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Association of an aromatase TTTA repeat polymorphism with circulating estrogen, bone structure, and biochemistry in older women

Management of Hip Fractures in the Elderly

Osteoporosis is a disease that is strongly genetically determined. Aromatase converts androgens to estradiol in postmenopausal women, therefore polymorphisms of the gene for this enzyme may be associated with bone mass and fracture. We investigated the association of the TTTA microsatellite polymorphism in intron 4 of the aromatase (CYP19) gene with bone mineral density (BMD) and fracture in 1,257 women aged 70 yr and greater. The data obtained were stratified based on the presence or absence of a [TTTA]n of 7 (A2), determined from a preliminary analysis of hip dual-energy X-ray absorptiometry BMD, which was present in 27% of the population. The presence of an A2 allele was associated with a higher free estradiol index (0.52 +/- 0.49, P = 0.049) compared with the absence of an A2 allele (0.47 +/- 0.45); higher BMD at all sites of the hip (3.4% total hip, 2.3% femoral neck, 3.6% intertrochanter, 4.1% trochanter) and the lumbar spine (12.7%); higher values for the calcaneal quantitative ultrasound parameters broadband ultrasound (1.3%), speed of sound (0.4%), and stiffness (3.7%); and higher peripheral quantitative computed tomography measures for total (3.4%), trabecular (3.3%), and cortical BMD (3.3%) and the derived stress strain index (SSI) parameters SSI polar (6.4%) and SSI x (6.8%) values. A lower deoxypryridinoline creatinine ratio was observed in subjects with an A2 allele (30.3 +/- 10.4 vs. 27.1 +/- 9.1, P = 0.03). The A2 allele was associated with a lower prevalence of vertebral fracture in subjects who were osteoporotic (odds ratio 0.27, confidence interval 0.09-0.79). Therefore, a common polymorphism of the aromatase gene, perhaps in linkage disequilibrium with a functionally significant CYP19 polymorphism, is associated with bone structure and bone turnover, either by local effects or by effects on circulating bioactive estrogen

Two-phase whole-body skeletal scintigraphy in children - Revisiting the usefulness of the early blood pool phase

MSTS 2018 - Femur Mets and MM

The usefulness of whole-body blood pool imaging as part of Tc-99m methylene diphosphonate (MDP) skeletal scintigraphy in detection of marrow infiltrative processes and unexpected soft-tissue and visceral abnormalities is demonstrated via illustrative case examples. Technical aspects of this simple and fast scanning technique are also highlighted. © 2013 Springer-Verlag Berlin Heidelberg.

Patella instability in children and adolescents

OAK 3 - Non-arthroplasty tx of OAK

Patellar instabilities are the most common knee pathologies during growth. Congenital dislocations are rare. Extensive, early soft tissue releases relocate the extensor mechanism and may enable normal development of the femoro-patellar anatomy.Conservative management is the preferred strategy after a 'first-time' traumatic dislocation. In cases with concomitant anatomical predisposing factors such as trochlear dysplasia, malalignment, malrotation or ligamentous laxity, surgical reconstruction must be considered. The same applies to recurrent dislocations with pain, a sense of instability or re-dislocations which may also lead to functional compensatory mechanisms (quadriceps-avoiding gait in knee extension) or cartilaginous lesions with subsequent patello-femoral osteoarthritis. The decision-making process guiding surgical re-alignment includes analysis with standard radiographs and MRI of the trochlear groove, joint cartilage and medial patello-femoral ligament (MPFL). Careful evaluation of dynamic and static stabilisers is essential: the medial patello-femoral ligament provides stability during the first 20degree of flexion, and the trochlear groove thereafter.Excessive femoral anteversion, general ligamentous laxity with increased femoro-tibial rotation, patella alta and increased distance between the tibial tuberosity and the trochlear groove must also be taken into account and surgically corrected.In cases with ongoing dislocations during skeletal immaturity, soft tissue procedures must suffice: reconstruction of the medial patello-femoral ligament as a standalone procedure or in conjuction with more complex distal realignment of the quadriceps mechanism may lead to a permanent stable result, or at least buys time until a definitive bony procedure is performed. Cite this article: Hasler CC, Studer D. Patella instability in children and adolescents. EFORT Open Rev 2016;1:160-166. DOI: 10.1302/2058-5241.1.000018.

Monocyte chemotactic protein-1 inhibits chondrogenesis of synovial mesenchymal progenitor cells: an in vitro study

OAK 3 - Non-arthroplasty tx of OAK

Osteoarthritis (OA) is a multifactorial, often progressive, painful disease. OA often progresses with an apparent irreversible loss of articular cartilage, exposing underlying bone, resulting in pain and loss of mobility. This cartilage loss is thought to be permanent due to ineffective repair and apparent lack of stem/progenitor cells in that tissue. However, the adjacent synovial lining and synovial fluid are abundant with mesenchymal progenitor/stem cells (synovial mesenchymal progenitor cells [sMPCs]) capable of differentiating into cartilage both in vitro and in vivo. Previous studies have demonstrated that MPCs can home to factors such as monocyte chemotactic protein 1 (MCP-1/CCL2) expressed after injury. While MCP-1 (and its corresponding receptors) appears to play a role in recruiting stem cells to the site of injury, in this study, we have demonstrated that MCP-1 is upregulated in OA synovial fluid and that exposure to MCP-1 activates sMPCs, while concurrently inhibiting these cells from undergoing chondrogenesis in vitro. Furthermore, exposure to physiological (OA knee joint synovial fluid) levels of MCP-1 triggers changes in the transcriptome of sMPCs and prolonged exposure to the chemokine induces the expression of MCP-1 in sMPCs, resulting in a positive feedback loop from which sMPCs cannot apparently escape. Therefore, we propose a model where MCP-1 (normally expressed after joint injury) recruits sMPCs to the area of injury, but concurrently triggers changes in sMPC transcriptional regulation, leading to a blockage in the chondrogenic program. These results may open up new avenues of research into the lack of endogenous repair observed after articular cartilage injury and/or arthritis.

Sepsis and the scalpel: anatomic compartments and the diabetic foot

DOD - Acute Comp Syndrome CPG

The foot comprises 3 compartments bounded by bone and fascia, each compartment containing muscle and vascular and nervous structures. Infection leading to an increase in pressures in the compartments results in rapid necrosis, a pathologic process characteristic of diabetic feet. Treatment involves fasciotomy and complete debridement of devitalized tissue with possible amputation of the involved digits. Knowledge of the anatomic structure of the foot and its compartments is therefore essential in effectively managing the diabetic foot.

Head and neck pathology interactions with clinical outcomes

Dental Implant Infection

The relationships between craniofacial and other medical pathologies are not always obvious but may be very significant as they influence the extent of disease, accuracy of differential diagnoses, treatment schedules, and appropriateness and utilization of health-care resources. Among the relationships discussed are periodontal and endodontic infections, bacteremias and antibiotics, iatrogenics, viral and fungal infections, oncological interactions, temporomandibular joint disease, dental implants, antidepressant therapy, psychiatric and neurological influences, and dental restorations.

Adverse ocular drug reactions recently identified by the National Registry of Drug-Induced Ocular Side Effects

MSTS 2018 - Femur Mets and MM

Purpose To report recent ocular adverse drug reactions identified by the National Registry of Drug-Induced Ocular Side Effects. Methods Case reports from the National Registry and the World Health Organization were collected and adverse drug reactions categorized as follows: certain, probable/likely, possible, unlikely, and conditional/unclassifiable. Results Bisphosphonates are associated with ocular inflammation, including the first reports of drug-related scleritis. Topiramate is shown to cause angle-closure glaucoma. Cetirizine can cause an oculogyric crisis, and there is strong evidence retinoids cause intracranial hypertension. Conclusion Recent reports to the National Registry have led to identification of new ocular adverse drug reactions. © 2004 by the American Academy of Ophthalmology.

Plerixafor: A chemokine receptor-4 antagonist for mobilization of hematopoietic stem cells for transplantation after high-dose chemotherapy for non-Hodgkin's lymphoma or multiple myeloma

MSTS 2018 - Femur Mets and MM

BACKGROUND: Autologous hematopoietic stem cell (HSC) transplantation is used to facilitate hematopoietic recovery after administration of high-dose chemotherapy in patients with Hodgkin's disease, non-Hodgkin's lymphoma (NHL), multiple myeloma (MM), leukemias, and some solid tumors. There are limitations to the existing methods of mobilizing CD34+ HSC with chemotherapy and/or granulocyte colony-stimulating factor (G-CSF). Plerixafor, a bicyclam molecule that acts as a pure antagonist of chemokine receptor-4, is approved by the US Food and Drug Administration for use in combination with G-CSF for mobilization of CD34+ HSC in patients with NHL or MM. OBJECTIVE: This review presents information on plerixafor, including its mechanism of action in mobilizing stem cells, pharmacokinetics, clinical efficacy, adverse effects, and pharmacoeconomic considerations. METHODS: MEDLINE, EMBASE (1996-June 2009), and International Pharmaceutical Abstracts (1970-June 2009) were searched on July 9, 2009, using the key words plerixafor and AMD3100 for reports relating to HSC mobilization. The search was updated on September 20, 2009, and again on January 30, 2010. The reference lists of identified articles were examined for additional abstracts and other sources of information. The journal Blood was searched online to identify abstracts presented at Annual Meetings of the American Society of Hematology. RESULTS: After administration of plerixafor, HSC migrate from the bone marrow into the peripheral blood, permitting collection by apheresis. Clinical trials in humans have found that the combination of G-CSF + plerixafor facilitates mobilization of HSC. In patients with MM without extensive previous treatment who were undergoing a first mobilization, the use of G-CSF + plerixafor was reported to double counts of circulating peripheral CD34+ HSC and thus double the number of CD34+ HSC collected in half as many apheresis procedures, although rates of engraftment, graft durability, transplantation, and survival outcomes were not significantly improved. In patients with Hodgkin's disease or NHL, in whom limited success in mobilization is expected, G-CSF + plerixafor also facilitated or improved mobilization with improved apheresis yields, again without significant improvement in outcomes. Common (> or = 20%) adverse events of plerixafor used in combination with G-CSF include diarrhea (37%), nausea (34%), injection-site reactions (34%), fatigue (27%), and headache (22%). Plerixafor 0.24 mg/kg SC is administered on the evening of the fourth day of G-CSF dosing, approximately 11 hours before the first apheresis session. Daily doses of plerixafor can be repeated up to 3 times on consecutive days to achieve adequate HSC collection. The average wholesale price of a 24-mg vial of plerixafor is $7500. CONCLUSIONS: Plerixafor is an effective agent for mobilizing CD34+ HSC. Long-term treatment outcomes are being studied in patients undergoing autologous transplantation of HSC mobilized with G-CSF + plerixafor.

Isolated patellofemoral osteoarthritis

Surgical Management of Osteoarthritis of the Knee CPG

Isolated patellofemoral osteoarthritis is now recognised to be more common than previously thought. The features and management are reviewed, including the various surgical options in symptomatic patients. The evidence base for managing patellofemoral osteoarthritis is behind that for the tibiofemoral joint. All treatments are based on uncontrolled observational case series, typically retrospectively reviewed. Fortunately the majority of patients with isolated patellofemoral degenerative changes do not need surgical treatment. Those who are symptomatic can usually be successfully treated with weight loss and quadriceps strengthening exercises

Hip adductor muscle strength in patients with varus deformed knee

Management of Hip Fractures in the Elderly

The isometric muscle strength of the muscles around 49 medial compartmental osteoarthritic knees of 32 women was measured quantitatively using a Musculater GT-50 (osteoarthritis group). The patients pushed up a pad containing an electrical sensor and values were compared with those obtained from the nonaffected knees of subjects (control group). The mean age of the patients in the osteoarthritis group was 62.3 years (range, 43-78 years). The control group consisted of 13 women (13 knees) with a mean age of 60.5 years (range, 49-73 years). In the osteoarthritis group, the medial joint space was preserved in 17 knees (Grade A), 23 knees had narrowing of the joint space (Grade 2), and nine knees showed joint space obliteration (Grade 3). Quadriceps strength was significantly weaker in Grade 2 knees than in Grade 0 knees; however, there was no significant difference in quadriceps to hamstrings ratio between each grade. The hip adductors to hamstrings ratio was significantly greater in Grade 2 knees than in Grade 0 knees, and was greater in Grade 3 knees than in Grade 0, Grade 1, and Grade 2 knees. The findings suggested that in patients with medial compartmental osteoarthritis of the knee, the hip adductor muscles may become strengthened to decrease varus decrease varus deformity of the limb

Mild traumatic brain injury and posttraumatic stress disorder: investigation of visual attention in Operation Iraqi Freedom/Operation Enduring Freedom veterans

Upper Eyelid and Brow Surgery

Mild traumatic brain injury (mTBI) and posttraumatic stress disorder (PTSD) are prevalent dual impairments in veterans returning from the wars in Iraq and Afghanistan. Attention problems are a common self-reported complaint of veterans with mTBI, but relatively few studies have investigated the types and levels of behavioral attentional deficits present in veterans with mTBI and PTSD. The purpose of this study was to compare visual attentional performance between samples of veterans with both mTBI and PTSD (mTBI+PTSD), PTSD only, and a control group. Overall, the attentional responses of the mTBI+PTSD group were slower than those of the PTSD and control groups. The response times were also more variable, suggesting difficulty with attentional vigilance. Additionally, we found evidence of hemispheric asymmetries in attentional performance. Participants with mTBI+PTSD were less efficient in orienting visual attention to stimuli flashed to the left visual field (LVF), suggesting a right hemisphere deficit. Overall, we found that veterans who had sustained an mTBI and had a coexisting PTSD diagnosis displayed longer response times and were less accurate than the PTSD and control groups, especially when cues were presented to the LVF.

Presence of microorganisms on the fitting denture complete surface: study 'in vivo'

Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures

It was the intention to study if glazing the fitting surface of maxillary dentures with a light-curing acrylic resin would diminish the bacterial counts. The study included the application of a photopolymerizing glaze to one half of the fitting denture surface; after 15 days microbial plaque was collected from a 1 cm2 area of the glazed and the untreated resin, respectively. At the same time bacteria were collected from a 1 cm2 area of the corresponding sites on the palatal mucosa. The application of the glaze had modified the number of bacteria cultured from the glazed surface versus the untreated surface. Denture surface: total aerobic bacteria, 1:4; aerobic streptococci, 1:4; aerobic staphylococci, 1:5; anaerobic bacteria, 1:3.5; mucosal surface aerobic bacteria, 1:4; streptococcal, 1:4. The differences were statistically significant at P<0.002. However, from a quantitative and qualitative point of view these differences were minor compared with the actual concentrations of the microorganisms of 104-106/cm2 observed on the fitting denture surface and the palatal mucosa

The natural history of intravascular lymphomatosis

MSTS 2022 - Metastatic Disease of the Humerus

Intravascular lymphomatosis (IVL) is a rare and clinically devastating form of extranodal B-cell non-Hodgkin's lymphoma. We performed a comprehensive analysis of the literature on IVL's published between 1959 and 2011 and evaluated the natural history as well as identified prognostic and predictive factors in patients. Nonparametric two-tailed Mann-Whitney U-test and Mantel-Cox log rank test were used to evaluate the survival intervals and prognostic factors. Multivariate analysis of variance (MANOVA) and chi-squared statistics were carried out to examine treatment-related predictive factors. Of the 740 patients with IVL, 651 (88%) had a diagnosis of B-cell lymphoma, 45 (6%) with T-cell lymphoma, and 12 patients (2%) with NK cell lymphoma. Central nervous system (CNS) IVL had the highest proportion of postmortem diagnosis, 250 (60%) compared to 21 (8%) of skin, 28 (11%) of bone marrow (BM) and spleen, and 17 (7%) of lung IVL's. Age <70 years (P = 0.0073), non-CNS site of initial diagnosis (P = 0.0014), lactate dehydrogenase (LDH) <700 (P = 0.0112), and rituximab treatment (P < 0.0001) were favorable prognostic factors. Gender, ethnicity, hemoglobin, BM biopsy, and the type of imaging studies used were not significant. Rituximab and doxorubicin treatment worked significantly better in patients with age >71 and LDH >577 compared to nonrituximab, nondoxorubicin regimens (MANOVA 2 degrees of freedom, P = 0.0345), with a median time from treatment to death of 20.0 (95% confidence interval [CI] 14.0-N/A, n = 14) months versus 2.0 (95%CI 0.5-N/A, n = 5) (chi(2) = 4.7, P = 0.0304). Patients with CNS IVL relapsed primarily in the CNS (88%) while same-organ relapse occurred less frequently in skin (23%), BM and spleen (50%) and lung (20%) IVL's. Our results indicate that IVL is primarily a disease of B-lymphoma cells. Timely diagnosis and treatment with rituximab-based chemotherapy improve patient survival. The pattern of recurrence is different between CNS IVL and IVL's in other organs.

Diagnosis of scaphoid fracture and dedicated extremity MRI

Distal Radius Fractures

We evaluated the value of dedicated extremity magnetic resonance imaging (E-MRI) in patients with clinical suspicion of a scaphoid fracture and normal initial radiographs. 52 patients underwent E-MRI within a mean of 4 (2-10) days after trauma. Follow-up radiographs were performed at average 11 (8-14) weeks after trauma, and these images were used as the "gold standard". A T1-weighted turbo gradient echo 3D and a tau short inversion recovery STIR were performed, both in coronal planes. The imaging time was less than 10 min. The images were evaluated independently by two radiologists. E-MRI detected occult fractures of the scaphoid in 9 patients, and of the distal radius in a further 6 patients. All these fractures were confirmed at follow-up radiographs. Furthermore, E-MRI revealed a fracture of the capitate bone in 1 patient, and of the triquetrum in 2 patients, and in 8 patients, bone bruise in 1 or more of the carpal bones. However, these fractures and bone lesions could not be confirmed by the follow-up radiographs. The agreement between the two examiners was high (kappa = 0.8) for E-MRI detection of fractures. E-MRI seems to be better than radiographs in the early diagnosis of occult fractures of the scaphoid bone and the wrist.

Prophylactic antibiotics to reduce the risk of urinary tract infections after urodynamic studies

Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures

BACKGROUND: There is a risk that people who have invasive urodynamic studies (cystometry) will develop urinary tract infections or bacteria in the urine or blood. However, the use of prophylactic antibiotics before or immediately after invasive cystometry or urodynamic studies is not without risks of adverse effects and emergence of resistant microbes. OBJECTIVES: To assess the effectiveness and safety of administering prophylactic antibiotics in reducing the risk of urinary tract infections after urodynamic studies. The hypothesis was that administering prophylactic antibiotics reduces urinary tract infections after urodynamic studies. SEARCH METHODS: We searched the Cochrane Incontinence Group Specialised Trial Register, MEDLINE (January 1966 to January 2009), CINAHL (January 1982 to January 2009), EMBASE (January 1966 to January 2009), PubMed (1 January 1980 to January 2009), LILACS (up to January 2009), TRIP database (up to January 2009), and the UK NHS Evidence Health Information Resources (searched 10 December 2009). We searched the reference lists of relevant articles, the primary trials and the proceedings of the International Urogynaecological Association International Continence Society and the American Urological Association for the years 1999 to 2009 to identify articles not captured by electronic searches. There were no language restrictions. SELECTION CRITERIA: All randomized controlled trials and quasi-randomized trials comparing the use of prophylactic antibiotics versus a placebo or no treatment in patients having urodynamic studies were selected. Two authors (PL and RF) independently performed the selection of trials for inclusion and any disagreements were resolved by discussion. DATA COLLECTION AND ANALYSIS: All assessments of the quality of trials and data extraction were performed independently by two authors of the review (PL and RF) using forms designed according to Cochrane guidelines. We attempted to contact authors of the included trials for any missing data. Data were extracted on characteristics of the study participants including details of previously administered treatments, interventions used, the methods used to measure infection and adverse events.Statistical analyses were performed according to Cochrane Collaboration guidelines. Data from intention-to-treat analyses were used where available. For the dichotomous data, results for each study were expressed as a risk ratio (RR) with 95% confidence interval (CI) and combined for meta-analysis using the Mantel-Haenszel method.The primary outcome was urinary tract infection. Heterogeneity was assessed by the P value and I(2) statistic. MAIN RESULTS: Nine randomized controlled trials involving the prophylactic use of antibiotics in patients having urodynamic studies were identified and these included 973 patients in total; one study was an abstract. Two further trials were excluded from the review. The methods of the included trials were poorly described.The primary outcome in all trials was the rate of developing significant bacteriuria, defined as the presence of more than 100,000 bacteria per millilitre of a mid-stream urine sample on culture and sensitivity testing. The other outcomes included pyrexia, haematuria, dysuria and adverse reactions to antibiotics.The administration of prophylactic antibiotics when compared to a placebo reduced the risk of significant bacteriuria (4% with antibiotics versus 12% without, risk ratio (RR) 0.35, 95% CI 0.22 to 0.56) in both men and women. The administration of prophylactic antibiotics also reduced the risk of haematuria (RR 0.46, 95% CI 0.23 to 0.91). However, there was no statistically significant difference in the primary outcome, risk of symptomatic urinary tract infection (40/201, 20% versus 59/214, 28%; RR 0.73, 95% CI 0.52 to 1.03); or in the risk of fever (RR 5.16, 95% CI 0.94 to 28.16) or dysuria (RR 0.83, 95% CI 0.5 to 1.36). Only two of 135 people had an adverse reaction to the antibiotics. The number of patients needed to treat with antibiotics to prevent bacteriuria was 12.3. Amongst women, the number needed to treat to prevent bacteriuria was 13.4; while amongst men it was 9.1 (number needed to treat = 1/ absolute risk reduction). AUTHORS' CONCLUSIONS: Prophylactic antibiotics did reduce the risk of bacteriuria after urodynamic studies but there was not enough evidence to suggest that this effect reduced symptomatic urinary tract infections. There was no statistically significant difference in the risk of fever, dysuria or adverse reactions. Potential benefits have to be weighed against clinical and financial implications, and the risk of adverse effects

Loosening of the Lubinus hip. 202 cases followed for 3-6 years

Management of Hip Fractures in the Elderly

Survivorship methods were applied to a consecutive series of 202 primary Lubinus total hip arthroplasties followed for 3 to 6 years. After 5 years, the revision rate was 3 percent, and the radiographic loosening rate was 13 percent for the socket and 10 percent for the stem

Control of postoperative pain following total knee arthroplasty: Is it necessary to associate sciatic nerve block to femoral nerve block?

Surgical Management of Osteoarthritis of the Knee CPG

BACKGROUND AND OBJECTIVES: Total knee arthroplasty (TKA) causes severe tissue trauma, leading to severe postoperative pain. Good postoperative analgesia is fundamental and one should consider that early mobilization of the joint is an important aspect to obtain good results. There is a controversy in the literature on the efficacy of isolated femoral nerve block. The objective of this study was to evaluate postoperative analgesia with the association of sciatic and femoral nerve block. METHODS: Seventeen patients undergoing TKA under spinal anesthesia were divided in two groups: A and B. In Group A (n = 9), femoral nerve block was performed, while in Group B (n = 8), femoral and sciatic nerve block were done. The blockades were done in the immediate postoperative period with 20 mL of 0.5% of ropivacaine. Pain was evaluated in the first 24 hours using the Visual Analog Scale and the verbal scale. The length of time between the nerve block and the first complaint of pain (M1) was also evaluated. RESULTS: The median of the duration of analgesia (M1) in Group A was 110 min, while in Group B it was 1285 min (p = 0.0001). There were no complications related to the technique used. CONCLUSIONS: Sciatic nerve block, when associated with femoral nerve block, under the conditions of the present study, improved significantly the quality of postoperative analgesia in TKA. (copyright) Sociedade Brasileira de Anestesiologia, 2007

An integer programming model for distal humerus fracture fixation planning

The Treatment of Pediatric Supracondylar Humerus Fractures AUC

OBJECTIVE: To demonstrate the feasibility of an integer programming model to assist in pre-operative planning for open reduction and internal fixation of a distal humerus fracture. MATERIALS AND METHODS: We describe an integer programming model based on the objective of maximizing the reward for screws placed while satisfying the requirements for sound internal fixation. The model maximizes the number of bicortical screws placed while avoiding screw collision and favoring screws of greater length that cross multiple fracture planes. RESULTS: The model was tested on three types of total articular fractures of the distal humerus. Solutions were generated using 5, 9, 21 and 33 possible screw orientations per hole. Solutions generated using 33 possible screw orientations per hole and five screw lengths resulted in the most clinically relevant fixation plan and required the calculation of 1,191,975 pairs of screws that resulted in collision. At this level of complexity, the pre-processor took 104 seconds to generate the constraints for the solver, and a solution was generated in under one minute in all three cases. CONCLUSION: Despite the large size of this problem, it can be solved in a reasonable amount of time, making use of the model practical in pre-surgical planning

Survival and prognosis in malignant giant cell tumor of bone: A population-based analysis from 1984 to 2013

MSTS 2022 - Metastatic Disease of the Humerus

Background: Malignant giant cell tumor of bone (MGCTB) is extremely rare. Currently, population-based prognosis studies are lacking. This study aimed to determine the impact of demographics, tumor characteristics, and treatment on prognosis among patients with MGCTB. Methods: The Surveillance, Epidemiology, and End Results database was used to identify patients with MGCTB from 1984 to 2013. Kaplan-Meier analyses were performed to determine the overall survival (OS). Univariable and multivariable Cox analyses were conducted to identify prognostic factors. Results: There were 250 patients with MGCTB included in our study. The multivariate Cox analysis revealed that age at diagnosis (hazard ratio [HR]: 1.09; 95% confidence interval [CI]: 1.07-1.11; P < 0.001), tumor size (HR: 7.04; 95% CI: 2.38-20.77; P < 0.001), tumor extension (regional vs. localized, HR: 2.64; 95% CI: 1.10-6.34; P=0.030; distant vs. localized, HR: 6.12; 95% CI: 2.27-16.49; P < 0.001), and radiotherapy (HR: 0.41; 95% CI: 0.18-0.89; P=0.025) were independent risk factors of OS in patients with MGCTB. Notably, tumor site (HR: 1.98; 95% CI: 0.99-4.00; P=0.055) exhibited borderline significance. Additionally, we found that patients with tumors measuring >70mm (P=0.015), located in the axial skeleton (P < 0.001) and presented with distant metastasis (P < 0.001) tended to receive radiotherapy. Moreover, a nomogram model integrating independent predictors was established to estimate the OS of patients with MGCTB. Conclusion: This study provides a population-based assessment of the largest number of patients with MGCTB. We found that older age, larger tumor size, regional or distant metastasis, and lack of radiotherapy was associated with poor OS. Surgical methods were not significantly associated with OS. Furthermore, we built a high-quality nomogram to predict 1-, 3-, and 5-year OS for patients with MGCTB. These findings may assist in the clinical diagnosis and treatment of MGCTB.

State of the art in geriatric rehabilitation. Part II: clinical challenges

Management of Hip Fractures in the Elderly

OBJECTIVES: To examine common clinical problems in geriatric rehabilitation and to make recommendations for current practice based on evidence from the literature. DATA SOURCES: A CINAHL database and two MEDLINE searches were conducted for 1980 to 2001. A fourth search was completed by using the Cochrane database. STUDY SELECTION: One author reviewed the references for relevance and another for quality. A total of 336 articles were considered relevant. Excluded articles were unrelated to geriatric rehabilitation or were anecdotal or descriptive reports on a small number of patients. DATA EXTRACTION: The following areas were the major geriatric rehabilitation subtopics identified in the search: frailty, comprehensive geriatric assessment, admission screening, assessment tools, interdisciplinary teams , hip fracture, stroke, nutrition, dementia, and depression. This article focuses on the latter 5 subtopics. The literature was reviewed by using a level-of-evidence framework. Level 1 evidence was a randomized controlled trial (RCT) or meta-analysis or systematic review of RCTs. Level 2 evidence included controlled trials without randomization, cohort, or case-control studies. Level 3 evidence involved consensus statements from experts, descriptive studies, or reports of expert committees. DATA SYNTHESIS: Of the 336 articles evaluated, 108 were level 1, 39 were level 2, and 189 were level 3. Recommendations were made for each subtopic according to the level of evidence in the specific area. In cases in which several articles were written on a topic with similar conclusions, we selected the articles with the strongest level of evidence, thereby reducing the total number of references. CONCLUSIONS: Frail older patients with hip fracture should receive geriatric rehabilitation. They should also be screened for nutrition, cognition, and depression. Older persons should receive nutritional supplementation when malnourished. If severe dysphagia occurs in stroke patients, gastrostomy tube feeding is superior to nasogastric tube feeding

Intravascular histiocytosis associated with bacterial endocarditis

Surgical Management of Osteoarthritis of the Knee CPG

Introduction: Intravascular histiocytosis is a rare benign cutaneous lesion of unknown pathogenesis, characterized by a reactive intravascular dermal proliferation of histiocytes. The majority of the reported cases showed an association with rheumatoid arthritis, tonsillitis, bacterial endocarditis. Cutaneus eruptions vary from erythematous and violaceous papules to plaques and indurated patches with a livedo-like pattern of erythema. Case report: A 63-year-old woman had a 6-month history of malaise, fever, and weight loss.Clinical examination showed violaceous indurated patches on the skin of her earlobes, elbows, knees, and upper arms. Based on clinical findings and positive Borrelia burgdorferi IgG antibodies, a diagnosis of an inflammatory-edematous stage of Acrodermatitis chronica atrophicans could not be excluded. Consequently, the patient was treated with Ceftriaxone and Cefuroxime which resulted in the diminishing of skin lesions. However, malaise and fever remained.Laboratory findings revealed anemia, leukopenia, thrombocytopenia, and elevated amounts of CRP, ESR, liver enzymes; abdominal ultrasound- dysmetabolic, enlarged liver, splenomegaly. Liver biopsy showed reactive changes and periportal steatosis of hepatocytes. On the basis of histology and immunohistochemistry of the skin (vascular proliferation, dilated clusters of capillaries in the dermis partly occluded by thrombi; CD3, CD20, S100, CD1a, CD34, CD31(-), LCA and CD68(+)- histiocytes), intravascular histiocytosis was diagnosed; transesophageal heart sonographyinfectious endocarditis. The patient was treated with Benzylpenicillin at 18,000,000 Units/day intravenously for 21 days. After valve replacement surgery, chronic active infectious endocarditis was verified. Conclusion: An improvement of skin lesions and general health after antibacterial therapy confirms the association of morphologically verified intravascular histiocytosis with infectious endocarditis

Cathepsin B mediates TRAIL-induced apoptosis in oral cancer cells

MSTS 2018 - Femur Mets and MM

PURPOSE: The death ligand TRAIL (tumor necrosis factor-related apoptosis inducing ligand) triggers apoptosis in a variety of cancer cells, which implies the potential for therapeutic applications. The purpose of this study was to investigate the role of the lysosomal protease cathepsin B (CB) in mediating TRAIL-induced cell death in oral squamous cell carcinoma (OSCC) cells. METHODS: OSCC cell lines from primary tumor and lymph node metastasis were examined for expression of apoptosis markers by Western blots, enzyme activity assays, nuclear fragmentation assays, and FACS analysis. Gene-specific ribozymes or chemical inhibitors were used to inhibit CB or caspases in target cells. RESULTS: TRAIL-induced activation of caspase-3, cleavage of Bid and poly-ADP-ribose polymerase, release of cytochrome c, and DNA fragmentation were blocked either by a pan-caspase inhibitor (zVAD-fmk) or a CB inhibitor (CA074Me), consistent with the involvement of TRAIL as well as CB in cell death. The primary tumor cells were more susceptible to apoptosis than their corresponding lymph node metastatic cells. Stable transfection of a ribozyme which inhibited CB expression also decreased the apoptotic process. CONCLUSIONS: We conclude that TRAIL-induced apoptotic cell death in OSCC cells is mediated through CB or through caspase activation. Our data point to a new tumor-suppressive role for CB in OSCC which is opposed to the invasion- and metastasis-promoting functions of lysosomal proteases.

Bilateral Total Hip and Knee Arthroplasties: Average 10-Year Follow-Up

OAK 3 - Non-arthroplasty tx of OAK

BACKGROUND: The present study investigates the clinical and radiographic outcomes in patients with all 4 major lower extremity joints replaced. METHODS: A retrospective review of our institution's database identified 125 patients in whom both hips and both knees were replaced. The mean time between the first and last arthroplasty was 6.6 years. Preoperative diagnoses included osteoarthritis in 80% and rheumatoid arthritis in 20%. The average age at the time of the first arthroplasty was 63.7 years. The mean follow-up for all arthroplasties was 10.5 years (range 2-31 years). Patients were then matched according to age, gender, diagnosis, prosthesis, and follow-up, to patients with single or bilateral total hip or total knee arthroplasty. RESULTS: There were 11 aseptic hip revisions (4.4%) and 3 aseptic knee revisions (1.2%). At final follow-up, 86% of hips and 83% of knees were rated with no or mild pain, 68% of patients rated walking as unlimited, and 98% of patients were able to satisfactorily negotiate stairs. Aseptic survivorship for all joint arthroplasties was 93.8% at 15 years. No statistical differences were noted in pain, function, stair, and walking scores between the matched groups. CONCLUSION: This report demonstrated excellent clinical, functional, and radiographic outcomes in patients with all 4 major lower extremity joints replaced. Walking aids were needed in 15% of patients, however. At final follow-up, this selected group of patients appears to fare just as well as patients with single or bilateral hip or knee arthroplasty with respect to pain and function.

Hybrid thin wire external fixation: an effective, minimally invasive, modular surgical tool for the stabilization of periarticular fractures

The Treatment of Pediatric Supracondylar Humerus Fractures AUC

Hybrid thin wire external fixation is an effective, minimally invasive treatment for the stabilization of periarticular, supracondylar, and pilon fractures. The extent of bone and soft-tissue loss, high risk of infection, and further damage to the soft tissues precludes open reduction and internal fixation as a safe treatment method. External fixation preserves the soft-tissue envelope with minimal damage and allows fracture stabilization, early loading, and mobilization, which promote bone healing

Effects of intravenous patient-controlled analgesia with morphine, continuous epidural analgesia, and continuous three-in-one block on postoperative pain and knee rehabilitation after unilateral total knee arthroplasty

Surgical Management of Osteoarthritis of the Knee CPG

In this study, we assessed the influence of three analgesic techniques on postoperative knee rehabilitation after total knee arthroplasty (TKA). Forty-five patients scheduled for elective TKA under general anesthesia were randomly divided into three groups. Postoperative analgesia was provided with i.v. patient-controlled analgesia (PCA) with morphine in Group A, continuous 3-in-1 block in Group B, and epidural analgesia in Group C. Immediately after surgery, the three groups started identical physical therapy regimens. Pain scores, supplemental analgesia, side effects, degree of maximal knee flexion, day of first walk, and duration of hospital stay were recorded. Patients in Groups B and C reported significantly lower pain scores than those in Group A. Supplemental analgesia was comparable in the three groups. Compared with Groups A and C, a significantly lower incidence of side effects was noted in Group B. Significantly better knee flexion (until 6 wk after surgery), faster ambulation, and shorter hospital stay were noted in Groups B and C. However, these benefits did not affect outcome at 3 mo. We conclude that, after TKA, continuous 3-in-1 block and epidural analgesia provide better pain relief and faster knee rehabilitation than i.v. PCA with morphine. Because it induces fewer side effects, continuous 3-in-1 block should be considered the technique of choice. IMPLICATIONS: In this study, we determined that, after total knee arthroplasty, loco-regional analgesic techniques (epidural analgesia or continuous 3-in-1 block) provide better pain relief and faster postoperative knee rehabilitation than i.v. patient-controlled analgesia with morphine. Because it causes fewer side effects than epidural analgesia, continuous 3-in-1 block is the technique of choice

The history of liposuction

Panniculectomy & Abdominoplasty CPG

This article aims to familiarize the reader with the history of liposuction. The author documents the landmark events and characters in the development of this revolutionary and widely known procedure. Included is a historical discussion of the obstacles and the triumphs the practitioners and the procedure itself has seen, as well as a review of relevant scientific data placed in its appropriate historical context up through modern day.

Patella height after high tibial osteotomy with internal fixation and early motion

Surgical Management of Osteoarthritis of the Knee CPG

The purpose of this study was to compare the incidence of patella infera in patients after high tibial osteotomy treated with either postoperative immobilization or internal fixation and early range of motion. A retrospective review of 98 patients with high tibial osteotomy was done at the authors' institution. Thirty-three patients who had secondary procedures such as concomitant ligamentous reconstruction with early motion were excluded. Therefore, 69 knees in 65 patients remained in the study cohort. Group A consisted of 32 patients (34 knees) treated with postoperative immobilization, whereas Group B included 33 patients (35 knees) treated with internal fixation and early motion. The preoperative and postoperative Insall-Salvati index, Blackburne-Peel index, and angular alignment were determined for each group. Between Groups A and B, the differences in the Insall-Salvati index and the Blackburne-Peel index were statistically significant, although the difference in angular correction was not significant. With rigid fixation and early motion the Insall-Salvati index showed that there was less postoperative shortening of the patellar tendon. The relationship of the patella to the remainder of the knee was affected less adversely as evidenced by the Blackburne-Peel index. High tibial osteotomy with internal fixation and early range of motion should result in a better knee and ease the subsequent performance of a total knee arthroplasty

Risk and mortality of traumatic brain injury in stroke patients: Two nationwide cohort studies

HipFx Supplemental Cost Analysis

Patients with stroke had higher incidence of falls and hip fractures. However, the risk of traumatic brain injury (TBI) and post-TBI mortality in patients with stroke was not well defined. Our study is to investigate the risk of TBI and post-TBI mortality in patients with stroke.Using reimbursement claims from Taiwan's National Health Insurance Research Database, we conducted a retrospective cohort study of 7622 patients with stroke and 30 488 participants without stroke aged 20 years and older as reference group. Data were collected on newly developed TBI after stroke with 5 to 8 years' follow-up during 2000 to 2008. Another nested cohort study including 7034 hospitalized patients with TBI was also conducted to analyze the contribution of stroke to post-TBI in-hospital mortality.Compared with the nonstroke cohort, the adjusted hazard ratio of TBI risk among patients with stroke was 2.80 (95% confidence interval = 2.58-3.04) during the follow-up period. Patients with stroke had higher mortality after TBI than those without stroke (10.2% vs 3.2%, P < .0001) with an adjusted relative risk (RR) of 1.46 (95% confidence interval = 1.15-1.84). Recurrent stroke (RR = 1.60), hemorrhagic stroke (RR = 1.68), high medical expenditure for stroke (RR = 1.80), epilepsy (RR = 1.79), neurosurgery (RR = 1.94), and hip fracture (RR = 2.11) were all associated with significantly higher post-TBI mortality among patients with stroke.Patients with stroke have an increased risk of TBI and in-hospital mortality after TBI. Various characteristics of stroke severity were all associated with higher post-TBI mortality. Special attention is needed to prevent TBI among these populations

The truth behind subchondral cysts in osteoarthritis of the knee

Surgical Management of Osteoarthritis of the Knee CPG

BACKGROUND: Subchondral cysts have always been taught to be one of the cardinal radiological features of knee osteoarthritis but are not well understood. We aimed to evaluate the radiological prevalence and epidemiology of subchondral cysts in patients with knee osteoarthritis to determine if they are truly a cardinal radiological feature. METHODS: All patients of a single surgeon with symptoms of knee osteoarthritis were selected for this study. All patients had failed a trial of conservative therapy and were planned for total knee arthroplasty. Patients with symptoms of and documentary evidence of inflammatory arthritis, other neurological and orthopaedic problems causing functional deficits were excluded from this study. A total of 806 plain radiographs were analyzed with the aid of an atlas for the presence of narrowed joint space, osteophytes, subchondral sclerosis and subchondral cysts. The radiological prevalence of each feature was then calculated. Demographics and pre-operative measurements were compared between patients with and without radiological evidence of subchondral cysts. RESULTS: Subchondral cysts were only present in 30.6% of the study population. Narrowed joint space was present in 99.5%, osteophytes in 98.1% and subchondral sclerosis in 88.3% of all radiographs. The differences in prevalence were statistically significant. There was a higher proportion of females in patients with radiological evidence of subchondral cysts. These patients also had a greater varus deformity preoperatively. CONCLUSION: With a radiological prevalence of 30.6%, subchondral cysts should not be considered a cardinal radiological feature of osteoarthritis. Subchondral cysts may be associated with the female gender and genu varum

Clinicians' recognition of 10 different types of distal radial fractures

Distal Radius Fractures

This study concerned baseline performance in recognition of 10 different types of distal radial fractures. Verbal tasks of admitting knowing about fractures and Visual tasks were designed for each fracture type. The Verbal task of admitting knowing consisted of a description with the relevant distinctive features of the fracture. The surgical resident was asked whether he admitted knowing the particular fracture described. The Visual task consisted of X-rays for which the subject had to label the fracture or identify its distinctive features. The test was presented to 30 surgical trainees working in five teaching hospitals. On the Verbal task of admitting knowing, scores were statistically significantly higher (68% "yes") than on the Visual task (33% correct). Responses met our criterion of 80% correct for the following fracture types: Colles's, distal forearm, and Smith's fracture. For seven other fracture types (combination radius and scaphoid, radial styloid process, dorsal Barton's, volar Barton's, pilon, chauffeur's, and lunate load fracture), the 80% criterion was not met. Analysis of the incorrect answers on the Visual task indicated that the surgical residents tended to label unknown fracture types as Colles's or Smith's fractures. Furthermore, the residents tended to overestimate their own diagnostic competence (overconfidence bias) for several fracture types. It was concluded that to improve diagnosis, the relevant distinctive features of distal radial fractures should be taught.

Classification of medial fractures of the femoral neck

Management of Hip Fractures in the Elderly

In order to regularize the classification of medial fractures of the femoral neck a retrospective analysis was made of fractures in adult patients treated in the University Hospital in Turku and also in the Municipal Hospital in the same city between 1964 and 1971. There were 446 cases of medial fracture of the femoral neck, 75 of which occurred in male patients and 368 in female patients. Medial fractures of the femoral neck were classified according to the scheme laid down by Garden (8) and Pauwels (18) and in addition, the situation of the level of the fracture in the femoral neck was determined according the method proposed by Brown and Abrami (3). No correlation could be found between either the division made by Garden and that made by Pauwels or between the situation of the level of the fracture in the femoral neck and the degree of primary dislocation in the fracture. Following Garden's classification, dislocated (stage 3 or stage 4) fractures were more common among women than men. Pauwels' figures showed that there were relatively more unstable fractures (groups 3--4) among men than among women. Among women patients the situation of the level of the fracture was, on the average, more medial than among men. The healing of fractures was evaluated according to the calssifications of Garden and Pauwels. That of Garden proved to be much more logical and from the point of view of prognosis of recovery, more reliable. The present authors recommend the classification made by Garden in cases of medial fracture of the femoral neck

Minimally displaced pediatric humerus lateral condyle fractures: risk factors for displacement and outcomes of delayed surgery

Pediatric Supracondylar Humerus Fracture 2020 Review

The purpose of this study was to identify risk factors for management failure in pediatric minimally displaced lateral condyle fractures of the distal humerus (LCHFx) and compare outcomes between initial nonoperative and operative cohorts. A retrospective chart review of LCHFx was conducted to identify children treated with displacement <2?mm and initial nonoperative management. Classification and Regression Trees (CART) were constructed to identify predictors for failure of nonoperative management (further displacement requiring operative intervention). One hundred forty nonoperative children met initial inclusion. CART analysis identified the internal oblique measurement of pre-treatment fracture displacement of >1.2?mm to be the most predictive of nonoperative failure. Fractures with displacement of >1.2?mm had a 58.3% rate of failure compared to 1.3% for those <1.2?mm of initial displacement (P?<?0.001). Thirty-seven percent of nonoperative children required revision treatment compared to only 12% of operative children (P?=?0.034). LCHFx with minimal displacement (1-2?mm) have a relatively high risk for failure when initially managed without surgery and should either be monitored closely or considered for early operative management when appropriate.

Epidemiology of osteoporosis

Management of Hip Fractures in the Elderly

Fragility fractures are now recognised as a major problem of public health. Although the prevalence of all fractures is similar among men and women, the vast majority of osteoporotic fractures occur in elderly women. These comprise vertebral compression fractures, Colles fractures at the wrist, and hip fracture, and to a lesser extent fractures at other sites. The incidence of vertebral and hip fracture increases exponentially with age. The reasons for this relate in part to the lower bone density of women at the time of maturity (peak bone density), and the accelerated bone loss that occurs after the menopause. Women live significantly longer than men, so that the prevalence of osteoporosis amongst elderly women is six-fold that of men. The age- and sex-specific incidence of osteoporotic fracture is rising in many countries, and if the current trends in the United Kingdom continue, then the number of hip fractures each year will more than double over the next 20 years. There is a marked geographic distribution in the incidence of hip fracture, and probably of other osteoporotic fractures. Indeed, the difference in incidence between communities is greater than the difference in incidence between sexes within communities. This suggests that the importance of gonadal insufficiency in women has been over-emphasised and that other factors, probably relating to life-style factors affecting peak bone density, account for ecological differences in incidence between communities and secular trends within communities

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OAK 3 - Non-arthroplasty tx of OAK

OBJECTIVES: To assess the association between intermediate and patient-centered outcomes and harms with physical therapy interventions in community-dwelling adults with chronic knee pain secondary to osteoarthritis and to examine validity and minimum clinically important differences of the tools for outcome measurement. DATA SOURCES: We searched major electronic bibliographic databases including MEDLINE, the Cochrane Library, the Physiotherapy Evidence Database, and Allied and Complementary Medicine and trial registries up to February 29, 2012. REVIEW METHODS: We performed a systematic review of randomized and nonrandomized studies published in English to synthesize rates or means of measured pain, function, and quality of life with physical therapy interventions. Observational studies provided evidence of the association between changes in knee joint functional tests and patient-centered outcomes and minimum clinically important differences in validated tools for outcome measures. We performed meta-analyses of standardized mean differences using random effects models to synthesize the evidence. RESULTS: Of 4,266 retrieved references, 154 eligible references examined the association between patient-centered and intermediate outcomes and 422 eligible references examined physical therapy interventions. Of these, 193 randomized controlled trials (RCTs) reported on knee pain, disability, quality of life, and functional outcomes after physical therapy interventions. Pooling criteria were met by 84 RCTs that provided evidence for 12 physical therapy interventions on pain (n = 58), physical function (n = 36), and disability (n = 29). Most studies reported physical therapy effects at followups of 3 months or less. Evidence on longer-term physical therapy effects was available for seven intervention-outcome pairs. Meta-analyses at the longest time of followup provided low-strength evidence that aerobic (n = 11) and aquatic exercise (n = 3) improved disability; aerobic exercise (n = 19), strengthening exercise (n = 17), and ultrasound (n = 6) reduced pain and improved function. Six of 11 individual RCTs demonstrated clinically important improvements in pain and disability with aerobic exercise. Pain relief was consistent in RCTs that reported physical therapist supervision of aerobic exercise. Diathermy, orthotics, and magnetic stimulation demonstrated no benefit. Limited direct comparative effectiveness evidence demonstrated similar benefits in disability measures with aerobic, aquatic, and strengthening exercise. Evidence from individual RCTs did not permit robust conclusions about which physical therapy interventions are most effective or whether differences in effect could be attributed to patient characteristics. Patients with high compliance to exercise tended to have better treatment responses. We found no association between the duration of examined interventions and better intermediate or patient-centered outcomes. Adverse events were uncommon and not severe enough to deter participants from continuing treatment. Gait, mobility restrictions, muscle strength, and range-of-motion measures were associated with disability measures in individual studies. Minimum clinically important differences in scales were determined for 26 tools but have not been used in RCTs to examine the clinical importance of improvements. The definition of the Patient Acceptable Symptom State that accounts for patient satisfaction was available for the Western Ontario McMaster Universities Osteoarthritis Index, the Visual Analog Scale for Pain, and the Patient Global Assessment Scale. CONCLUSIONS: Low-strength evidence suggested that core physical therapy interventions, including aerobic, aquatic, strengthening, and proprioception exercise, improved patient outcomes. Risk of bias in studies and heterogeneity in populations and physical therapy interventions downgraded the strength of evidence to low or moderate in most cases. Studies focused on a single modality of physical therapy rather than the combinations typically used in practice. Benefits with physical therapy interventions were not consistently evaluated according to the clinical importance of improvement in scales and tests. Adverse events were uncommon and not severe enough to deter participants from continuing treatment. Evidence about long-term adherence to and benefits of available physical therapy interventions is lacking.

Immunostained cathepsins B and L correlate with depth of invasion and different metastatic pathways in early stage gastric carcinoma

MSTS 2018 - Femur Mets and MM

BACKGROUND: With the recent development of minimal treatment for early stage gastric carcinoma, identifying specific indicators of the metastatic potential of primary tumors has become more important. Cathepsin B and cathepsin L, both lysosomal cysteine proteases, degrade the extracellular matrix during tumor progression. Although many studies have shown their relation to human cancer progression, little is known about their roles in the early stage. The clinicopathologic significance of cathepsins was therefore studied in early stage gastric carcinoma. METHODS: Expression of both cathepsins was studied immunohistochemically in 51 tissue specimens from gastric carcinomas that invaded the submucosal layer or muscularis propria. The relation between their expression and clinicopathologic factors was analyzed. RESULTS: Both cathepsins were expressed at higher levels in tumors that invaded the muscularis propria than in those within the submucosa (P < 0.05). In addition, tumors with lymphatic invasion showed higher cathepsin B expression than those without it (P < 0.05), whereas tumors with venous invasion showed higher cathepsin L expression than those without it (P < 0.05). No other clinicopathologic factors correlated with expression of either cathepsin. CONCLUSIONS: Tumors with overexpression of cathepsins have powerful potential for invasiveness in the early stage of gastric carcinoma. Moreover, the authors hypothesize that cathepsins may be one of the determinants of the metastatic route. To the authors' knowledge, this is the first report on specific proteases concerning the mode of metastasis, and the results of this study suggest that therapeutic strategies for early stage gastric carcinoma might need to be changed according to the status of cathepsins.

Microbial changes in periodontitis successfully treated by mechanical plaque removal and systemic amoxicillin and metronidazole

Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures

Scaling and root planing in conjunction with systemic administration of antibiotics is used for treatment of aggressive periodontitis. The study investigated the changes of the subgingival microbiota in a homogeneous cohort of 12 female Caucasian patients. Plaque samples were obtained from 4 defined deep lesions per patient at baseline and 2, 6, and 12 months after therapy (mechanical plaque removal, oral administration of amoxicillin and metronidazole). Amplification of the 16S rRNA gene, cloning, and sequencing were applied to identify microbial species. Porphyromonas gingivalis strains were typed by multilocus sequence typing. Despite of a favorable clinical outcome, 16S rRNA sequence analysis revealed only minor changes of the microbiota with a temporal reduction of P. gingivalis and of Treponema denticola-like phylotypes. In contrast to T. denticola, T. sokranskii-like phylotypes were not affected. In 4 patients with recurrent colonization by P. gingivalis, the bacterial clones were identical before and after therapy as evidenced by multilocus sequence typing suggesting clonal persistence or reinfection during the course of the study. In summary, despite a favorable clinical outcome, a transient effect on only few bacterial species was observed. (copyright) 2009 Elsevier GmbH. All rights reserved

What would you do? Case challenges in knee surgery: Four knee arthroplasties presenting with effusions

OAK 3 - Non-arthroplasty tx of OAK

Four total knee arthroplasty patients present with effusions from excess synovial fluid, pus, or blood. "Which fluid" and "why" are the important questions. Recent Guidelines for Diagnosis of Periprosthetic Infection from the American Academy of Orthopedic Surgeons provide a useful diagnostic algorithm. Leukocyte counts and differential, plus culture, are emphasized. Suspected inflammatory arthropathy led to an "anchoring bias" in the first case. Unsuspected bone loss posed a challenge in our second case, and the final cases suffered effusions from instability, often a difficult diagnosis to establish. © 2013 Elsevier Inc.

Gender differences influence the outcome of geriatric rehabilitation following hip fracture

Management of Hip Fractures in the Elderly

Hip fracture represents the most dramatic expression of the disease, in terms of morbidity, medical cost and mortality. The incidence of hip fracture increases substantially with age. The purpose of this study was to evaluate the association between gender and geriatric rehabilitation outcome after traumatic hip fracture. Ninety-nine community-dwelling elderly patients (older than 65 years), 64 women and 35 men, who were admitted to geriatric rehabilitation after operated hip fracture were studied. We assessed the patients' clinical and demographic data, preoperative risk (ASA), type of fracture and orthopedic repair, pain intensity (VAS), cognitive (MMSE), mood (Zung IDS), and functional status (FIM) on admission and at the end of geriatric rehabilitation. Men had higher mean number of comorbid conditions at the time of the fracture. Men recovered more from depressed mood in comparison with women during the rehabilitation. Significant improvement in FIM motor subscore on discharge was found in both groups. The FIM motor subscore gain was higher in men (24.47) in comparison with women (19.22, p=0.036). Those differences were demonstrated in mean subscores of transfers (p=0.004), and locomotion (p=0.019). Women were more functionally dependent in locomotion, transfers and sphincter control. There were no differences between the groups by duration on rehabilitation stay. Recovery after hip fracture depends in large part on the pre-fracture health and functional ability of the patient. Gender differences in functional recovery may affect therapeutic and rehabilitative decision making. Functional recovery after traumatic hip fracture was better in men in comparison with women

The metaphyseal bone defect in distal radius fractures and its implication on trabecular remodeling-a histomorphometric study (case series)

Distal Radius Fractures

BACKGROUND: The invention of the locking plate technology leads to alterations of treatment strategies at metaphyseal fracture sites with the concept of spontaneous remodeling of trabecular bone voids. Whereas trabecular regeneration has been proven in experimental animal studies, no histologic data exist on human fracture healing with special emphasis on bone voids. METHODS: In order to qualify the trabecular bone remodeling capacity in vivo, bone specimens from the metaphyseal bone void were analyzed 14 months after trauma using quantitative histomorphometry. Twenty-five patients with an unstable dorsally displaced distal radius fracture were fixed with a palmar locking plate without additional bone graft or substitute. At implant removal, specimens from the previous compression void were harvested with a trephine in a volar-dorsal direction. In 16 patients, histomorphometric analysis could be performed, comparing the dorsal trabecular network with the volar, non-compressed ultrastructure. RESULTS: Significant differences for bone volume/total volume (BV/TV), trabecular number (TbN) and trabecular separation (TbSp), but not for trabecular thickness (TbTh) and osteoid volume/total volume (OV/TV), were detected. Neither patient age, defect size nor gender had a significant influence on bone remodeling. CONCLUSIONS: The results of this study indicate that trabecular bone remodeling does not lead to pre-trauma bone quality in metaphyseal bone compression voids following reduction and application of a locking plate.

Apoptosis - A significant cause of bone cell death in osteonecrosis of the femoral head

AAHKS (2) Corticosteroids

Osteonecrosis of the femoral head usually affects young individuals and is responsible for up to 12% of total hip arthroplasties. The underlying pathophysiology of the death of the bone cells remains uncertain. We have investigated nitric oxide mediated apoptosis as a potential mechanism and found that steroid- and alcohol-induced osteonecrosis is accompanied by widespread apoptosis of osteoblasts and osteocytes. Certain drugs or their metabolites may have a direct cytotoxic effect on cancellous bone of the femoral head leading to apoptosis rather than purely necrosis. © 2004 British Editorial Society of Bone and Joint Surgery.

The classification of degenerative hip disease

Management of Hip Fractures in the Elderly

It is probable that both genetic and environmental factors play some part in the aetiology of most cases of degenerative hip disease. Geneticists have identified some single gene disorders of the hip, but have had difficulty in identifying the genetics of many of the common causes of degenerative hip disease. The heterogeneity of the phenotypes studied is part of the problem. A detailed classification of phenotypes is proposed. This study is based on careful documentation of 2003 consecutive total hip replacements performed by a single surgeon between 1972 and 2000. The concept that developmental problems may initiate degenerative hip disease is supported. The influences of gender, age and body mass index are outlined. Biomechanical explanations for some of the radiological appearances encountered are suggested. The body weight lever, which is larger than the abductor lever, causes the abductor power to be more important than body weight. The possibility that a deficiency in joint lubrication is a cause of degenerative hip disease is discussed. Identifying the phenotypes may help geneticists to identify genes responsible for degenerative hip disease, and eventually lead to a definitive classification

Pelvic fractures. Assessment by conventional radiography and CT

Management of Hip Fractures in the Elderly

Sixty-two patients with pelvic fractures were evaluated by conventional radiography and CT. A correct pathoanatomic classification of the fractures was most often obtained by conventional radiography, but CT added information regarding acetabular fractures and involvement of the posterior part of the pelvic ring. Besides, CT was essential in the detection of intraarticular fragments and lesions of the femoral head. Classification of pelvic ring fractures by the pattern of traumatic forces was easily obtainable by conventional radiography, but often difficult to achieve by CT

Rigid internal fixation of the sternum in postoperative mediastinitis

DoD SSI (Surgical Site Infections)

Objective: The current standard treatment of mediastinitis following median sternotomy is radical sternal debridement and obliteration of anterior mediastinal dead space with muscle or omental flaps. This report describes and reviews our experiences with a new technique of sternal salvage based on osseous quantitative bacteriologic assessment and rigid fixation in patents with postoperative mediastinitis. Design: A retrospective review of 29 patients treated with sternal rigid internal fixation. Setting: Two tertiary care academic medical centers in Chicago, Ill, and Ann Arbor, Mich. Patients: Patients with postoperative mediastinitis following median sternotomy who underwent rigid internal fixation of retained sternum. Intervention: Following debridement, quantitative bacteriologic assessment and sternal vascularity were assessed. Sternal segments with good vascularity and in bacteriologic balance were anatomically reduced and rigidly fixed to each other with titanium miniplates in 24 patients with postoperative mediastinitis. Five of the 29 patients, at high risk for mediastinitis, underwent rigid internal fixation immediately after their cardiac procedure. Main Outcome Measures: Resolution of infection, wounds remaining closed, and stable sternums. Results: Bony union was obtained in 27 (93%) of 29 patients. The postoperative hospital stay ranged from 5 to 84 days, with a mean stay of 17 days and a median stay of 7 days. Length of stay was directly related to pulmonary function, which correlated with preoperative intubation status. Conclusions: Radical sternal debridement may not be necessary in all patients with postoperative mediastinitis following median sternotomy. Sternal salvage can safely and reliably be performed with a combination of clinical assessment of vascularity and osseous quantitative bacteriologic assessment. Anatomic reduction of the viable sternal segments is possible even in severely osteoporotic bone.

Clinical and ultrasonographic predictors of joint replacement for knee osteoarthritis: results from a large, 3-year, prospective EULAR study

Surgical Management of Osteoarthritis of the Knee CPG

OBJECTIVES: To determine clinical and ultrasonographic predictors of joint replacement surgery across Europe in primary osteoarthritis (OA) of the knee. METHODS: This was a 3-year prospective study of a painful OA knee cohort (from a EULAR-sponsored, multicentre study). All subjects had clinical evaluation, radiographs and ultrasonography (US) at study entry. The rate of knee replacement surgery over the 3-year follow-up period was determined using Kaplan-Meier survival data analyses. Predictive factors for joint replacement were identified by univariate log-rank test then multivariate analysis using a Cox proportional-hazards regression model. Potential baseline predictors included demographic, clinical, radiographic and US features. RESULTS: Of the 600 original patients, 531 (88.5%), mean age 67+/-10 years, mean disease duration 6.1+/-6.9 years, had follow-up data and were analysed. During follow-up (median 3 years; range 0-4 years), knee replacement was done or required for 94 patients (estimated event rate of 17.7%). In the multivariate analysis, predictors of joint replacement were as follows: Kellgren and Lawrence radiographic grade (grade > or =III vs <III, hazards ratio (HR) = 4.08 (95% CI 2.34 to 7.12), p<0.0001); ultrasonographic knee effusion (> or =4 mm vs <4 mm) (HR = 2.63 (95% CI 1.70 to 4.06), p<0.0001); knee pain intensity on a 0-100 mm visual analogue scale (> or =60 vs <60) (HR = 1.81 (95% CI 1.15 to 2.83), p=0.01) and disease duration (> or =5 years vs <5 years) (HR=1.63 (95% CI 1.08 to 2.47), p=0.02). Clinically detected effusion and US synovitis were not associated with joint replacement in the univariate analysis. CONCLUSION: Longitudinal evaluation of this OA cohort demonstrated significant progression to joint replacement. In addition to severity of radiographic damage and pain, US-detected effusion was a predictor of subsequent joint replacement

Pelvic fractures. Assessment by conventional radiography and CT

Management of Hip Fractures in the Elderly

Sixty-two patients with pelvic fractures were evaluated by conventional radiography and CT. A correct pathoanatomic classification of the fractures was most often obtained by conventional radiography, but CT added information regarding acetabular fractures and involvement of the posterior part of the pelvic ring. Besides, CT was essential in the detection of intraarticular fragments and lesions of the femoral head. Classification of pelvic ring fractures by the pattern of traumatic forces was easily obtainable by conventional radiography, but often difficult to achieve by CT

Risk factors for failure of locked plate fixation of distal femur fractures: an analysis of 335 cases

DoD SSI (Surgical Site Infections)

OBJECTIVES: Locked plating has become a standard method to treat supracondylar femur fractures. Emerging evidence indicates that this method of treatment is associated with modest failure rates. The goals of this study were to determine risk factors for complications and to provide technical recommendations for locked plating of supracondylar femur fractures. DESIGN: Retrospective review. SETTING: Three level I or II trauma centers. PATIENTS/PARTICIPANTS: Three hundred twenty-six patients with 335 distal femur fractures (OTA 33A or C, 33% open) treated with lateral locked plates were studied. The average patient age was 57 years (range 17-97 years), 55% were women, 34% were obese, 19% were diabetic, and 24% were smokers. INTERVENTION: All patients were managed with open reduction internal fixation using a lateral distal femoral locked plate construct that included locked screws in the distal fragment and nonlocked, locked, or a combination of locked and nonlocked screws in the proximal fragment. MAIN OUTCOME MEASUREMENTS: Risk factors for reoperation to promote union, deep infection, and implant failure. RESULTS: After the index procedure, 64 fractures (19%) required reoperation to promote union, including 30 that had a planned staged bone grafting because of the metaphyseal defect after debridement of an open fracture. Independent risk factors for reoperation to promote union and deep infection included diabetes and open fracture. Risk factors for proximal implant failure included open fracture, smoking, increased body mass index, and shorter plate length. CONCLUSIONS: The identified risk factors for reoperation to promote union and complications included open fracture, diabetes, smoking, increased body mass index, and shorter plate length. Most factors are out of surgeon control but are useful when considering prognosis. Use of relatively long plates is a technical factor that can reduce risk for fixation failure. LEVEL OF EVIDENCE: Prognostic level II. See instructions for authors for a complete description of levels of evidence.

Simple treatment for torus fractures of the distal radius

Distal Radius Fractures

Torus (buckle) fractures of the distal radius are common in childhood. Based on the results of a postal questionnaire and a prospective, randomised trial, we describe a simple treatment for this injury, which saves both time and money. Over a six-month period, we randomised 201 consecutive patients with this injury to treatment with either a traditional forearm plaster-of-Paris cast or a 'Futura-type' wrist splint. All patients were treated for a period of three weeks, followed by clinical and radiological review. There was no difference in outcome between the two groups, and all patients had a good result. Only one patient did not tolerate the splint which was replaced by a cast. The questionnaire showed a marked variation in the way in which these injuries are treated with regard to the method and period of immobilisation, the number of follow-up visits and radiographs taken. We suggest that a 'Futura-type' wrist splint can be used to treat these fractures. The patient should be reviewed on the following day to confirm the diagnosis and to give appropriate advice. There is no evidence that further follow-up is required. This simple treatment has major benefits in terms of cost and reduction of the number of attendances.

Hydroxychloroquine sulphate in prevention of deep venous thrombosis following fracture of the hip, pelvis, or thoracolumbar spine

Management of Hip Fractures in the Elderly

One hundred and fifty-three patients, forty-eight to ninety-seven years old, were included in a double-blind placebo-controlled investigation of the usefulness of hydroxychloroquine sulphate for the prevention of deep venous thrombosis in patients with fractures of the hip, pelvis, or thoracolumbar spine. The results indicated that this drug can reduce the number of thrombeombolic complications significantly (p less than 0.005), a finding that corresponds to the results obtained with other drugs such as coumarin derivatives or dextran 70

Adamantinoma of long bones. A clinicopathologic study of 85 cases

MSTS 2018 - Femur Mets and MM

A study of 85 adamantinomas of long bones revealed that 70 were in the tibia (11 of which also involved the fibula), six were in the femur, three were in the ulna, two were in the humerus, two were in the fibula, one was in the radius, and one arose in the soft tissue anterior to the tibia. Most patients presented with pain and swelling and were aged 10 to 30 years. The histologic appearance was that of epithelial islands in a fibrous stroma, usually with a prominent vascular pattern and a transition between the two. Twenty-six (31%) patients had recurrent local disease, 13 (15%) developed lung metastasis, and six (7%) had lymph node metastasis. Nine patients with lung metastasis had preceding recurrent local disease. Risk factors for recurrent or metastatic disease included male sex, pain, symptoms of less than 5 years' duration, and initial treatment by biopsy, curettage, excision, or resection. The only histologic feature associated with an increased recurrence rate was lack of squamous differentiation. Eleven patients died of their disease, and seven are alive with metastatic disease. Forty-one patients were still alive without disease 1 month to 47 years after treatment. Our results indicate that amputation or, when technically feasible, wide en bloc resection is the treatment of choice. All patients require long-term follow-up for evidence of local recurrence or lung metastasis.

Long-bone fractures in young children: distinguishing accidental injuries from child abuse

The Treatment of Pediatric Supracondylar Humerus Fractures AUC

While testifying in child abuse cases, physicians have been frustrated by the lawyer who asks, "Doctor, how did this injury happen?" The medical records and radiographs of 215 children younger than the age of 3 with fractures evaluated by a pediatric service during a 5-year period were retrospectively reviewed in an attempt to elucidate the mechanism of childhood fractures. Based on these reviews, two clinicians and two pediatric radiologists rated the likelihood that the fracture was either accidental or due to child abuse. Long-bone fractures were strongly associated with abuse. This report focuses on the 39 children with either humeral or femoral fractures. Fourteen children had humerus fractures. Eleven were considered to be the result of child abuse, and 3 the result of accidents. The latter 3 were supracondylar elbow fractures in children who fell from a tricycle, a rocking horse, or downstairs. Humerus fractures other than supracondylar fractures were all found to be due to abuse. There were 25 femur fractures. Nine were found to be from abuse, 14 were found to be from accidents, and 2 could not be rated. Sixty percent of femur fractions in infants younger than 1 year of age were due to abuse. Although it is taught that femur fractures in young children are inflicted unless proven otherwise, in this study it was found that femur fractures often are accidental and that the femur can be fractured when the running child trips and falls

Mechanisms of osteolytic bone destruction

MSTS 2018 - Femur Mets and MM

Tumours which involve the skeleton do so by producing humoral factors which increase osteoclast and osteoblast activity. Increases in osteoclast activity lead to osteolytic bone destruction and sometimes to hypercalcaemia. Osteolytic metastases are common, and are found most often in patients with lung and breast cancer and in myeloma. The tumour-associated factors responsible are multiple and probably different in each case. Osteoblastic metastases occur most frequently in metastatic cancer of the prostate, and are due to osteoblast stimulating factors released by the tumour cells which have not, as yet, been identified. Agents such as bisphosphonates which inhibit osteoclastic bone resorption are useful in the prevention and treatment of patients with osteolytic metastases, although the precise mechanisms by which these agents work are not yet understood. [References: 71]

Association of laterality and size of perfusion lesions on neurological deficit in acute supratentorial stroke

Upper Eyelid and Brow Surgery

BACKGROUND: The influence of lesion size and laterality on each component of the National Institutes of Health Stroke Scale has not been delineated. The objective of this study was to use perfusion-weighted imaging to characterize the association of ischaemic volume and laterality on each component item and the total score of the <National Institutes of Health Stroke Scale. METHODS: We analysed consecutive right-handed patients with first-ever supratentorial acute ischaemic strokes who underwent acute perfusion-weighted imaging at a single centre. Perfusion deficits were defined as mean transit time > 10 s. Ordinal regression was used to clarify the relationship between ischaemic volume, laterality, and <National Institutes of Health Stroke Scale scores. RESULTS: Among 111 patients, 58 were left-hemisphere stroke, and 53 right-hemisphere stroke. Median ischaemic volume was 53 ml in left-hand stroke and 65 ml in right-hand stroke and median total National Institutes of Health Stroke Scale was 10 in left-hand stroke and eight in right-hand stroke. For individual National Institutes of Health Stroke Scale items, ischaemic volume correlated most closely with commands and visual field and most weakly with ataxia and neglect. Left-hand stroke predicted higher scores of total National Institutes of Health Stroke Scale and National Institutes of Health Stroke Scale items of questions, commands, right limb weakness, and language. Right-hand stroke predicted higher scores of left limb weakness and extinction. CONCLUSIONS: Larger perfusion defects contribute to higher scores on the total and most individual items of the National Institutes of Health Stroke Scale. However, lesion laterality contributes substantially to half the item scores, with greater association of left than right-brain side. These findings indicate that imaging-deficit correlations will be improved by designating lesions into an atlas, taking into account side in addition to size.

Modifications of femoral component design in multi-radius total knee arthroplasty lead to higher lateral posterior femoro-tibial translation

OAK 3 - Non-arthroplasty tx of OAK

PURPOSE: As the aims of changes in total knee arthroplasty (TKA) designs are to reinstate more natural kinematics, the current study evaluated the in vivo kinematics in patients who underwent a cruciate retaining gradually changing femoral radius ("G-CURVE") against a cruciate retaining conventional changing femoral radius ("J-CURVE") geometry TKA design. The hypothesis of the study is that the G-CURVE design would allow a substantial increase in the femoral rollback compared to the J-CURVE design. METHODS: Retrospective study design. Thirty patients were included (G-CURVE, n = 20; J-CURVE, n = 10). Single-plane fluoroscopic analysis and marker-based motion capture gait analysis was performed to analyse dynamic tibiofemoral motion during weight-bearing and unloaded activities at 24 month after index surgery. RESULTS: The analysis of the medial and lateral points on the tibia plateau during the unloaded flexion-extension and the weight-bearing lunge activities revealed a significant difference in femoral rollback in G-CURVE TKA above 60° (p = 0.001) and 30° (p = 0.02) of knee flexion, respectively. Moreover, the lateral condyle of the G-CURVE showed a higher extent of femoral rollback while the lateral condyle of the J-CURVE rolled forward. CONCLUSION: At 2 years post-operative, the G-CURVE TKA showed significant differences in femoro-tibial translation in comparison with the J-CURVE system, in vivo. The G-CURVE resulted in an increased lateral rollback and simultaneously in an elimination of the paradoxical medial roll-forward present in the J-CURVE design. Moreover, knee kinematics analysis showed significant differences between unloaded and weight-bearing conditions revealing the impact of load and muscle force. The analysis conducted in this study contributes to further understand the principal movement characteristics in widely used older designs in comparison with recently developed concepts to get a better overview on their potential benefits on in vivo kinematics.III.

Hospital readmissions after surgical treatment of proximal humerus fractures: Is arthroplasty safer than open reduction internal fixation?

HipFx Supplemental Cost Analysis

Background: With technologic advances such as locked periarticular plating, hemiarthroplasty of the humeral head, and more recently reverse total shoulder replacement, surgical treatment of proximal humerus fractures has become more commonplace. However, there is insufficient information regarding patient outcomes after surgery, such as the frequency of unplanned hospital readmissions and factors contributing to readmission. Questions/purposes: We measured (1) the frequency of unplanned hospital readmissions after surgical treatment of proximal humerus fractures, (2) the medical and surgical causes of readmission, and (3) the risk factors associated with unplanned readmissions. Methods: The State Inpatient Database from seven different states was used to identify patients who underwent treatment for a proximal humerus fracture with open reduction and internal fixation (ORIF), hemiarthroplasty of the humeral head, or reverse total shoulder arthroplasty from 2005 through 2010. The database was used to measure the 30-day and 90-day readmission rates and identify causes and risk factors for readmission. Multivariate modeling and a Cox proportional hazards model were used for statistical analysis. Results: A total of 27,017 patients were included with an overall 90-day readmission rate of 14% (15% for treatment with ORIF, 15% for reverse total shoulder arthroplasty, and 13% for hemiarthroplasty). The majority of readmissions were associated with medical diagnoses (75%), but treatment with ORIF was associated with the most readmissions from surgical complications, (29%) followed by reverse total shoulder arthroplasty (20%) and hemiarthroplasty (16%) (p < 0.001). Risk of readmission was greater for patients who were female, African American, discharged to a nursing facility, or had Medicaid insurance. Conclusions: As the majority of unplanned hospital readmissions were associated with medical diagnoses, it is important to consider patient medical comorbidities before surgical treatment of proximal humerus fractures and during the postoperative care phase. Level of Evidence: Level III, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence. (copyright) 2014 The Association of Bone and Joint Surgeons(registered trademark)

No-Drain Single Incision Liposuction Pull-Through Technique for Gynecomastia

Panniculectomy & Abdominoplasty CPG

BACKGROUND: Several different methods have been proposed for treatment of gynecomastia, depending on the amount of breast enlargement and skin redundancy. The liposuction pull-through technique has been proposed as an efficacious treatment for many gynecomastia cases. This work aims to study the outcome of this technique when applied as an outpatient procedure, without the use of drains and through a single incision. METHODS: Fifty-two patients with bilateral gynecomastia without significant skin excess were included in this study. The liposuction pull-through technique was performed through a single incision just above the inframammary fold and without the use of drains. Patients were followed up for 6 months. RESULTS: The proposed technique was able to treat the gynecomastia in all patients, with a revision rate of 1.9% to remove residual glandular tissues. There were no seromas, hematomas, nipple distortion, permanent affection of nipple sensation or wound healing problems. CONCLUSION: The liposuction pull-through technique is an effective treatment for gynecomastia without significant skin redundancy. It combines the benefits of the direct excision of glandular tissues, with the minimally invasive nature of liposuction. Performing the procedure through a single incision without the use of drains and without general anesthesia is a safe alternative. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors http://www.springer.com/00266 .

Migration of press-fit cups fixed with poly-L-lactic acid or titanium screws: a randomized study using radiostereometry

Surgical Management of Osteoarthritis of the Knee CPG

The early migration of porous acetabular cups was studied in 43 patients with osteoarthrosis. The patients were randomly allocated to additional fixation of the cup with either biodegradable poly-L-lactic acid screws or titanium screws. Radiostereometric evaluation was done during the first 2 years after the procedure in 43 hips (23 with poly-L-lactic acid screws and 20 with titanium screws). At the 2-year follow-up, cups fixed with poly-L-lactic acid screws had migrated significantly more in the proximal-distal (p < 0.05) and medial-lateral (p < 0.05) directions. Cups with titanium screws displayed more pronounced rotations around the longitudinal axis (p < 0.05). Postoperatively, on the lateral view, there was an increased occurrence of radiolucencies at the dome of the cups fixed with poly-L-lactic acid screws (p < 0.05). The clinical result did not differ between the two groups. Inferior implant-bone contact in the poly-L-lactic acid group, local changes of the bone quality, and diminishing support of the poly-L-lactic acid screws caused by their degradation with time could be reasons for the different pattern of migration observed

The effects of clopidogrel (Plavix) and other oral anticoagulants on early hip fracture surgery

Management of Hip Fractures in the Elderly

OBJECTIVE: Risk for bleeding complications during and after early hip fracture surgery for patients taking clopidogrel and other anticoagulants have not been defined. The purpose of this study is to assess the perioperative bleeding risks and clinical outcome after early hip fracture surgery performed on patients taking clopidogrel (Plavix) and other oral anticoagulants. DESIGN: Study design is a retrospective cohort analysis using data extracted from hospital records and state death records

Slight undercorrection following total knee arthroplasty results in superior clinical outcomes in varus knees

OAK 3 - Non-arthroplasty tx of OAK

Purpose: Restoration of correct alignment is one of the main objectives of total knee arthroplasty (TKA). However, the influence of residual malalignment on clinical and functional outcomes is currently uncertain. This study was therefore undertaken to ascertain its influence in patients undergoing TKA for varus osteoarthritis of the knee. Methods: A cohort of 132 consecutive patients (143 knees) with pre-operative varus alignment was evaluated with a mean follow-up period of 7.2 years. Based upon the post-operative alignment, patients were stratified into three groups: neutral, mild varus, and severe varus. These groups were compared with respect to clinical and functional outcomes. Results: All patients had post-operative improvements in Knee Society Score (KSS). Knees that were left in mild varus scored significantly better for the KSS and the Western Ontario and McMaster Universities Arthritis Index, compared with knees that were corrected to neutral and knees that were left in severe varus exceeding 6°. No revisions occurred in any of the groups at midterm follow-up. Conclusion: The results of this study contradict the conventional assumption that correction to neutral mechanical alignment leads to the best outcome following TKA. Patients with pre-operative varus had better clinical and functional outcome scores if the alignment was left in mild varus, as compared with patients with an alignment correction to neutral. Level of evidence: Therapeutic study, Level III. © 2013 Springer-Verlag Berlin Heidelberg.

The epidemic of hip fractures: are we on the right track?

Management of Hip Fractures in the Elderly

BACKGROUND: Hip fractures are a public health problem, leading to hospitalization, long-term rehabilitation, reduced quality of life, large healthcare expenses, and a high 1-year mortality. Especially older adults are at greater risk of fractures than the general population, due to the combination of an increased fall risk and osteoporosis. The aim of this study was to determine time trends in numbers and incidence rates of hip fracture-related hospitalizations and admission duration in the older Dutch population. METHODS AND FINDINGS: Secular trend analysis of all hospitalizations in the older Dutch population (>/=65 years) from 1981 throughout 2008, using the National Hospital Discharge Registry. Numbers, age-specific and age-adjusted incidence rates (per 10,000 persons) of hospital admissions and hospital days due to a hip fracture were used as outcome measures in each year of the study. Between 1981 and 2008, the absolute number of hip fractures doubled in the older Dutch population. Incidence rates of hip fracture-related hospital admissions increased with age, and were higher in women than in men. The age-adjusted incidence rate increased from 52.0 to 67.6 per 10,000 older persons. However, since 1994 the incidence rate decreased (percentage annual change -0.5%, 95% CI: -0.7; -0.3), compared with the period 1981-1993 (percentage annual change 2.3%, 95% CI: 2.0; 2.7). The total number of hospital days was reduced by a fifth, due to a reduced admission duration in all age groups. A possible limitation was that data were obtained from a linked administrative database, which did not include information on medication use or co-morbidities. CONCLUSIONS: A trend break in the incidence rates of hip fracture-related hospitalizations was observed in the Netherlands around 1994, possibly as a first result of efforts to prevent falls and fractures. However, the true cause of the observation is unknown

Changes in rates of arthroscopy due to degenerative knee disease and traumatic meniscal tears in Finland and Sweden

OAK 3 - Non-arthroplasty tx of OAK

BACKGROUND AND PURPOSE: Knee arthroscopy is commonly performed to treat degenerative knee disease symptoms and traumatic meniscal tears. We evaluated whether the recent high-quality randomized control trials not favoring arthroscopic surgery for degenerative knee disease affected the procedure incidence and trends in Finland and Sweden. PATIENTS AND METHODS: We conducted a bi-national registry-based study including all adult (aged >=18 years) inpatient and outpatient arthroscopic surgeries performed for degenerative knee disease (osteoarthritis (OA) and degenerative meniscal tears) and traumatic meniscal tears in Finland between 1997 and 2012, and in Sweden between 2001 and 2012. RESULTS: In Finland, the annual number of operations was 16,389 in 1997, reached 20,432 in 2007, and declined to 15,018 in 2012. In Sweden, the number of operations was 9,944 in 2001, reached 11,711 in 2008, and declined to 8,114 in 2012. The knee arthroscopy incidence for OA was 124 per 10(5) person-years in 2012 in Finland and it was 51 in Sweden. The incidence of knee arthroscopies for meniscal tears coded as traumatic steadily increased in Finland from 64 per 10(5) person-years in 1997 to 97 per 10(5) person-years in 2012, but not in Sweden. INTERPRETATION: The incidence of arthroscopies for degenerative knee disease declined after 2008 in both countries. Remarkably, the incidence of arthroscopy for degenerative knee disease and traumatic meniscal tears is 2 to 4 times higher in Finland than in Sweden. Efficient implementation of new high-quality evidence in clinical practice could reduce the number of ineffective surgeries.

Medicolegal evaluation of vascular injuries of limbs in Turkey

MSTS 2018 - Femur Mets and MM

This study evaluated 372 cases of post-traumatic extremity vessel lesions, for which the Forensic Medicine Council, Istanbul, Turkey prepared medicolegal evaluation reports between 1998 and 2000. The study group (n = 372) comprised of 346 men (93.0%) and 26 women (6.9%), and their ages ranged between 6 and 73 years (30.18±6.13). There were 378 artery (74.5%), and 131 vein injuries (25.5%) out of a total of 509 limb vascular injuries. The most frequently injured arteries and veins were the femoral artery (n = 73), and the deep femoral vein (n = 41), respectively. The causes of injuries were as follows: cutting and stabbing complements, in 160 cases (43.0%); gunshots in 136 cases (36.6%); traffic accidents in 52 cases (14%); work accidents in 23 cases (6.2%); and blunt trauma in one case (0.3%). These injuries were accompanied by local nerve lesions (27.1%), local bone lesions (37.1%), and injuries to other organs (11.0%). The medicolegal assessments by the Forensic Medicine Council showed that there were risk of death in 371 cases. Additionally, there was 'organ dysfunction' in 37 (9.9%) and 'organ loss' in 53 (14.2%) cases. The results of this study suggested that the main causes of severe vascular injuries (i.e. those accompanied by bone and nerve lesions) had serious consequences such as amputation, permanent disorders or loss of function and were caused by gunshot and traffic accidents. © 2003 Elsevier Ltd and AFP. All rights reserved.

Variations in morphological and biomechanical indices at the distal radius in subjects with identical BMD

Distal Radius Fractures

Determination of osteoporotic status is based primarily on areal bone mineral density (aBMD) obtained through dual X-ray absorptiometry (DXA). However, many fractures occur in patients with T-scores above the WHO threshold of osteoporosis, in part because DXA measures are insensitive to biomechanically important alterations in bone quality. The goal of this study was to determine--within groups of subjects with identical radius aBMD values--the extant variation in densitometric, geometric, microstructural, and biomechanical parameters. High resolution peripheral quantitative computed tomography (HR-pQCT) and DXA radius data from males and females spanning large ranges in age, osteoporotic status, and anthropometrics were compiled. 262 distal radius datasets were processed for this study. HR-pQCT scans were analyzed according to the manufacturer's standard clinical protocol to quantify densitometric, geometric, and microstructural indices. Micro-finite element analysis was performed to calculate biomechanical indices. Factor of risk of wrist fracture was calculated. Simulated aBMD calculated from HR-pQCT data was used to group scans for evaluation of variation in quantified indices. Indices reflecting the greatest variation within aBMD level were BMD in the central portion of the trabecular compartment (max CV 142), trabecular heterogeneity (max CV 90), and intra-cortical porosity (max CV 151). Of the biomechanical indices, cortical load fraction had the greatest variation (max CV 38). Substantial variations in indices reflecting density, structure, and biomechanical competence exist among subjects with identical aBMD levels. Overlap of these indices among osteoporotic status groups reflects the reported incidence of osteoporotic fracture in subjects classified as osteopenic or normal.

Low width of tubular bones is associated with increased risk of fragility fracture in elderly men--the MINOS study

Distal Radius Fractures

The risk of fragility fractures in elderly men is only partly explained by areal bone mineral density (aBMD) measured by dual X-ray absorptiometry (DXA). Several studies suggest the importance of bone morphology for the risk of fracture. The aim of this study was to assess the value of bone size and estimated structural parameters for the prediction of incident fractures in a large cohort of men. This study was made in 759 men aged 50-85 from the MINOS cohort. During a 90-month follow-up, 74 men sustained incident vertebral and peripheral fractures. Areal BMD was measured by DXA at femoral neck, distal radius and distal ulna. Estimates of structural bone parameters and volumetric BMD (vBMD) were derived from aBMD measured by DXA. Given the limited number of fractures, the predictive value of investigated parameters was assessed for peripheral and vertebral fractures jointly by using logistic regression. Men who sustained the fractures had, at baseline, lower aBMD (3.5-6.5%), lower bone mineral content (BMC 5.4-8.7%) and lower cortical thickness (3.5-6.9%) compared with the men without fracture. At all the three skeletal sites, aBMD, BMC, width, cortical area and thickness, cross-sectional moment of inertia (CSMI), and section modulus predicted incident fractures (O.R. = 1.28-1.92 per 1 SD decrease, P < 0.05-0.0001). Fracture risk was weakly associated with vBMD for ulna (O.R. = 1.25 per 1 SD decrease, P < 0.05) but not for femoral neck or radius. After adjustment for aBMD, bone width remained a significant predictor of fractures (O.R. = 1.37-1.48 per 1 SD decrease, P < 0.02-0.01). Men with osteopenia (BMD T score < -1) and low bone width (T score < -1) had the fracture incidence similar to that observed in men with BMD T score < -2. Bone width and aBMD of the femoral neck and radius were predictive of fractures in 49 men with the incident peripheral fractures, whereas their O.R. did not attain the level of statistical significance in 25 men with the incident vertebral fractures. Men, who had both low aBMD and low CSMI ( both T scores < -1), had the fracture risk 3.8 to 4.2 higher than the reference group (both T scores >or= -1). Men, who had both low aBMD and low section modulus (both T scores < -1), had the fracture risk 2.1 to 4.1 higher than the reference group (both T scores >or= -1). In conclusion, men who sustained a fragility fracture during a 90-month follow-up had, at baseline, lower BMC because they had narrower bones but not necessarily less dense. In elderly men, small bone width, low BMC and poor resistance to bending may increase bone fragility. Low bone width seems to be associated with an increased fracture risk in elderly men regardless of aBMD.

The comparison of bedside point-of-care ultrasound and computed tomography in elbow injuries

Pediatric Supracondylar Humerus Fracture 2020 Review

OBJECTIVE: The objective of the study was to compare the efficacy of point-of-care ultrasound (POCUS) and computed tomography (CT) in the diagnosis of the fracture of the bones that form the elbow joint and the determination of treatment method in elbow injuries. METHODS: Forty-nine patients aged 5 to 65 years, who were admitted with low-energy elbow injuries, had at least 1 fracture of the elbow joint bones, and underwent CT scanning, were included in this study. Before the initiation of the study, orthopedic surgeons and emergency physicians determined a common treatment based on the fracture characteristics. Patients were first evaluated with direct radiography, and then with POCUS by trained emergency physicians. Emergency physicians made treatment decisions based on the ultrasonography results. Then, CT scans were performed. The CT images were interpreted by radiologists. Orthopedic surgeons made treatment decisions based on the CT interpretations. RESULTS: Forty-nine patients with elbow injury were included in the study. Eighteen (37%) patients were women, and 31 (63%) were men. The mean age was 21 ± 15 years. Compared with CT, sensitivity, specificity, positive predictive value, and negative predictive value of POCUS in fracture detection were 97%, 88%, 94%, and 93%, respectively. Although the sensitivity and specificity of POCUS in the decision for reduction were 95% and 100%, respectively, it was 93% and 100% in the decision for surgery. CONCLUSION: In conclusion, POCUS was shown to be successfully applied in the diagnosis and management of elbow injuries, in which direct radiography was inefficient and CT scans were required.

Influence of heterotopic ossification of the hip on bone densitometry: a study in spinal cord injured patients

Management of Hip Fractures in the Elderly

OBJECTIVE: To evaluate (1) the magnitude of falsely elevated bone density results caused by heterotopic ossification (HO) around the hip and (2) effect of age of patients when the measurement was taken, age of patients at injury, and age of injury (time since event) to the prevalence of HO. SUBJECTS AND METHODS: We blindly analyzed plain radiographs of the hip [(obtained within 1 month of dual energy X-ray absorptiometry (DEXA)] in 107 spinal cord injured (SCI) patients for HO and matched the result to the three regions of interest (ROI): the femoral neck, Ward's triangle, and the trochanter. The influence of HO on bone densitometric values was determined by the analysis of variance (ANOVA) and post-hoc analysis. RESULTS: Nineteen (18%) patients had HO; overlying the femoral neck (79%), trochanter (74%) and Ward's triangle (37%), respectively. Significant elevation of densitometric values (P < 0.05 or less) was observed in a various magnitude at each ROI, with the greatest elevation at Ward's triangle. The prevalence of HO was high when the patients were injured at age range of 20-39 years. CONCLUSIONS: HO around the hip can cause significantly elevated bone densitometry results at all ROIs, which can obscure underlying osteoporosis, leading to underestimation of fracture risk. Determination of bone density in this region with corresponding plain radiographs would be of help. In SCI patients, prevalence of HO was high when the age of patients at injury was 20-39 years

Extended femoral osteotomy for revision of hip arthroplasty: results and complications

Management of Hip Fractures in the Elderly

Seventy-five revision total hip arthroplasties (73 patients) performed using an extended greater trochanteric osteotomy for exposure and an extensively porous-coated uncemented stem were reviewed after 2 years (range, 1 to 5). The mean osteotomy length was 14 cm (range, 7 to 19 cm) and fixation was with at least 2 cables. One stem was revised at 4 months for stem subsidence and loosening. Of the remaining 74 osteotomies, 73 healed without further procedures. A single nonunion was reoperated at 4 months and healed. Sixty-eight of 73 osteotomies healed with no migration and 5 did with less than 5 mm of proximal migration of the osteotomy fragment. Complications included 3 intraoperative and 1 postoperative osteotomy fragment fractures. Extended trochanteric osteotomy, executed preserving the fragment's vascularity and fixed with rigid fixation, can be performed with a low rate of complications

Early one-stage closure in patients with abdominal compartment syndrome: fascial replacement with human acellular dermis and bipedicle flaps

DOD - Acute Comp Syndrome CPG

Decompressive celiotomy for the treatment of abdominal compartment syndrome (ACS) often results in wounds that are difficult to close. These complicated wounds are frequently managed with a 3-staged surgical approach employing a planned ventral hernia. The authors describe an alternative closure with a single operation using a commercially available human acellular dermis (HACD) as a fascial substitute. Soft tissue coverage is obtained at the same operation by means of bilateral bipedicle flaps. The cohort consisted of 9 patients, ages 19 to 77 years old. On average patients were closed on the ninth postoperative day (range, 3 to 30 days) and were discharged from the trauma center on average 8 days (range, 5 to 29 days) after the abdominal closure. Complications developed in 3 (33%) patients. These complications included a flap hematoma, wound infection, and recurrent hernia. There were no postoperative fistulas. This procedure allows for early, single-staged closure of the abdomen after abdominal compartment syndrome. Once closed, patients were able to be discharged from the hospital early and without need for specialized wound care. Further investigation on the usefulness of this technique is required.

Medial comminution as a risk factor for the stability after lateral-only pin fixation for pediatric supracondylar humerus fracture: an audit

Pediatric Supracondylar Humerus Fracture 2020 Review

BACKGROUND AND PURPOSE: Closed reduction and lateral-only pin fixation is one of the common treatment methods for displaced supracondylar fracture in children. However, several risk factors related to the stability have been reported. The aim of this study was to evaluate the medial comminution as a potential risk factor related to the stability after appropriate lateral-only pin fixation for Gartland type III supracondylar humerus fracture. METHODS: Sixty-seven patients with type III supracondylar fractures who were under the age of 12 years were included. Immediate postoperative and final Baumann and humerocapitellar angles were measured. Pin separation at fracture site was evaluated to estimate the proper pin placement. Presence of the medial comminution was recorded when two pediatric orthopedic surgeons agreed to the loss of cortical contact at the medial column by the small butterfly fragment or comminuted fracture fragments. Factors including age, sex, body mass index, pin number, pin separation at fracture site, and medial comminution were analyzed. RESULTS: Medial comminution was noted in 20 patients (29.8%). The average pin separation at fracture site was significantly decreased in patients with medial comminution compared to patients without medial comminution (P=0.017). A presence of medial comminution was associated with a 4.151-fold increase in the log odds for the Baumann angle changes of more than average difference between immediate postoperative and final follow-up angle (P=0.020). CONCLUSION: When lateral-only pin fixation is applied for Gartland type III supracondylar humerus fracture in children, the medial comminution may be a risk factor for the stability because of the narrow pin separation at fracture site. We recommend additional medial pin fixation for supracondylar humerus fracture with medial comminution.

Two-stage revision using extended trochanteric osteotomy for prolonged septic hip arthroplasty

Management of Hip Fractures in the Elderly

The authors have carried out two-stage revision on 5 patients using extended trochanteric osteotomy for prolonged septic hip arthroplasty. At the initial surgery, a lateral approach was used to perform an osteotomy of the femur between the trochanters. Then, the osteotomy line was extended to the tip of the femoral prosthesis. After removing the prosthesis, septic granulation was sufficiently curetted and antibiotic-impregnated bone cement beads were used to fill the defect. At the second surgery, a posterolateral approach was used to revise the total hip arthroplasty fixed with bone cement. The outcome of all 5 cases was good. There has been no recurrence of infection or loosening of the prosthesis during the follow-up period

Managing menopausal symptoms after cancer: An evidence-based approach for primary care

MSTS 2018 - Femur Mets and MM

â?¢ Impaired ovarian function and menopausal symptoms are common after cancer treatment. â?¢Menopausal symptoms often occur at an earlier age in women with cancer, and may be more severe than in natural menopause; they may be the most persistent and troubling sequelae of cancer. â?¢ A third of female patients with cancer report dissatisfaction with the quality and length of physicianepatient discussions about reproductive health, including menopause. â?¢ Systemic menopausal hormone therapy is the most effective treatment for menopausal symptoms, but it is not suitable for all patients after cancer - where it is unsuitable, alternative effective non-hormonal treatments are available. â?¢ Effective pharmacological agents available to treat vasomotor symptoms include selective serotonin reuptake inhibitors, serotoninenoradrenaline reuptake inhibitors, clonidine and gabapentin. There is increasing evidence supporting cognitive behavioural therapy for the treatment of vasomotor symptoms, in self-help or group settings. â?¢ Vaginal atrophy can be treated with vaginal (topical) oestrogen with minimal systemic absorption; topical vaginal lubricants may help with vaginal dryness and dyspareunia, with some evidence suggesting that silicone-based products may be more effective than water-based ones. â?¢ Bone health may be impaired in post-menopausal women with cancer or in cancer survivors, particularly in women with treatment-related menopause or in women receiving antioestrogen therapies; this should be managed in addition to menopausal symptoms. â?¢ Primary care physicians should be aware of the troublesome and ongoing nature of menopausal symptoms after cancer, should discuss them with all patients after cancer treatment, and should consider treatment or referral to a specialist for appropriate management.

The relationship of the medially-offset stem of the tibial component to the medial tibial cortex in total knee replacements in Korean patients

Surgical Management of Osteoarthritis of the Knee CPG

We examined the placement of the stem in relation to the medial tibial cortex when using total knee replacements (TKRs) with medially-offset tibial stems in Korean patients. Measurements were performed on the pre- and post-operative radiographs of 246 osteoarthritic knees replaced between January 2005 and May 2006 using the Genesis II or E-motion TKR with a medially-offset stem. Pre-operatively, we measured the distance between the mechanical axis and that of the tibial shaft and post-operatively, that between the midline of the tibial stem and the axis of the shaft. Knees were identified in which there was radiological contact between the tip of the stem and the medial tibial cortex. The mechanical axis was located medial to the axis of the shaft in 203 knees (82.5%). Post-operatively, the midline of the tibial stem was located medial to the tibial shaft axis in 196 knees (79.7%). In 16 knees (6.5%) there was radiological contact between the tibial stem or cement mantle and the medial tibial cortex. Our study has shown that the medially-offset stem in the tibial component may not be a good option for knees undergoing replacement for advanced osteoarthritis in some Korean patients

Comparison of the efficacy and safety of naproxen CR and nabumetone in the treatment of patients with osteoarthritis of the knee

OAK 3 - Non-arthroplasty tx of OAK

OBJECTIVE: To comparre the safety and efficacy of naproxen CR (1,000 mg once daily) with that of nabumetone (1,000 mg once daily) in the treatment of patients with symptomatic knee osteoarthritis(OA). METHODS: A total of 159 Korean patients (80 in the naproxen CR group and 79 in the nabumetone group) were enrolled in this 4�week, single�blind, controlled, randomized, parallel study and an intention�to�treat model was used for data analysis. Six efficacy parameters were measured: Lequesne index, visual analogue pain scale at rest and atactivity, patient's and physician's global assessment, and time to walk 50 feet. RESULTS: Significant improvement in all efficacy parameters except time to walk 50 feet occurred at Week 2 and Week 4 in both groups. Themean improvement from baseline at Week 2 and Week 4 for the efficacy variables was not different between naproxen CR and nabumetone group. Twenty�four patients (30%) in the naproxen CR group and 18 patients (22.8%) in the nabumetone group withdrew from the study. Among them, only 1patient in the naproxen CR group terminated the study prematurely due to an adverse event of dyspepsia. No statistically significant difference in the frequency of adverse events, including gastrointestinal symptoms, was observed between these 2 groups during the treatment period. Significant laboratory abnormalities also did not occur during the study period in both groups. CONCLUSIONS: Naproxen CR is an effective and tolerable drug in the treatment of knee OA. Efficacy and safety profiles are comparable to those of nabumetone.

Effects of payment changes on trends in post-acute care

Management of Hip Fractures in the Elderly

OBJECTIVE: To test how the implementation of new Medicare post-acute payment systems affected the use of inpatient rehabilitation facilities (IRFs), skilled nursing facilities (SNFs), and home health agencies. DATA SOURCES: Medicare acute hospital, IRF, and SNF claims; provider of services file; enrollment file; and Area Resource File data. STUDY DESIGN: We used multinomial logit models to measure realized access to post-acute care and to predict how access to alternative sites of care changed in response to prospective payment systems. DATA EXTRACTION METHODS: A file was constructed linking data for elderly Medicare patients discharged from acute care facilities between 1996 and 2003 with a diagnosis of hip fracture, stroke, or lower extremity joint replacement. PRINCIPAL FINDINGS: Although the effects of the payment systems on the use of post-acute care varied, most reduced the use of the site of care they directly affected and boosted the use of alternative sites of care. Payment system changes do not appear to have differentially affected the severely ill. CONCLUSIONS: Payment system incentives play a significant role in determining where Medicare beneficiaries receive their post-acute care. Changing these incentives results in shifting of patients between post-acute sites

Normal sequential changes in neutrophil CD64 expression after total joint arthroplasty

OAK 3 - Non-arthroplasty tx of OAK

Background: Neutrophil CD64 has been reported to be a sensitive and specific infection marker. Its measurement is thus considered to be useful in early diagnosis of post-operative periprosthetic infection. However, even its normal sequential changes after non-infectious total joint arthroplasty have remained ambiguous. Accordingly, we analyzed 2-week sequential neutrophil CD64 expression changes after total joint arthroplasty in order to clarify its normal postoperative kinetics. Patients and method: From 41 patients who underwent primary total joint arthroplasties, peripheral blood samples were obtained at 1 day before (baseline) and 1, 3, 5, 7, and 14 days after surgery, and CD64 expression per cell was quantitatively measured. C-reactive protein (CRP) level, erythrocyte sedimentation rate (ESR) and white blood cell count (WBC) were simultaneously measured. Results: No cases of postoperative local infection were observed. Levels of CD64 significantly elevated from day 1, peaked at day 3, and decreased significantly following day 5. Statistical analysis confirmed that significant differences existed between the baseline level and the levels at days 1 and 3, while no significant differences existed between the baseline level and those at days 5, 7 or 14. In 17 patients, CD64 peaked at over 2,000 molecules/cell, the level reported to be a cutoff value for distinguishing infection. Multiple regression analysis showed that the sole parameter of baseline CD64 level significantly explained the peak CD64 level. Postoperative CD64 peaks ranged from 1.6 to 2.7 times (median 1.9) the baseline levels. CRP, ESR and WBC also showed rapid elevations and all but WBC remained significantly higher than baseline at day 14. Conclusion: CD64 levels rise significantly, peaking within about 3 days following normal total joint arthroplasty, but decrease rapidly to near baseline within about 5 days. The data obtained can be expected to form a possible basis for early diagnosis of postoperative periprosthetic infection. © 2013 The Author(s).

Synovitis and silicone joint implants: A summary of reported cases

Distal Radius Fractures

Case reports of synovitis associated with silicone implant arthroplasty have appeared in the literature since 1974. The objective of the current study was to identify and characterize all published case reports detailing synovitis following the use of silicone finger, trapezium, scaphoid, lunate, ulnar head/wrist, radial head, or toe implants. A computerized search of the literature identified 53 pertinent articles. A total of 175 patients underwent revision surgery of 182 implants due to synovitis. Of the 182 implants, 65 (36 percent) were scaphoid of lunate implants. The next most commonly affected implant was the great toe (38 implants, 21 percent), followed by the trapezium (34 cases, 19 percent), the ulnar head/wrist (27 cases, 15 percent), the finger (10 cases, 5 percent), the radial head (7 cases, 4 percent), and the navicular (1 case, 0.5 percent). Radiographic evidence of bone cysts or lysis was noted in 131 of 182 cases (72 percent). Implant wear (fracture, fragmentation, surface erosion, or compression deformity) was described in 127 of 182 cases (70 percent). The mean interval between arthroplasty and the first onset of clinical synovitis was 34 months. Incidence rates for synovitis by implant type could not be extrapolated directly from this review. Most articles were case reports and did not comment on the full cohort of patients receiving a specific type of implant. In an effort to derive 'denominator data' for estimates of incidence, the major manufacturer of silicone implants provided information regarding total annual sales of silicone joint implants during the interval 1975-1994. Using sales data as denominators and reported cases of synovitis as numerators, the incidence of synovitis by implant type was then estimated. The lowest incidence of silicone synovitis was noted for the most widely used type of implant, the finger; 0.004 percent (10 of 257,800). The next most commonly used implant (toe) was associated with an incidence of synovitis of 0.02 percent (38 of 155,900). The highest incidence of silicone synovitis was noted for carpal bone implants; 0.2 percent (66 of 31,700).

Avascular necrosis of the femoral head following intertrochanteric fracture

Management of Hip Fractures in the Elderly

Two cases are reported of avascular necrosis of the femoral head occurring as a late complication of an intertrochanteric fracture. The cases are presented to emphasize the importance of including this condition in the differential diagnosis of any late clinical deterioration following such an injury

The Utility of the Early Postoperative Follow-up and Radiographs After Operative Treatment of Supracondylar Humerus Fractures in Children

Pediatric Supracondylar Humerus Fracture 2020 Review

BACKGROUND: Supracondylar humerus (SCH) fractures are common elbow injuries in pediatric patients. The American Academy of Orthopedic Surgeons published guidelines for the standard of care in the treatment of displaced SCH fractures, however, no recommendations for follow-up care were made. With the recent push to eliminate unnecessary radiographs and decrease health care costs, many are questioning postoperative protocols. The purpose of our study was to evaluate the utility of the 1-week follow-up appointment after closed reduction and percutaneous pinning (CRPP) of displaced SCH fractures. METHODS: A retrospective review performed at a single institution from 2014 to 2016 included patients under 14 years of age with a closed, displaced SCH fracture treated with CRPP. Exclusion criteria included patients without complete clinical or radiographic follow-up. Variables examined included time to initial follow-up, change in treatment plan after 1-week x-rays, complications, demographics, fracture type, pin number and configuration, reduction parameters, immobilization, time to pin removal, duration of casting, and clinical outcome. RESULTS: A total of 412 patients were divided into 2 groups based on time to initial follow-up. Overall, 368 had an initial follow-up at 7 to 10 days (group 1) and 44 at 21 to 28 days (group 2). There was no difference in age, sex, fracture type, pin configuration, or a number of pins between groups. Statistically significant findings included time to initial follow-up and days to pin removal (group 1 at 26.2â??d vs. group 2 at 23.8â??d), type of immobilization (group 1 with 5% circumferential casts and group 2 with 70%), and time to surgery (26.2 vs. 62.9â??h, respectively). There was no significant difference in complication rates and only a 0.5% rate of change in management in group 1. CONCLUSIONS: Early postoperative follow-up and radiographs did not change the patient outcome and might be eliminated in children with displaced SCH fractures treated with CRPP. Given the current focus of on efficiency and cost-effective care, eliminating the 1-week postoperative appointment would improve appointment availability and decrease medical cost. LEVEL OF EVIDENCE: Level III-Therapeutic.

Treatment with subantimicrobial dose doxycycline improves the efficacy of scaling and root planing in patients with adult periodontitis

Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures

BACKGROUND: In a previous study, subantimicrobial dose doxycycline (SDD) significantly improved clinical parameters associated with periodontal health in patients with adult periodontitis (AP) when used as an adjunct to a maintenance schedule of supragingival scaling and dental prophylaxis. In this double-blind, placebo-controlled, parallel-group, multicenter study, the efficacy and safety of SDD were evaluated in conjunction with scaling and root planing (SRP) in patients with AP. METHODS: Patients (n = 190) received SRP at the baseline visit and were randomized to receive either SDD 20 mg bid or placebo bid for 9 months. Efficacy parameters included the per-patient mean changes in clinical attachment level (CAL) and probing depth (PD) from baseline, the per-patient percentages of tooth sites with attachment loss (AL) > or = 2 mm and > or = 3 mm from baseline, and the per-patient percentage of tooth sites with bleeding on probing. Prior to analysis, tooth sites were stratified by the degree of disease severity evident at baseline RESULTS: In tooth sites with mild to moderate disease and severe disease (n = 183, intent-to-treat population), improvements in CAL and PD were significantly greater with adjunctive SDD than with adjunctive placebo at 3, 6, and 9 months (all P <0.05). In tooth sites with severe disease, the per-patient percentage of sites with AL > or = 2 mm from baseline to month 9 was significantly lower with adjunctive SDD than with adjunctive placebo (P<0.05). Improvements in clinical outcomes occurred without detrimental shifts in the normal periodontal flora or the acquisition of doxycycline resistance or multiantibiotic resistance. SDD was well tolerated, with a low incidence of discontinuations due to adverse events. CONCLUSIONS: The adjunctive use of SDD with SRP is more effective than SRP alone and may represent a new approach in the long-term management of AP

Corticoperiosteal flap in the treatment of nonunions and small bone gaps: technical details and expanding possibilities

DoD SSI (Surgical Site Infections)

The corticoperiosteal flap from the medial femoral condyle (CP) has proved to be highly reliable in the management of persistent, recurrent nonunion. However, much of the related literature has focussed on the flap aspects of the procedure and not so much on bone work-up. We present a series of 25 patients with nonunions and small bone gaps irresponsive to conventional therapy that were successfully treated with a CP with/without the addition of non-vascularised bone graft from the iliac crest. Different technical options of bone reconstruction are possible and discussed: CP plus non-structural bone chips, CP plus structural bi/tricortical struts or CP plus vascularised cancellous bone from the femoral condyle. A stable internal fixation was performed in all cases. Clinical and radiological evidence of healing was obtained in all the patients. Donor-site complications were few and transient (suture intolerance, seroma and numbness in the saphenous territory). No fracture of the femur, knee instability or stiffness has been observed. The corticoperiosteal flap from the femoral condyle is an excellent source of vascularisation and osteogenic stimulus to the nonunion site and highly effective in the management of persistent nonunions and small bone gaps. When needed, a structural corticocancellous strut from the iliac crest (along with a stable internal fixation) provides the greatest stability and the possibility of a prompt rehabilitation and functional recovery. The corticoperiosteal flap has succeeded in revascularising these highly demanding grafts and in allowing a 100% union rate.

Manipulation under anaesthesia post total knee replacement: Long term follow up

Surgical Management of Osteoarthritis of the Knee CPG

A reduced range of motion post total knee replacement (TKR) is a recognised problem. Manipulation under anaesthesia (MUA) is commonly performed in the stiff post-operative TKR. Long-term results are variable in the literature. We retrospectively reviewed, prospectively collected data on 48 patients followed up since 1996 from one centre, over an average of 7.5. years, (range 1 to 10. years) and report on the long-term results. During the study period 2.3% of TKRs underwent MUA. The mean time to MUA post TKR was 12.3. weeks (range 3 to 48). Pre MUA, the mean flexion was 53(degrees). The mean immediate passive flexion post MUA was 97(degrees), an improvement of 44(degrees) (Range 10(degrees) to 90(degrees), p < 0.05). By 1. year, the mean flexion was 87(degrees), an improvement of 34(degrees), (range - 15(degrees) to 70(degrees), p < 0.05). At 10. years the mean flexion was 86(degrees), (range 55(degrees) to 100(degrees), p < 0.05).We found no difference in the gain in range of motion (ROM) between knees manipulated before or after 12. weeks. Additionally, the gain was no different in stiff knees with a pre TKR ROM < 90(degrees), compared to a pre TKR ROM > 90(degrees). There were no complications as a result of MUA. However, one patient was eventually revised at 2 years secondary to low grade infection. Our findings show that MUA is a safe and effective method at improving the ROM in a stiff post-operative TKR. The improvement is maintained in the long term irrespective of time to MUA and range of motion pre TKR. (copyright) 2011

The safety of peri-articular local anaesthetic injection for patients undergoing total knee replacement with autologous blood transfusion: a randomised trial

Surgical Management of Osteoarthritis of the Knee CPG

Intra-operative, peri-articular injection of local anaesthesia is an increasingly popular way of controlling pain following total knee replacement. At the same time, the problems associated with allogenic blood transfusion have led to interest in alternative methods for managing blood loss after total knee replacement, including the use of auto-transfusion of fluid from the patient's surgical drain. It is safe to combine peri-articular infiltration with auto-transfusion from the drain. We performed a randomised clinical trial to compare the concentration of local anaesthetic in the blood and in the fluid collected in the knee drain in patients having either a peri-articular injection or a femoral nerve block. Clinically relevant concentrations of local anaesthetic were found in the fluid from the drains of patients having peri-articular injections (4.92 mug/ml (sd 3.151)). However, none of the patients having femoral nerve blockade had detectable levels. None of the patients in either group had clinically relevant concentrations of local anaesthetic in their blood after re-transfusion. The evidence from this study suggests that it is safe to use peri-articular injection in combination with auto-transfusion of blood from peri-articular drains during knee replacement surgery

Sequential changes and pattern of bone-specific alkaline phosphatase after trauma

Management of Hip Fractures in the Elderly

Serum activity of bone specific alkaline phosphatase, a product of differentiated osteoblasts, is thought to mirror fracture healing. The precise time course after various conditions involving bone healing is, however, poorly described. The aim of our study was to evaluate sequential changes of bone alkaline phosphatase over a period of 20 weeks in traumatized patients with and without bone injuries. The bone isoenzyme of alkaline phosphatase was determined in frozen serum samples using a new automated procedure based on the wheat germ lectin precipitation method. Patients were stratified into different groups: 1. ST - soft tissue injury without bone participation; 2. DF - diaphysial fracture of tibia or femur; 3. MT - patients suffering from multiple traumas; 4. PF - proximal femur fracture, treated with dynamic hip screw; and 5. EP - femur neck fracture, treated with cemented endoprosthesis. Similar values were obtained in all measured groups on the day of admission (ST 35.83 (plus or minus) 6.15 U/I; PF 27.37 (plus or minus) 4.43 U/I; EP 31.09 (plus or minus) 7.42 U/I). In the following measurements, enzyme activity decreased significantly in all groups to reach a nadir within the first week, ranging between 41 and 82% of the activity immediately postoperative. Thereafter, a substantial increase occurred in all groups investigated. In the ST group, this increase led to an activity level that was comparable to the first posttraumatic value (39.06 (plus or minus) 7.81 U/I). In contrast, average values in all other groups revealed a further increase, which was significantly elevated compared to measurements taken the first day after trauma (DF 74.36 (plus or minus) 10.84 U/I; MT 177.87 (plus or minus) 30.0 U/I; PF 93.39 (plus or minus) 22.08 U/I; EP 51.52 (plus or minus) 7.33 U/I). Additionally, the time to reach the peak in enzyme activity differed between groups. In the MT group, it was observed as early as 3 weeks after injury, in the DF group the peak was reached as late as 6 weeks after trauma. The results of the study indicate that bone alkaline phosphatase activity undergoes a specific pattern of changes after trauma. It may be assumed that the initial decrease is part of a general stress response to trauma and operation. The subsequent increase seems to depend from the magnitude of bone repair and the type of fracture healing, e. g. diaphysial fracture healing takes longer time than cancellous bone healing. These results seem to be a useful basis in order to establish a laboratory monitoring of fracture healing in subsequent studies

Do systemic antibiotics increase the survival of a full thickness graft on the nose?

Reconstruction After Skin Cancer

BACKGROUND: Full thickness grafts on the nose do not always heal without problems. Partial or entire necrosis of the graft is likely to lead to less favourable cosmetic results and prolonged wound care. No consensus exists as to the use of systemic antibiotics to increase the success rate of survival of a full thickness skin graft on the nose after non-melanoma skin cancer surgery. OBJECTIVE: The objective of the study was to evaluate the effect of systemic antibiotics on the survival of full thickness grafts on the nose. METHODS: We performed a randomized, controlled trial in which we compared azithromycin with standard treatment in 30 patients, who underwent a full thickness graft reconstruction of a surgical defect on the nose after surgery for non-melanoma skin cancer. Percentage survival of the graft was the main outcome measure. RESULTS: A statistically significant difference in favour of the grafts treated with azithromycin was seen (P=0.002). Of all the variables analysed, only smoking had a significant negative effect on the survival of the graft. CONCLUSIONS: Systemic antibiotics with an accurate bacterial spectrum should be advised in full thickness skin graft reconstruction after surgery for non-melanoma skin cancer of the nose. Smoking should be strongly discouraged.

Infection of a total knee arthroplasty with Rothia dentocariosa: Brief report and review of the literature

Surgical Management of Osteoarthritis of the Knee CPG

A normal inhabitant of the human oral cavity, Rothia dentocariosa, is commonly associated with dental caries and periodontal disease but is a rare cause of systemic infection. Due to its variable Gram-stain appearance and resemblance to other gram-positive bacteria, R. dentocariosa should be considered in the differential diagnosis of a systemic infection with gram-positive organisms, especially in patients with dental disease. We present the first reported case of R. dentocariosa prosthetic joint infection and a review of the literature. Copyright (copyright) 2005 by Lippincott Williams & Wilkins

The distal radius, the most frequent fracture localization in humans: a histomorphometric analysis of the microarchitecture of 60 human distal radii and its changes in aging

Management of Hip Fractures in the Elderly

BACKGROUND: The distal radius is the most frequent fracture localization in humans. Although younger patients receive a distal radius fracture after an adequate trauma, elderly patients suffer fractures through low-energy mechanisms. Low-energy fractures are hallmarks of osteoporosis. Osteoporotic changes of the distal radius are well described by DXA and peripheral quantitative computed tomography measurements. However, to date, the effects of aging on the microarchitecture of the distal radius have not been investigated. METHODS: To investigate whether the microarchitecture of the human distal radius shows osteoporotic changes in bone mass and structure during aging, we dissected out 60 complete human distal radii from 30 age- and gender-matched patients at autopsy. Each of the three different age groups (group I: 20-40 years, group II: 41-60 years, group III: 61-80 years) was represented by 10 autopsy cases and 20 specimens (double-sided extraction), respectively. The specimens were analyzed by peripheral quantitative computed tomography, contact-radiography, and histomorphometry. RESULTS: We observed a significant age-related decrease in bone mass, bone mineral density and an increase in typical osteoporotic changes of the bone microarchitecture in female distal radius specimens. Comparable observations of age-related changes have not been made in male specimens. CONCLUSIONS: The distal radius is a location of osteoporosis-specific bone changes. Our data provide evidence for the occurrence of typical osteoporotic changes, especially postmenopausal osteoporotic changes, in the distal radius during aging

Gait analysis before and after corrective osteotomy in patients with knee osteoarthritis and a valgus deformity

OAK 3 - Non-arthroplasty tx of OAK

PURPOSE: In this prospective study, the changes in kinetics and kinematics of gait and clinical outcomes after a varus osteotomy (tibial, femoral or double osteotomy) in patients with osteoarthritis (OA) of the knee and a valgus leg alignment were analysed and compared to healthy subjects. METHODS: Twelve patients and ten healthy controls were included. Both kinetics and kinematics of gait and clinical and radiographic outcomes were evaluated. RESULTS: The knee adduction moment increased significantly postoperatively (p < 0.05) and almost similar to the control group. Patients showed less knee and hip flexion/extension motion and moment during gait pre- and postoperatively compared to the controls. A significant improvement was found in WOMAC [80.8 (SD 16.1), p = 0.000], KOS [74.9 (SD 14.7), p = 0.018], OKS [21.2 (SD 7.5), p = 0.000] and VAS-pain [32.9 (SD 20.9), p = 0.003] in all patients irrespective of the osteotomy technique used. The radiographic measurements showed a mean hip knee ankle (HKA) angle correction of 10.4degree (95 % CI 6.4degree-14.4degree). CONCLUSION: In patients with knee OA combined with a valgus leg alignment, the varus-producing osteotomy is a successful treatment. Postoperatively, the patients showed kinetics and kinematics of gait similar as that of a healthy control group. A significant increase in the knee adduction moment during stance phase was found, which was related to the degree of correction. The HKA angle towards zero degrees caused a medial shift in the dynamic knee loading. The medial shift will optimally restore cartilage loading forces and knee ligament balance and reduces progression of OA or the risk of OA. A significant improvement in all clinical outcomes was also found. Level of evidence: Iii.

Juxta-articular Plate Fixation in Distal Radius Intra-articular Fractures with Accompanying Volar Free Fragments beyond the Watershed Line

Distal Radius Fractures

Background: Although distal radius fractures (DRF) are common fractures, intra-articular comminuted DRF with volar free fragments are uncommon. There is considerable difficulty in the fixation of free fragments beyond the watershed line using the existing volar locking plate. We aimed to examine the efficacy and potential complications associated with the use of juxta-articular volar plates in intra-articular DRF accompanied by free fragments beyond the watershed line. Methods: The patients were enrolled in a consecutive manner between 2007 and 2016. In cases of DRF with free fragments beyond the watershed line, we employed a 2.4-mm small fragment juxta-articular volar locking compression plate using a volar Henry approach. A total of 32 patients were included in this study. There were 15 males and 17 females with a mean age of 52.3 years (range, 33 to 69 years). The mean follow-up period was 14.5 months (range, 10 to 24 months). Preoperative radiographs and three-dimensional computed tomography images were used to analyze fracture patterns and assess the free fragments beyond the watershed line. The mean number of free fracture fragments beyond the watershed line was 2.33. Plain radiographs of immediate postoperative and last follow-up were used to confirm fracture union, incongruence, radial height, volar tilt, radial inclination, and arthritic changes. For functional assessment, we measured grip strength, range of motion (ROM), modified Mayo wrist score (MMWS) and determined Disabilities of Arm, Shoulder and Hand (DASH) scores at the last follow-up. Postoperative complications were monitored during the follow-up period. Results: All patients obtained sound union without significant complications. At the last follow-up, 16 cases presented with an articular step-off of more than 1 mm (mean, 1.10 mm). The mean MMWS was 76.3 (range, 55 to 90), mean DASH score was 15.38 (range, 9 to 22), mean visual analogue scale score for pain was 1.2 and mean grip strength was 75.5% of the opposite side. The mean ROM was 74.3degree for volar flexion and 71.5degree for dorsiflexion. Conclusions: In cases of intra-articular DRF with free fragments beyond the watershed line, a volar approach with use of a juxtaarticular plate provided favorable outcomes without significant complications.

Primary angiosarcoma of bone a retrospective analysis of 60 patients from 2 institutions

MSTS 2018 - Femur Mets and MM

Background: Angiosarcoma of bone is a rare high-grade malignant vascular tumor. The literature regarding treatment and outcome of patients with this tumor is limited. We performed a 2 institutional retrospective study to analyze treatment and survival of patients with angiosarcoma of bone. Patients and Methods: We reviewed patients with the histologic diagnosis of primary angiosarcoma of bone treated from 1980 to 2009. Demographic details, histology, treatment, and survival were reviewed. Results: A total of 38 men and 22 women (median age, 54 y) were recruited. Most lesions occurred in the femur and the pelvis. Metastatic disease at presentation was diagnosed in 24 patients (40%). Forty-three patients underwent surgery, with 30 of them achieving surgical complete remission (SCR). Radiotherapy was applied to 17 patients, and chemotherapy to 13/35 and 15/22 patients with localized and metastatic disease, respectively. The 5-year overall survival (OS) was 20%: 33% for patients with localized disease and 0% for metastatic patients. Higher 5-year OS was reported for patients who achieved SCR (46%) than for those who did not (0%). In nonmetastatic patients, a trend toward improved survival was observed after SCR and adjuvant chemotherapy based on cisplatin, doxorubicin, and ifosfamide. Fifteen patients received chemotherapy for metastases. Two RECIST partial responses of 13 evaluable patients were documented (paclitaxel [n = 1] and doxorubicin [n = 1]). Stable disease was observed in 2 patients. Conclusions: Complete surgical resection is essential for outcome. Survival of patients with metastatic or unresectable disease is very poor. Activity of taxanes and anthracycline was observed in the metastatic setting and merits further evaluation.

Efficacy of a 12-month, monitored home exercise programme compared with normal care commencing 2 months after total knee arthroplasty: a randomized controlled trial

OAK 3 - Non-arthroplasty tx of OAK

To evaluate the efficacy of a delayed home exercise programme compared with normal care after primary total knee arthroplasty. Single-blind, prospective, randomized, controlled trial. A total of 108 participants (61% females, mean age 69 years [standard deviation 8.7]), were randomized to a home-based exercise group (EG, n = 53) or to a control group (CG, n = 55). Two months post-operatively, the EG received a home exercise programme, while the CG received no additional guidance. The outcome measurements were: pain and disability, measured using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC); health-related quality of life (HRQoL), measured using the Short Form-36 questionnaire (SF-36); maximal walking speed; isometric knee muscle strength; and the Timed Up and Go (TUG) test. Measurements were made at baseline and at 12 months thereafter. At the 12-month follow-up, maximal walking speed (p < 0.001) and knee flexion strength (p = 0.009) were significantly greater in the EG. Both groups showed similar improvements in all of the WOMAC subscale scores, the SF-36 summary scores and the TUG time. Home-based training was not superior to normal care with regard to pain, disability or HRQoL, but resulted in greater improvement in objectively measured physical performance.

Co-stimulatory and adhesion molecules of dendritic cells in rheumatoid arthritis

Surgical Management of Osteoarthritis of the Knee CPG

Dendritic cells (DCs) in the rheumatoid arthritis (RA) joint mediate the immunopathological process and act as a potent antigen presenting cell. We compared the expression of co-stimulatory and adhesion molecules on DCs in RA patients versus controls with traumatic joint lesions and evaluated the correlation between the immunophenotypical presentation of DCs and the clinical status of the disease. Samples of peripheral venous blood, synovial fluid (SF) and synovial tissue (ST) were obtained from 10 patients with RA at the time of hip or knee replacement and from 9 control patients with knee arthroscopy for traumatic lesions. Clinical status was appreciated using the DAS28 score. Blood, SF and dissociated ST cell populations were separated by centrifugation and analyzed by flow cytometry. Cells phenotypes were identified using three-color flow cytometry analysis for the following receptors HLA-DR, CD80, CD83, CD86, CD11c, CD18, CD54, CD58, CD3, CD4, CD8, CD19, CD20, CD14, CD16, CD56. HLA-DR molecules, co-stimulatory receptors CD80, CD86, CD83 and adhesion molecules CD18, CD11c, CD54, CD58, were analyzed by two-color immunofluorescence microscopy on ST serial sections. In patients with active RA (DAS28>5.1) we found a highly differentiated subpopulation of DCs in the ST and SF that expressed an activated phenotype (HLA-DR, CD86+, CD80+, CD83+, CD11c+, CD54+, CD58+). No differences were found between circulating DCs from RA patients and control patients. Our data suggest an interrelationship between clinical outcome and the immunophenotypical presentation of DCs. Clinical active RA (DAS28>5.1) is associated with high incidence of activated DCs population in the ST and SF as demonstrated by expression of adhesion and co-stimulatory molecules

Improving medication adherence through patient education distinguishing between appropriate and inappropriate utilization. Patient Education Study Group

OAK 3 - Non-arthroplasty tx of OAK

OBJECTIVE: To evaluate the effectiveness of a computer assisted educational intervention to facilitate appropriate utilization of an antiinflammatory medication (Arthrotec) and investigate the mechanism by which it produces these effects. METHODS: A double blind, multicenter, randomized, controlled trial studied patients over age 50 years with hip or knee osteoarthritis (OA). All patients (n = 252) were treated with the medication (diclofenac + misoprostol). Patients randomized to the experimental group interacted with a computer program delivering information about their disease, the medication, its intended and side effects, appropriate utilization (distinguishing between appropriate versus inappropriate continuation and discontinuation of medication), patient involvement in treatment related decision making, and communication with service providers. In the control condition, another computer program presented generic information about OA. Data were collected at pre�test, post�test, and 8 week followup. RESULTS: Appropriate utilization of the medication occurred more frequently in the experimental than the control group (p<0.029). Compared to controls, the experimental group demonstrated significant improvements in knowledge, realistic expectations of drug benefits, perceived ease of adherence, and self�efficacy (all p<0.05). There was no difference between the groups with regard to illness intrusiveness, pain, or disability, but there was a greater improvement in stiffness in the experimental group (�0.63; 95% CI �0.81 to �0.45) compared to the control group (�0.39; 95% CI �0.53 to �0.25) at a level of p = 0.04. CONCLUSION: In conditions such as OA, where patient involvement in decision making is essential to the effectiveness of care, computer assisted education focussing on appropriate vs inappropriate continuation and discontinuation of medications has the potential to improve knowledge, increase self�efficacy, maintain realistic expectations, and facilitate adherence, resulting in more beneficial clinical outcomes.

Monteggia fractures in children and adults

Distal Radius Fractures

The eponymous term "Monteggia fracture" is most precisely used to refer to dislocation of the proximal radioulnar joint in association with a forearm fracture. It is the character of the ulnar fracture, rather than the direction of radial head dislocation, that is useful in determining the optimal treatment of Monteggia fractures in both children and adults. Stable anatomic reduction of the ulnar fracture results in anatomic reduction of the radial head. The notoriously poor results of treatment of Monteggia fractures in adults improved dramatically after the development of modern techniques of plate-and-screw fixation, which facilitate early mobilization by ensuring anatomic reduction. The relatively good results associated with nonoperative treatment of pediatric Monteggia injuries reflect the prevalence of stable (incomplete) fractures in children. Unstable (complete) ulnar fractures are prone to residual or recurrent displacement and may require operative fixation. Late reconstruction of chronic Monteggia lesions in children can be complicated and unpredictable. The key to a good outcome after a Monteggia-type fracture-dislocation of the forearm remains early recognition of proximal radioulnar dissociation. [References: 20]

Supervised exercise plus acupuncture for moderate to severe knee osteoarthritis: a small randomised controlled trial

Surgical Management of Osteoarthritis of the Knee CPG

OBJECTIVES: Although total knee replacement (TKR) is cost effective and successful in most cases, patient-reported outcome measures demonstrate 20% of people remain unsatisfied at 1 year after a technically successful procedure. Our group has previously shown that patients with severe knee osteoarthritis (OA) awaiting surgery can achieve a short-term reduction in symptom severity when treated with acupuncture, and that a trend towards improved walking distance, as a measure of function, is achieved with preoperative supervised exercise. The aim of this study was to evaluate the effect of combined acupuncture and physiotherapy on preoperative and postoperative pain and function. METHODS: A total of 56 patients awaiting TKR surgery were randomised to receive either combined physiotherapy and acupuncture or a standardised exercise and advice leaflet. Pain and function were measured primarily using the Oxford Knee Score (OKS), with assessments at baseline prior to intervention, 6 and 12 weeks after intervention and at 3 months postoperatively. RESULTS: Due to the introduction of the 18-week waiting times target during this study, the required sample size was not achieved. There were no significant differences demonstrated between the control and treatment groups for OKS. Seven patients withdrew from surgery because of symptomatic improvement in their knees: six from the treatment group and one from the control group (OR 7.64, 95% CI 0.86 to 68.20). CONCLUSIONS: This study demonstrated that the use of combined acupuncture and physiotherapy in the treatment of patients with moderate to severe knee OA preoperatively did not improve patient outcome postoperatively. As the study was underpowered, a larger trial is required to examine this result further

Suction drains, quilting sutures, and fibrin sealant in the prevention of seroma formation in abdominoplasty: which is the best strategy?

Panniculectomy & Abdominoplasty CPG

BACKGROUND: Seroma is the most common complication in abdominoplasty and abdominal ultrasound is one of the best noninvasive methods for diagnosing seroma formation. The aim of this study was to compare the use of suction drains, quilting sutures, and fibrin sealant in abdominoplasty to determine the best strategy to prevent seroma formation. METHODS: Forty-three female patients, aged 20-66 years, nonsmokers, with Nahas' type III deformities, and body mass index (BMI) ranging from 18.0 to 24.9 kg/m(2), underwent abdominoplasty between March and October 2008 in a public hospital setting. The patients were randomly allocated to one of three treatment groups: DN group (n = 15), abdominoplasty with suction drains alone; QS group (n = 13), abdominoplasty with quilting suture between the subcutaneous tissue of the flap and musculoaponeurotic layer of the anterior abdominal wall; and FS group (n = 15), abdominoplasty with fibrin sealant. All patients underwent ultrasound examination on postoperative days 15 and 30 for detection of abdominal fluid collections. RESULTS: The groups were homogeneous for age and BMI. There was a significant reduction in seroma formation between postoperative days 15 and 30 in the three groups (DN group, P = 0.0003; QS group, P = 0.0011; and FS group, P = 0.0003). Seroma formation was significantly higher in the FS group (H = 6.04, P < 0.05) compared with the DN and QS groups on postoperative day 15. CONCLUSION: Seroma formation was significantly lower in the DN and QS groups compared with the FS group on postoperative day 15.

Spectroscopic measurement of cartilage thickness in arthroscopy: ex vivo validation in human knee condyles

Surgical Management of Osteoarthritis of the Knee CPG

PURPOSE: To evaluate the accuracy of articular cartilage thickness measurement when implementing a new technology based on spectroscopic measurement into an arthroscopic camera. METHODS: Cartilage thickness was studied by ex vivo arthroscopy at a number of sites (N = 113) in human knee joint osteoarthritic femoral condyles and tibial plateaus, removed from 7 patients undergoing total knee replacement. The arthroscopic image spectral data at each site were used to estimate cartilage thickness. Arthroscopically derived thickness values were compared with reference cartilage thickness as measured by 3 different methods: needle penetration, spiral computed tomography scanning, and geometric measurement after sample slicing. RESULTS: The lowest mean error (0.28 to 0.30 mm) in the regression between arthroscopic and reference cartilage thickness was seen for reference cartilage thickness less than 1.5 mm. Corresponding values for cartilage thickness less than 2.0 and 2.5 mm were 0.32 to 0.40 mm and 0.37 to 0.47 mm, respectively. Cartilage thickness images--created by pixel-by-pixel regression model calculations applied to the arthroscopic images--were derived to demonstrate the clinical use of a camera implementation. CONCLUSIONS: On the basis of this investigation on osteoarthritic material, when one is implementing the spectroscopic method for estimating cartilage thickness into an arthroscopic camera, errors in the range of 0.28 to 0.30 mm are expected. This implementation does not, however, influence the fact that the spectral method performs less well in the cartilage thickness region from 1.5 to 2.5 mm and cannot assess cartilage thicker than 2.5 mm. CLINICAL RELEVANCE: Imaging cartilage thickness directly in the arthroscopic camera video stream could serve as an interesting image tool for in vivo cartilage quality assessment, in connection with cartilage diagnosis, repair, and follow-up

Incidence of Atypical Femur Fractures in Cancer Patients: The MD Anderson Cancer Center Experience

MSTS 2022 - Metastatic Disease of the Humerus

Atypical femoral fractures (AFFs) are rare adverse events attributed to bisphosphonate (BP) use. Few cases of AFF in cancer have been described; the aim of this study is to identify the incidence and risk factors for AFF in a large cancer center. This retrospective study was conducted at the MD Anderson Cancer Center. The incidence rate of AFF among BP users was calculated from January 1, 2004 through December 31, 2013. The control group (n = 51) included 2 or 3 patients on BPs matched for age (=1 year) and gender. Logistic regression analysis was used to assess the relationship between clinical characteristics and AFF. Twenty-three AFF cases were identified radiographically among 10,587 BP users, the total BP exposure was 53,789 months (4482 years), and the incidence of AFF in BP users was 0.05 cases per 100,000 person-years. Meanwhile, among 300,553 patients who did not receive BPs there were 2 cases of AFF as compared with the 23 cases noted above. The odds ratio (OR) of having AFF in BP users was 355.58 times higher (95% CI, 84.1 to 1501.4, p < 0.0001) than the risk in non-BP users. The OR of having AFF in alendronate users was 5.54 times greater (OR 5.54 [95% CI, 1.60 to 19.112, p = 0.007]) than the odds of having AFF among other BP users. Patients who were on zoledronic acid (ZOL) had smaller odds of developing AFF compared with other BP users in this matched case control sample. AFFs are rare, serious adverse events that occur in patients with cancer who receive BP therapy. Patients with cancer who receive BPs for prior osteoporosis therapy or for metastatic cancer are at higher risk of AFF. © 2016 American Society for Bone and Mineral Research.

A 10-year study of the changes in the pattern and treatment of 6,493 fractures

The Treatment of Pediatric Supracondylar Humerus Fractures AUC

A total of 6,493 fractures was studied from 6,389 children younger than 16 years admitted as inpatients to one center in a 10-year period. The boy-to-girl ratio increased from 1.4:1 in the infants to 4.9:1 in the adolescents. The most common fractures were the distal radius (20.2%), supracondylar fracture of the humerus (17.9%), forearm shaft (14.9%), and the tibial shaft (11.9%). A distinct age-specific fracture pattern also was found, with supracondylar fracture of the humerus being the most common fracture in the age 0- to 3-year (26.7%) and the 4- to 7-year (31.6%) groups and distal radius in the 8- to 11-year and the 12- to 16-year groups (24.3 and 25.7%, respectively). Although the overall pattern of the major fractures had not changed over the 10-year period, significant changes in the treatment pattern were observed. The closed-reduction and percutaneous pinning rates increased from 9.5 to 38.7% in fracture of the distal radius, 4.3 to 40% in the supracondylar humerus, and 1.8 to 22% in the forearm shaft. The changes in treatment pattern were also accompanied by a corresponding decrease in the open-reduction rate and hospital stay periods from <10% to 38% of patients being discharged within 1 day of admission in the 10-year period

Anaphylactic shock in pregnancy: a case study and review of the literature

Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures

We describe a 22-year-old previously healthy primigravida who presented with spontaneous rupture of membranes at 40 weeks of gestation. Because of her history of inadequate prenatal care, a chemoprophylaxis regimen against group B streptococcal infection was prescribed upon admission. Within a few minutes after initiation of an i.v. infusion of penicillin G, the patient developed generalized erythema and severe hypotension, which was essentially unresponsive to intravenous boluses of ephedrine. Following stabilization of maternal blood pressure with incremental doses of epinephrine, emergency cesarean section was performed with delivery of a severely depressed neonate. Postoperative recovery of the mother was uneventful, although the baby was diagnosed to have suffered significant neurological damage. This unfortunate event highlights the therapeutic dilemma in anaphylaxis during pregnancy, a relatively rare but potentially life-threatening event. A critical review of the scientific literature reveals several etiological agents for anaphylaxis during the perioperative period, with penicillin as the leading cause of anaphylaxis-related mortality. Although epinephrine is the vasopressor of choice during hemodynamic resuscitation in the non-pregnant patient, during pregnancy it may pose a risk to the placental-fetal circulation. Additionally, upon review of the various published reports to date, timing and mode of delivery of the neonate in the face of anaphylactic shock remains controversial

Efficacy and safety of strontium ranelate in the treatment of osteoporosis in men

Management of Hip Fractures in the Elderly

CONTEXT: Strontium ranelate reduces vertebral and nonvertebral fracture risk in postmenopausal osteoporosis. OBJECTIVE: The objective of this study was to determine the efficacy and safety of strontium ranelate in osteoporosis in men over 2 years (main analysis after 1 year). Design: This was an international, unbalanced (2:1), double-blind, randomized placebo-controlled trial (MALEO [MALE Osteoporosis]). SETTING: This international study included 54 centers in 14 countries. Participants: Participants were 261 white men with primary osteoporosis. Intervention: Strontium ranelate at 2 g/d (n = 174) or placebo (n = 87) was administered. MAIN OUTCOME MEASURES: Lumbar spine (L2-L4), femoral neck, and total hip bone mineral density (BMD), biochemical bone markers, and safety were measured. RESULTS: Baseline characteristics were similar in both groups in the whole population (age, 72.9 +/- 6.0 years; lumbar spine BMD T-score, -2.7 +/- 1.0; femoral neck BMD T-score, -2.3 +/- 0.7). Men who received strontium ranelate over 2 years had greater increases in lumbar spine BMD than those who received placebo (relative change from baseline to end, 9.7% +/- 7.5% vs 2.0% +/- 5.5%; between-group difference estimate (SE), 7.7% (0.9%); 95% confidence interval, 5.9%-9.5%; P < .001). There were also significant between-group differences in relative changes in femoral neck BMD (P < .001) and total hip BMD (P < .001). At the end of treatment, mean levels of serum cross-linked telopeptides of type I collagen, a marker of bone resorption, were increased in both the strontium ranelate group (10.7% +/- 58.0%; P = .022) and the placebo group (34.9% +/- 65.8%; P < .001). The corresponding mean changes of bone alkaline phosphatase, a marker of bone formation, were 6.4% +/- 28.5% (P = .005) and 1.9% +/- 25.4% (P = .505), respectively. After 2 years, the blood strontium level (129 +/- 66 mumol/L) was similar to that in trials of postmenopausal osteoporosis. Strontium ranelate was generally well tolerated. CONCLUSIONS: The effects of strontium ranelate on BMD in osteoporotic men were similar to those in postmenopausal osteoporotic women, supporting its use in the treatment of osteoporosis in men

Knee joint kinetics in response to multiple three-dimensional printed, customised foot orthoses for the treatment of medial compartment knee osteoarthritis

OAK 3 - Non-arthroplasty tx of OAK

The knee adduction moment is consistently used as a surrogate measure of medial compartment loading. Foot orthoses are designed to reduce knee adduction moment via lateral wedging. The 'dose' of wedging required to optimally unload the affected compartment is unknown and variable between individuals. This study explores a personalised approach via three-dimensional printed foot orthotics to assess the biomechanical response when two design variables are altered: orthotic length and lateral wedging. Foot orthoses were created for 10 individuals with symptomatic medial knee osteoarthritis and 10 controls. Computer-aided design software was used to design four full and four three-quarter-length foot orthoses per participant each with lateral posting of 0degree 'neutral', 5degree rearfoot, 10degree rearfoot and 5degree forefoot/10degree rearfoot. Three-dimensional printers were used to manufacture all foot orthoses. Three-dimensional gait analyses were performed and selected knee kinetics were analysed: first peak knee adduction moment, second peak knee adduction moment, first knee flexion moment and knee adduction moment impulse. Full-length foot orthoses provided greater reductions in first peak knee adduction moment (p = 0.038), second peak knee adduction moment (p = 0.018) and knee adduction moment impulse (p = 0.022) compared to three-quarter-length foot orthoses. Dose effect of lateral wedging was found for first peak knee adduction moment (p < 0.001), second peak knee adduction moment (p < 0.001) and knee adduction moment impulse (p < 0.001) indicating greater unloading for higher wedging angles. Significant interaction effects were found for foot orthosis length and participant group in second peak knee adduction moment (p = 0.028) and knee adduction moment impulse (p = 0.036). Significant interaction effects were found between orthotic length and wedging condition for second peak knee adduction moment (p = 0.002). No significant changes in first knee flexion moment were found. Individual heterogeneous responses to foot orthosis conditions were observed for first peak knee adduction moment, second peak knee adduction moment and knee adduction moment impulse. Biomechanical response is highly variable with personalised foot orthoses. Findings indicate that the tailoring of a personalised intervention could provide an additional benefit over standard interventions and that a three-dimensional printing approach to foot orthosis manufacturing is a viable alternative to the standard methods.