PROSPERO Protocol CRD42018075929). The search was carried out in Medline, Embase, Cochrane and LILACS. No language or date limits were set. Observational studies were included: cases and controls, and cohorts. The revision of titles and abstracts and the reading of the full texts was performed in a paired manner. The quality of the evidence was evaluated with the Newcastle-Ottawa tool. The initial search found 1279 titles and abstracts. We excluded 115 duplicates, and 1153 in the reading of titles and abstracts. Three articles met the inclusion criteria and were of acceptable quality. The incidence of severe CKD after hip or knee arthroplasty was 1.2% at 1 year up to 6.5% at 9 years. The evidence of the incidence and risk factors associated with CKD in patients undergoing arthroplasty is very scarce and het-No erogeneous. Further primary studies are required in order to have more valid and trustable results.

Prediction of pelvic lymph node metastasis by the ratio of cathepsin B to stefin A in patients with prostate carcinoma

MSTS 2018 - Femur Mets and MM

BACKGROUND: Pathologic grade and/or histologic score, extraprostatic extension indicated by invasion of the prostatic capsule, margin, and/or seminal vesicles by prostate cancer cells, serum total prostate-specific antigen (PSA), free PSA, complexed PSA levels and/or their ratios, regional pelvic lymph node metastases, and clinical staging have been used to diagnose and monitor the treatment of prostate carcinoma (PC) patients. The Gleason grading system is also used to grade/score a patient's stage of disease, with lower to higher scores indicating progression of PC. However, Gleason's system cannot be used to distinguish biologically aggressive PCs within a single Gleason score. Our objective was to identify subpopulations (or clones) of aggressive prostate cancers within an individual Gleason score by utilizing biological molecule(s) that also facilitate cancer cell invasion to prostatic stroma and metastasis to the lymph nodes. MATERIALS AND METHODS: Specimens were collected from 97 patients with PC and from 8 patients with benign prostatic hyperplasia. These patients had not been treated with hormonal and/or chemotherapeutic agents before undergoing a prostatectomy at the Minneapolis Veterans Affairs Medical Center. Formalin-fixed, paraffin or paraplast-embedded prostate tissue sections were stained with hematoxylin and eosin for pathologic diagnosis and adjacent sections were stained for for immunohistochemical study. We also collected data on age, race, extraprostatic extension, margin status, seminal vesicle, and lymph node invasion by cancer cells, clinical stage at prostatectomy, and mortality/survival data, including the available presurgery and postsurgery serum total PSA and prostatic acid phosphatase concentrations in patients. Immunohistochemical localization of mouse or rabbit anti-cathepsin B (CB) antibody IgG and mouse antihuman stefin (cystatin) A IgG was quantified using a computer-based image analysis system equipped with Metamorph software. RESULTS: CB and stefin A identified aggressive and less aggressive clones of PCs within an individual Gleason score. Tumors with a Gleason Score of 6 that are similar histologically and morphologically were heterogeneous with respect to the ratios of CB to stefin A (CB > stefin A, CB = stefin A, and CB < stefin A). We also found a significant positive association (P = 0.0066) between ratios of CB and stefin A (CB > stefin A) and the incidence of pelvic lymph node metastases, but not with ratios of CB less than stefin A and/or ratios of CB equal to stefin A. Patients with Gleason 7 PCs had a higher incidence of positive lymph nodes than those with Gleason Score 6 tumors. Our data indicated that mortality rates increased in patients when the ratios of CB were greater than stefin A. CONCLUSIONS: PC within an individual Gleason score is a heterogeneous tumor that contains clones or subpopulations of aggressive and less aggressive tumors that can be defined by the ratios of CB to stefin A. PC with an aggressive clone can be identified when the ratio of CB is greater than that of stefin A. Less aggressive clones are identified when the ratio of CB is less than that of stefin A or when the ratio of CB is equal to that of stefin A. The ratios of CB to stefin A can be used in the differential diagnosis and treatment of patients with PC. This is the first report to identify phenotypes of aggressive and less aggressive PCs within a Gleason score.

Association between bone scan index and activities of daily living in patients with advanced non-small cell lung cancer

MSTS 2018 - Femur Mets and MM

Purpose: The aim of this retrospective cross-sectional study was to investigate the association between the bone scan index (BSI) and activities of daily living (ADL) in patients with advanced non-small cell lung cancer (NSCLC). Methods: Among patients with advanced NSCLC, subjects who underwent bone scintigraphy were recruited from this study. Clinical information about patients, including the Barthel Index of ADL, was extracted from their medical charts. Variables including the age, sex, BSI, presence/absence skeletal-related events (SREs), diagnostic state (initial vs. relapse), and history of use of certain medications (e.g. opiates) were evaluated as factors possibly associated with the Barthel Index. In Addition, associations between these factors, including the Barthel Index, with the overall survival were also assessed. Results: A total of 111 patients with bone metastases were selected. The BSI and Barthel Index of the patients were 1.59 ± 2.25 and 69.7 ± 19.6, respectively. Multivariable analysis identified age (�70 years), a high BSI (�1.0), and presence of SREs were as factors statistically significantly associated with lower values of the Barthel Index (<75). On the other hand, Cox proportional hazards analysis identified low values of the Barthel Index (<75), use of opiates, and male sex as significant factors associated with a shorter overall survival; the BSI was not associated with the overall survival in the patients with advanced NSCLC in this study. Conclusion: The results suggest that a high BSI (�1.0) is an independent predictor of poor ADL in patients with NSCLC, while showing no correlation with the overall survival.

Outcomes Following Temporary Kapandji Pinning Technique and Distal Radial LCP Fixation for Intra-Articular Fractures of the Displaced Distal Radius

Distal Radius Fractures

In partially or completely displaced intra-articular fracture of the distal radius , achieving satisfactory reduction and maintenance of good reduction before applying the plate may be difficult. Especially to accomplish the anatomic volar tilt remains a problem. Typically, the Kapandji technique has been described to reduce and stabilize a large displaced and extra-articular fracture of the distal radius. We present the results of a prospective series using the temporary Kapandji technique for K-wire intrafocal fixation followed by rigid fixation with distal radial locking compression plate. The mean follow-up period totaled 12 months. A total of 57 patients were evaluated by radiographic and clinical review. The modified Mayo wrist score was used for postoperative patient evaluation. The clinical results on follow-up were good to excellent. Minimal joint stiffness and functional outcomes of the wrist and elbow were satisfactory. Statically significant differences were found between the preoperative and postoperative radiologic parameters. No skin infection due to K-wire insertion was noted, and the fracture healed completely in every case. This paper reports the results of 57 cases of intra-articular fractures of the distal radius treated by Kapandji wires as a reduction tool and definitive fixation by the application of a locked volar plate. It could be performed easily and reliably. K-wires were used to temporarily maintain reduction throughout the rigid fixation without further displacement in the follow-up clinic. The results proved appropriate, and the technique has merit, as it obviates the need for dorsal exposure in most cases.

Multiple myeloma: progress in management aimed at improving QoL

MSTS 2018 - Femur Mets and MM

Despite the major recent strides achieved in myeloma treatment owing to the implementation of new anti-myeloma agents, bone destruction is still a leading cause of deterioration in quality of life (QoL) for affected patients. With improvement of survival, bone management will become more important for maintaining QoL especially in elderly patients; novel treatment modalities with bone anabolic activity are highly anticipated, as a means of restoring bone in bone destructive lesions as well as from the aspect of preventing bone destruction with currently available anti-resorptive agents. Long-term management of myeloma bone disease in the era of these new agents and a perspective on the development of new bone modifying agents will be discussed.

The evaluation of effectiveness of a topical formulation of linseed oil in patients with knee osteoarthritis

OAK 3 - Non-arthroplasty tx of OAK

INTERVENTION: Diclofenac gel 1%,three times a day,topically on painful knee Intervention 1: linseed oil,three times a day on,topically on painful knee. Intervention 2: Diclofenac gel 1%,three times a day,topically on painful knee. linseed oil,three times a day on,topically on painful knee Placebo Treatment � Drugs CONDITION: Gonarthrosis knee osteoarthritis. ; Gonarthrosis PRIMARY OUTCOME: Visual analogue scale. Timepoint: At the beginning of intervention,after2 weeks then after 4 weeks from the beginning of intervention. Method of measurement: Asking the patients. SECONDARY OUTCOME: Function in daily living (ADL). Timepoint: At the beginning of intervention,after 2 weeks then 4 weeks afterthe beginning of intervention. Method of measurement: KOOS questionnaire. Function in sport and recreation(Sport/Rec). Timepoint: At the beginning of intervention,after 2 weeks then 4 weeks afterthe beginning of intervention. Method of measurement: KOOS questionnaire. Knee related quality of life(QOL). Timepoint: At the beginning of intervention,after 2 weeks then 4 weeks afterthe beginning of intervention. Method of measurement: KOOS questionnaire. Other Symptoms. Timepoint: At the beginning of intervention,after 2 weeks then 4 weeks afterthe beginning of intervention. Method of measurement: KOOS questionnaire. Pain. Timepoint: At the beginning of intervention,after 2 weeks then 4 weeks afterthe beginning of intervention. Method of measurement: KOOS questionnaire. INCLUSION CRITERIA: INCLUSION CRITERIA: the age between 35�70 years;at least having pain in one knee for past 3 months;recognition of osteoarthritis by the doctor according to American college of rheumatology classification criteria; recognition of grade I to III osteoarthritis by the doctor according to Kellegren�Lawrence(K�L)grading scale;absence of any congenital abnormality in lower extremity;written informed consent for inclusion. Exclusion Criteria: sensitivity and allergy to linseed or diclofenac gel or acetaminophen;skin disease in knee;patients with secondary osteoarthritis due to other bone joint disorders like rheumatoid arthritis, gout, infected arthritis, metabolic arthritis, traumatic arthritis; joint replacement; oral and topical use of corticostreoid in past 14 days;knee corticosteroid or hyaluronic acid injection in the past 90 days; other articular corticosteroid or hyaluronic acid injection in the past 1 month;topical or oral usage of painkillers in past 3 days;c

Falls in elderly patients with glaucoma

Upper Eyelid and Brow Surgery

We analyzed the determinants of serious falls among 489 ambulatory elders aged 65 years and older who received a comprehensive examination at a glaucoma consultation service. For the previous year, at least one fall requiring medical attention or restricted activity was reported by 9.6% (95% confidence interval [CI], 7.0% to 12.2%) of participants. Using logistic regression to adjust for potential confounding variables, the greatest single risk factor for falls was the use of nonmiotic topical eye medications (odds ratio [OR], 5.4; 95% Cl, 1.8 to 16.4). Additional risk factors for falls were female sex (OR, 2.3; 95% Cl, 1.1 to 4.7) and use of cardiac medications (OR, 2.5; 95% Cl, 1.1 to 5.6). Three other characteristics were also associated with the risk of falls: use of miotic eye medications (OR, 3.2; 95% Cl, 1.0 to 10.1); visual field impairment of 40% or greater (OR, 3.0; 95% Cl, 0.94 to 9.8); and use of sedatives (OR, 2.4; 95% Cl, 0.89 to 6.7). These findings suggest that ocular and systemic medications are the major predictors of falls even in this elderly population seeking ophthalmologic care for glaucoma. Medications appear to pose a greater risk for falls than even major visual impairment.

Surgery-triggered and non surgery-triggered Bisphosphonate-related Osteonecrosis of the Jaws (BRONJ): A retrospective analysis of 567 cases in an Italian multicenter study

MSTS 2018 - Femur Mets and MM

Invasive local procedures are often reported in clinical history of patients suffering from Bisphosphonates-Related Osteonecrosis of the Jaws (BRONJ) but over 40% of spontaneous forms have been also described in literature. We compared age, gender, underlying bone disorders, bisphosphonate therapy, clinical features and surgical outcome of 205 cases (36.2%) of BRONJ non surgery-triggered (group 1) with 362 (63.8%) cases of surgery-triggered forms (group 2). Differences between group 1 and 2 were analysed using Mann-Whitney U and Ï?2 tests. Statistical analysis was performed using STATA 8. Zoledronate was the most used type of bisphosphonate (63.4% versus 69.0%) and the mandible was the most frequently involved site (63.9% versus 63.4%) in both groups. BRONJ in group 1 was more frequently multicentric (9.3% versus 5%, p < 0.05), had a lower clinical stage (45.9% versus 13.8% in stage 1, p < 0.01) and had a better outcome after surgical therapy (improvement in 74.1% versus 58.6%, p < 0.05). The high prevalence of non surgery-triggered forms of BRONJ should be considered by oncologists, haematologists and general physicians who are advised to inform their patients regarding the importance of preventive dental protocols to control the possible causes of osteonecrosis not related to dental invasive procedures. © 2010 Elsevier Ltd. All rights reserved.

Comparison of the sensitivity of 99mTc-methyl diphosphonate bone scan with the skeletal X-ray survey in multiple myeloma

MSTS 2018 - Femur Mets and MM

In the diagnosis of multiple myeloma (MM), the radiological skeletal survey (RSS) was proven to be most useful for the detection of bone lesions. Since 1961, a new technique radioisotopic bone scan (RIBS), for the detection of such lesions, using 85Sr and 99mTc, has been shown to be highly sensitive for the detection of skeletal metastases of epithelial tumors. We have studied 30 patients with plasma cell dyscrasia (PCD) by both methods and concluded that RSS is clearly superior to RIBS in PCD. As RIBS detected less than 50% of the lesions demonstrated by RSS there seems to be no indication for a routine RIBS in the initial work-up of patients suspected to have PCD. However, due to the fact that RIBS is useful for the detection of new bone formation it has a certain value in the localization of pathological fractures in MM, mainly in vertebral compression.

Prevention of dislocation in total hip revision surgery using a dual mobility design

Management of Hip Fractures in the Elderly

Background: Postoperative dislocation is the commonest complication following revision total hip arthroplasty (THA). Hypothesis and type of study: Dual mobility cups are supposed to reduce the risk of THA instability. The present retrospective study tested this hypothesis on revision THAs and also, assessed this design contribution to acetabular fixation longevity. Materials and methods: The series was homogeneous and continuous, comprising a total of 163 revision THAs: 110 of them were bipolar revisions and 53 were restricted to the acetabular component exchange. Mean patient age was 68.7 years (range: 34-92 years). Novae(trademark) (SERF, Decines) dual mobility cups were used in all cases: 110 cementless cups were used and 53 cups were cemented in a Kerboull reinforcement ring due to severe acetabular bone loss. Results: Mean patients' follow-up (FU) was 60.4 (plus or minus) 17.6 months. There were six early dislocations (which were reduced without additional surgery and remained recurrence-free) and two cases of acetabular loosening. The total postoperative dislocation rate at the end of follow-up was 3.7% and the 7-year cup survivorship rate was 96.1% (95% CI: 92.8-99.2%). In revision for aseptic loosening, the instability rate was 2.9%; in the higher instability risk groups (i.e., revision for infection and or recurrent instability) the dislocation rate was respectively 9% and 0%. Discussion: Dual mobility cups provided a dislocation rate of only 3.7% in revision THA, comparable to the one reported with standard implants for primary THA. This kind of cup design is especially suited to deal with high instability risk revision cases, where constrained components are generally recommended. It can also be indicated in cases of aseptic loosening, where it resulted in a 2.9% dislocation rate and only two impending failures of fixation. In terms of mechanical failure rate, these numbers compare well to the ones pertaining to tripolar and constrained implants. These later alternatives remain possible options but are not fully efficient in terms of long-term stability and fixation longevity. Level of study: Level IV, retrospective or records-based. (copyright) 2009 Elsevier Masson SAS. All rights reserved

Operating room ventilation with laminar airflow shows no protective effect on the surgical site infection rate in orthopedic and abdominal surgery

Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures

Objective: To evaluate whether operating room (OR) ventilation with (vertical) laminar airflow impacts on surgical site infection (SSI) rates. Design: Retrospective cohort-study based on routine surveillance data. Patients and Methods: Sixty-three surgical departments participating voluntarily in the German national nosocomial infections surveillance system "KISS" were included (a total of 99,230 operations). Active SSI surveillance was performed according to the methods and definitions given by the US National Nosocomial Infection Surveillance system. Surgical departments were stratified according to type of OR ventilation used: (1) turbulent ventilation with high-efficiency particulate air-filtered air, and (2) HEPA-filtered (vertical) laminar airflow ventilation. Multivariate analyses were performed by the generalized estimating equations method to control for the following variables as possible confounders: (a) Patient-based: wound contamination class, ASA score, operation duration, patients' age and gender, endoscopic operation; (b) Hospital-based: the number of beds in the hospital, its academic status, operation frequency, and long-term participation in KISS. Results: The risk for severe SSI after hip prosthesis implantation was significantly higher using laminar airflow OR ventilation (1.63 < 1.06; 2.52>), as compared with turbulent ventilation. The adjusted odds ratios for the other operative procedures analyzed were: knee prosthesis 1.76 < 0.80, 3.85>; appendectomy 1.52 < 0.91, 2.53>; cholecystectomy 1.37 < 0.63, 2.97>; colon surgery 0.85 < 0.49, 1.49>; and herniorrhaphy 1.48 < 0.67; 3.25>. Conclusions: Unexpectedly, in this analysis, which controlled for many patient and hospital-based confounders, OR ventilation with laminar airflow showed no benefit and was even associated with a significantly higher risk for severe SSI after hip prosthesis. (copyright) 2008 by Lippincott Williams & Wilkins

The Feasibility of a Comprehensive Behavioral Intervention in Patient Post TKA

OAK 3 - Non-arthroplasty tx of OAK

Patients who undergo a replacement of their knees are generally older adults who have dealt with severe knee pain and joint degeneration for a long time. The majority of them are sedentary, and around 1/3 are obese. The knee replacement surgery decreases knee pain and helps patients to live a better life. However, after the surgery, some patients have difficulty performing basic activities such as walking, or going up�down stairs, and the majority remains sedentary and gain weight. These combined problems leave patients at risk of worsening their health. Therefore, a treatment that takes care of all these combined problems is needed. We propose an all�inclusive treatment, called comprehensive behavioral intervention (CBI) that intends to improve the long�term effects of exercise programs. The CBI combines exercise program with promotion of physical activity, orientation on healthy nutrition, and an education approach that promotes self�initiative towards healthy habits. The overall aim of this proposed study is to test how patients post TKA will like the CBI program, how safe the program is, and adapt the program as needed for better acceptability. We believe the CBI will be safe, well tolerated, and will improve the ability of patients to perform physical tasks. We also believe the program will increase the amount of physical activity, will promote maintenance of healthy weight, and will help the patients to obtain and maintain healthy habits. In this study subjects will be selected by a flip of a coin to receive either our CBI program or a more traditional exercise program. Subjects will be tested before and after the treatments. Our measures of main interest are how well subjects move around and how physically active they are. We are also interested on the effect of the interventions on body weight, blood pressure, eating habits, and general health. The team of researchers for this study includes several disciplines. The proposed study will defend the need for a larger study that can have a very important impact on the public health of patients post TKA. The reason for the public health impact is if the physical limitations experiences by patients post TKA are left untreated, they tend to get worse. Furthermore, by increasing physical activity and promoting healthy weight, it may improve general health and prevent chronic diseases. Last, developing educational intervention that promotes self�initiative will result in long�term health benefits post TKA.

Early Improvement in Pain and Functional Outcome but Not Quality of Life After Surgery for Metastatic Long Bone Disease

MSTS 2022 - Metastatic Disease of the Humerus

BACKGROUND: Bone metastases represent the most frequent cause of cancer-related pain, affecting health-related quality of life and creating a substantial burden on the healthcare system. Although most bony metastatic lesions can be managed nonoperatively, surgical management can help patients reduce severe pain, avoid impending fracture, and stabilize pathologic fractures. Studies have demonstrated functional improvement postoperatively as early as 6 weeks, but little data exist on the temporal progress of these improvements or on the changes in quality of life over time as a result of surgical intervention. QUESTIONS/PURPOSES: (1) Do patients' functional outcomes, pain, and quality of life improve after surgery for long bone metastases? (2) What is the temporal progress of these changes to 1 year after surgery or death? (3) What is the overall and 30-day rate of complications after surgery for long bone metastases? (4) What are the oncologic outcomes including overall survival and local disease recurrence for this patient population? METHODS: A multicenter, prospective study from three orthopaedic oncology centers in Quebec, Canada, was conducted between 2008 and 2016 to examine the improvement in function and quality of life after surgery for patients with long bone metastases. During this time, 184 patients out of a total of 210 patients evaluated during this period were enrolled; of those, 141 (77%) had complete followup at a minimum of 2 weeks (mean, 23 weeks; range, 2-52 weeks) or until death, whereas another 35 (19%) were lost to followup but were not known to have died before the minimum followup interval was achieved. Pathologic fracture was present in 34% (48 of 141) of patients. The median Mirel's score for those who underwent prophylactic surgery was 10 (interquartile range, 10-11). Surgical procedures included intramedullary nailing (55), endoprosthetic replacement (49), plate osteosynthesis (31), extended intralesional curettage (four), and allograft reconstruction (two). Seventy-seven percent (108 of 141) of patients received radiotherapy. The Musculoskeletal Tumor Society (MSTS), Toronto Extremity Salvage Score (TESS), Brief Pain Inventory (BPI) form, and Quality Of Life During Serious Illness (QOLLTI-P) form were administered pre- and postoperatively at 2 weeks, 6 weeks, 3 months, 6 months, and 1 year. Analysis of variance followed by post hoc analysis was conducted to test for significance between pre- and postoperative scores. The Kaplan-Meier estimate was used to calculate overall survivorship and local recurrence-free survival. A p value of < 0.05 was considered statistically significant. RESULTS: MSTS and BPI pain scores improved at 2 weeks when compared with preoperative scores (MSTS: 39% +/- 24% pre- versus 62% +/- 19% postoperative, mean difference [MD] 23, 95% confidence interval [CI], 16-32, p < 0.001; BPI: 52% +/- 21% pre- versus 30% +/- 21% postoperative, MD 22, 95% CI, 16-32, p < 0.001). Continuous and incremental improvement in TESS, MSTS, and BPI scores was observed temporally at 6 weeks, 3 months, 6 months, and 1 year; for example, the TESS score improved from 44% +/- 24% to 73% +/- 21% (MD 29, p < 0.001, 95% CI, 19-38) at 6 months. We did not detect a difference in quality of life as measured by the QOLLTI-P score (6 +/- 1 pre- versus 7 +/- 4 postoperative, MD 1, 95% CI, -0.4 to 3, p = 0.2). The overall and 30-day rates of systemic complications were 35% (49 of 141) and 14% (20 of 141), respectively. The Kaplan-Meier estimates for overall survival were 70% (95% CI, 62.4-78) at 6 months and 41% (95% CI, 33-49) at 1 year. Local recurrence-free survival was 17 weeks (95% CI, 11-24). CONCLUSIONS: Surgical management of metastatic long bone disease substantially improves patients' functional outcome and pain as early as 2 weeks postoperatively and should be considered for impending or pathologic fracture in patients whose survival is expected to be longer than 2 weeks provided that there are no immediate contraindications. Quality of life in this patient population did not improve, which may be a function of patient selection, concomitant chemoradiotherapy regimens, disease progression, or terminal illness, and this merits further investigation. LEVEL OF EVIDENCE: Level II, therapeutic study.

Chemokine receptor CCR2 is expressed by human multiple myeloma cells and mediates migration to bone marrow stromal cell-produced monocyte chemotactic proteins MCP-1, -2 and -3

MSTS 2018 - Femur Mets and MM

The restricted bone marrow (BM) localisation of multiple myeloma (MM) cells most likely results from a specific homing influenced by chemotactic factors, combined with the proper signals for growth and survival provided by the BM microenvironment. In analogy to the migration and homing of normal lymphocytes, one can hypothesise that the BM homing of MM cells is mediated by a multistep process, involving the concerted action of adhesion molecules and chemokines. In this study, we report that primary MM cells and myeloma derived cell lines (Karpas, LP-1 and MM5.1) express the chemokine receptor CCR2. In addition, we found that the monocyte chemotactic proteins (MCPs) MCP-1, -2 and -3, three chemokines acting as prominent ligands for CCR2, are produced by stromal cells, cultured from normal and MM BM samples. Conditioned medium (CM) from BM stromal cells, as well as MCP-1, -2 and -3, act as chemoattractants for human MM cells. Moreover, a blocking antibody against CCR2, as well as a combination of neutralizing antibodies against MCP-1, -2 and -3, significantly reduced the migration of human MM cells to BM stromal cell CM. The results obtained in this study indicate the involvement of CCR2 and the MCPs in the BM homing of human MM cells.

Appropriate hinge position for prevention of unstable lateral hinge fracture in open wedge high tibial osteotomy

DoD SSI (Surgical Site Infections)

AIMS: Open wedge high tibial osteotomy (OWHTO) for medial-compartment osteoarthritis of the knee can be complicated by intra-operative lateral hinge fracture (LHF). We aimed to establish the relationship between hinge position and fracture types, and suggest an appropriate hinge position to reduce the risk of this complication. PATIENTS AND METHODS: Consecutive patients undergoing OWHTO were evaluated on coronal multiplanar reconstruction CT images. Hinge positions were divided into five zones in our new classification, by their relationship to the proximal tibiofibular joint (PTFJ). Fractures were classified into types I, II, and III according to the Takeuchi classification. RESULTS: Among 111 patients undergoing OWHTOs, 22 sustained lateral hinge fractures. Of the 89 patients without fractures, 70 had hinges in the zone within the PTFJ and lateral to the medial margin of the PTFJ (zone WL), just above the PTFJ. Among the five zones, the relative risk of unstable fracture was significantly lower in zone WL (relative risk 0.24, confidence interval 0.17 to 0.34). CONCLUSION: Zone WL appears to offer the safest position for the placement of the osteotomy hinge when trying to avoid a fracture at the osteotomy site. Cite this article: Bone Joint J 2017;99B10:1313-18.

Hip resurfacing in a district general hospital: 6-year clinical results using the ReCap hip resurfacing system

Management of Hip Fractures in the Elderly

Background: The purpose of our study was to prospectively report the clinical results of 280 consecutive hips (240 patients) who received a ReCap Hip Resurfacing System implant (Biomet Inc., Warsaw, USA) in a single district general hospital. Literature reports a large variation in clinical results between different resurfacing designs and published results using this particular design are scarce. Methods. Mean follow up was 3.3 years (1.0 to 6.3) and four patients were lost to follow-up. All patients were diagnosed with end-stage hip osteoarthritis, their mean age was 54 years and 76.4% of all patients were male. Results: There were 16 revisions and four patients reported a Harris Hip Score <70 points at their latest follow up. There were no pending revisions. Kaplan-Meier implant survival probability, with revision for any reason as endpoint, was 93.5% at six years follow-up (95%-CI: 88.8-95.3). There were no revisions for Adverse Reactions to Metal Debris (ARMD) and no indications of ARMD in symptomatic non-revised patients, although diagnostics were limited to ultrasound scans. Conclusions: This independent series confirms that hip resurfacing is a demanding procedure, and that implant survival of the ReCap hip resurfacing system is on a critical level in our series. In non-revised patients, reported outcomes are generally excellent. (copyright) 2012 van der Weegen et al.; licensee BioMed Central Ltd

Treatment of solitary bone cysts with allogenic bone graft and platelet-rich plasma. A preliminary report

The Treatment of Pediatric Supracondylar Humerus Fractures AUC

The treatment of solitary bone cysts remains controversial. The high recurrence rate after operative treatment calls for the search of new effective treatment methods. The aim of this study was to evaluate the outcomes of treatment of solitary bone cysts with platelet-rich plasma (PRP) and allogenic bone grafts. The study group consisted of 9 patients (4 males and 5 females) with the diagnosis of solitary bone cyst. Their mean age was 12 years and 2 months (range: 6 to 17 years). All patients were symptomatic in routine daily activities. There was a coexisting fracture within the cyst wall in three patients. The operative procedure included removal of the cyst wall soft-tissue lining and filling of the cavity with deep frozen, gamma irradiated morselized allogenic bone grafts mixed with PRP. The PRP was prepared preoperatively with the GPS System (Gravitational Platelet Separation System, Biomet Merck). In six patients with an existing or impending fracture in particularly large cysts, fixation was used. For the cysts located close to the epiphysis (2 femurs, 1 humerus) we used an IM nail or DHS. For three cysts located in the diaphyseal region of the humerus we used an Ilizarov fixator. Three cysts with lower risk of impending fracture were left without fixation. The mean follow-up period was 19.5 months (range: 12 to 30). We noted no procedure-related complications and no refracture during the observation period. Bleeding from the wound was minimal, possibly as a result of PPP use. The wounds healed without swelling or excessive scar formation. After 12 months all the cysts were completely filled with new bone and were staged as Neer stage I. All the patients were asymptomatic. The use of PRP with allogenic bone grafts appears as a promising method for the treatment of solitary bone cysts. Further studies on larger patients series with longer follow-up will be necessary to answer the question whether this method will provide a lower recurrence rate compared to other forms of treatment

Factors associated with low body mass index and weight loss in nursing home residents

Management of Hip Fractures in the Elderly

BACKGROUND: Undernutrition in nursing home residents is a significant and possibly modifiable public health problem. We evaluated the hypothesis that some potentially modifiable factors are associated with resident undernutrition. METHODS: This study is a cross-sectional, secondary data analysis of 6,832 community nursing home residents sampled from 202 nursing homes in 7 states. Data were from the Minimum Data Set (MDS), and HCFA-mandated resident assessment instrument used in U.S. community nursing homes. Two dependent variables represented undernutrition: (a) low body mass index (BMI), defined as the lowest quartile BMI of the sample (19.42 kg/m2 and below); and (b) weight loss, an MDS measure defined as 5% decrease in weight in 30 days, or a 10% decrease in 180 days (9.9% of the sample). Independent variables included resident demographics, eating-related variables, variables measuring functional, cognitive, and affective statuses, and medical conditions. Separate logistic regression models were estimated for low BMI and weight loss to test multivariate associations. RESULTS: Poor oral intake, eating dependency, decubiti, and chewing problems increase the likelihood of both low BMI and weight loss. Female gender, age 85 or older, bedfast, and hip fracture increase the odds of low BMI only; depressed behaviors and two or more chronic diseases increase the odds of weight loss only. CONCLUSION: Undernutrition in nursing home residents is a multifactorial syndrome. Improved oral feeding methods and treatment of depression are potentially important ways to counteract undernutrition in nursing home residents by targeting reversible features

Prosthetic treatment of hip fractures in the elderly patient

Management of Hip Fractures in the Elderly

As the elderly population in our society significantly increases, the incidence of displaced femoral neck fractures will increase proportionally. Three surgical procedures are available to treat such fractures: internal fixation, hemiarthroplasty (unipolar or bipolar), and total hip arthroplasty. Long-term costs and efficacy of these three procedures vary, primarily due to postoperative complications. Thus, it is imperative that all surgeons conduct a proper preoperative evaluation of each patient before choosing the optimal treatment plan. Internal fixation has been shown to be more beneficial for physiologically younger patients who sustain displaced femoral neck fractures. However, the choice between hemiarthroplasty and total hip arthroplasty in the geriatric patient remains difficult. This article aims to provide a practical algorithm for the treatment of these patients

Quantifying the Effects of Different Treadmill Training Speeds and Durations on the Health of Rat Knee Joints

OAK 3 - Non-arthroplasty tx of OAK

BACKGROUND: Walking and running provide cyclical loading to the knee which is thought essential for joint health within a physiological window. However, exercising outside the physiological window, e.g. excessive cyclical loading, may produce loading conditions that could be detrimental to joint health and lead to injury and, ultimately, osteoarthritis. The purpose of this study was to assess the effects of a stepwise increase in speed and duration of treadmill training on knee joint integrity and to identify the potential threshold for joint damage. METHODS: Twenty-four Sprague-Dawley rats were randomized into four groups: no exercise, moderate duration, high duration, and extra high duration treadmill exercise. The treadmill training consisted of a 12-week progressive program. Following the intervention period, histologic serial sections of the left knee were graded using a modified Mankin Histology Scoring System. Mechanical testing of the tibial plateau cartilage and RT-qPCR analysis of mRNA from the fat pad, patellar tendon, and synovium were performed for the right knee. Kruskal-Wallis testing was used to assess differences between groups for all variables. RESULTS: There were no differences in cartilage integrity or mechanical properties between groups and no differences in mRNA from the fat pad and patellar tendon. However, COX-2 mRNA levels in the synovium were lower for all animals in the exercise intervention groups compared to those in the no exercise group. CONCLUSIONS: Therefore, these exercise protocols did not exceed the joint physiological window and can likely be used safely in aerobic exercise intervention studies without affecting knee joint health.

Disaster nephrology: Crush injury and beyond

DOD - Acute Comp Syndrome CPG

Disasters result in a substantial number of renal challenges, either by the creation of crush injury in victims trapped in collapsed buildings or by the destruction of existing dialysis facilities, leaving chronic dialysis patients without access to their dialysis units, medications, or medical care. Over the past two decades, lessons have been learned from the response to a number of major natural disasters that have impacted significantly on crush-related acute kidney injury and chronic dialysis patients. In this paper we review the pathophysiology and treatment of the crush syndrome, as summarized in recent clinical recommendations for the management of crush syndrome. The importance of early fluid resuscitation in preventing acute kidney injury is stressed, logistic difficulties in disaster conditions are described, and the need for an implementation of a renal disaster relief preparedness program is underlined. The role of the Renal Disaster Relief Task Force in providing emergency disaster relief and the logistical support required is outlined. In addition, the importance of detailed education of chronic dialysis patients and renal unit staff in the advance planning for such disasters and the impact of displacement by disasters of chronic dialysis patients are discussed. © 2014 International Society of Nephrology.

A preliminary study of the clinical application of optic pathway diffusion tensor tractography in suprasellar tumor surgery: preoperative, intraoperative, and postoperative assessment

Upper Eyelid and Brow Surgery

OBJECT Visual impairments are the most common objective manifestations of suprasellar lesions. Diffusion tensor imaging (DTI) is a noninvasive MRI modality that depicts the subcortical white matter tracts in vivo. In this study the authors tested the value of visual pathway tractography in comparison with visual field and visual acuity analyses. METHODS This prospective study consisted of 25 patients with progressive visual impairment due to suprasellar mass lesions and 6 control patients with normal vision without such lesions. Visual acuity, visual field, and the optic fundus were examined preoperatively and repeated 1 week and 3 months after surgery. Visual pathway DTI tractography was performed preoperatively, intraoperatively immediately after tumor resection, and 1 week and 3 months after surgery. RESULTS In the control group, pre- and postoperative visual status were normal and visual pathway tractography revealed fibers crossing the optic chiasm without any alteration. In patients with suprasellar lesions, vision improved in 24 of 25. The mean distance between optic tracts in tractography decreased after tumor resection and detectable fibers crossing the optic chiasm increased from 12% preoperatively to 72% postoperatively 3 months after tumor resection, and undetectable fibers crossing the optic chiasm decreased from 88% preoperatively to 27% postoperatively 3 months after tumor resection. Visual improvement after tumor removal 1 week and 3 months after surgery was significantly correlated with the distance between optic tracts in intraoperative tractography (p < 0.01). CONCLUSIONS Visual pathway DTI tractography appears to be a promising adjunct to the standard clinical and paraclinical visual examinations in patients with suprasellar mass lesions. The intraoperative findings, in particular the distance between optic tract fibers, can predict visual outcome after tumor resection. Furthermore, postoperative application of this technique may be useful in following anterior optic pathway recovery.

Simultaneous versus staged bilateral unicompartmental knee replacement

OAK 3 - Non-arthroplasty tx of OAK

We prospectively followed 171 patients who underwent bilateral unicompartmental knee replacement (UKR) over a period of two years. Of these, 124 (72.5%) underwent a simultaneous bilateral procedure and 47 (27.5%) underwent a staged procedure. The mean cumulative operating time and length of hospital stay were both shorter in the simultaneous group, by 22.5 minutes (p < 0.001) and three days (p < 0.001), respectively. The mean reduction in haemoglobin level post-operatively was greater by 0.15 g/dl in the simultaneous group (p = 0.023), but this did not translate into a significant increase in the number of patients requiring blood transfusion (p = 1.000). The mean hospital cost was lower by $8892 in the simultaneous group (p < 0.001). There was no significant difference in the rate of complications between the groups, and at two-year follow-up there was no difference in the outcomes between the two groups. We conclude that simultaneous bilateral UKR can be recommended as an appropriate treatment for patients with bilateral medial compartment osteoarthritis of the knee. ©2013 The British Editorial Society of Bone & Joint Surgery.

Effectiveness and safety of tapentadol prolonged release with tapentadol immediate release on-demand for the management of severe, chronic osteoarthritis-related knee pain: Results of an open-label, phase 3b study

OAK 3 - Non-arthroplasty tx of OAK

This open-label, phase 3b study (ClinicalTrials.gov Identifier: NCT00983073) evaluated the effectiveness, and tolerability of tapentadol for severe, chronic osteoarthritis knee pain that was inadequately managed with World Health Organization (WHO) Step I or II analgesics or co-analgesics, or that was not treated with regular analgesics. Prior to starting study treatment, patients discontinued any WHO Step II analgesics, while Step I analgesics and/or co-analgesics were continued at the same dose. Patients received tapentadol prolonged release (50-250 mg bid) during a 5-week titration period and a 7-week maintenance period. Doses of tapentadol immediate release 50 mg (�twice/day; 4� hours apart) were permitted throughout the study (total daily dose of tapentadol prolonged and immediate release, �250 mg bid). The primary endpoint was the change in pain intensity on an 11-point numerical rating scale-3 (NRS-3; recalled average pain intensity [11-point NRS] during the last 3 days) from baseline to Week 6, using the last observation carried forward (LOCF) to impute missing pain intensity scores. The mean (standard deviation) change from baseline to Week 6 (LOCF) in pain intensity was -3.4 (2.10; P< 0.0001) for all patients evaluated for effectiveness (n = 195). Significant decreases in pain intensity were also observed at Weeks 6, 8, and 12 (all P < 0.0001) using observed-case analysis. Corresponding significant improvements from baseline to Weeks 6 and 12 were observed in the Western Ontario and McMaster Universities osteoarthritis index, the EuroQol-5 Dimension health status questionnaire, the Short Form-36 health survey, and the Hospital Anxiety and Depression Scale (all P�0.0103). Treatment-emergent adverse events were in line with those observed in previous studies of tapentadol prolonged release. Overall, the results of this study indicate that tapentadol treatment results in significant improvements in pain intensity, health-related quality of life, and function in patients with inadequately managed, severe, chronic osteoarthritis knee pain. © 2012 Steigerwald et al, publisher and licensee Dove Medical Press Ltd.

Future perspectives: the need for large clinical trials

Management of Hip Fractures in the Elderly

Fragility fractures represent a growing problem with large economic and patient burdens that are likely to increase as the population ages. The elderly patient with osteopenic bone presents a unique surgical challenge with appreciable risks associated with each surgical treatment option. As demonstrated in this supplement, the current evidence suggests that the best surgical treatment options for patients with fragility fractures remains largely unknown. Additional evidence, from large clinical trials, is required before definitive treatment recommendations can be made in many cases. In this article, we review the example of the femoral neck fracture to illustrate this point

Clinical consequences of vertebral fractures

Management of Hip Fractures in the Elderly

People with vertebral fractures have greater pain, disability, and healthcare utilization, on average, than those without fractures. Most studies of acute pain and disability have been limited to patients with clinically diagnosed fractures (a subset of all symptomatic patients), representing about one third of all patients with fractures identified radiographically. Acute symptoms vary widely. Some patients experience intolerable pain that can be completely debilitating for several weeks or months, whereas about half of all patients with radiographically identified fractures report having had no symptoms. The reasons for this variability are unknown. Chronic pain and disability among patients with vertebral fractures are significantly greater on average than among people without fractures, even after adjusting for comorbid conditions that are common among the elderly. Similar to acute symptoms, chronic symptoms vary widely and often persist for at least several years. The risk of pain and disability increases progressively with the number and severity of vertebral deformities: the risk is multiplied several times with each additional fracture. On average, physical function is impaired among people with vertebral fractures, whether or not they currently report back pain. Declines in physical function and changes in appearance contribute to social isolation and loss of self-esteem, impairing quality of life. The cumulative impact of vertebral fractures on quality of life may rival that of hip fractures because hip fractures are less frequent and occur later in life. As many as 40% of symptomatic vertebral fractures are initially misdiagnosed, signaling a need for greater awareness among physicians and patients. Prevention of initial vertebral fractures should be actively encouraged; even if the initial fracture is asymptomatic, it indicates a greatly increased risk of subsequent fractures, pain, and physical impairment

Asian-specific total knee system: 5-14 year follow-up study

Surgical Management of Osteoarthritis of the Knee CPG

BACKGROUND: Knee size and body size differ in Asians compared with Caucasians. Nevertheless, many total knee arthroplasty (TKA) prostheses used worldwide are made for Western Caucasian subjects. As a result, an Asian's knee might not fit these prostheses. We studied the Flexible Nichidai Knee (FNK) system, a new model of TKA for Asian patients. The purpose of this report is to investigate the outcomes of this prosthesis retrospectively. METHODS: We investigated 1055 primary TKAs in 595 patients who underwent FNK for osteoarthritis (OA) in Japan and were followed for > 5 years. The knee score and function score were used for clinical evaluation. We examined the range of motion (ROM) preoperatively and at final follow-up and radiographic assessments. In addition, postoperative complications were investigated. A survivorship analysis was also conducted using two endpoints: revision for any reason and aseptic failure. RESULTS: 890 knees in 502 patients were available for study (follow-up rate of 96.0%). The mean follow-up term was 8.3 years (range, 5.0-14.1 years). The knee and function score significantly improved from 41.3 to 90.3 and from 39.1 to 76.2 points, respectively (p < 0.001). The mean ROM in FNK posterior cruciate retaining (CR) type and FNK posterior-stabilized (PS) type ameliorated significantly from 107.8 degrees and 95.6 degrees to 110.7 degrees and 110.4 degrees , respectively (p < 0.01). Ten knees underwent revision surgery (infection in 3 cases, instability in 2, loosening in 2, and non-union of femoral supracondylar fracture, severe pain, and recurrent hemarthrosis in 1 each). The survivorship rate was 99.4% (95% CI, 99.0-99.8) at 5 years (n = 952 patients at risk) and 96.2% (95% CI, 91.9-100) at 12.5 years (n = 49 patients at risk). CONCLUSION: The FNK prosthesis for Asians achieved excellent mid- to long-term survivorship and clinical results

Poor glycemic control is associated with low BMD detected in premenopausal women with type 1 diabetes

DoD SSI (Surgical Site Infections)

Summary: The etiology of bone fragility in individuals with type 1 diabetes is unknown. This study demonstrated that bone turnover favors resorption and that poor glycemic control is associated with low bone mineral density (BMD) and low bone turnover, in premenopausal women with type 1 diabetes. The results could inform future interventions. Introduction: Low BMD and fracture may be complications of type 1 diabetes. We sought to determine the roles of bone turnover and glycemic control in the etiology of low BMD. Methods: Premenopausal women from the Wisconsin Diabetes Registry Study and matched controls were compared (n?=?75 pairs). Heel and forearm BMD were measured, and hip and spine BMD were measured in a subset. Markers of bone formation (osteocalcin) and resorption (NTx), and glycemic control (HbA1c) were determined. Results: Age ranged from 18 to 50 years with a mean of 28, and 97% were Non-Hispanic white. Among women with diabetes, mean disease duration was 16 years and current HbA1c was 8%. Compared to controls, women with diabetes had a high prevalence of previous fracture (37% vs. 24%) and low BMD for age (heel or forearm: 49% vs. 31%), low heel and forearm BMD, and low osteocalcin levels. Levels of NTx were similar, suggesting uncoupled turnover favoring resorption. Poor glycemic control was associated with low BMD at all bone sites except the spine, and with low osteocalcin and NTx levels. Conclusions: Optimal glycemic control may prevent low BMD and altered bone turnover in type 1 diabetes, and decrease fracture risk. © 2008 International Osteoporosis Foundation and National Osteoporosis Foundation.

Prevention of hip fractures

Management of Hip Fractures in the Elderly

The effort to identify elderly people at high risk of hip fracture can reasonably focus on patients who are prone to falling (identified by several criteria, including a history of falling) and perhaps those who are likely to be the most osteopenic. Efforts at treatment must be individualized. Increased use of estrogens by women now going through menopause may improve the statistics on hip fracture, beginning 10 to 20 years from now. Meanwhile, the tailoring of interventions in elderly people to prevent falls, to counter osteoporosis, and to identify and treat correctable causes of osteopenia may produce a more immediate improvement in the statistics

Repair of the triangular ligament in Colles' fracture. No effect in a prospective randomized study

Distal Radius Fractures

We present a prospective and randomized study of two different treatments of extraarticular Colles' fracture with a fractured ulnar styloid. The study comprised 41 patients with 2 years' follow-up; 22 patients were treated with closed manipulation and an above-the-elbow plaster cast, whereas in 19 patients the avulsed ulnar styloid was transfixed and/or the triangular ligament was repaired after closed reduction of the fractured radius. In all the operated on patients, a complete rupture of the triangular ligament was found. Good reduction of all the fractures was achieved primarily according to the radiographic examination. At follow-up the alignment had deteriorated, with no difference between the two treatment groups. Neither did the findings in the wrist arthrograms differ between the two groups nor did the subjective complaints of the patients. We conclude that repair of the ruptured triangular ligament in extraarticular fractures of the distal radius is not better than conventional treatment.

Prostate cancer with bone metastases: A clinical profile

MSTS 2018 - Femur Mets and MM

Purpose. Metastasis to bone commonly causes high morbidity and mortality rates in patients with advanced prostate cancer. Prostate-specific antigen (PSA) and bone scans are important modalities for evaluating and following the disease progression. We reviewed clinical symptoms, laboratory data, treatment and prognosis in order to analyze patients with bone-metastasized prostate cancer. Methods. From January 1995 to December 2003, a total of 284 patients with prostate cancer were admitted to the China Medical University Hospital; of them, 97 patients were diagnosed as having bone metastases. The clinical files of the 97 patients with bone metastases were reviewed. The patients were categorized into two groups: group 1 comprised those in whom primary prostate cancer and bone metastases were identified simultaneously; group 2 was composed of those with bone metastases found after identification and treatment of prostate cancer. Results. Bone metastasis was found in 34.2% (97/284 patients) of prostate cancer patients. Of the 97 patients with bone metastasis, the mean age was 71.5 years (range, 49 to 89 years) when prostate cancer was first diagnosed. Axial bones were more affected than appendicular bones. At the time bone metastasis was diagnosed, 69 patients (71.1%) had bone pain, 28 patients (28.8%) were asymptomatic and 6 patients in group 1 and 7 patients in group 2 had a serum PSA value less than 10 ng/mL. Four patients underwent surgical treatment for their pathological femoral fracture, resulting in good pain relief. The survival rate after bone metastasis had developed was not statistically significant between groups 1 and 2 (p>0.05). Of the 3 factors being examined, the age at diagnosis of prostate cancer, the PSA value at first positive bone scan, and initial location and number of bone metastases did not statistically affect the survival rate in these two groups (p>0.05). Conclusions. A serum PSA level â?¥ 10 ng/mL is an important marker in the metastatic work-up of prostate cancer; however bone metastases cannot be ruled out in patients with a serum PSA value of less than 10 ng/mL. There was no difference in the survival rate between untreated and treated prostate cancer patients with bone metastases. The age of the patient, the initial PSA value and the location of bone metastases did not appear to affect the outcome of the disease.

Wrist-Spanning Fixation of Radiocarpal Dislocation: A Cadaveric Assessment of Ulnar Translation

Distal Radius Fractures

Background: Radiocarpal dislocations represent a high-energy wrist injury that can occur with or without concomitant fractures about the wrist. Poor outcomes are often due to radiocarpal instability and secondary ulnar translation. The purpose of this cadaveric study is to determine if there is any difference in the radiographic parameters in a wrist dislocation model given the different location of distal fixation. Methods: Ten paired fresh cadaver upper extremities were fluoroscopically evaluated with posterior-anterior (PA) and lateral views. We created a radiocarpal dislocation model and applied a dorsal bridge plate to either the second or third metacarpal. Repeat PA and lateral fluoroscopic views were obtained for evaluation of radial inclination, radial height, volar tilt, ulnar variance, radiolunate angle, radioscaphoid angle, scapholunate angle, radial rotation index, and four indices for ulnar translation (Taleisnik, Gilula, McMurtry, and Chamay). Results: Bridge plate application to the second metacarpal resulted in a significantly greater incidence of ulnar translation compared to the third metacarpal. Application to either metacarpal resulted in extension of the carpus relative to the radius. Conclusions: A more anatomic radiocarpal relationship was restored more often when distal fixation of the dorsal wrist-spanning bridge plate was applied to the third metacarpal. Further investigation is warranted to determine clinical relevance of these findings in conjunction with clinical and radiographic outcomes.

The Contribution of Genes to Osteoarthritis

Surgical Management of Osteoarthritis of the Knee CPG

Osteoarthritis (OA) is the most prevalent form of arthritis in the elderly. A large body of evidence, including familial aggregation and classic twin studies, indicates that primary OA has a strong hereditary component that is likely polygenic in nature. Furthermore, traits related to OA, such as longitudinal changes in cartilage volume and progression of radiographic features, are also under genetic control. In recent years, several linkage analysis and candidate gene studies have been performed and have unveiled some of the specific genes involved in disease risk, such as FRZB and GDF5. The authors discuss the impact that future genome-wide association scans can have on our understanding of the pathogenesis of OA and on identifying individuals at high risk for developing severe OA. (copyright) 2008 Elsevier Inc. All rights reserved

Work and power of the knee flexor and extensor muscles in patients with osteoarthritis and after total knee arthroplasty

Surgical Management of Osteoarthritis of the Knee CPG

INTRODUCTION: The inflammatory manifestations of knee osteoarthritis (OA) lead to muscle inhibition and hypotrophy, resulting in a reduction in total muscle work and muscle power. Total knee arthroplasty (TKA) is the most adequate surgery for the treatment of advanced OA. However, its effects on muscle functional behavior have not been well understood. OBJECTIVE: To compare the total work and power of the knee flexor and extensor muscles in patients with OA (20) and in patients post-TKA (12) at two angular velocities (60 masculine/sec and 240 masculine/sec). Methods: An isokinetic Biodex dynamometer was used to assess muscle power and total work during isokinetic contractions. Two-way ANOVA for repeated measures was used to compare total muscle work and muscle power between the groups (SPSS software, version 13.0; significance level, P < 0.05). RESULTS: There was no difference between the OA and TKA groups for the total work of both knee extensors and flexors at the two angular velocities (P > 0.05). In addition, no difference was observed in the muscle power of the knee extensors and flexors (P > 0.05). CONCLUSION: Total work and power were similar in the OA and TKA groups, suggesting that TKA did not improve functional capacity, which was similar in both groups

Laser-assisted endoscopic reduction malarplasty in Asians: quick combined surgery

Upper Eyelid and Brow Surgery

Removal of unwanted prominent cheek bones is of major importance to Korean women for correction of their unfavorable impression. We usually use a endoscope for reducing the external scar, but in endoscopic bone contouring surgery, it is important to prevent any damage to surrounding soft tissue during osteotomy and to control bleeding, without any facial nerve damage, with a clean endoscopic visual field. We used endoscopic surgery equipment, an ultrashort-pulsed endoscopic contact Nd-Yag laser (Japan SLT), and various laser fiber tips and osteotomes. Twenty-one patients who underwent laser-associated endoscopic reduction malarplasty with more than 1 year of follow-up were evaluated. Compared to conventional endoscopic osteotomy, this combined procedure was found to be safe and effective in endoscopic reduction malarplasty, due to the clean visual field and excellent hemostasis provided.

Treatment options for lentigo maligna

Reconstruction After Skin Cancer

Lentigo maligna (LM) is the most common type of melanoma in situ. As LM is related to cumulative sun exposure, it often presents on the face of elderly patients. In this paper we will discuss the advantages and disadvantages of the most common treatments for LM in the Netherlands, such as conventional surgery, micrographic surgery, imiquimod with or without ablative laser therapy and close follow up.

Quantitative computed tomography of the lumbar spine, not dual x-ray absorptiometry, is an independent predictor of prevalent vertebral fractures in postmenopausal women with osteopenia receiving long-term glucocorticoid and hormone-replacement therapy

AAHKS (2) Corticosteroids

OBJECTIVE: To determine which measurement of bone mineral density (BMD) predicts vertebral fractures in a cohort of postmenopausal women with glucocorticoid-induced osteoporosis. METHODS: We recruited 114 subjects into the study. All had osteopenia of the lumbar spine or hip, as demonstrated by dual x-ray absorptiometry (DXA), and were receiving long-term glucocorticoids and hormone replacement therapy (HRT). Measurements of BMD by DXA of the lumbar spine, hip (and subregions), and forearm (and subregions), quantitative computed tomography (QCT) of the spine and hip (n = 59), and radiographs of the thoracolumbar spine were performed on all subjects to assess prevalent vertebral fractures. Vertebral fracture prevalence, as determined by morphometry, required a >or=20% (or >or=4-mm) loss of vertebral body height. Demographic information was obtained by questionnaire. Multiple regression and classification and regression trees (CART) analyses were used to assess predictors of vertebral fracture. RESULTS: Twenty-six percent of the study subjects had prevalent fractures. BMD of the lumbar spine, total hip and hip subregions, as measured by QCT, but only the lumbar spine and total hip, as measured by DXA, were significantly associated with prevalent vertebral fractures. However, only lumbar spine BMD as measured by QCT was a significant predictor of vertebral fractures. CART analysis showed that a BMD value <0.065 gm/cm(3) was associated with a 7-fold higher risk of fracture than a BMD value >or=0.065 gm/cm(3). CONCLUSION: In postmenopausal women with osteoporosis induced by long-term glucocorticoid treatment who are also receiving HRT, BMD of the lumbar spine as measured by QCT, but not DXA, is an independent predictor of vertebral fractures.

Hyperthermic antiblastic perfusion with alpha tumor necrosis factor and doxorubicin for the treatment of soft tissue limb sarcoma in candidates for amputation: Results of a phase I study

MSTS 2018 - Femur Mets and MM

To improve the therapeutic effectiveness of hyperthermic antiblastic perfusion (HAP), the association of recombinant tumor necrosis factor alpha (rTNFα), doxorubicin, and true hyperthermia (41°C) was employed for the treatment of soft tissue limb sarcoma. A dose-escalation study according to Fibonacci's modified scheme was conducted, starting with a rTNFα dose of 0.5-3.3 mg. The doxorubicin doses (0.7 and 1.4 mg for the upper and lower limbs, respectively) and temperature level (41°C) remained unchanged. Eighteen patients have been treated thus far: 9 males and 9 females of a mean age of 33 years (range: 24-71 years). The tumor was located in the upper limb in one patient and in the lower limbs in seventeen. Only 16 patients were evaluable, as 2 refused further treatment after the perfusion. In terms of local toxicity, a grade I limb reaction was observed in 3 patients, a grade II or III in 10 patients, and a grade IV in 5 patients, showing a strict correlation between the TNF dose and the grade of limb reaction. In fact, a grade III-IV limb reaction was observed in 66.6% of the patients treated with >1 mg of rTNFα. The maximum tolerable dose in association with doxorubicin and true hyperthermia (41°C) was 2.4 mg. Eleven patients showed a good pathological response (>75%) and five patients showed a partial response (>25%-<75%). In no case was stable or progressive disease observed. The postperfusional tumor shrinkage permitted limb-sparing surgery in 75% of the patients, all of whom were candidates for amputation before HAP. No recurrences have been observed thus far. Two patients developed regional disease: one presented with a skip femur metastasis that disappeared after radiotherapy and systemic chemotherapy; the second developed regional node involvement, requiring a radical node dissection. Another patient had pulmonary metastases, 2 months after the HAP, which were resected. At a median follow-up of 12 months, all the patients are living without disease. The results of this phase I study suggest that the association of rTNFα, doxorubicin, and true HAP (41°C) by regional perfusion is feasible and safe at a maximum tolerable rTNFα dose of 2.4 mg. However, because no correlation was found between the amount of rTNFα and the tumor response, 1 mg is recommended as the dose able to provide a high tumor necrosis rate and low local and systemic toxicity. This association appears to play an important role in the neoadjuvant treatment of soft tissue limb sarcoma.

Evaluation of porous block hydroxylapatite for augmentation of alveolar ridges

Dental Implant Infection

Twenty-nine alveolar ridges were augmented with porous block hydroxylapatite (HA). Sixty-five percent of the implants had to be partially or totally removed within one year. Thirty-eight percent of the patients had significant delay in receiving their dentures because of delayed healing.

Outcomes following hip and knee replacement in diabetic versus nondiabetic patients and well versus poorly controlled diabetic patients: a prospective cohort study

OAK 3 - Non-arthroplasty tx of OAK

Background and purpose â?? The impact of diabetes and glycemic control before joint replacement on clinical and patient-reported outcomes is unclear. We compared pain, function, complications, and length of hospital stay in diabetic and nondiabetic patients receiving primary total hip (THR) or knee replacement (TKR) and compared these outcomes in patients with poorly controlled versus well-controlled diabetes. Patients and methods â?? We conducted a prospective cohort study of patients undergoing primary THR (n = 300) or TKR (n = 287) for osteoarthritis. Self-reported diabetes and glycemic control (HbA1c â?¤ or >7%) extracted from medical notes were used. Adjusted comparisons were performed with generalized linear models including body mass index (BMI) and comorbidities. Results â?? Diabetes prevalence was 11% (THR 8%; TKR 14%). Diabetic patients were more likely to have a higher BMI and greater number of comorbidities. The median length of hospital stay was 1 day longer in diabetic patients (p = 0.004), but this attenuated after adjustments for BMI and comorbidities (p = 0.3). Inpatient pain was greater for diabetic patients but attenuated following adjustment. The 12-month postoperative WOMAC subscales were similar by diabetes status following adjustment. There was little evidence of difference in outcomes according to glycemic control. Interpretation â?? The associations between diabetes and worse postoperative outcomes in patients undergoing THR or TKR for osteoarthritis appear to be predominantly due to associated obesity and comorbidities. In diabetic patients there is little evidence of association between postoperative outcome and preoperative glycemic control. The underlying mechanisms and causal pathways of obesity, diabetes, and multimorbidity that lead to worse outcomes after joint replacement are not well known.

Periarticular local anesthesia does not improve pain or mobility after THA

AAHKS (4) Acetaminophen

Background Periarticular infiltration of local anesthetic, NSAIDs, and adrenaline have been reported to reduce postoperative pain, improve mobility, and reduce hospital stay for patients having THAs, but available studies have not determined whether local anesthetic infiltration alone achieves similar improvements. Questions We therefore asked whether periarticular injection of a local anesthetic during THA reduced postoperative pain and opioid requirements and improved postoperative mobility. Methods We randomized 96 patients to either treatment (n = 50) or control groups (n = 46). Before wound closure, the treatment group received local infiltration of 160 mL of levobupivacaine with adrenaline. The control group received no local infiltration. We assessed postoperative morphine consumption and pain during the 24 hours after surgery. Mobilization was assessed 24 hours postoperatively with supine-to-sit and sit-to-stand transfers, timed 10-m walk test, and timed stair ascent and descent. Patients and assessing physiotherapists were blind to study status. Result We observed no differences in postoperative morphine consumption, time to ascend and descend stairs, or ability to transfer between treatment and control groups. The treatment group reported more pain 7 to 12 hours postoperatively, but there were no differences in pain scores between groups at all other postoperative intervals. The treatment group showed increased postoperative walking speed greater than 6 m, but not greater than 10 m, compared with the control group. Conclusions Periarticular infiltration of local anesthetic during THA did not reduce postoperative pain or length of hospital stay and did not improve early postoperative mobilization. © The Association of Bone and Joint Surgeons® 2012.

Osteocyte recruitment declines as the osteon fills in: interacting effects of osteocytic sclerostin and previous hip fracture on the size of cortical canals in the femoral neck

Management of Hip Fractures in the Elderly

There is little information on the distribution of osteocytes within the individual cortical osteon, but using direct 3-D imaging in a single subject, Hannah et al. found a gradient with a two-fold higher density of cells adjacent to the cement line compared to near the canal. Since a limiting factor for bone formation might be the availability of osteoblasts due to their recruitment as osteocytes, we studied distributions of osteonal osteocytes in frozen sections of the femoral neck cortex. Osteocytes were stained with an anti-sclerostin antibody and counter-stained with toluidine blue. Adjacent sections were stained for alkaline phosphatase (ALP). Each osteonal osteocyte was categorised as being sclerostin-positive (scl+) or negative (scl-). ImageJ was used to measure the perimeter and area of each osteon and canal, while special purpose routines were used to measure the minimum distances of each osteocyte from the cement line and the canal. Canal area was strongly correlated with osteon area. Osteocytes were most dense close to the cement line; and their areal density within the matrix declined up to three-fold between the cement line and the canal, depending on osteon diameter. Large and small osteons had similar densities of osteocytes close to the cement line, but fractured neck of femur cases had significantly lower densities of osteocytes close to the canal. Higher osteocyte density close to the canal was associated with ALP expression. It is concluded that entombment of osteocytes newly drawn from the osteoblast pool into the mineralising matrix is independent of preceding bone resorption depth. As osteonal infilling proceeds, osteocyte formation declines more rapidly than matrix formation, leading to a progressive reduction in osteocyte density. A shrinking supply of precursor osteoblasts due to previous osteocyte recruitment, apoptosis, or both could produce this effect. In a statistically significant contrast, sclerostin negative osteocytes adjacent to the canal had the expected effect of reducing canal size in controls but this was not seen in hip fracture. This demonstrated the failure of osteonal osteoblasts to sustain bone formation through a complete remodelling cycle in osteoporosis, perhaps due to insufficient osteoblasts remaining capable of mineralized matrix formation. The failure of osteocytic sclerostin suppression to associate with bone formation in these osteons might alternatively be explained by downstream interference with sclerostin's effect on wnt signalling

Surgical management of persistent intoeing gait due to increased internal tibial torsion in children

OAK 3 - Non-arthroplasty tx of OAK

BACKGROUND: Intoeing gait is frequently seen in developing children, and in most cases it resolves with growth. However, persistent, extreme intoeing gait, due to increased internal tibial torsion, may disrupt gait function. At our institution, children with symptomatic intoeing gait are evaluated per a standardized protocol, which includes quantitative gait analysis. When the primary cause is increased internal tibial torsion, surgical correction by supramalleolar tibial rotational osteotomy is recommended. METHODS: The study design was a retrospective case series, with normative controls (31 children), of typically developing children with symptomatic intoeing gait who were treated by isolated supramalleolar tibial rotation osteotomy (28 children, with 45 treated extremities). Preoperative and 1-year postoperative physical examination, kinematic, kinetic, and pedobarographic data were compared. Patient-reported and parent-reported outcomes in functional and satisfaction domains were assessed by items on a 7-point questionnaire. RESULTS: Internal tibial torsion, foot progression angle, and knee rotation were normalized following tibial rotation osteotomy. Compensatory external hip rotation and external knee progression angle were significantly improved but not normalized following tibial rotation osteotomy. An increased coronal plane knee varus moment was significantly decreased following surgery. Increased sagittal and transverse plane knee moments were significantly decreased but not normalized following surgery. Significant improvements were observed with respect to tripping, falling, foot/ankle pain, and knee pain following surgery. CONCLUSIONS: Children with symptomatic intoeing gait because of increased internal tibial torsion have characteristic primary and compensatory kinematic gait deviations that result in increased loading about the knee during the stance phase of gait. Correction of the internal tibial torsion by rotation osteotomy improves, but does not normalize, all the kinematic and kinetic gait deviations associated with intoeing gait. The association between increased internal tibial torsion and degenerative arthritis of the knee in adults may be a consequence of longstanding increased loading of the knee joint due to the kinematic gait deviations seen with intoeing gait. LEVEL OF EVIDENCE: Therapeutic intervention, level III. Copyright © 2014 by Lippincott Williams & Wilkins.

Alendronate Treatment of Osteoporosis in Rheumatoid Arthritis

Distal Radius Fractures

Primary objectives: � to assess the effect of discontinuation of alendronate (ALN) on C�terminal telopeptide crosslinks (CTX) and Type 1 procollagen amino�terminal�propeptide (P1NP) after 6 months � to assess the effect of discontinuation of ALN on bone mineral density (BMD) on DXA scans at 2 years Secondary objectives: � to assess the effect of discontinuation of ALN on vBMD on HRpQCT scans at 2 years � to assess the effect of discontinuation of ALN on biochemical markers of bone metabolism after 6 and 24 months � to evaluate and compare the changes in vBMD in cancellous and cortical bone respectively, after discontinuation of ALN � to evaluate the correlation between RA activity measured by DAS28�CRP and bone metabolism Interventions: Participants will be randomized to one of two groups: � Group 1 (Alendronate group, N=80): alendronate 70mg/weekly, calcium 800 mg/day and vitamin D 38 µg/day � Group 2 (Placebo group, N=80): alendronate�placebo, calcium 800 mg/day and vitamin D 38 µg/day Concomitant treatment of RA: Patients included in this trial will be treated according to the national Danish guidelines for treatment of RA Assignment of intervention: The Hospital Pharmacy in Aarhus will carry out the randomization. Using the web�based programme randomization.com a list of distribution is produced. The randomization will be stratified according to which type of treatment the patients receives for RA. All patients receiving traditional DMARDs such as methotrexate, sulfasalazine, hydroxychloroquine, leflunomide or a combination hereof will be allocated to grop A. All patients receiving any kind of biological treatment (bDMARDs) e.g. infliximab will be allocated to group B. When requesting randomization from the hospital pharmacy, the investigator will note if the patient is group A or B. Both group A and B will undergo randomization 1:1 in the ALN and placebo groups, using block randomization in blocks of 6. Participant timeline: Patients will be seen at a screening visit, at baseline and after 3, 6, 12, and 24 months Procedures at screening: informed consent procedures, full medical history, full physical examination, 12� lead EKG, screening blood samples, DXA scan Procedures at all other visits: focused physical exam of joints and back, measurement of blood pressure, pulse and temperature, calculation of DAS28�CRP and HAQ scores, screening for adverse events, routine and project blood samples. At baseline visit: HRpQCT scan and Xrays of hands and feet At visit 12 months: DXA and HRpQCT scans At visit 24 months: DXA and HRpQCT scans, xrays of hands and feet Clinical laboratory tests: � routine analyses include: alkaline phosphatase, creatinine, alanine aminotransferase (ALT), platelet count, Hemoglobin, white blood cells, absolute neutrophil count, absolute lymphocyte count, CRP (total 8ml) � screening analyses: routine analysis as well as s�FSH and/or HCG (women only), calcium, PTH, vitamin�D status, TSH (total 16 ml) � primary project analyses include: CTX and P1NP (total 4 ml) � secondary project analysis include: bone specific alkaline phosphatase, RANK�L, sclerostin, tumor necrosis factor, osteoprotegrin, P1NP, osteocalcin, IL�6, IL�17 (total 8 ml) � extra blood bank sample � 3ml serum, 2 ml plasma and full blood for storage and later analysis DXA scan: Study participants will be scanned using a Hologic discovery machine.To ensure comparative results, the same machine will be used for each participant at each scan. Lumbar spine anterior�posterior and left hip pictures are recorded following local guidelines. HR�pQCT scan: Bone structure will be measured at metacarpals 2�4 and proximal radius using the model XTREME CT�I SCANCO MEDICAL AG; SCHWEIZ. A 2,7 cm long area over the right hand second and third metacarpophalangeal joint is scanned. After this a 0,9 cm long part of the distal radius is scanned The 3D dataset will be analyzed and number and volume of erosions calculated. Volumetric BMD is calculated for both cortical and trabecular bone, tr becular number and separation according to the built�in software. X�rays of hands and feet: Standardized X�rays of the hands/forearms and upper feet in separate AP (dorsopalmar) projections of each hand and wrist and dorsoplantar projections of the feet Images of the hands will be centered around the 2nd and 3rd MCPjoints The foot must not be tilted in the case of suboptimal projections of the MTP�joints. All images will be scored centrally according to the Sharp�van der Heide score system. DAS28�CRP: A clinical activity score for arthritis activity is calculated by means of � number of tender and swollen joint scores including the following twenty eight joints: shoulders, elbows, wrists, metacarpophalangeal joints, proximal interphalangeal joints and the knees. � crp�measurement � general health assessment by the doctor using a VAS�scale A number between 0 and 10 is calculated. Values <2,6 are considered in remission, values >2,6 are considered as evidence of disease activity Harms: The dose of radiation is estimated to 0,07mSievert, as each HR�pQCT scan contributes with 0,012mS, each DXAscan 0,01mS and each Xray status of hands and feet 0,008mS. The average annual background radiation exposure in Denmark is 3mSievert. Thus the participants will receive an increased radiation dose corresponding to 9 days of background radiation. The HR�pQCT�scans require fixation of the hand for 8 and 3 minutes respectively, which might cause slight discomfort. Safety measures: All routine biochemical markers (visit 1�5) will be analyzed and evaluated promptly. An increase in alkaline phosphatase of more than 100% will lead to the participant being called in for an extra visit for further evaluation of the cause. The patient will be withdrawn from the study if there is suspicion of accelerated bone loss. All fractures will be recorded and in the case of low�energy fracture the patient will be withdrawn from the study. The 12 month DXA scans will be reviewed and a BMD decrease of more than 5% will lead to exclusion from the study.

Abdominoplasty in the Overweight and Obese Population: Outcomes and Patient Satisfaction

Panniculectomy & Abdominoplasty CPG

BACKGROUND: Abdominoplasty is a safe, efficacious body contouring procedure commonly performed on patients after massive weight loss or pregnancy, or because of general aging. However, complication rates and patient satisfaction levels remain largely unexplored for the overweight and obese patient population. The purpose of this study was twofold: to determine the complication rate and to gauge the psychological impact of abdominoplasty in the overweight or obese patient. METHODS: A retrospective review was conducted of consecutive overweight and obese patients undergoing abdominoplasty or panniculectomy over a 12-year period from January of 2004 to December of 2016. Patient medical records were reviewed to identify patient demographics and comorbidities, operative details, and postoperative course. A patient survey was used to assess satisfaction, personal experience with complications, and the recovery process. RESULTS: Forty-six total patients underwent abdominoplasty or panniculectomy during the 12-year period and met the criterion of body mass index greater than or equal to 25 kg/m. The average patient body mass index was 32.0 kg/m, with the majority of the patients categorized as overweight. The average abdominal resection weight was 4834.9 g. Major complications, defined as complications requiring return to the operating room, occurred in four patients (8.7 percent). Minor complications, defined as complications that could be handled in an office setting, occurred in 18 patients (39.1 percent). Thirty-six patients (78.3 percent) responded to the survey. The overwhelming majority of patients who responded to the survey [n = 35 (97.2 percent)] stated that they were satisfied with the final outcome and would choose to have the procedure again. CONCLUSION: Abdominoplasty and panniculectomy in overweight and obese patients are associated with an elevated complication rate, yet patient satisfaction is overwhelmingly high, suggesting the viability of body contouring procedures in this patient population. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Parenteral administration of ketoprofen in osteoarthritis: a double-blind trial versus the N-methyl-d-glucamine salt of indomethacin

OAK 3 - Non-arthroplasty tx of OAK

In a double�blind trial 40 patients with ostheoarthritis were treated for relief of pain with ketoprofen or with the N�methyl�d�glucamine salt of indomethacin, both drugs being administered i.m. at the dosage of 100 mg/day for 12 days. Ketroprofen and the indomethacin salt significantly improved pain, functional capacity and walking distance, while only the former reduced the knee size in the patients with gonarthritis. The two drugs showed roughly the same latency period and the same duration of activity. Ketoprofen was perfectly tolerated: on the contrary, in one patient treated with the indomethacin salt, the treatment was stopped because of vascular hypotension and cutaneous rash. A significant increase of blood urea nitrogen was observed only in the group of patients treated with the indomethacin salt.

Total knee and hip replacement for patients with haemophilia: Brno experience

Surgical Management of Osteoarthritis of the Knee CPG

Introduction: Haemarthrosis is a common complication in haemophilia, often resulting in joint degeneration requiring total joint replacement. Patients and methods: We have reviewed twenty total knee and hip replacements performed from 2000 to 2009. Twelve total knee arthroplasties (3 bilateral) and 8 hip arthroplasties (5 multi-joint hip and knee replacement) have been performed in 15 cases of haemophilia (9 patients with severe and 4 with mild haemophilia A, 2 patients with severe haemophilia B). Patient age varied from 38 to 77 years (median 53). Postoperative thromboembolic prophylaxis with low molecular weight heparin was used in all patients. Results: Median duration of hospitalization at orthopaedic department was 19 days, median follow-up was 62 months, median cumulative dose of clotting factor during hospitalization at orthopaedic department was 63,500 IU for all patients (not including one patient with anamnestic response to FVIII inhibitor), and 66,500 IU for severe haemophiliacs. Median range of motion of the knee joint was 27 preoperatively and improved to 73 postoperatively. Median range of motion of hip joint was unchanged (0-90). Complications: Femur fracture above prosthesis in one case, bleeding in two cases, and two knee joints had to be mobilized (each joint twice) under anaesthesia for stiffness after arthroplasty. Conclusion: Total hip and knee arthroplasty in the case of haemophilia patients is a useful procedure to improve quality of life with good functional results in most cases, particularly for knee joints, despite postoperative stiffness in some cases and risk of late infection when bleeding is not adequately treated

Jaw complications associated with bisphosphonate use in patients with plasma cell dyscrasias

MSTS 2018 - Femur Mets and MM

Osteonecrosis of the jaw has been linked with bisphosphonate use in breast cancer and multiple myeloma patients. We report 17 cases of patients with plasma cell dyscrasia being treated with bisphosphonate who developed osteonecrosis/osteomyelitis of the jaw. Seventeen patients evaluated at our institution between 1998 and 2005 are reported. All were being treated with bisphosphonates for a median of 5 mo prior to the onset of jaw symptoms. Sixteen of the 17 patients are 51 yr or older. None of the patients had been irradiated in the jaw nor had obvious osseous manifestation of multiple myeloma in the jaw. Thirteen patients were receiving zoledronic acid and four patients were receiving pamidronate at the onset of jaw symptoms. Six of the 17 did receive both agents at some time and all of these individuals were receiving zoledronic acid at diagnosis. Microorganisms were isolated in 7/17 patients with the most common organism being actinomycosis. We have initiated the following guidelines in an effort to ameliorate the incidence of this complication. Patients should have a full dental examination at the time of diagnosis of the plasma cell dyscrasia especially if bisphosphonates are to be considered as part of the therapy. In addition, bisphosphonates are held for a period of 3 mo prior to invasive dental procedures to allow for the osteoclastic recovery, therefore enhanced debris removal and lessening the chance of creating a fertile bacterial medium. Following the dental procedure we would re-introduce bisphosphonates only after the healing process is complete. Finally, multiple myeloma patients diagnosed with jaw osteonecrosis probably have a concurrent infection and should be aggressively treated with antibiotics.

Economic consequences of venous thromboembolism following major orthopedic surgery

HipFx Supplemental Cost Analysis

BACKGROUND: Venous thromboembolism (VTE) is a frequent and potentially costly complication of major orthopedic surgery. OBJECTIVE: To estimate the economic consequences of VTE following major orthopedic surgery. METHODS: Using a large healthcare claims database, we identified all patients who underwent total hip replacement, major knee surgery, or hip fracture repair from January 1993 to December 1998. Patients with clinical VTE (cases) were identified based on a diagnosis of deep vein thrombosis or pulmonary embolism within 90 days of surgery (index admission) and > or =1 prescription for warfarin or unfractionated heparin within 30 days of the date of initial VTE diagnosis. Each case was matched (using age and procedure type) to 2 randomly selected patients who did not have any claims for clinical VTE (matched controls). Utilization and billed charges were then examined over a 90-day period following admission. Cases were stratified based on whether VTE was first noted during the index admission or thereafter. RESULTS: A total of 11 960 patients were identified who underwent total hip replacement, major knee surgery, or hip fracture repair (n = 3171, 3955, 4834, respectively). Over a 90-day period, 259 patients (2.2%) developed clinical VTE. Most cases (61.8%) occurred after hospital discharge. For patients with in-hospital VTE, mean length of stay for the index admission was 4.5 days longer than that of matched controls (11.1 vs 6.6); by day 90, there was a 5.4-day difference in total hospital days. Mean billed charges for the index admission were 17,552 higher US dollars (52,037 US dollars vs 34,485 US dollars); the difference rose to 18,834 US dollars by day 90 (54,480 US dollars vs 35,646 US dollars). For patients who developed clinical VTE following hospital discharge, there was a 3.4-day difference in total hospital days at day 90 (10.2 vs 6.8) as a result of readmissions for VTE; mean total billed charges at day 90 were 5765 US dollars higher (41,411 US dollars vs 35,646 US dollars). CONCLUSIONS: Among patients who have undergone major orthopedic surgery, the economic consequences of VTE are substantial, regardless of the setting in which it occurs

Quantitative index for deciding whether to administer preventive anticoagulant therapy in osteoarthritis patients undergoing total knee arthroplasty

Surgical Management of Osteoarthritis of the Knee CPG

BACKGROUND: The 2008 American Academy of Orthopedic Surgeons recommended that surgeons assess the relative risks of venous thromboembolism and bleeding in patients undergoing total knee arthroplasty (TKA). In this situation, a quantitative index is required for deciding whether to administer preventive anticoagulant therapy for deep venous thrombosis (DVT). In this study, we investigated the risk factors for DVT after TKA. METHODS: We included 102 patients (122 knees) who underwent primary TKA for osteoarthritis of the knee between October 2007 and March 2010. DVT was evaluated using lower limb venous ultrasonography. Cutoff values for individual risk factors were determined using a receiver-operating characteristic analysis, and the patients were grouped according to the cutoff values; the odds ratios (95 % CI) were also investigated. The Wilcoxon signed-rank test and chi 2 test were also used. RESULTS: DVT was positive in 25 knees (20.5 %). Three risk factors for DVT after TKA were identified: age 76 years or older, preoperative maximum soleus vein (MAX-SV) diameter of 6.0 mm or greater, and preoperative D-dimer value of 1.1 mug/dl or higher. The incidence of DVT was significantly higher in the group with two or more risk factors than in the group with one or no risk factors (p = 0.0001). CONCLUSIONS: Development of postoperative DVT correlated significantly with the presence of the following risk factors: age 76 years or older, preoperative MAX-SV diameter of 6.0 mm or greater, and a preoperative D-dimer value of 1.1 mug/dl or higher. Considering the risk-benefit ratio, avoiding preventive anticoagulant therapy following TKA can be an option for patients with osteoarthritis with one or no risk factors

Implementing international osteoarthritis treatment guidelines in primary health care: study protocol for the SAMBA stepped wedge cluster randomized controlled trial

OAK 3 - Non-arthroplasty tx of OAK

BACKGROUND: Previous research indicates that people with osteoarthritis (OA) are not receiving the recommended and optimal treatment. Based on international treatment recommendations for hip and knee OA and previous research, the SAMBA model for integrated OA care in Norwegian primary health care has been developed. The model includes physiotherapist (PT) led patient OA education sessions and an exercise programme lasting 8-12 weeks. This study aims to assess the effectiveness, feasibility, and costs of a tailored strategy to implement the SAMBA model. METHODS/DESIGN: A cluster randomized controlled trial with stepped wedge design including an effect, process, and cost evaluation will be conducted in six municipalities (clusters) in Norway. The municipalities will be randomized for time of crossover from current usual care to the implementation of the SAMBA model by a tailored strategy. The tailored strategy includes interactive workshops for general practitioners (GPs) and PTs in primary care covering the SAMBA model for integrated OA care, educational material, educational outreach visits, feedback, and reminder material. Outcomes will be measured at the patient, GP, and PT levels using self-report, semi-structured interviews, and register based data. The primary outcome measure is patient-reported quality of care (OsteoArthritis Quality Indicator questionnaire) at 6-month follow-up. Secondary outcomes include referrals to PT, imaging, and referrals to the orthopaedic surgeon as well as participants' treatment satisfaction, symptoms, physical activity level, body weight, and self-reported and measured lower limb function. The actual exposure to the tailor made implementation strategy and user experiences will be measured in a process evaluation. In the economic evaluation, the difference in costs of usual OA care and the SAMBA model for integrated OA care will be compared with the difference in health outcomes and reported by the incremental cost-effectiveness ratio (ICER). DISCUSSION: The results from the present study will add to the current knowledge on tailored strategies, which aims to improve the uptake of evidence-based OA care recommendations and improve the quality of OA care in primary health care. The new knowledge can be used in national and international initiatives designed to improve the quality of OA care. TRIAL REGISTRATION: ClinicalTrials.gov NCT02333656.

Randomised controlled trial of extraarticular gold bead implantation for treatment of knee osteoarthritis: a pilot study

OAK 3 - Non-arthroplasty tx of OAK

The primary objective of this double�blind, randomised, controlled trial was to determine if implanting gold beads at five acupuncture points around the knee joint improves 1�year outcomes for patients with osteoarthritis (OA) of the knee. Participants were 43 adults aged 18�80 years with pain and stiffness from non�specific OA of the knee for over a year. The intervention was blinded implantation of gold beads at five acupuncture points around the affected knee through a hypodermic needle, or needle insertion alone. Primary outcome measures were knee pain, stiffness and function assessed by the patient at 0, 1, 3, 6, 9 and 12 months and knee score and knee function assessed by an orthopaedic surgeon at 0, 6 and 12 months. Within the first month, three patients dropped out. The remaining 21/19 patients in the intervention/control groups generally improved, but there was no statistically significant difference between the groups. The improvement was shown in the patients' self�assessment scores that decreased from randomisation until 1 year later (intervention/control group, medians): pain �1.92/�2.18 (P = 0.95, F test, general linear mixed model); stiffness �0.93/�0.43 (P = 0.11); function �7.23/�3.36 (P = 0.63). The surgeon's scores also generally improved, i.e. increased: knee score +16.4/+8.2 (P = 0.65); knee function +10.5/+5.8 (P = 0.79). In the protocol�based subgroup analysis, the 15 intervention patients of the 32 patients who had a positive response to the initial conventional acupuncture had greater relative improvements in self�assessed outcomes. The treatment was well tolerated. This 1�year pilot study indicates that extraarticular gold bead implantation is a promising treatment modality for patients with OA of the knee. The new treatment should be tested in a larger trial including only patients who respond positively to initial conventional acupuncture.

Effect of age on susceptibility to post-traumatic infection in the elderly

Management of Hip Fractures in the Elderly

Previous work has demonstrated an age-related decline in neutrophil function, including a decline in phagocytic capacity, with age in healthy individuals. This decline in function may contribute to increased susceptibility to bacterial infections in the elderly population. The present study has investigated the effects of age on susceptibility to infection and neutrophil function in elderly humans following mild trauma. Specifically, we have measured neutrophil function in 44 patients, all of whom had no significant co-morbidity, were over 65 years old (mean age 82.5 years) and had sustained a fractured neck of femur. We obtained neutrophils and examined the process of microbial engulfment by phagocytosis and the bactericidal mechanism of superoxide production. In the 5-week period after trauma, almost half of the elderly trauma patients succumbed to bacterial or fungal infection, with a predominance of chest and urinary tract infections. When examining neutrophil function, a decline in superoxide production was observed in neutrophils from the elderly trauma group at the time of hip fracture when compared with those from healthy elderly controls, and this was maintained 5 weeks after trauma. This was accompanied by an age-related reduction in phagocytic function during this period. We propose that trauma and an age-related decline in neutrophil function combine to decrease the immune response to bacteria in the elderly

Curcuminoids extract, hydrolyzed collagen and green tea extract synergically inhibit inflammatory and catabolic mediator's synthesis by normal bovine and osteoarthritic human chondrocytes in monolayer

OAK 3 - Non-arthroplasty tx of OAK

The main objective of this study was to assess the in vitro effects of curcuminoids extract, hydrolyzed collagen and green tea extract in normal bovine chondrocytes and osteoarthritic human chondrocytes cultured in monolayer. This study also investigated the synergic or additive effects of these compounds. Enzymatically isolated primary bovine or human chondrocytes were cultured in monolayer until confluence and then incubated for 24 hours or 48 hours in the absence or in the presence of interleukin-1beta and with or without curcuminoids extract, hydrolyzed collagen or green tea extract, added alone or in combination, at different concentrations. Cell viability was neither affected by these compounds, nor by interleukin 1beta. In the absence of interleukin-1beta, compounds did not significantly affect bovine chondrocytes metabolism. In human chondrocytes and in the absence of interleukin 1beta, curcuminoids extract alone or in combination with hydrolyzed collagen and green tea extract significantly inhibited matrix metalloproteinase-3 production. In interleukin-1beta-stimulated bovine chondrocytes, interleukin-6, inducible nitric oxide synthase, cyclooxygenase2, matrix metalloproteinase 3, a disintegrin and metalloproteinase with thrombospondin type I motifs 4 and a disintegrin and metalloproteinase with thrombospondin type I motifs 5 expressions were decreased by curcuminoids extract alone or in combination with hydrolyzed collagen and green tea extract. The combination of the three compounds was significantly more efficient to inhibit interleukin-1beta stimulated matrix metalloproteinase-3 expression than curcuminoids extract alone. In interleukin-1beta-stimulated human chondrocytes, nitric oxide, interleukin-6 and matrix metalloproteinase 3 productions were significantly reduced by curcuminoids extract alone or in combination with hydrolyzed collagen and green tea extract. These findings indicate that a mixture of curcuminoids extract, hydrolyzed collagen and green tea extract has beneficial effects on chondrocytes culture in inflammatory conditions and provide a preclinical basis for the in vivo testing of this mixture.

Evaluation of acute traumatic hemarthrosis of the knee joint

Surgical Management of Osteoarthritis of the Knee CPG

Acute hemarthrosis of the knee usually results from a significant injury. Preoperative assessment, examination under anesthesia, and arthroscopic examination were conducted on patients with a total of 132 acutely injured knees associated with hemarthrosis and minimal clinical laxity to determine the presence and extent of injury to ligamentous and/or intra-articular structures. Partial or complete tear of the anterior cruciate ligament was found in 101 (77%) of the knees. Peripheral meniscal tears were responsible for the hemarthrosis in 17 cases (13%), and osteochondral fractures were found in 11 cases (8%). Injury to the anterior cruciate ligament was frequently associated with concomitant injury to other structures: meniscal tears (61%), ligament/capsular injury (40%), and hyaline chondral damage (16%). Patients' responses to preoperative anterior drawer, pivot shift, and Lachman tests were within normal limits in 18%, 29%, and 73% of cases, respectively. Patients under anesthesia responded to the anterior drawer and pivot shift tests normally 50% and 74% of the time. The Lachman test, performed under anesthesia, was 98% accurate in predicting anterior cruciate injury. Experience gained in evaluating posttraumatic hemarthrosis of the knee suggests clinical examination alone may not demonstrate the severity of many of these injuries. Arthroscopy, although not necessary to determine competence of the anterior cruciate ligament, is invaluable in determining the existence of other injuries with or without an associated anterior cruciate ligament tear

Completely displaced distal radius fractures with intact ulnas in children

Distal Radius Fractures

Completely displaced distal radius fractures with intact ulnas are uncommon, difficult-to-reduce fractures in children. Ten of these fractures were retrospectively reviewed from a series of more than 600 forearm fractures. Eight of ten patients were available for follow up clinically and radiologically at an average of 21 months. Considerable remodeling was noted including two fractures that were left in an overriding position of 10 mm. If angulation does not exceed 16°C of radial deviation and 20°C of dorsal angulation, repeat manipulations need not be performed. Stimulation of growth by the fracture restored radial length. Thus, reduction of the overriding is unnecessary.

Wearable Sensor-based Balance Training for Patients With Knee Osteoarthritis

OAK 3 - Non-arthroplasty tx of OAK

The exercise intervention procedure is based on wearable sensor game�based balance�training program (Exergame). Subjects will perform progressive balance exercises such as ankle reaching or weight shifting, obstacle crossing, and ankle trail making task (i.e. motor�cognitive task). Real�time visual/audio lower�extremity joint motion feedback will be provided using wearable sensors (LEGSys, Biosensics LLC, Cambridge, MA, USA) to assist and encourage subjects to accurately execute each exercise task. The same wearable sensor technology is also used to quantify changes in balance and gait. Changes in balance, gait, fear of falling, physical activity, pain, and quality of life parameters will be assessed at the beginning and conclusion of the training program. Subjects will perform sensor�based interactive balance training (on computer screen), 2 x week, for a period of 6 weeks. The training consists of three balance tasks shown on a computer screen (1. ankle reaching task or weight shifting , 2. obstacle negotiation task, and 3. ankle trail making task (i.e. motor�cognitive task) intended to improve postural stability.

Goniometric alignment of the normal knee joint and the factors which affect it

OAK 3 - Non-arthroplasty tx of OAK

OBJECTIVES: Establishing a normative database for anterior plane knee joint alignment in a population is helpful in assessing patients with disorders of the knee joint specially osteoarthritis. Therefore we aimed at establishing the normal alignment in the Sri Lankan adult population using the goniometer which is an inexpensive and simple method of measurement. METHODS: A total of 420 healthy adult volunteers (210 men and 210 women) above 25 years of age were recruited and the anterior plane knee alignment was measured using a hand held metal goniometer. RESULTS: The mean knee joint alignment was 180.56degree (SD 2.39) and 183.04degree (SD 2.34) in males. The knee joints of the females were varus-oriented by, 2.48degree than those of males (p< 0.0001). In the females the knee joint alignment showed a gradually varus inclination with increasing age (p< 0.05). Lifting heavy weights in males caused a significant varus inclination of the knee joint while BMI and squatting for long periods did not have an effect on the normal alignment. CONCLUSIONS: Female knees are more varus inclined than that of males in the Sri Lankan participants and this inclination increases with age. Reasons for this could be genetic and lifestyle differences and may partly explain the reason for the predominance of varus osteoarthritis in Sri Lankan females.

Accurate alignment and high function after kinematically aligned TKA performed with generic instruments

Surgical Management of Osteoarthritis of the Knee CPG

Purpose: Performing kinematically aligned total knee arthroplasty (TKA) with generic instruments is less costly than patient-specific instrumentation; however, the alignment and function with this new technique are unknown. Methods: One hundred and one consecutive patients (101 knees) treated with kinematically aligned TKA, implanted with use of generic instruments, were prospectively followed. The medial collateral ligament was not released. The lateral collateral ligament was released in the 17 % of patients with a fixed valgus deformity. Six measures of alignment were categorized from a scanogram of the extremity, an axial scan of the knee, and an intraoperative measurement. Both the Oxford Knee and

Unicompartmental total knee arthroplasty

Surgical Management of Osteoarthritis of the Knee CPG

This article traces the evolution of unicondylar design and examines its indications, common aspects of surgical technique independent of design, results, and complications. The dichotomy of opinion concerning unicompartmental knee arthroplasty may reflect differences in patient selection, prosthesis selection, and surgical technique

The K stitch for hypertelorbitism: improved soft tissue correction with glabellar width reduction

Upper Eyelid and Brow Surgery

After correction of moderate to severe hypertelorbitism (greater than 40 mm interdacryon distance) with facial bipartition or orbital box osteotomy, excess glabellar soft tissue and brow width should be addressed. Traditional methods described used a midline excision down the forehead and nasal dorsum, and left an unsightly scar. With a series of 12 patients, the authors document the K stitch technique with no external vertical scar. A mean 38.8% reduction of interbrow distance was noted using this technique. Two patients underwent revisions, and two patients had temporary eyelid ptosis. All patients reported satisfaction once the skin contracture was completed.

The Patient's Perception Does Not Differ Following Subvastus and Medial Parapatellar Approaches in Total Knee Arthroplasty: A Simultaneous Bilateral Randomized Study

OAK 3 - Non-arthroplasty tx of OAK

This simultaneous bilateral randomized study investigated whether patients would perceive the difference between the subvastus approach (SVA) and the medial parapatellar approach (MPA) after total knee arthroplasty (TKA). In 50 patients scheduled to undergo same-day bilateral TKA, one knee was randomly assigned to SVA and the other to MPA. Patient-reported measures (pain, Western Ontario McMaster University Osteoarthritis Index score, and side preference) and physician-assessed measures (isokinetic muscle strength, range of motion, and Knee Society score) were compared. No differences were observed in the patient-reported measures and physician-assessed measures, with the exception of greater quadriceps strength at postoperative 1. week in knees that underwent SVA. Patients receiving contemporary perioperative management after same-day bilateral TKA do not perceive any difference between knees that underwent SVA or MPA.

Correlation of bone mineral density measured by qualitative ultrasound and dual energy x-ray absorptiometry

Management of Hip Fractures in the Elderly

Osteoporosis is a systemic skeletal disease characterized by low bone mass and microarchitectural deterioration of bone tissue, with consequential increase in bone fragility and susceptibility to fracture. Bone mineral density (BMD) is an important determinant factor of fracture risk. Fifty-eight healthy postmenopausal women aged 53-91 years were included in the study. The subjects were divided into three age groups. Heel bone (calcaneus) BMD detected by qualitative ultrasound (QUS) was correlated with lumbar spine and proximal femur BMD detected by dual energy x-ray absorptiometry (DEXA). Also, subject age and anthropometric parameters (body weight and height) were correlated with BMD values in the calcaneus, spine and proximal femur. A chart was made of T-score conversion for lumbar spine according to T-score of heel bone detected by QUS. Calcaneal BMD showed best correlation in group 2 (58-67 yrs) with total femoral BMD (R=0.72) and intertrochanteric area (R=0.719), both statistically significant (p1=0.0007, p1<0.001; p2=0.0008, p2<0.001). There was no significant correlation between any of the calculated BMD values (calcaneus, lumbar spine and proximal femur) and age, body weight or body height. According to our conversion chart, when T-score calculated on ultrasound densitometry is equal or below -1 it yields a final T-score of lumbar spine between -1 and -2.5, which according to WHO criteria is diagnosed as osteopenia. This makes ultrasound densitometry an excellent screening method to identify patients at a risk of fracture

Arthroscopic scoring system of meniscal healing following medial meniscus posterior root repair

OAK 3 - Non-arthroplasty tx of OAK

PURPOSE: Medial meniscus posterior root tear (MMPRT) leads to a rapid degradation of articular cartilage. In the treatment of MMPRT, transtibial pullout repair demonstrates a high clinical survival rate. However, there is no reliable method to evaluate the meniscal healing after surgery. We propose an arthroscopic scoring system for evaluating the meniscal healing status. The aim of this study was to investigate the correlations between second-look arthroscopic scores and clinical outcomes after transtibial pullout repair. METHODS: Twenty patients who had MMPRTs underwent transtibial pullout repairs. Clinical outcomes were assessed using the Japanese Knee Injury and Osteoarthritis Outcome Score (KOOS) and pain score evaluated by visual analogue scale at preoperatively and 1 year postoperatively. The healing status of repaired MM was assessed at one year post-operatively using a semi-quantitative arthroscopic scoring system (total, 10 points) composed of three evaluation criteria: (i) anteroposterior width of bridging tissues, (ii) stability of the MM posterior root, and (iii) synovial coverage of the sutures. Linear regression analysis was used to assess the correlation between second-look arthroscopic scores and clinical outcomes. RESULTS: Transtibial pullout repairs of MMPRTs significantly improved clinical evaluation scores at one year post-operatively. A median of second-look arthroscopic scores was 6.5 (5.75-8). A good correlation was observed between the arthroscopic score and KOOS quality of life (QOL) subscale. A moderate negative correlation between the arthroscopic score and pain score was observed. CONCLUSIONS: This study demonstrated that our semi-quantitative scoring system of meniscal healing correlated with the KOOS QOL subscale following MMPRT transtibial pullout repair. Our results suggest that the second-look arthroscopic score using this system may be a useful scale to determine and compare the healing status of the MM posterior root.

Infection of apical dentin and root-end cavity disinfection

Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures

INTRODUCTION: The purpose of this study was to assess Enterococcus faecalis penetration into the dentin of the apical 3 mm and bacterial death after the application of either chlorhexidine or laser to root-end cavities. METHODS: Root canals of 60 single-rooted teeth were prepared. In part 1, cementum was removed semicircumferentially from 21 roots, and the smear layer was removed from 15 roots using 17% EDTA/cetrimide. Teeth were inoculated and incubated with E. faecalis for 10 days, rinsed, and live/dead stained. The effect of cementum and smear on bacterial penetration was assessed by confocal laser scanning microscopy (CLSM). In part 2, 39 teeth had root ends resected and cavities ultrasonically prepared. Inoculated roots were assigned to 1 of the following 3 groups: (1) root-end cavities irrigated with 0.2 % chlorhexidine, (2) root-end cavities irradiated with a laser for 20 seconds at 1.5 W, or (3) root-end cavities that received no treatment. Roots were live/dead stained, sectioned, and examined by CLSM. The depth of the bacterial penetration and bacterial survival were compared using the Mann-Whitney U test. RESULTS: The presence of a smear layer and/or cementum did not significantly affect bacterial penetration. In root-end cavities, chlorhexidine was more effective than laser (P < .001), reducing bacterial viability by 93% versus 70% with a laser. CONCLUSIONS: E. faecalis invaded the entire width of dentin in the apical 3 mm irrespective of the smear layer and/or cementum. Chlorhexidine was more effective than laser in disinfecting root-end cavities

Is aquatic exercise more effective than land-based exercise for knee osteoarthritis?

OAK 3 - Non-arthroplasty tx of OAK

BACKGROUND: This study aimed to systemically review the effectiveness of aquatic exercise (AQE) compared to land-based exercise (LBE) in treating knee osteoarthritis (OA). METHODS: The Medline, Embase, Web of Science, Cochrane Central Register of Controlled Clinical Trials, CINAHL, and psyclNFO databases were comprehensively searched for randomized controlled trials (RCTs) evaluating the effectiveness of AQE and LBE for knee OA from their inception date to September 24, 2018. The risk of bias was examined using the Cochrane Collaboration Tool, and Review Manager 5.3 was used for data collation and analysis. RESULTS: Eight RCTs were included, involving a total of 579 patients. The meta-analysis showed that there was no significant difference between AQE and LBE for pain relief, physical function, and improvement in the quality of life, for both short- and long-term interventions, in patients with knee OA. However, the adherence and satisfaction level for AQE was higher than for LBE. Compared to no intervention, AQE showed a mild effect for elevating activities of daily living (standardized mean difference [SMD]: -0.55, 95% confidence interval [CI] [-0.94, -0.16], P = .005) and a high effect for improving sports and recreational activities (SMD: -1.03, 95% CI [-1.82, -0.25], P = .01). CONCLUSION: AQE is comparable to LBE for treating knee OA.

Factors influencing discharge location following hip fracture

Management of Hip Fractures in the Elderly

INTRODUCTION: Outcome measures following hip fracture usually consider morbidity and mortality following injury.(5) Few studies have looked at post injury discharge location as an outcome measure following hip fracture. Discharging patients to a different location frequently delays discharge whilst the necessary social arrangements are made. Early identification of these patients could reduce these delays. The aim of this study was to determine factors influencing discharge location following hip fracture. METHODS: Three thousand two hundred and forty consecutive patients were admitted to our centre with a fractured neck of femur. Data was prospectively collected by independent audit clerks on a standardised proforma. Our outcome measure was whether the patient was discharged from hospital either to their place of normal residence or to an alternative location. Factors influencing discharge location were identified using multivariate logistic regression analysis. RESULTS: Increasing age was associated with increasing risk of requiring discharge to an alternative location (DAL) (p<0.001). This risk rose from 13% in the sixth decade by approximately 10% every additional decade. Males were 2.5 times more likely than females to require DAL. Patients who were more independent prior to injury were less likely to require DAL. Patients who sustained their injury whilst in hospital were 2.3 times more likely to require DAL compared to those who fell in their own homes. CONCLUSION: The following risk factors are associated with increased risk of requiring discharge to an alternative location: (1) pre-injury dependence, (2) increasing age, (3) male sex, (4) injury sustained whilst in hospital. Early identification of patients requiring DAL could reduce inpatient delays

Hormonal replacement therapy in the prevention and treatment of glucocorticoid-induced osteoporosis

AAHKS (2) Corticosteroids

Hypogonadism is a complication of glucocorticoid therapy. Postmenopausal women on glucocorticoids suffer more fractures than premenopausal women on glucocorticoids. The use of oral contraceptives has been recommended in hypo- and amenorrhoeic premenopausal women receiving high doses of corticosteroids, as long as its use is compatible with other medical conditions of the patient. In postmenopausal women, the effect of hormonal replacement therapy in glucocorticoid-induced osteoporosis has only been studied in small prospective trials. These studies show an increase in bone density in the spine. The effect on hip bone density was not consistent. No data are available on the effect of hormonal replacement therapy on fracture incidence in glucocorticoid-induced osteoporosis. Bisphosphonates are an alternative for hormonal replacement therapy in women and men that do not tolerate hormonal replacement therapy or when contraindications for hormonal replacement therapy are present. Further prospective studies will be necessary before hormonal replacement therapy can be recommended in the prevention of glucocorticoid-induced osteoporosis in men and women.

Hamstring donor-site block for pain control after ACL reconstruction

Surgical Management of Osteoarthritis of the Knee CPG

Hamstring Donor-Site Infiltration for Pain Control After ACL ReconstructionIntroduction: Perioperative pain associated with the hamstring donor site harvest is a common problem for outpatients following Anterior Cruciate Ligament (ACL) repair. Our institution typically provides femoral nerve blockade for these procedures. However, this block does not provide complete analgesia for posterior knee or hamstring donor site pain. While sciatic nerve blockade is an effective therapy for treating this residual pain, it is often not performed for a variety of reasons. Local infiltration has been a valuable technique for control of pain related to other orthopedic procedures. We have instituted a practice of infiltration of local anesthetic along the hamstring tendon donor site during ACL repair.Methods: Following IRB approval, data from 21 consecutive patients undergoing outpatient ACL repair with hamstring autograft were collected. Data were collected on intraoperative and PACU narcotic administration, nausea, rate of hospital admission and pain scores in recovery phases one and two, as well as times to discharge and complications. Patients with femoral nerve catheters or incomplete data related to pain scores were excluded from analysis. There were no exclusions based on patient factors including (age, sex, ASA score, or other comorbidities). The local infiltration was performed with 20 ml of 0.125% bupivacaine injected along the tract of hamstring graft harvest. This was done by injecting local anesthetic with a slip tip catheter through a pediatric red rubber Foley catheter styleted with a disposable ETT stylet. Femoral nerve blocks were performed preoperatively with variable volumes of either bupivacaine 0.25% or 0.5% with or without epinephrine. All femoral nerve blocks were placed with nerve stimulation and ultrasound guidance; LMAs were placed for operative airway management in all patients. A numerical pain scale was used for evaluating pain scores where 0 represents no pain and 10 represents the worst pain imaginable. There was no standardization of intraoperative pain management.Results: Baseline characteristics between groups were not statistically significant when calculating two tailed Student T testing. Figure 1 Local anesthetic dosing and non narcotic drug dosing were similar between groups. PACU stays, narcotic use and pain scores did not differ significantly.(Figure Presented) Discussion: This study suggests that there are no differences in any of the measured variables between groups. The trends even seem to suggest that increased pain was noted in the infiltration group. This may represent a bias towards performing this block in patients deemed to be more challenging from a pain management perspective. This study is clearly limited in that it is a non-randomized, retrospective chart review and therefore future controlled studies may be warranted. The number of patients in this study is also low and further randomized larger scale trials are warranted before the debate on this procedure can be closed

Do indomethacin or radiation for heterotopic ossification prophylaxis increase the rates of infection or wound complications after acetabular fracture surgery?

DoD SSI (Surgical Site Infections)

OBJECTIVES: To compare the rates of infection and wound complications in patients undergoing operative fixation (ORIF) of acetabular fractures receiving HO prophylaxis using indomethacin or radiation therapy (XRT) versus no prophylaxis. DESIGN: Retrospective cohort SETTING: : Level I trauma center PATIENTS:: We reviewed 473 patients undergoing ORIF of acetabular fractures via posterior, combined, or extensile surgical approaches from 2012-2017, with median follow-up of 13 months (0.5-77 months). MAIN OUTCOME MEASUREMENT: Rates of infection and wound complications stratified according to their HO prophylaxis method: indomethacin, XRT, and no prophylaxis. RESULTS: Overall, 167 patients (35.3%) received indomethacin, 104 patients (22.0%) received post-operative XRT, and 202 patients (42.7%) received no prophylactic treatment. There was no difference between the 3 groups for the risk of SSI (p=0.280). The XRT group had significantly increased risk of non-infectious wound complications (20.2%) compared to the indomethacin group (6.6%, p=0.002) and the no prophylaxis group (5.0%, p<0.0001). Multivariate analysis revealed XRT remained a significant risk factor for non-infectious wound complications compared to no prophylaxis (OR 5.39; 95% CI 2.37-12.22; p<0.0001). CONCLUSIONS: Although there is no difference between XRT, indomethacin, and no HO prophylaxis for the risk of SSI, the use of XRT results in more than 5 times increased risk of non-infectious wound complications compared to no prophylaxis. This increased risk should be considered when contemplating XRT for HO prophylaxis in acetabular fracture patients. LEVEL OF EVIDENCE: Therapeutic Level III.

Diagnostic accuracy of computed tomography-guided biopsy in pathological fractures

MSTS 2022 - Metastatic Disease of the Humerus

BACKGROUND: Obtaining a histological diagnosis is essential for appropriate management of pathological fractures. Computed tomography (CT) is an accurate method of obtaining diagnosis for musculoskeletal tumours. We analysed whether diagnostic accuracy was maintained in the evaluation of pathological fractures. METHODS: A retrospective review of 101 consecutive patients presenting to our tertiary musculoskeletal tumour centre with pathological fracture was performed. Patients underwent core needle biopsy under CT guidance of pathological fractures diagnosed by plain radiography and either CT or magnetic resonance imaging. The histopathology of the CT-guided biopsy was compared with the sample obtained from open biopsy or definitive surgery to determine diagnostic accuracy. RESULTS: The mean age at diagnosis was 52 +/- 20 years (range: 18-85) in a cohort of 46 men and 55 women. Diagnostic accuracy of CT-guided biopsy was 82.18%. There were 65 malignant and 36 benign tumours with diagnostic accuracy of 86.15% and 80.56%, respectively. The positive predictive value for a malignant tumour was 98.21% whilst it was 93.1% for benign tumours. The femur (53 cases) and humerus (25 cases) were the commonest bones fractured. The most frequent diagnoses were metastasis (20.79%), giant cell tumour (17.82%), osteosarcoma (9.90%) and myeloma (9.90%). There were no complications of CT-guided biopsy. CONCLUSION: Pathological fracture does not confound the diagnosis of musculoskeletal tumours. CT-guided biopsy is an accurate diagnostic tool in the evaluation of pathological fractures. Final diagnosis and management should be made in the context of appropriate anatomical and functional imaging using a multidisciplinary approach.

Clodronate in the management of different musculoskeletal conditions

OAK 3 - Non-arthroplasty tx of OAK

INTRODUCTION: Clodronic acid is a non-nitrogen-containing bisphosphonate largely used from some decades in the prevention and treatment of postmenopausal and secondary osteoporosis. in addition to antiresorptive activity, clodronate has shown anti-inflammatory and analgesic properties, and modulatory effects on bone and cartilage metabolism. EVIDENCE ACQUISITION: A literature review has been conducted to characterize the mechanism of action of clodronate and to retrieve available evidence about the use of clodronate in primary and secondary osteoporosis, and its potential role in other musculoskeletal conditions and orthopedic surgery. EVIDENCE SYNTHESIS: The efficacy and safety of the available clodronate formulations (oral, intravenous and intramuscular) in the prevention and treatment of postmenopausal and secondary osteoporosis, including corticosteroid-induced osteoporosis and bone mass loss secondary to endocrine, gastrointestinal and neoplastic diseases, have been demonstrated in a variety of clinical trials. The analgesic, anti-inflammatory, bone- and chondro-modulating properties of clodronate have allowed to expand its use in other musculoskeletal conditions to those currently approved. clodronate has proven to be beneficial in the treatment of osteoarthritis of the knee and of the hand, in the management of complex regional pain syndrome, and in the peri- and postoperative phase in subjects undergoing arthroplasty. CONCLUSIONS: The analysis of the available literature has shown that clodronate has relevant musculoskeletal effects beyond the antiresorptive activity. Further research is needed to better position clodronate therapy in the management of these conditions and to define the optimal formulation and dose regimen in any of the tested new indications.

Unusual Vascular Complications Associated with Transradial Coronary Procedures Among 10,324 Patients: Case Based Experience and Treatment Options

DOD - Acute Comp Syndrome CPG

OBJECTIVES: We aimed to present our experience regarding the unusual vascular complications and specific treatment strategies in patients who underwent transradial coronary procedure (TRC). BACKGROUND: Transradial access provides lower vascular access site complication rates compared with transfemoral access. However, there is lack of data obtained from large study populations concerning the incidence and treatment strategies of hemorrhagic and vascular complications following a TRC in the literature. METHODS: 10,324 patients (2,652 patients with percutaneous coronary intervention and 7,672 patients with a diagnostic transradial coronary angiography) who underwent a TRC from February 2010 to December 2014 were reviewed to identify cases of large hematoma, perforation, arteriovenous fistula, and pseudoaneurysm. RESULTS: The observed incidence was 0.44% (45 patients) for all unusual vascular and hemorrhagic complications. Of these 45 patients; 32 patients (0.31%) presented with large hematoma (>=6cm), 8 patients (0.08%) presented with perforation, 4 patients (0.04%) presented with arteriovenous fistula (AVF), and only 1 case (0.009%) presented with radial artery pseudoaneurysm. Forty-one of forty-five patients were managed with mechanical compression. Surgery was performed in only 3 cases; a patient with a brachial artery perforation leading to compartment syndrome, a patient with AVF resulting in limb ischemia, and a patient with radial artery pseudoaneurysm. A right internal mammarian artery perforation resulting in huge breast hematoma was treated via endovascular graft stent implantation. CONCLUSIONS: Hemorrhagic and vascular complications are rarely seen during TRC. However, majority of these complications could be managed conservatively without a requirement for surgical reconstruction. Copyright © 2015, Wiley Periodicals, Inc.

Patellofemoral arthroplasty: the impact of design on outcomes

Surgical Management of Osteoarthritis of the Knee CPG

The results of patellofemoral arthroplasty have been improved over the three decades that the procedure has been used for the treatment of patellofemoral arthritis. Specifically, there has been a reduction in the incidence of patellofemoral-related problems, such as patellar maltracking and catching, after patellofemoral arthroplasty. While these problems were often attributed to errors in surgical technique or component malposition, it is likely that many were related to flawed trochlear component designs. Contemporary patellofemoral arthroplasties have a reduced incidence of the problems related to patellar maltracking that typically plagued earlier generation designs. Further study will likely prove contemporary patellofemoral arthroplasty to be an effective treatment for the management of isolated patellofemoral arthritis, with predictable outcomes and a low incidence of complications

Transarticular fixation with the capacity for motion in fracture dislocations of the elbow

Distal Radius Fractures

Post-traumatic stiffness of the elbow joint is a frequent result of immobilisation leading to severe disability in the use of the upper extremity. Recognition of the tendency to stiffness leads to the assumption that the strong self-healing forces of the capsule and ligament apparatus converts the initial instability of the joint after ligament disrupture, into a high-grade undirected stability following immobilisation. Directed stability as it is produced by the natural ligament apparatus of the joint on the other hand produces a guided movement of the joint in one direction. These theoretical considerations lead to the idea that the self-healing forces of the ligament apparatus under continous guided movement of the joint will result in a stable and movable joint to allow healing of the compromised soft tissue envelope and moreover to maintain free soft tissue access without compromising the stability. For this a unilateral fixator with motion capacity was developed. The joint bridging application approaches the humerus and ulna from the lateral side. The proximal pin group is inserted into the proximal region of the humerus respecting the radial nerve. The distal pin group is implanted from the dorsal side into the middle third of the ulna. The fixator has a hinge joint. The design of the fixator clamps, bars and the hinge joint allows simple alignment with the rotational axis of the elbow. Pro- and supination of the forearm is unhindered. Flexion and extension can be permitted according to the soft tissue situation. Copyright (C) 2000 Elsevier Science Ltd.

Comorbidities Only Account for a Small Proportion of Excess Mortality After Fracture: A Record Linkage Study of Individual Fracture Types

Pediatric Supracondylar Humerus Fracture 2020 Review

Nonhip, nonvertebral (NHNV) fractures constitute the majority of osteoporotic fractures, but few studies have examined the association between these fractures, comorbidity, and mortality. Our objective was to examine the relationship between individual nonhip, nonvertebral fractures, comorbidities, and mortality. The prospective population-based cohort of 267,043 subjects (45 and Up Study, Australia) had baseline questionnaires linked to hospital administrative and all-cause mortality data from 2006 to 2013. Associations between fracture and mortality were examined using multivariate, time-dependent Cox models, adjusted for age, prior fracture, body mass index, smoking, and comorbidities (cardiovascular disease, diabetes, stroke, thrombosis, and cancer), and survival function curves. Population attributable fraction was calculated for each level of risk exposure. During 1,490,651 person-years, women and men experienced 7571 and 4571 fractures and 7064 deaths and 11,078 deaths, respectively. In addition to hip and vertebral fractures, pelvis, humerus, clavicle, rib, proximal tibia/fibula, elbow and distal forearm fractures in both sexes, and ankle fractures in men were associated with increased multivariable-adjusted mortality hazard ratios ranging from 1.3 to 3.4. Comorbidity independently added to mortality such that a woman with a humeral fracture and 1 comorbidity had a similarly reduced 5-year survival as that of a woman with a hip fracture and no comorbidities. Population mortality attributable to any fracture without comorbidity was 9.2% in women and 5.3% in men. All proximal nonhip, nonvertebral fractures in women and men were associated with increased mortality risk. Coexistent comorbidities independently further increased mortality. Population attributable risk for mortality for fractures was similar to cardiovascular disease and diabetes, highlighting their importance and potential benefit for early intervention and treatment. © 2018 American Society for Bone and Mineral Research.

Pain in Osteochondral Lesions of the Ankle - an Investigation Based on Data from the German Cartilage Registry (KnorpelRegister DGOU)

Osteochondritis Dissecans 2020 Review

BACKGROUND: The aim of the study was to investigate parameters influencing the preoperative pain intensity in patients with osteochondral lesions of the ankle. The evaluation covered patient-related parameters such as age, sex, body mass index (BMI), as well as defect-related parameters, such as localisation, size and stage (according to the classification of the International Cartilage Repair Society [ICRS] and the Berndt-Harty-Loomer classification). We also examined the correlation between the different surgical techniques and additional factors, such as debridement of an impingement or stabilisation of the ankle on the one hand, and the preoperative pain intensity on the other. MATERIAL AND METHODS: 259 patients with osteochondral lesions of the ankle were operated in 32 clinical centres between October 2014 and December 2016 and enrolled consecutively in the German Cartilage Registry (KnorpelRegister DGOU). 151 patients were available for analysis. The preoperative pain intensity was assessed at the time of surgery with online questionnaires, using the Numeric Rating Scale for pain (NRS). RESULTS: The median preoperative pain intensity in the complete study population (nâ??=â??151) was 3 (range 0â??-â??10). There was no correlation between the age and the preoperative pain intensity (ρâ??=â??-â??0.06). Further, there was not detected a difference between the two genders according to the preoperative pain intensity (pâ??=â??0.31). In female patients a higher BMI correlated with a higher preoperative pain intensity (ρâ??=â??0.16). Within the group of patients with a solitary treated talus lesion there was no difference according to the preoperative pain intensity between the different localizations of the defect (medial vs. lateral talus) (pâ??=â??0.82). Within the group of patients with a solitary treated talus or tibia lesion there was no correlation between the defective area or the lesion stage according to the ICRS classification on the one hand, and the preoperative pain intensity on the other (ρâ??=â??0.09, and ρâ??=â??0.04, respectively). According to the Berndt-Harty-Loomer classification a higher lesion stage (stage four and five) was associated with a higher preoperative pain intensity (ρâ??=â??0.13). There was no difference according to the preoperative pain intensity between the group of patients that received a debridement of a bony or soft tissue impingement in addition to the cartilage therapy and the group of patients without this kind of additional therapy (pâ??=â??0.10). Further, there was no difference according to the preoperative pain intensity between the group of patients that received a stabilisation of the ankle joint in addition to the cartilage therapy and the group of patients without a stabilisation procedure (pâ??=â??0.83). CONCLUSION: Osteochondral lesions of the ankle can be associated with a moderate and in some cases high pain intensity. In female patients a higher BMI is associated with a higher pain intensity. Further, a higher lesion stage according to the Berndt-Harty-Loomer classification is associated with a higher pain intensity, which highlights the clinical relevance of this classification.

Effectiveness of exercise therapy in hip osteoarthritis

AAHKS (4) Acetaminophen

INTERVENTION: The intervention group received 12 supervised, (once per week, sustaining 45 minutes), rehabilitation sessions at baseline and four additional booster sessions at a point one year later. A physiotherapist working in primary care led supervised rehabilitation sessions for exercise groups consisting of ten participants at any given time. Following supervision, participants were recommended to perform the exercises using the same protocol three times per week for 3 years. The exercise programme was developed with common training principles as well as with the results of the other studies. It consisted of mainly strengthening exercises. The intensity of exercise training was not individually adjusted for each participant; they were recommended to perform strengthening exercise with maximum speed and power. Each training session started with a warm�up session with marching in place using arms as part of the movement for one minute. Stepping forward, backward, sideways in place for 2 minutes and finally cycling the legs in a supine position for 1 minute. The strengthening section included seven different exercises for hip and knee flexors, extensors, hip abductors and adductors and for pelvic and abdominal muscles for 30 � 35 minutes. The stretching section consisted of six different, analogues muscle flexibility exercises for hip, knee and ankle flexors and extensors and hip adductors, holding each position for 30 seconds with tailored intensity. Participants in the GP�care group (no intervention) received standard care. CONDITION: Osteoarthritis of the hip ; Musculoskeletal Diseases ; Coxarthrosis PRIMARY OUTCOME: 1. Self�reported pain and disease specific physical function were assessed by using the pain and functioning subscales of the WOMAC ; 2. Self�reported generic physical function was assessed by using the physical function score of the Finnish�validated SF�36 (36�item) Health Survey; 3. Economic effectiveness was assessed by evaluating the number of doctor visits (associated with hip OA) and physiotherapy (sum score of using physiotherapy including exercise programme and/or inpatient rehabilitation associated with hip OA). The need of surgery (total hip replacement) and drug use (non�opioid analgesic (paracetamol, non steroidal anti�inflammatory drugs [NSAIDs]) and weak opioid (tramadol, codeine) concerning hip OA were also assessed. ; ; Assesssed at the following timepoints: 0, 3, 6, 12, 18, 24 and 36 months. SECONDARY OUTCOME: Objective functional scores:; 1. Passive internal rotation and flexion of the hip joint; 2. Extensor power of lower limb; 3. Six Minute Walk Test (6MWT) ; 4. Ten�Metre Walk Test; 5. Timed Up & Go (TUG) test ; 6. Sock Test; ; Assessed at the following timepoints: 0, 3, 12, 24 and 36 months. INCLUSION CRITERIA: 1. Both males and females, aged from 55 to 80 years 2. Unilateral or bilateral radiographic hip OA (X�ray less than 3 years old) 3. Pain experience in the hip region within the preceding month as indicated in the clinical criteria of the American College of Rheumatology

The burden of chronic elbow dislocations in Cambodia and early results of a cost-effective surgical approach

Pediatric Supracondylar Humerus Fracture 2020 Review

Chronic elbow dislocation presents a surgical challenge and there is difficulty in balancing stability with early mobilisation. We present a series of 103 patients treated with open reduction via a posterior approach and provide early results of an alternative combined medial and lateral approach (Soddo technique, Anderson et al.). Of the 103 patients, 81% initially consulted a traditional healer and the mean dislocation period was 11 weeks. There was significant loss to follow-up. Only 12 patients having undergone the posterior approach had complete datasets. The mean preoperative arc of movement was 10° and the postoperative arc was 65° at a mean follow-up of 16 weeks. Five patients treated with the Soddo technique had sufficient follow-up data. The mean preoperative arc was 20° and the mean postoperative arc was 95° (mean follow-up of 20 days). Those having undergone the Soddo technique achieved a 20° greater increase in range of movement and no re-dislocations.