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How Are Obesity and Body Composition Related to Patellar Cartilage? A Systematic Review

OAK 3 - Non-arthroplasty tx of OAK

OBJECTIVE: The aim of this review was to systematically examine the evidence for an association between measures of obesity [weight and body mass index (BMI)] and body composition (fat mass and fat-free mass) and patellar cartilage, assessed using magnetic resonance imaging. METHODS: Three electronic databases (MEDLINE, EMBASE, and CINAHL) were searched up to April 2016 using full text and MeSH terms to identify studies examining the associations between obesity and body composition, and patellar cartilage. Two independent reviewers extracted the data and assessed the methodological quality of included studies. RESULTS: Seventeen studies were included: 5 cross-sectional, 10 cohort studies measuring outcomes at 2 timepoints, and 2 longitudinal studies assessing outcome only at the timepoint. Eleven studies were of high or moderate quality. In asymptomatic middle-aged adults, elevated body weight and BMI were systematically associated with worse patellofemoral cartilage scores. There was more consistent evidence for patellar cartilage defects than patellar cartilage volume, particularly in women. Increased BMI was also consistently associated with increased cartilage loss in longitudinal studies, although not all attained statistical significance. CONCLUSION: There is a need for more high-quality research to confirm these findings and to better explain the relative contributions of metabolic and biomechanical factors to the initiation of patellofemoral osteoarthritis, to devise effective strategies to manage this common and disabling condition.

An eye movement study on the role of the visual field defect in pure alexia

Upper Eyelid and Brow Surgery

Pure alexia is a severe impairment of word reading which is usually accompanied by a right-sided visual field defect. Patients with pure alexia exhibit better preserved writing and a considerable word length effect, claimed to result from a serial letter processing strategy. Two experiments compared the eye movements of four patients with pure alexia to controls with simulated visual field defects (sVFD) when reading single words. Besides differences in response times and differential effects of word length on word reading in both groups, fixation durations and the occurrence of a serial, letter-by-letter fixation strategy were investigated. The analyses revealed quantitative and qualitative differences between pure alexic patients and unimpaired individuals reading with sVFD. The patients with pure alexia read words slower and exhibited more fixations. The serial, letter-by-letter fixation strategy was observed only in the patients but not in the controls with sVFD. It is argued that the VFD does not cause pure alexic reading.

Who decides on the need for antibiotic prophylaxis in patients with major arthroplasties requiring dental treatment: is it a joint responsibility?

Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures

The role of antibiotic prophylaxis in patients with prosthetic joints who require dental treatment is controversial. A Working Party of the British Society for Antimicrobial Chemotherapy (BSAC) recently suggested that there was no evidence to support the use of antibiotic prophylaxis in these patients. The purpose of this study was to determine how closely these recommendations were being followed by maxillofacial surgeons (MFS), and to see if there was any consensus on the management of these patients between MFS and orthopaedic surgeons (OPS). With the aid of a postal questionnaire, the opinions of 250 consultant MFS and OPS were sought, response rates were 148 (59.2%) and 113 (41.2%), respectively. Of the OPS, 77.7% always recommended the use of antibiotic prophylaxis as opposed to only 29% of MFS. There were also wide differences in opinion with regard to the antibiotic that should be used in these patients, with the majority of OPS suggesting a cephalosporin, although this may not be the most efficacious antibiotic for oral streptococci. We conclude that this important matter seems to be far from satisfactorily resolved and that further cooperation between the specialties is required to produce guidelines for the safe and effective management of this increasing group of patients

Evaluation of Posterior Cruciate Ligament and Intercondylar Notch in Subjects With Anterior Cruciate Ligament Tear: A Comparative Flexed-Knee 3D Magnetic Resonance Imaging Study

OAK 3 - Non-arthroplasty tx of OAK

Purpose: To determine if posterior cruciate ligament (PCL) and intercondylar notch (IN) morphometries and volumetrics act as risk factors for anterior cruciate ligament (ACL) tears. Methods: A prospective case-controlled magnetic resonance imaging (MRI) study was conducted with subjects presenting noncontact knee injuries. Exclusion criteria were previous surgery, PCL tear, osteoarthritis, tumors, or infectious and inflammatory conditions. All participants underwent a flexed-knee 3-dimensional (3D) magnetic resonance imaging (MRI) to uniformly straighten PCL. MR images were independently reviewed by 2 radiologists and assessed for 2D and 3D measurements (bicondylar width; IN angle, depth, width, and cross-sectional area; PCL width, thickness, and cross-sectional area; and IN and PCL volumes). Clinical profiles were tabulated and subjects were divided into cases (ACL tear) and controls (without ACL tear). Results: The study was composed of 50 cases versus 52 controls (N = 102), with a mean age of 36.8 years. There was no difference between groups (P >.05) regarding age, gender, body mass index, time from injury, Tegner score, flexion angle, limb side, intensity of injury, or familial or opposite limb history of tear. Agreement between readers ranged from substantial to almost perfect. Subjects with ACL tear presented with lower IN width, lower IN minus PCL widths, lower Notch Width Index, higher PCL/IN width proportion, higher PCL thickness, lower IN depth minus PCL thickness, and higher PCL thickness/IN depth proportion (P <.05). Moreover, higher PCL/IN cross-sectional area proportion, higher PCL volumes (OR = 9.01), and higher PCL/IN volume proportion were also found in cases. Conclusions: Our study shows that subjects with ACL tears present not only reduced IN but also larger PCL dimensions. These findings, isolated and combined, and especially PCL volume, might be suggestive as risk factors for ACL tears owing to the reduction of its space inside the IN. Level of Evidence: Level III, comparative group.

Review of antibiotics and indications for prophylaxis

Dental Implant Infection

Antibiotic prophylaxis to prevent infective endocarditis has been controversial through the years, with various changes made to recommendations provided to treating physicians and dentists. The dentist must always use his or her best judgment when applying any guideline. However, it is important to remember that the guidelines may be cited in any malpractice litigation as evidence of the standard of care. Early diagnosis with prompt treatment with effective antimicrobial therapy is the best way to lower the mortality and morbidity. When prescribing antibiotics, the clinician must realize that the overprescription of antibiotics has led to resistance to antibiotic regimens and the rise of antibiotic-resistant bacteria. Copyright © 2012 Elsevier Inc. All rights reserved.

The measurement of calcium-regulating hormones in clinical medicine

MSTS 2018 - Femur Mets and MM

Assays of serum immunoreactive parathyroid hormone are clinically useful in the differential diagnosis of hypercalcaemic states and in the assessment of the severity of parathyroid bone disease in uraemic patients. Serum immunoreactive calcitonin measurements are essential in the investigation of individuals who might be suffering from medullary carcinoma and may be used in the detection of metastases. Serum 25-hydroxyvitamin D assays should be performed in patients receiving pharmacological doses of vitamin D to monitor patient compliance and to prevent the occurrence of vitamin D intoxication. Low values in patients with renal failure and in patients with malabsorption are highly suggestive of the presence of osteomalacia. The measurement of serum levels of dihydroxylated vitamin D metabolites is currently of doubtful relevance though such measurements may become useful in monitoring patients receiving these compounds therapeutically.

A paradigm shift in endodontic management of immature teeth: conservation of stem cells for regeneration

Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures

OBJECTIVE: This article will review the new concept of regenerative endodontics in the management of immature permanent teeth. The potential role of stem cells to regenerate immature permanent teeth after conservative treatment will be discussed. DATA AND SOURCES: Two sets of data source are focused in this review: (i) the characterization of various dental stem cells discovered since 2000 and (ii) recent clinical case reports showing that after conservative treatment, severely infected immature teeth with periradicular periodontitis and abscess can undergo healing and apexogenesis or maturogenesis. RESULTS: A new protocol of treating endodontically involved immature permanent teeth based on published articles to date is summarized in the review. The key procedures of the protocol are (1) minimal or no instrumentation of the canal while relying on a gentle but thorough irrigation of the canal system, (2) the disinfection is augmented with intra-canal medication of a triple-antibiotic paste between appointments, and (3) the treated tooth is sealed with mineral trioxide aggregate (MTA) and glass ionomer/resin cement at the completion of the treatment. Periodical follow-ups will take place to observe any continued maturation of the root. CONCLUSION: While more clinical research is needed, regenerative endodontics promotes a paradigm shift in treating endodontically involved immature permanent teeth from performing apexification procedures to conserving any dental stem cells that might remain in the disinfected viable tissues to allow tissue regeneration and repair to achieve apexogenesis/maturogenesis

Institutionalized patients with hip fractures: characteristics associated with returning to community dwelling

Management of Hip Fractures in the Elderly

The authors sought to identify patient- and nursing home-specific characteristics associated with a return to community living among patients with hip fractures discharged initially to nursing homes. One hundred eighty-nine free-living elderly patients were admitted for hip fractures to a 1,120-bed community hospital during 1984-1986. At hospital discharge, 114 (60%) of these patients were institutionalized. One year later, 49/114 (43%) had returned to the community. Three factors independently correlated with patients' return to community living: being discharged to a nursing home with a large ratio of annual admissions to number of beds (RR = 2.51, 95% CI 1.65, 3.94), achieving any in-hospital ambulation (RR = 4.24, 95% CI 1.77, 8.14), and receiving conventional Medicare insurance (RR = 0.37, 95% CI 0.05, 0.53). These data suggest the existence of patient and nursing home features that identify those institutionalized patients with hip fractures who are more likely to return to community dwelling

Real world outcomes with Bortezomib Thalidomide dexamethasone and Cyclophosphamide Bortezomib dexamethasone induction treatment for transplant eligible multiple myeloma patients in a Latin American country. A Retrospective Cohort Study from Grupo Argentino de Mieloma Multiple

MSTS 2022 - Metastatic Disease of the Humerus

Data about treatment outcomes and toxicity in Latin America are scarce. There are differences with central countries based on access to healthcare system and socioeconomic status. Argentinean Society of Hematology recommends bortezomib-based triplets for induction treatment of transplant eligible newly diagnosed multiple myeloma patients. Most common options are CyBorD (cyclophosphamide, bortezomib and dexamethasone) and VTD (bortezomib, thalidomide and dexamethasone). Main goal of our retrospective, multicentric study was to compare very good partial response rate (VGPR) or better after induction treatment in a real-world setting in Argentina. Secondary objectives included comparison of complete response (CR) post-induction and after bone marrow transplantation, grade 3-4 adverse events (AEs), progression-free survival (PFS) and overall survival (OS). Three hundred twenty-two patients were included (median age at diagnosis: 57 years; 52% male; 28% had ISS3; 14% with high-risk cytogenetics; median follow up: 34 months). CyBorD was indicated in 74% and 26% received VTD. In VTD arm, 72.62% of patients achieved at least VGPR vs 53.36% receiving CyBorD (odds ratio, OR: 1.96 [95% confidence interval, CI: 1.08-3.57; P = .026] after adjusting by age, ISS [International Staging System], lactate dehydrogenase levels (LDH) and cytogenetic risk. Difference in VGPR was 19.26% (95% CI: 15-24). CR rate were 35.92% (VTD) vs 22.55% (CyBorD) (adjusted OR: 2.13 [95% CI: 1.12-4.05]). Difference in CR was 13.37% (95% CI: 9.6-17.53). Adverse events (AEs) were more common with VTD (69.05% vs 55.46% for CyBorD; P = .030), especially grade 3-4 neuropathy (P = .005) and thrombosis (P = .001). Thromboprophylaxis was inadequate in 20.24% of patients. Hematological AEs were more common with CyBorD, especially thrombocytopenia (P = .017). PFS and OS at 24 months were not different between treatments. In this real-world setting, VTD was associated with better CR and VGPR than CyBorD. Nevertheless, CyBorD continues to be the preferred induction regimen in Argentina, based on safety profile. Frontline autologous stem cell transplantation improves quality of responses, especially in countries with limited access to new drugs.

Nutritional Support for Bariatric Surgery Patients: The Skin beyond the Fat

Panniculectomy & Abdominoplasty CPG

Body contouring surgery after the massive weight loss due to bariatric surgery deals with different kinds of complications. The aim of this review is to analyze the role that some nutrients may play in tissue healing after surgery, thus helping plastic surgeons to improve the aesthetic and health outcomes in massive weight loss patients under a multidisciplinary approach. As a matter of fact, preoperative nutritional deficiencies have been shown for vitamins and minerals in a large percentage of post-bariatric patients. Preoperative deficiencies mainly concern iron, zinc, selenium, and vitamins (both fat-soluble and water-soluble), but also total protein. During the postoperative period, these problems may increase because of the patients' very low intake of vitamins and minerals after bariatric surgery (below 50% of the recommended dietary allowance) and the patients' low compliance with the suggested multivitamin supplementation (approximately 60%). In the postoperative period, more attention should be given to nutritional aspects in regard to the length of absorptive area and the percentage of weight loss.

The use of complementary health approaches among patients with knee osteoarthritis in Pakistan: A hospital based survey

OAK 3 - Non-arthroplasty tx of OAK

Aim of the work: This study aimed to document the trends of complementary health approaches in Pakistani patients with knee osteoarthritis (KOA) and consider them in relation to demographic factors. Patients and methods: A cross-sectional survey was carried out at the outpatient department, Armed Forces Institute of Rehabilitation Medicine (AFIRM), Rawalpindi, Pakistan. Recruited patients fulfilled the American College of Rheumatology criteria for KOA. Results: Of 300 patients (mean age: 62 ± 10 years), majority were male (68%), in age group 61-70 years (37.3%), with monthly income <10.000 Pakistani Rupees (75.3%) and educational level from grade 6-10 (48%). Most patients were from urban areas (51.3%) belonging to the Punjab province (83.3%). Complementary health approaches were used by 45.3% of the patients. Most individuals used single therapy at a time (58.1%) and preferred therapeutic massage (63.2%). Nutritional supplements were used in 13.2%. Patients adopted these therapies chiefly based on self-knowledge (33.8%), primarily for pain relief (85.3%) and used them in combination with conventional medicines on a daily basis or at least five times a week (in 75%). The use of complementary health approaches was significantly more common in rural population (p = 0.023), in individuals who were illiterate or had education from grade 1-5 (p = 0.038) and individuals falling in age group of 41-50 years (p = 0.008). Conclusions: The use of complementary health approaches is common in Pakistani KOA patients who are primarily rural-based, young and less educated. Massage is the preferred complementary health approach and most patients practice a single approach at a time in combination with conventional medicines.

Basic principles of nuclear medicine techniques for detection and evaluation of trauma and sports medicine injuries

DOD - Acute Comp Syndrome CPG

Nuclear medicine skeletal imaging is a very sensitive technique for evaluating bone and muscle abnormalities because it can detect minor changes in metabolism and blood flow. The specificity of bone imaging, however, depends on the ability of the nuclear medicine physician to make a differential diagnosis. To aid in making a specific diagnosis, this article describes the various patterns of abnormality in stress fractures, tibial stress syndrome (shin splints), compartment syndrome, enthesopathy, and traumatic fractures. The characteristic scintigraphic appearance of joint injuries, muscle injuries (rhabdomyolysis), and radionuclide arthrography is discussed and the way the scan patterns change with time in these various disorders is described. A brief summary of the basic anatomy and physiology of bone and muscle in normal and injured tissue is presented and the basic mechanisms which cause the various abnormal scan patterns is postulated. In addition, a staging system for stress fractures is presented to help direct the referring physician toward the proper management of the injured patient. In most cases, nuclear medicine skeletal imaging can be used to differentiate between acute muscle injury, tibial stress syndrome, skeletal injury (periosteal reaction, stress fracture, and traumatic fracture) or an abnormality that is entirely associated with the joint or connective tissue. This differential diagnosis is easier if the nuclear medicine procedure is performed within a few days after the onset of injury. [References: 55]

Elastic stable intramedullary nailing in paediatric traumatology at Yopougon Teaching Hospital (Abidjan)

DoD SSI (Surgical Site Infections)

CONTEXT: Elastic stable intramedullary nailing has revolutionised the treatment of fractures in children. AIM: To report our experience with this current technique of management of fractures in children. METHODS AND MATERIALS: A retrospective study of all children with fractures treated by this method from November 2003 to June 2006 at the Paediatric Surgery Department of Yopougon Teaching Hospital, Abidjan, Cote d'Ivoire. Data were recorded from their medical charts regarding demographics, fracture patterns, associated injuries, morbidity, and outcome. RESULTS: A total of 38 children (14 boys; mean age, 11.7 years; range, 9-15 years) with 41 fractures, sited at femur (n=15), humerus (n=8), tibia and fibula (n=6), forearm (n=7), and radial neck (n=5), associated with other injuries in 7 cases, were enrolled in the study. The mean interval for surgery was 6.8 days. Open reduction was required 5 times (12.1%). The hospital stay was in the range 5-12 days. Minor adverse events were 1 (2.4%) early tibial loss of reduction, 3 (7.3%) skin irritations and 2 (4.8%) transient knee limitations. Complications (17.3%) included 2 axial (4.8%) and 1 rotational (2.4%) femoral malunions below 15degree; 3 elbow (7.3%) and 1 knee stiffness (2.4%) in openly reduced cases. Solid consolidation was achieved in all cases, with no disturbance in standard union times. At a mean follow-up period of 16 months (range, 9-28 months), all but 3 patients with opened joints recovered full range of motion, and none showed either limp and gait anomalies or re-fracture after removal of wires. CONCLUSION: Elastic stable intramedullary nailing in children fractures is easy to perform and has little complications if a proper technique is used.

Analgesic control and functional outcome after knee arthroscopy: results of a randomized double-blinded trial comparing a hyaluronic acid supplement with bupivacaine

OAK 3 - Non-arthroplasty tx of OAK

OBJECTIVE: Hyaluronic acid (HA) is a naturally occurring substance within normal synovial joints. Although its efficacy in treating osteoarthritis has been evaluated, it has not been established whether it is of benefit after routine arthroscopic procedures. We hypothesized that immediate supplementation with HA after completion of arthroscopy would result in improved short-term analgesic and functional outcomes after knee arthroscopy. DESIGN: Double-blinded randomized controlled trial. SETTING: Tertiary referral center. PATIENTS: One hundred ten patients presenting for routine arthroscopic procedures were invited to participate in the study. After exclusion criteria were applied, 98 patients were randomized to receive either 10 mL of 0.5% bupivacaine or 3 mL of HA into the joint immediately after completion of surgery. INTERVENTIONS: After completion of surgery, all patients were randomized to receive either 10 mL of 0.5% bupivacaine or 3 mL of HA into the knee joint. MAIN OUTCOME MEASURES: Visual analogue scale (VAS) pain scores were obtained at baseline; 1, 2, and 24 hours; and 1, 2, and 6 weeks after surgery. Western Ontario and McMaster Universities (WOMAC) and Tegner-Lysholm scores were obtained at baseline and then at 1, 2, and 6 weeks after surgery. RESULTS: Forty-nine patients received intra-articular bupivacaine and 49 received HA. There was no statistical difference in any of the outcome measures (VAS pain scores, WOMAC, and Tegner-Lysholm) at any time point between the groups overall. CONCLUSIONS: There was no benefit of HA injection immediately at the end of knee arthroscopy in the first 6 weeks after surgery. CLINICAL RELEVANCE: Routine use of HA at the time of knee arthroscopy cannot be recommended.

(iv) Hindfoot arthritis

Surgical Management of Osteoarthritis of the Knee CPG

Ankle and subtalar arthritis are commonly encountered by foot and ankle surgeons, but their prevalence is not as common as arthritis of the hip or knee.Trauma is the most common aetiology for both, but primary osteoarthritis and inflammatory arthropathies are also encountered.Clinical and radiological assessments are vital for correct diagnosis and for formulating an appropriate management plan. The recognition of abnormal alignment is particularly important as failure to do so will result in poor clinical outcomes of treatment.Both conditions can be managed using non-operative and operative treatment. Ankle arthritis in particular has generated much controversy with regards to the definitive treatments of arthrodesis and arthroplasty. (copyright) 2011 Elsevier Ltd

The effects of 8-year pamidronate treatment on skeletal morbidity in patients with advanced multiple myeloma

MSTS 2018 - Femur Mets and MM

Background. In patients with multiple myeloma (MM) osteolytic bone destruction progresses despite a reduction of tumor mass achieved with chemotherapy. The aim of the study was to evaluate the efficacy of pamidronate, an inhibitor of osteoclastic bone resorption administered to MM patients receiving anti-myeloma chemotherapy acc. to the VMCP/VBAP alternating regimen. Material and method. 46 patients with stage III myeloma and osteolytic lesions received either pamidronate (Aredia; Novartis) 60 mg i.v. in 4 - hour infusions monthly (n=23) or chemotherapy alone (control group n=23). Results. On comparison of consecutive skeletal X-ray surveys performed after 6, 12, 18, 24, 30, 36, 42, 48, 54 and 66 cycles of pamidronate the progression of osteolysis was respectively found in 67%, 39%, 27%, 20%, 25%, 25%, 60%, 80%, 92% and 96% of patients. In the control group the corresponding figures were: 79%, 70%, 30%, 44%, 50%, 40%, 66% and 100% (p>0,16). Median time to the occurrence of the first skeletal-related event was 13 months in the pamidronate group and 7 months in the control group. The mean number of skeletal events (pathologic fractures, radiation or surgery of bones and spinal cord compression) per year in the first 4 years of treatment was 1.42 in the pamidronate group and 1.96 in the control group. During further treatment these values reached 0.51 vs 0.9, respectively (p=0.08). At the end of the 8 years the proportion of patients who had developed skeletal events (excluding vertebral fractures) was lower in the pamidronate group as compared to the control group - 52% vs 56%, respectively (p=0.42). The ratio of patients with vertebral pathologic fractures was identical - 76% vs 75%, but the number of vertebral fractures was lower in the pamidronate group than in the control group - 50 vs 71, respectively (1.2 vs 1.77 per year in the first 4 years p=0.07 and 0.84 vs 0.91 in the next 4 years of treatment). During the 4 latter years of study decreases of the blood hemoglobin level occurred with the same frequency among the pamidronate patients and in controls. No significant differences of patient survival were observed between the pamidronate group and the control group (median: 21 vs 20 months from randomization, p=0.78 and median: 50 vs 45 months since MM diagnosis, p=0.20). 5-year and 8-year survival was 48% and 30%, respectively, for patients receiving pamidronate, as compared to 17% and 13%, respectively for patients receiving chemotherapy only. Conclusions. Long-term pamidronate treatment moderately reduces myeloma-related skeletal morbidity. As the treatment duration lengthens the effect of pamidronate on skeletal morbidity becomes less pronounced and the difference in the incidence of anaemia between the pamidronate group and the controls is much less distinct.

Electrodiagnostic evaluation of the ulnar nerve

The Treatment of Pediatric Supracondylar Humerus Fractures AUC

Electrodiagnostic methods and their significance for the diagnosis of a lesion of the ulnar nerve are discussed. For different lesion locations (upper arm, elbow, forearm, wrist, and palm), various electrodiagnostic methods are discussed. An overview of the existing literature is given. The diagnostic importance is reported herein, and aspects of applications are discussed. This review is intended to support the electrodiagnostic physician in the selection and application of the correct methods in the diagnosis of a lesion of the ulnar nerve. (copyright) 2007 by Begell House, Inc

Exosomes derived from miR-140-5p-overexpressing human synovial mesenchymal stem cells enhance cartilage tissue regeneration and prevent osteoarthritis of the knee in a rat model

OAK 3 - Non-arthroplasty tx of OAK

OBJECTIVES: Osteoarthritis (OA) is the most common joint disease throughout the world. Exosomes derived from miR-140-5p-overexpressing synovial mesenchymal stem cells (SMSC-140s) may be effective in treating OA. We hypothesized that exosomes derived from SMSC-140 (SMSC-140-Exos) would enhance the proliferation and migration abilities of articular chondrocytes (ACs) without harming extracellular matrix (ECM) secretion. METHODS: SMSCs were transfected with or without miR-140-5p. Exosomes derived from SMSCs or SMSC-140s (SMSC-Exos or SMSC-140-Exos) were isolated and identified. Proliferation, migration and ECM secretion were measured in vitro and compared between groups. The mechanism involving alternative Wnt signalling and activation of Yes-associated protein (YAP) was investigated using lentivirus, oligonucleotides or chemical drugs. The preventative effect of exosomes in vivo was measured using Safranin-O and Fast green staining and immunohistochemical staining. RESULTS: Wnt5a and Wnt5b carried by exosomes activated YAP via the alternative Wnt signalling pathway and enhanced proliferation and migration of chondrocytes with the side-effect of significantly decreasing ECM secretion. Highly-expressed miR-140-5p blocked this side-effect via RalA. SMSC-140-Exos enhanced the proliferation and migration of ACs without damaging ECM secretion in vitro, while in vivo, SMSC-140-Exos successfully prevented OA in a rat model. CONCLUSIONS: These findings highlight the promising potential of SMSC-140-Exos in preventing OA. We first found a potential source of exosomes and studied their merits and shortcomings. Based on our understanding of the molecular mechanism, we overcame the shortcomings by modifying the exosomes. Such exosomes derived from modified cells hold potential as future therapeutic strategies.

Lateral meniscus allograft transplantation: clinical and anatomic outcomes after arthroscopic implantation with tibial tunnels versus open implantation without tunnels

OAK 3 - Non-arthroplasty tx of OAK

UNLABELLED: Meniscus allograft transplantation (MAT) is used to treat patients with knee pain after total or subtotal meniscectomy. The graft can be inserted during open or arthroscopic surgery. The objectives are anatomic horn positioning and strong fixation to the bone and capsule of an appropriately sized graft. HYPOTHESIS: Arthroscopic MAT with trans-tibial bone fixation ensures better mid-term functional outcomes and limits allograft extrusion. PATIENTS AND METHODS: We conducted a retrospective single-centre study of 23 consecutive patients who underwent MAT between 2001 and 2010. Among them, 11 had open surgery and anchoring of the horns without tunnels and 12 had arthroscopically-assisted surgery with bony fixation of the horns through trans-tibial tunnels. The two groups were comparable at baseline. Mean follow-up was 66.1 months. Post-operative outcomes were assessed using the IKDC score and KOOS, standard radiographs of both knees, and either magnetic resonance imaging or computed arthrotomography. We measured joint space narrowing, meniscal extrusion in the sagittal and coronal planes; and the degree of cartilage coverage by the graft using an index developed for this study. RESULTS: The overall failure rate was 17.4% (4/23, two cases each of complete and partial graft removal). Joint space narrowing increased by 28% versus the pre-operative value (P=0.009). IKDC and KOOS values were not significantly different between the two groups. Absolute meniscus extrusion was greater in the arthroscopy group (4mm vs. 3mm, P=0.03). DISCUSSION: Osteoarthritis of the transplanted compartment is unavoidable. Open surgery is associated with less meniscal extrusion. The clinical outcomes are independent from the technique used. Other factors require investigation, including graft rehabilitation, quality peripheral suturing, and intermeniscal ligament reconstruction. LEVEL OF EVIDENCE: IV, retrospective study.

The use of the McKeever metallic hemiarthroplasty for unicompartmental arthritis

Surgical Management of Osteoarthritis of the Knee CPG

We reviewed the results of sixty-one McKeever unicompartmental arthroplasties performed by the senior one of us (T. P.) for osteoarthritis of the knee. The average follow-up was five years (range, two to thirteen years). Forty-four (72 per cent) of the arthroplasties were rated as good to excellent. The average postoperative range of motion in these knees was 110 degrees. Six knees were rated as fair and eleven knees, as poor. The poor results appeared to be caused by degenerative arthritis involving ipsilateral compartments that had not been resurfaced with an implant

A guide instrument for high tibial osteotomy

Surgical Management of Osteoarthritis of the Knee CPG

Fifty-two patients (52 knees) with medial gonarthrosis were subjected to high tibial osteotomy using the Tjornstrand guide instrument. The intended wedge was calculated from a whole lower limb radiograph. The correction aimed at was an overcorrection of 4 degrees in valgus of the hip-knee-ankle angle. All but 1 case were corrected to +/- 3 degrees of the intended angle. All but two cases healed within +/- 3 degrees of the achieved surgical correction, i.e., a substantial improvement compared with our previous freehand technique where one fifth were outside this interval. We conclude that in knee surgery a guide is as important for osteotomies as for arthroplasties

Examination of muscle strength and pressure pain thresholds in knee osteoarthritis: test-retest reliability and agreement

OAK 3 - Non-arthroplasty tx of OAK

BACKGROUND AND PURPOSE: Knee osteoarthritis (OA) is associated with reduced muscle strength and pain sensitization. The purpose of this study was to determine intrarater reliability and agreement (measurement error) of isometric knee extensor and flexor muscle strength assessed using handheld dynamometry and of pressure pain thresholds (PPT; a measure of pain sensitization) from the knee, the leg, and the forearm assessed using handheld algometry in knee OA. METHODS: A total of 20 subjects with knee OA participated in 2 sessions separated by 1 week. The highest of 4 examinations and the mean of the 3 highest examinations of muscle strength and the first and the mean of 2 PPT examinations were applied in the statistical analyses. Intrarater reliability was assessed using a 2-way random-effects model, consistency-type intraclass correlation coefficient, whereas agreement was assessed using 95% limits of agreement (LOA) as a percentage of the mean (LOA%). RESULTS: Intraclass correlation coefficients for muscle strength were between 0.78 and 0.91 when using the highest examination and were between 0.86 and 0.94 when using the mean of the 3 highest examinations. Intraclass correlation coefficients for PPT were between 0.53 and 0.87 when using the first examination and were between 0.84 and 0.91 when using the mean of 2 examinations. Agreement (LOA%) for muscle strength ranged from 38.3% to 47.3% when using the highest examination and from 40.4% to 53.3% when using the mean of the 3 highest examinations. Agreement for PPT ranged from 54.2% to 80.6% when using the first examination and from 50.6% to 58.9% when using the mean of 2 PPT examinations. DISCUSSION: A tendency toward improved intraclass correlation coefficients and LOA% (only for PPTs) was found when using the mean of more than 1 examination for both muscle strength and PPTs. Intrarater reliability was high to very high, whereas the LOA/LOA% indicated relatively high measurement errors. CONCLUSIONS: Examination of muscle strength and PPTs in knee OA is reliable, but affected by the measurement error, which is important to consider when reporting the results of clinical trials and in clinical practice.

Case Presentation of Soft Tissue Defect after Bimalleolar Fracture Osteosynthesis

DoD SSI (Surgical Site Infections)

A 59-year-old patient presented in the ER with wound dehiscence and skin necrosis on the right ankle, with osteosynthesis implant visible, after open reduction and fixation with plate and screws, performed abroad, 16 days prior to the presentation, for a bimalleolar fracture. The patient was admitted to the plastic surgery department, where surgical debridement of the necrotic tissue was initially performed. Postoperatively, the patient was treated with Negative-pressure wound therapy (VAC dressing) and Platelet rich plasma (PRP) therapy. Upon obtaining granulation tissue without signs of infection, a sural fasciocutaneous flap was performed to cover the skin defect. Proper graft integration and healing was observed.

Documenting the cognitive status of hip fracture patients using the Short Portable Mental Status Questionnaire

Management of Hip Fractures in the Elderly

AIMS AND OBJECTIVES: The aim of this study was to describe how nurses document their subjective assessment of the patients' cognitive status in the patients' records and to compare this documentation with an assessment made using a validated evaluation instrument in older patients with a hip fracture. BACKGROUND: There are indications that older people with a hip fracture and impaired cognitive ability do not receive optimal care and that they suffer from a disproportionately high number of complications. Preventing and rapidly detecting confusion is probably an effective strategy for improving care for these patients. To be able to prevent care-related complications and plan for future nursing and medical care, it is necessary to identify patients with impaired cognitive ability. DESIGN: Clinical trial including 362 patients. METHODS: The patients' cognitive function was assessed by a research nurse using a validated instrument, the Short Portable Mental Status Questionnaire, and an independent subjective assessment was made by a ward nurse. The agreement between these assessments was analysed. RESULTS: An assessment of cognitive function by the ward nurse was lacking in 12% of the patients. The assessment made by the nurses did not correspond to the level of orientation according to Short Portable Mental Status Questionnaire in 24% of the patients. In the vast of majority of these cases, the patients were documented as being cognitively alert although they were cognitively impaired according to the Short Portable Mental Status Questionnaire. Among the patients who were cognitively oriented according to the Short Portable Mental Status Questionnaire, the nurses' assessment identified 97% as oriented, but among the patients with impaired cognitive ability according to the Short Portable Mental Status Questionnaire, only 58% were identified as being cognitively impaired by the ward nurses. CONCLUSIONS: An assessment of cognitive function is still lacking in nursing records for a substantial number of older people with a hip fracture and cognitive dysfunction is frequently underdiagnosed in routine health care. RELEVANCE TO CLINICAL PRACTICE: Patient care could be improved if the patients' cognitive function was assessed regularly and objectively by means of a validated evaluation instrument

Computer navigation-assisted versus minimally invasive TKA: benefits and drawbacks

DoD SSI (Surgical Site Infections)

UNLABELLED: Computer-navigated and minimally invasive TKAs are emerging technologies that have distinct strengths and weaknesses. We compared duration of surgery, length of hospitalization, Knee Society scores, radiographic alignments, and complications in two unselected groups of 81 consecutive knees that underwent TKA using either a minimally invasive approach or computer navigation. The two groups were operated on by two different surgeons over differing timeframes. The mean surgical time was longer in the navigated group by 63 minutes. The Knee Society scores and lengths of hospitalization of the two groups were similar. The postoperative component alignments of the two groups were similar; the mean femoral valgus and tibial varus angles of the navigation group changed from 96 degrees and 88 degrees preoperatively to 95 degrees and 89 degrees postoperatively, respectively, and in the minimally invasive group, the mean femoral valgus angles and tibial varus angles changed from 97 degrees and 88 degrees preoperatively to 95 degrees and 89 degrees postoperatively, respectively. There were 11 major and three minor complications in the navigation group, including one revision, two femoral shaft fractures, four reoperations for knee stiffness, and four instances of bleeding from tracker sites. We believe the higher incidence of complications in addition to the longer operative time in the navigated group may outweigh any potential radiographic benefits. LEVEL OF EVIDENCE: Level II, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Hip fracture prevention: a review

Management of Hip Fractures in the Elderly

The incidence of hip fractures worldwide is expected to almost quadruple in the next 60 years. Increased cost-containment pressures will focus attention not only on improvements in hip fracture treatment but also on prevention. Three approaches that can prevent hip fractures--preventing falls, preventing and treating bone fragility, and using external hip protectors--are reviewed. Although it is impossible to prevent all hip fractures, these methods may significantly reduce the annual incidence of these fractures

Cardiac malformations associated with the congenital nephrotic syndrome

Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures

The association of cardiac malformation with the congenital nephrotic syndrome (CNS) has been previously reported in only one family. We report four patients with CNS: three with pulmonary valve stenosis (one requiring valvuloplasty) and one with discrete subaortic stenosis requiring surgical resection. We conclude that the cardiac status of all patients with CNS should be reviewed regularly by a paediatrician, with a low threshold for referral to a cardiologist, as flow murmurs due to chronic anaemia may obscure cardiac pathology. It is important to diagnose any associated cardiac lesions as these may require intervention, and may also predispose to the development of bacterial endocarditis if surgical or dental procedures are undertaken without appropriate antibiotic prophylaxis

Fixed bearing lateral unicompartmental knee arthroplasty-Short to midterm survivorship and knee scores for 101 prostheses

OAK 3 - Non-arthroplasty tx of OAK

Background: Isolated unicompartmental knee arthritis is less common laterally than medially. Lateral unicompartmental knee arthroplasty (UKA) constitutes only 1% of all knee arthroplasty performed. Use of medial UKA is supported by several published series showing good long-term survivorship and patient satisfaction, in large patient cohorts. Results of lateral UKA however have been mixed. We present the short and mid-term survivorship and 5-year clinical outcome of 101 lateral UKAs using a single prosthesis. Methods: Over a 9. year period, 100 patients who satisfied inclusion criteria underwent a lateral fixed-bearing unicompartmental arthroplasty. American Knee Society (AKSS), Oxford Knee (OKS) and modified Western Ontario McMaster Universities Arthritis Index (WOMAC) scores were completed preoperatively and at 1, 2 and 5. years postoperatively. Kaplan-Meier survival analysis was used to determine the 2-year and 5-year survivorship, using revision for any cause as end point. Results: Survivorship was 98.7% and 95.5% at 2 and 5. years respectively. 1 knee was revised for subsidence of the tibial component and 1 knee for progression of medial compartment osteoarthritis. Of a possible 35 knees in situ at 5. year follow-up, 33 knees were fully scored. Median AKSS, OKS and modified WOMAC scores were 182, 41, and 16 respectively. Conclusions: The mid-term survivorship and outcome scores at 5-years suggest that lateral unicompartmental knee arthroplasty provides a valuable alternative to total joint replacement in selected patients with isolated lateral tibio-femoral arthritis at mid-term follow-up.Level II evidence. © 2014 Elsevier B.V.

The recurrence of Helicobacter pylori infection: Incidence and variables influencing it. A critical review

Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures

The rate of H. pylori recurrence after eradication of the microorganism seems to be relatively low, at least in developed countries, where the mean annual reinfection rate is of approximately 3% per patient-year of follow-up, although the risk of reinfection in some developing regions is considerably higher. Several findings suggest that recrudescence rather than reinfection is likely to be responsible for most cases of recurrence: (i) the recurrences decrease with time and decline sharply after the first year, and (ii) studies using molecular fingerprinting techniques (polymerase chain reaction [PCR]) confirm that the identified microorganisms (before and after therapy) are usually genetically identical. The lower the efficacy of an antibiotic therapy, the greater the likelihood that recurrence occur, again suggesting that in these cases temporary "clearance" has been achieved rather than true eradication. The value of the (13)C-urea breath test after treatment is higher in those patients who suffer a recurrence; therefore, selection of a lower cut-off value may be helpful to maintain the diagnostic accuracy of posttreatment breath test, and thus preventing recrudescences. The observation of a pattern of histological (active) gastritis without the concomitant finding of H. pylori must raise the suspicion of a diagnostic error. Some studies suggest that recurrence is relatively infrequent, even if the patient's spouse is H. pylori-positive, suggesting that the patient's partner does not act as a reservoir for the reinfection. However, other investigators achieve contrary results, although a common exogenous source of H. pylori (for both partner's infection and patient's reinfection) cannot be ruled out. The oral cavity may be a potential source for recrudescence of gastric infection after successful therapy. When peptic ulcer reappears (sometimes with bleeding recurrence) or gastric MALT (mucosa-associated lymphoid tissue) lymphoma relapses after previous H. pylori eradication, recolonization of the gastric mucosa by the organism has almost always occurred. (copyright) 2005 by Am. Coll. of Gastroenterology Published by Blackwell Publishing

Effect of alendronate on risk of fracture in women with low bone density but without vertebral fractures: results from the Fracture Intervention Trial

Management of Hip Fractures in the Elderly

CONTEXT: Alendronate sodium reduces fracture risk in postmenopausal women who have vertebral fractures, but its effects on fracture risk have not been studied for women without vertebral fractures. OBJECTIVE: To test the hypothesis that 4 years of alendronate would decrease the risk of clinical and vertebral fractures in women who have low bone mineral density (BMD) but no vertebral fractures. DESIGN: Randomized, blinded, placebo-controlled trial. SETTING: Eleven community-based clinical research centers. SUBJECTS: Women aged 54 to 81 years with a femoral neck BMD of 0.68 g/cm2 or less (Hologic Inc, Waltham, Mass) but no vertebral fracture; 4432 were randomized to alendronate or placebo and 4272 (96%) completed outcome measurements at the final visit (an average of 4.2 years later). INTERVENTION: All participants reporting calcium intakes of 1000 mg/d or less received a supplement containing 500 mg of calcium and 250 IU of cholecalciferol. Subjects were randomly assigned to either placebo or 5 mg/d of alendronate sodium for 2 years followed by 10 mg/d for the remainder of the trial. MAIN OUTCOME MEASURES: Clinical fractures confirmed by x-ray reports, new vertebral deformities detected by morphometric measurements on radiographs, and BMD measured by dual x-ray absorptiometry. RESULTS: Alendronate increased BMD at all sites studied (P<.001) and reduced clinical fractures from 312 in the placebo group to 272 in the intervention group, but not significantly so (14% reduction; relative hazard [RH], 0.86; 95% confidence interval [CI], 0.73-1.01). Alendronate reduced clinical fractures by 36% in women with baseline osteoporosis at the femoral neck (>2.5 SDs below the normal young adult mean; RH, 0.64; 95% CI, 0.50-0.82; treatment-control difference, 6.5%; number needed to treat [NNT], 15), but there was no significant reduction among those with higher BMD (RH, 1.08; 95% CI, 0.87-1.35). Alendronate decreased the risk of radiographic vertebral fractures by 44% overall (relative risk, 0.56; 95% CI, 0.39-0.80; treatment-control difference, 1.7%; NNT, 60). Alendronate did not increase the risk of gastrointestinal or other adverse effects. CONCLUSIONS: In women with low BMD but without vertebral fractures, 4 years of alendronate safely increased BMD and decreased the risk of first vertebral deformity. Alendronate significantly reduced the risk of clinical fractures among women with osteoporosis but not among women with higher BMD

The American Society of Shoulder and Elbow Therapists' consensus statement on rehabilitation following arthroscopic rotator cuff repair

Pediatric Supracondylar Humerus Fracture 2020 Review

This is a consensus statement on rehabilitation developed by the American Society of Shoulder and Elbow Therapists. The purpose of this statement is to aid clinical decision making during the rehabilitation of patients after arthroscopic rotator cuff repair. The overarching philosophy of rehabilitation is centered on the principle of the gradual application of controlled stresses to the healing rotator cuff repair with consideration of rotator cuff tear size, tissue quality, and patient variables. This statement describes a rehabilitation framework that includes a 2-week period of strict immobilization and a staged introduction of protected, passive range of motion during weeks 2-6 postoperatively, followed by restoration of active range of motion, and then progressive strengthening beginning at postoperative week 12. When appropriate, rehabilitation continues with a functional progression for return to athletic or demanding work activities. This document represents the first consensus rehabilitation statement developed by a multidisciplinary society of international rehabilitation professionals specifically for the postoperative care of patients after arthroscopic rotator cuff repair. Level of evidence: Level V; Expert Opinion.

Evaluation of cathepsin D and epidermal growth factor receptor in prostate carcinoma

MSTS 2018 - Femur Mets and MM

Differential reactivity for cathepsin D (cath-D) and epidermal growth factor receptor (EGFR) was compared in 102 archival cases of human primary prostatic carcinoma and nine prostate carcinoma metastases by immunohistochemical techniques using commercially available antibodies (Ciba-Corning, Triton Diagnostics Division, Alameda, CA). Western immunoblotting confirmed that the anti-cath-D and anti-EGFR antibodies recognized the appropriate-sized proteins in extracts of human prostatic carcinoma cell lines. For immunohistochemical analysis, the primary prostate carcinomas ranged from Gleason's combined scores of 2 to 9. High-grade prostatic intraepithelial neoplasia was coexistent in 79 of the cases. Immunohistochemical staining was scored by summing the intensity of staining (0 to 3+) weighted by the percentage of tumor staining at each intensity (H score, theoretical range 0 to 300). Heterogenous moderate to strong reactivity with anti-cath-D was detected in 96 of 102 cases of primary prostate carcinoma (94%), with a mean H score of 176.5. EGFR reactivity was much less common and less strong, with 41 of 102 primary prostate carcinomas staining (40%) at a mean H score intensity of 29.2. The immunohistochemical (H) scores of cath-D and EGFR reactivity both significantly correlated with the Gleason's combined score of the tumors. There was no significant correlation between the cath-D and EGFR scores. Ninety-nine percent of the examples of prostatic intraepithelial neoplasia were reactive with anti-cath-D, with no clear correlation between the intensity of staining of prostatic intraepithelial neoplasia and the adjacent carcinoma.(ABSTRACT TRUNCATED AT 250 WORDS)

Polymorphism of the vitamin D receptor gene and corticosteroid-related osteoporosis

Management of Hip Fractures in the Elderly

Corticosteroid therapy (CST) is associated with reduced intestinal calcium absorption, bone loss and increased fracture risk. As polymorphisms of the vitamin D receptor (VDR) gene may be associated with bone mineral density (BMD) and intestinal calcium absorption, we asked whether patients with a given VDR genotype receiving CST may be at increased or decreased risk for corticosteroid-related bone loss and osteoporosis. We measured areal BMD (g/cm2) by dual-energy X-ray absorptiometry in 193 women (50 premenopausal, 143 postmenopausal) and 70 men with rheumatoid arthritis (n = 44), obstructive airway diseases (n = 128) and other corticosteroid-treated diseases (n = 91). All patients received a cumulative dose greater than 1.8 g per year or a minimum of 5 mg daily of prednisolone or equivalent for at least 1 year. VDR alleles were typed by polymerase chain reaction assay based on the polymorphic BsmI and TaqI restriction sites. BMD in patients was expressed as a Z-score (mean +/- SEM) derived from age- and gender-matched controls. BMD was reduced in patients at the lumbar spine (bb, -0.52 +/- 0.12; Bb, -0.47 +/- 0.11; BB, -0.65 +/- 0.18 SD; p < 0.01), femoral neck (bb, -0.46 +/- 0.10; Bb, -0.34 +/- 0.10; BB, -0.54 +/- 0.14 SD; p < 0.01), Ward's triangle (bb, -0.44 +/- 0.10; Bb, -0.31 +/- 0.10; BB, -0.45 +/- 0.13 SD; p < 0.01), and trochanter (bb, -0.50 +/- 0.10; Bb, -0.30 +/- 0.10; BB, -0.44 +/- 0.14 SD; p < 0.01). However, there was no significant difference in the deficit in BMD in any of the genotypes, either before or after adjusting for age, sex, body mass index, disease type, age at onset of disease, disease duration, cumulative steroid dosage, smoking status and dietary calcium intake. Similarly, there were no detectable differences between the BsmI genotypes and the rate of bone loss in 79 patients with repeated BMD measurements at an interval of 4-48 months. The data suggest that the VDR genotypes may not be a means of identifying patients at greater risk of corticosteroid-related bone loss

North American male reference population for speed of sound in bone at multiple skeletal sites

Management of Hip Fractures in the Elderly

Alternatives to dual-energy X-ray absorptiometry (DXA) have been sought to increase access to low-cost osteoporosis risk assessment. Early quantitative ultrasound (QUS) systems measured speed of sound (SOS) and broadband ultrasound attenuation (BUA) at the calcaneus, and these were demonstrated to be good predictors of hip fracture risk. Recent studies have demonstrated the usefulness of other peripheral sites to assess bone status. The Sunlight Omnisense (Sunlight Medical, Rehovot, Israel) is a portable, inexpensive QUS device capable of multiple-site SOS measurement. To provide a robust male reference database, 588 healthy Caucasian males aged 20-90 yr were recruited from 6 centers across North America. SOS measurements were taken at the distal 1/3 radius, proximal third phalanx, midshaft tibia, and fifth metatarsal. A female reference database has previously been collected at North American sites. The results indicate that SOS in males exhibits an age-related decline beginning in the fifth decade at the radius, phalanx, and metatarsal, whereas the tibial SOS remains nearly constant until the ninth decade. Although females reach a higher-peak SOS than males at most sites, SOS is higher in males at all sites after the sixth decade, as a result of a more gradual decline in SOS. Longitudinal monitoring of healthy men should be performed to confirm these cross-sectional results

Barriers and Facilitators Associated with Non-Surgical Treatment Use for Osteoarthritis Patients in Orthopaedic Practice

OAK 3 - Non-arthroplasty tx of OAK

INTRODUCTION: International evidence-based guidelines for the management of patients with hip and knee osteoarthritis (OA) recommend to start with (a combination of) non-surgical treatments, and using surgical intervention only if a patient does not respond sufficiently to non-surgical treatment options. Despite these recommendations, there are strong indications that non-surgical treatments are not optimally used in orthopaedic practice. To improve the adoption of non-surgical treatments, more insight is needed into barriers and facilitators of these treatments. Therefore, this study assessed which barriers and facilitators are associated with the use and prescription of different non-surgical treatments before hip and knee OA in orthopaedic practice among patients and orthopaedic surgeons in the Netherlands. MATERIALS AND METHODS: We performed two internet-based surveys among 172 orthopaedic surgeons and 174 OA patients. Univariate association and multivariable regression techniques are used to identify barriers and facilitators associated with the use of non-surgical treatments. RESULTS: Most barriers and facilitators among patients were associated with the use of physical therapy, lifestyle advice and dietary therapy. Among orthopaedic surgeons, most were associated with prescription of acetaminophen, dietary therapy and physical therapy. Examples of barriers and facilitators among patients included "People in my environment had positive experiences with a surgery" (facilitator for education about OA), and "Advice of people in my environment to keep on moving" (facilitator for lifestyle and dietary advice). For orthopaedic surgeons, examples were "Lack of knowledge about guideline" (barrier for lifestyle advice), "Agreements/ deliberations with primary care" and "Easy communication with a dietician" (facilitators for dietary therapy). Also the belief in the efficacy of these treatments was associated with increased prescription. CONCLUSIONS: Strategies to improve non-surgical treatment use in orthopaedic practice should be targeted at changing the beliefs of orthopedic surgeons, communication with other OA care providers and involving patient's environment in OA treatment.

A technical report reviewing the use of the 11-mm Gamma nail: interoperative femur fracture incidence

Management of Hip Fractures in the Elderly

Two years after the first large series on the Gamma nail, the authors analyze 119 surgical procedures for proximal femur fractures performed using the 11 mm Gamma nail. The study was performed by 24 surgeons (from six orthopedics departments) at different levels of learning, as in the previous study. The small-sized nail allows an easier surgical procedure and a manual introduction of the nail even in small femurs, as suggested by the previous experience. A careful operative technique and a 2 mm overreaming, which was almost always adopted, explains the decrease in interoperative and postoperative complications (evaluated in 88 cases), compared to the last case report published in 1991. No interoperative shaft fractures occurred in 119 nailings

A randomised controlled trial of a self-management education program for osteoarthritis of the knee delivered by health care professionals

OAK 3 - Non-arthroplasty tx of OAK

INTRODUCTION: Our aim in the present study was to determine whether a disease-specific self-management program for primary care patients with osteoarthritis (OA) of the knee (the Osteoarthritis of the Knee Self-Management Program (OAK)) implemented by health care professionals would achieve and maintain clinically meaningful improvements in health-related outcomes compared with a control group. METHODS: Medical practitioners referred 146 primary care patients with OA of the knee. Volunteers with coexistent inflammatory joint disease or serious comorbidities were excluded. Randomisation was to either a control group or the OAK group. The OAK group completed a 6-week self-management program. The control group had a 6-month waiting period before entering the OAK program. Assessments were taken at baseline, 8 weeks and 6 months. The primary outcomes were the results measured using the Western Ontario and McMaster Universities Arthritis Index (WOMAC) Pain and Function subscales on the Short Form 36 version 1 questionnaire (SF-36) Secondary outcomes were Visual Analogue Scale (VAS) pain, Timed Up & Go Test (TUG), knee range of motion and quadriceps and hamstring strength-isometric contraction. Responses to treatment (responders) and minimal clinically important improvements (MCIIs) were determined. RESULTS: In the OAK group, VAS pain improved from baseline to week 8 from mean (SEM) 5.21 (0.30) to 3.65 (0.29) (P </= 0.001). During this period, improvements in the OAK group compared with the control group and responses to treatment were demonstrated according to the following outcomes: WOMAC Pain, Physical Function and Total dimensions, as well as SF-36 Physical Function, Role Physical, Body Pain, Vitality and Social Functioning domains. In addition, from baseline to week 8, the proportion of MCIIs was greater among the OAK group than the control group for all outcomes. For the period between baseline and month 6, WOMAC Pain, Physical Function and Total dimensions significantly improved in the OAK group compared to the control group, as did the SF-36 Physical Function, Role Physical, Body Pain, Vitality and Social Functioning domains, as well as hamstring strength in both legs. During the same period, the TUG Test, range of motion extension and left-knee flexion improved compared with the control group, although these improvements had little clinical relevance. CONCLUSIONS: We recorded statistically significant improvements compared with a control group with regard to pain, quality of life and function for participants in the OAK program on the basis of WOMAC and SF-36 measures taken 8 weeks and 6 months from baseline.

Corrective supracondylar humeral osteotomies using the small AO external fixator

The Treatment of Pediatric Supracondylar Humerus Fractures AUC

Traditional methods of correcting malunited distal humeral fractures in children involve complex wedge osteotomies held with pins or internal fixation devices. These require a large exposure and challenging fixation. We elected to perform simple transverse osteotomies, without wedges, using a lateral incision. These were maintained by the small AO external fixator. Between 1987 and 2004, five children with malunited distal humeral fractures were treated. Angular and rotational correction was obtained in each case. Bony union occurred at an average of 8 weeks. A simple osteotomy held by the small AO external fixator provides accurate correction, precise adjustability, and solid stability

Sex differences in quadriceps strength in OA

OAK 3 - Non-arthroplasty tx of OAK

The purposes of this study were to determine 1) whether sex differences in quadriceps torque and isotonic power persist when controlling for muscle volume (i. e., torque/muscle volume and power/muscle volume) in participants with knee osteoarthritis (OA) and 2) the factors responsible for potential sex differences. Isometric torque, isotonic power (the product of torque and velocity, measured at 10, 20, 30, 40 and 50% maximal voluntary contraction; MVC) and maximal unloaded velocity were assessed in men (n=16, mean age=62.1 +/- 7.2) and women (n=17, mean age=60.4 +/- 4.3) with knee OA. Torque and power were normalized to muscle volume. The interpolated twitch technique was used to measure voluntary activation (VA) and evoked twitch and torque-frequency characteristics were measured to obtain information about muscle fibre distribution. Torque and power at all loads were significantly lower in women (p<0.05). Sex differences in power were reduced by 50% when controlling for muscle volume but were still significant at 10-40% MVC (p<0.05). No differences in VA, torque-frequency properties or time-to-peak tension of the evoked twitch were observed (p>0.05). These results suggest that only minor sex differences in torque and power persist when controlling for muscle volume. As VA and contractile property differences were not observed, other factors seem to be responsible.

Survivorship and patient satisfaction of a fixed bearing unicompartmental knee arthroplasty incorporating an all-polyethylene tibial component

Surgical Management of Osteoarthritis of the Knee CPG

We report the survivorship of 91 fixed bearing unicompartmental arthroplasties with all-polyethylene tibial components (Preservation DePuy UK), which were used for medial compartment osteoarthritis in 79 patients between 2004 and 2007. The satisfaction level of patients who had not undergone revision of the implant was also recorded. For comparison, we reviewed 49 mobile bearing unicompartmental arthroplasties (Oxford UKA Biomet UK Ltd), which had been used in 44 patients between 1998 and 2007. Mean length of follow-up of patients with the fixed bearing implant was 44.7 months (range 24-74 months) and for the mobile bearing replacement, the mean follow-up was 67.6 months (24-119). In the fixed bearing design, at maximum follow-up period of 74 months, eight implants (8.8%) had been revised (or were listed for revision) to Total Knee Replacement and in the mobile bearing design over the maximum follow-up period of 119 months there had been only one revision (2.0%). Patients who had not undergone revision were asked if they were satisfied with their knee following the unicompartmental arthroplasty. In the fixed bearing design, 83.5% said that they were satisfied with the outcome of the operation compared to 93.9% of the patients receiving the mobile bearing design. We conclude that there is a higher incidence of revision of this fixed bearing design using an all-polyethylene tibial component compared to the mobile bearing design. We found that those patients who had not required revision had a lower rate of satisfaction with the fixed bearing compared to the mobile bearing design

A randomized trial of arthroscopic surgery for osteoarthritis of the knee

OAK 3 - Non-arthroplasty tx of OAK

BACKGROUND: The efficacy of arthroscopic surgery for the treatment of osteoarthritis of the knee is unknown. METHODS: We conducted a single-center, randomized, controlled trial of arthroscopic surgery in patients with moderate-to-severe osteoarthritis of the knee. Patients were randomly assigned to surgical lavage and arthroscopic debridement together with optimized physical and medical therapy or to treatment with physical and medical therapy alone. The primary outcome was the total Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score (range, 0 to 2400; higher scores indicate more severe symptoms) at 2 years of follow-up. Secondary outcomes included the Short Form-36 (SF-36) Physical Component Summary score (range, 0 to 100; higher scores indicate better quality of life). RESULTS: Of the 92 patients assigned to surgery, 6 did not undergo surgery. Of the 86 patients assigned to control treatment, all received only physical and medical therapy. After 2 years, the mean (+/-SD) WOMAC score for the surgery group was 874+/-624, as compared with 897+/-583 for the control group (absolute difference [surgery-group score minus control-group score], -23+/-605; 95% confidence interval [CI], -208 to 161; P=0.22 after adjustment for baseline score and grade of severity). The SF-36 Physical Component Summary scores were 37.0+/-11.4 and 37.2+/-10.6, respectively (absolute difference, -0.2+/-11.1; 95% CI, -3.6 to 3.2; P=0.93). Analyses of WOMAC scores at interim visits and other secondary outcomes also failed to show superiority of surgery. CONCLUSIONS: Arthroscopic surgery for osteoarthritis of the knee provides no additional benefit to optimized physical and medical therapy. (ClinicalTrials.gov number, NCT00158431.)

Problem elbow fractures in children

The Treatment of Pediatric Supracondylar Humerus Fractures AUC

In this article guidelines are given for the treatment of pediatric elbow fractures, including supracondylar, medial epicondylar, lateral condylar, proximal radial, and olecranon fractures. Treatment techniques are described in detail and suggestions are provided to minimize complications

Multicenter study of unicompartmental knee revision. PCA, Marmor, and St Georg compared in 3,777 cases of arthrosis

Surgical Management of Osteoarthritis of the Knee CPG

The prospective Swedish Knee Arthroplasty Project contained 772 PCA, 1564 Marmor and 1441 St Georg unicompartment prostheses, implanted for gonarthrosis during the period December 1983-July 1990. Follow-up was performed in September 1991. There was a significant difference in the cumulative revision rate after only 2 years, increasing to 15 percent for the PCA, compared with 5-7 percent for the two other types. The difference between PCA and Marmor/St Georg was loosening of the femoral component. Major polyethylene wear was noted in a quarter of the revised PCA tibial components. The wear pattern of Marmor/St Georg was not analyzed in this study

Primary metastatic osteosarcoma: presentation and outcome of patients treated on neoadjuvant Cooperative Osteosarcoma Study Group protocols

MSTS 2022 - Metastatic Disease of the Humerus

PURPOSE: To determine demographic data and define prognostic factors for long-term outcome in patients presenting with high-grade osteosarcoma of bone with clinically detectable metastases at initial presentation. PATIENTS AND METHODS: Of 1,765 patients with newly diagnosed, previously untreated high-grade osteosarcomas of bone registered in the neoadjuvant Cooperative Osteosarcoma Study Group studies before 1999, 202 patients (11.4%) had proven metastases at diagnosis and therefore were enrolled onto an analysis of demographic-, tumor-, and treatment-related variables, response, and survival. The intended therapeutic strategy included pre- and postoperative multiagent chemotherapy as well as aggressive surgery of all resectable lesions. RESULTS: With a median follow-up of 1.9 years (5.5 years for survivors), 60 patients were alive, 37 of whom were in continuously complete surgical remission. Actuarial overall survival rates at 5 and 10 (same value for 15) years were 29% (SE = 3%) and 24% (SE = 4%), respectively. In univariate analysis, survival was significantly correlated with patient age, site of the primary tumor, number and location of metastases, number of involved organ systems, histologic response of the primary tumor to preoperative chemotherapy, and completeness and time point of surgical resection of all tumor sites. However, after multivariate Cox regression analysis, only multiple metastases at diagnosis (relative hazard rate [RHR] = 2.3) and macroscopically incomplete surgical resection (RHR = 2.4) remained significantly associated with inferior outcomes. CONCLUSION: The number of metastases at diagnosis and the completeness of surgical resection of all clinically detected tumor sites are of independent prognostic value in patients with proven primary metastatic osteosarcoma.

The two-part proximal humeral fracture: a review of operative treatment using two techniques

Management of Hip Fractures in the Elderly

A review of 45 patients who have undergone surgery for two-part fractures of the proximal humerus (Neer Group III) is reported using two operative techniques, AO plating and intramedullary Rush pins. Good functional results were obtained using the former technique in seven out of eight of the patients under the age of 50 years who mainly sustained their original injury as a result of high-energy motor vehicle accidents. However, in the more common low-energy, osteoporotic fracture in the elderly population, results were unsatisfactory in 12 out of 14 cases where AO plating was used, usually as a result of fixation failure. The Rush pin technique produced more reliable results in this age group, with satisfactory functional scores being obtained in 16 out of 23 patients. It is suggested that the Rush pin technique is preferable to plate fixation in the more common osteoporotic insufficiency fracture in the elderly

Clinical features of group B Streptococcus prosthetic joint infections and molecular characterization of isolates

Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures

Twelve group B Streptococcus (GBS) prosthetic joint infection (PJI) cases are reported. The mean patient age was 55 years. Eleven infections were caused by GBS alone. The associated isolates belonged to phylogenetic lineages different from those that cause neonatal meningitis. The clinical outcome was favorable for the eight patients for whom follow-up data were available

Genu recurvatum as a complication after total knee arthroplasty

Surgical Management of Osteoarthritis of the Knee CPG

A 73-year-old female patient underwent total knee arthroplasty for arthrosis. After surgery, recurvatum instability over 55 degrees occurred. Two years later, primary endoprosthesis was removed and a revision endoprosthesis implanted. However, complete deformity occurred again. Two years later, the thickest revision polyethylene tibial implant was implanted on the same endoprosthesis. In spite of using knee orthosis, recurvatum deformity returned. Seven months later, new revision rotating hinge prosthesis was implanted. This procedure seems to have solved the problem. The knee deformity in this specific case was larger than the deformity in cases reported so far, and it was solved after three surgical procedures. Rotating hinge prosthesis seems to be the method of choice for immediate repair of recurvatum instability after total knee arthroplasty

Competitive advantages of the rehabilitation methods under development as a strategic factor of their introduction efficiency (Through the example of phytocomplex SMC-electrophoresis)

OAK 3 - Non-arthroplasty tx of OAK

The risk reduction when introducing new rehabilitation methods into practical health care requires analyzing their competitive advantages at the development stage. The goal is to assess the competitiveness and positioning of the rehabilitation methods under development through the example of phytocomplex SMC-electrophoresis, and to substantiate the strategic role of the obtained results for introducing the method into medical practice. Materials and methods. 19 experts participated in assessing competitiveness. Positioning included a survey of 72 patients suffering from knee osteoarthritis. The method of SWOT analysis was used in the work. Results and discussion. Higher competitive advantages of the developed method â?? phytocomplex SMC-electrophoresis-were determined as compared with traditional SMC therapy and drug therapy. The most important parameters included the method efficiency (rank 17), the duration of remission (rank 16), and regression of clinical symptoms (rank 15). Strengths and weaknesses of the method, opportunities and threats for its introduction into medical practice were revealed and structured. Conclusion. The opportunity of assessing competitive advantages of the developed rehabilitation methods by using results of clinical and preclinical researches is shown. Recommendations on forming a strategic plan for introducing a new method on the market are given.

The AO Pediatric Comprehensive Classification of Long Bone Fractures (PCCF): Part I: Location and morphology of 2,292 upper extremity fractures in children and adolescents

Distal Radius Fractures

Background and purpose â?? To achieve a common understanding when dealing with long bone fractures in children, the AO Pediatric Comprehensive Classification of Long Bone Fractures (AO PCCF) was introduced in 2007. As part of its final validation, we present the most relevant fracture patterns in the upper extremities of a representative population of children classified according to the PCCF. Patients and methods â?? We included children and adolescents (0â??17 years old) diagnosed with 1 or more long bone fractures between January 2009 and December 2011 at the university hospitals in Bern and Lausanne (Switzerland). Patient charts were retrospectively reviewed and fractures were classified from standard radiographs. Results â?? Of 2,292 upper extremity fractures in 2,203 children and adolescents, 26% involved the humerus and 74% involved the forearm. In the humerus, 61%, and in the forearm, 80% of single distal fractures involved the metaphysis. In adolescents, single humerus fractures were more often epiphyseal and diaphyseal fractures, and among adolescents radius fractures were more often epiphyseal fractures than in other age groups. 47% of combined forearm fractures were distal metaphyseal fractures. Only 0.7% of fractures could not be classified within 1 of the child-specific fracture patterns. Of the single epiphyseal fractures, 49% were Salter-Harris type-II (SH II) fractures; of these, 94% occurred in schoolchildren and adolescents. Of the metaphyseal fractures, 58% showed an incomplete fracture pattern. 89% of incomplete fractures affected the distal radius. Of the diaphyseal fractures, 32% were greenstick fractures. 24 Monteggia fractures occurred in pre-school children and schoolchildren, and 2 occurred in adolescents. Interpretation â?? The pattern of pediatric fractures in the upper extremity can be comprehensively described according to the PCCF. Prospective clinical studies are needed to determine its clinical relevance for treatment decisions and prognostication of outcome.

Supracondylar fractures of the humerus. Assessment of cubitus varus by the Baumann angle

The Treatment of Pediatric Supracondylar Humerus Fractures AUC

A simple method of radiological assessment has been used to measure the angle between the long axis of the humeral shaft and the growth plate of the capitellum (the Baumann angle). In the normal arm a significant relationship was found between the Baumann angle and the carrying angle. The Baumann angle was also measured after reduction of supracondylar fractures of the humerus and was found to correlate well with the final carrying angle measured at follow-up. There was no significant difference between the Baumann angle after reduction and that measured at follow-up; and it is suggested that this angle after reduction can be reliably used to predict accurately the final carrying angle

Comparison Between Intravenous and Intra-articular Regimens of Tranexamic Acid in Reducing Blood Loss During Total Knee Arthroplasty

Surgical Management of Osteoarthritis of the Knee CPG

Tranexamic acid is an antifibrinolytic drug used widely to prevent bleeding. Its use in reducing bleeding during total knee arthroplasty surgery is well proven but there is no final consensus regarding the regimen. The purpose of our study was to compare the effectiveness of intravenous and intra-articular regimen of tranexamic acid during the total knee arthroplasty surgery. A total of 40 patients were received three doses of intravenous tranexamic acid during total knee arthroplasty surgery. Intra-articular tranexamic acid was used in 40 patients during the surgery. We concluded that intra-articular tranexamic acid is equally effective as three dose intravenous regimen in reducing blood loss during total knee arthroplasty surgery. (copyright) 2014 Elsevier Inc

Secondary patella resurfacing in painful non-resurfaced total knee arthroplasties: A study of survival and clinical outcome from the Norwegian Arthroplasty Register (1994â??2011)

OAK 3 - Non-arthroplasty tx of OAK

Purpose: In Norway, 19 % of revisions of non-resurfaced total knee arthroplasties done for knee pain between 1994 and 2011 were Secondary Patella Resurfacing (SPR). It is, however, unclear whether SPR actually resolves the pain. The aim was to investigate prostheses survival and clinical outcomes following SPR. Method: A total of 308 knees (301 patients) with SPR were used to assess implant survival, and a sub-cohort (n = 114 out of 301 patients) with Patient Reported Outcome Measures (PROMs) data were used to assess the clinical outcomes. The EuroQol (EQ-5D), the Knee Injury and Osteoarthritis Outcome Score, and Visual Analogue Scales on satisfaction and pain were used to collect PROM data. Outcomes were analysed by Kaplan-Meier, Cox regression, and multiple linear regression. Results: The five- and ten-year Kaplan-Meier survival percentages were 91 % and 87 %, respectively. Overall, 35 knees were re-revised at a median follow-up of eight years and pain alone (10 knees) was the main cause of re-revision. Younger patients (<60 years) had nearly nine times higher risk of re-revision compared to older patients (>70 years) (RR = 8.6; p < 0.001). Mean EQ-5D index score had improved from 0.41 (SD 0.21) preoperative to 0.56 (SD 0.25) postoperative following SPR. A total of 63 % of patients with PROM data were satisfied with the outcomes of SPR. Conclusion: The long-term prostheses survival following SPR was satisfactory, although not as good as for primary knee replacement. Patientsâ?? health related quality of life improved significantly following SPR. Still, more than a third of patients with PROMs data were dissatisfied with the outcomes of the SPR procedure.

Cathepsin B may be a potential biomarker in cervical cancer

MSTS 2018 - Femur Mets and MM

Cathepsin B is a protease which is able to digest extracellular matrix. It is currently unknown whether cathepsin B plays a role in cervical cancer development and progression. With Q-PCR and Western blotting, we observed cathepsin B expression in cervical cancer cell line Hela cells. After the gene was silenced in HeLa cells with SiRNA, we confirmed that cathepsin B expressions at both mRNA and protein levels were significantly reduced. At the same time, cell proliferation, migration and invasion of the HeLa cells were significantly decreased compared to control cells. In addition, a significant regression of tumor growth in nude mice which received the siRNA targeted cathepsin B HeLa cells was observed. We further studied the expression of cathepsin B in a series of 169 clinical samples, including 56 invasive cervical squamous carcinoma, 85 CINs and 28 normal cervical tissues. It was found that cathepsin B expression in invasive carcinomas was significantly higher than that in the CINs and normal tissues (P<0.01). In addition, cathepsin B expression in the invasive carcinomas was positively correlated to tumor invasion depth and lymphatic metastasis. Our results indicate that cathepsin B may be a potential biomarker for further strategical clinical studies in cervical cancer.

Primary stenting versus balloon angioplasty for stenotic and occlusive lesions of the iliac artery

Management of Hip Fractures in the Elderly

This is the protocol for a review and there is no abstract. The objectives are as follows:To determine and compare the patency rates of the two treatment methods, as assessed by:1. Clinical (resolution of symptoms and signs, improvement in quality of life).2. Objective clinical measurements (ankle brachial pressure index, treadmill walking distance).3. Imaging (Doppler, Computed Tomography Angiography (CTA), Magnetic Resonance Angiography (MRA) and Digital Subtraction Angiography (DSA))

Delaying ACL reconstruction and treating with exercise therapy alone may alter prognostic factors for 5-year outcome: an exploratory analysis of the KANON trial

OAK 3 - Non-arthroplasty tx of OAK

AIM: Identify injury-related, patient-reported and treatment-related prognostic factors for 5-year outcomes in acutely ACL-ruptured individuals managed with early reconstruction plus exercise therapy, exercise therapy plus delayed reconstruction or exercise therapy alone. METHODS: Exploratory analysis of the Knee Anterior Cruciate Ligament, Nonsurgical versus Surgical Treatment (KANON) trial (ISRCTN84752559). Relationships between prognostic factors (baseline cartilage, meniscus and osteochondral damage, baseline extension deficit, baseline patient-reported outcomes, number of rehabilitation visits, graft/contralateral ACL rupture, non-ACL surgery and ACL treatment strategy) and 5-year Knee Injury and Osteoarthritis Outcome Score (KOOS) pain, symptoms, sport/recreation and quality of life (QOL) scores were explored using multivariable linear regression. Estimates were adjusted for sex, age, body mass index, preinjury activity level, education and smoking. RESULTS: For all participants (n=118), graft/contralateral ACL rupture, non-ACL surgery and worse baseline 36-item Short-Form Mental Component Scores were associated with worse outcomes. Treatment with exercise therapy alone was a prognostic factor for less knee symptoms compared with early reconstruction plus exercise therapy (regression coefficient 10.1, 95% CI 2.3 to 17.9). Baseline meniscus lesion was associated with worse sport/recreation function (-14.4, 95% CI -27.6 to -1.3) and osteochondral lesions were associated with worse QOL (-12.3, 95% CI -24.3 to -0.4) following early reconstruction plus exercise therapy. In the same group, undergoing additional non-ACL surgery and worse baseline KOOS scores were prognostic for worse outcome on all KOOS subscales. Following delayed reconstruction, baseline meniscus damage was a prognostic factor for less pain (14.3, 95% CI 0.7 to 27.9). Following exercise therapy alone, undergoing non-ACL surgery was prognostic for worse pain. CONCLUSIONS: Treatment-dependent differences in prognostic factors for 5-year outcomes may support individualised treatment after acute ACL rupture in young active individuals. TRIAL REGISTRATION NUMBER: Current Controlled Trials ISRCTN84752559.

Lymphedema: a comprehensive review

Panniculectomy & Abdominoplasty CPG

BACKGROUND: Lymphedema is a chronic, debilitating condition that has traditionally been seen as refractory or incurable. Recent years have brought new advances in the study of lymphedema pathophysiology, as well as diagnostic and therapeutic tools that are changing this perspective. OBJECTIVE: To provide a systematic approach to evaluating and managing patients with lymphedema. METHODS: We performed MEDLINE searches of the English-language literature (1966 to March 2006) using the terms lymphedema, breast cancer-associated lymphedema, lymphatic complications, lymphatic imaging, decongestive therapy, and surgical treatment of lymphedema. Relevant bibliographies and International Society of Lymphology guidelines were also reviewed. RESULTS: In the United States, the populations primarily affected by lymphedema are patients undergoing treatment of malignancy, particularly women treated for breast cancer. A thorough evaluation of patients presenting with extremity swelling should include identification of prior surgical or radiation therapy for malignancy, as well as documentation of other risk factors for lymphedema, such as prior trauma to or infection of the affected limb. Physical examination should focus on differentiating signs of lymphedema from other causes of systemic or localized swelling. Lymphatic dysfunction can be visualized through lymphoscintigraphy; the diagnosis of lymphedema can also be confirmed through other imaging modalities, including CT or MRI. The mainstay of therapy in diagnosed cases of lymphedema involves compression garment use, as well as intensive bandaging and lymphatic massage. For patients who are unresponsive to conservative therapy, several surgical options with varied proven efficacies have been used in appropriate candidates, including excisional approaches, microsurgical lymphatic anastomoses, and circumferential suction-assisted lipectomy, an approach that has shown promise for long-term relief of symptoms. CONCLUSIONS: The diagnosis of lymphedema requires careful attention to patient risk factors and specific findings on physical examination. Noninvasive diagnostic tools and lymphatic imaging can be helpful to confirm the diagnosis of lymphedema or to address a challenging clinical presentation. Initial treatment with decongestive lymphatic therapy can provide significant improvement in patient symptoms and volume reduction of edematous extremities. Selected patients who are unresponsive to conservative therapy can achieve similar outcomes with surgical intervention, most promisingly suction-assisted lipectomy.

GUEPAR unicompartmental Lotus prosthesis for single-compartment femorotibial arthrosis. A five- to nine-year follow-up study

Surgical Management of Osteoarthritis of the Knee CPG

The results of 52 Groupe d'utilisation et d'experimentation des prostheses articulaires (GUEPAR) unicompartmental Lotus knee prostheses implanted for osteoarthritis of the knee are analyzed with a follow-up time exceeding five years (five to nine years). Thirty-five knees had no weight-bearing pain, six knees had slight pain, three knees had moderate pain, and eight knees had revisions. Except for one complication from infection, all the poor results (eight revisions and three knees with moderate pain) in terms of pain can be explained by mechanical causes, i.e., femorotibial subluxation, loosening of the tibial component, or narrowing of the nonprosthetic femorotibial space. Because the cause of these poor results appears to be due to malposition of the prosthesis component, or to components that are too thick with an inadequate mechanical axis, the precision of the surgical procedure is important

Pain management protocols, peri-operative pain and patient satisfaction after total knee replacement: a multicentre study

Surgical Management of Osteoarthritis of the Knee CPG

In a prospective multicentre study we investigated variations in pain management used by knee arthroplasty surgeons in order to compare the differences in pain levels among patients undergoing total knee replacements (TKR), and to compare the effectiveness of pain management protocols. The protocols, peri-operative levels of pain and patient satisfaction were investigated in 424 patients who underwent TKR in 14 hospitals. The protocols were highly variable and peri-operative pain levels varied substantially, particularly during the first two post-operative days. Differences in levels of pain were greatest during the night after TKR, when visual analogue scores ranged from 16.9 to 94.3 points. Of the methods of managing pain, the combined use of peri-articular infiltration and nerve blocks provided better pain relief than other methods during the first two post-operative days. Patients managed with peri-articular injection plus nerve block, and epidural analgesia were more likely to have higher satisfaction at two weeks after TKR. This study highlights the need to establish a consistent pain management strategy after TKR

Hematopoietic progenitor cell transplantation toxicities in multiple myeloma patients with bisphosphonate-induced osteonecrosis of the jaw: a longitudinal cohort study

MSTS 2018 - Femur Mets and MM

PURPOSE: There is no information regarding the toxicity associated with autologous hematopoietic progenitor cell transplantation (AHPCT) in patients with multiple myeloma (MM) who have bisphosphonate-induced osteonecrosis of the jaw (ONJ). There is also limited information regarding long-term outcome of these patients. METHODS: In this retrospective cohort study, we compared the toxicity after AHPCT in MM patients with and without ONJ. We also analyzed the response rate and overall survival of this population of patients. RESULTS: During the study period, 176 patients underwent AHPCT at our institution for MM. Ten patients with ONJ prior to AHPCT were matched to 40 control patients without ONJ. The incidence and severity of transplantation-associated toxicities were similar in both groups, including mucositis, 50 % in patients with ONJ vs. 68 % in controls (p = 0.889) and febrile days, median 1 vs. 3 days, respectively (p = 0.524). Myeloid engraftment and hospital length of stay were also similar between patients with ONJ and controls. There were significantly more complete remissions in patients with ONJ than in control patients (45 % vs. 15 %, p = 0.0336), but survival between the groups was not significantly different (log-rank p = 0.0818). CONCLUSIONS: We conclude that the incidence and severity of transplantation-associated toxicities are similar in MM patients with and without ONJ. Long-term survival was also similar between both groups.

Mode of debridement, negative-pressure therapy combined with tissue transplantation for treatment of complicated and refractory wounds

Upper Eyelid and Brow Surgery

METHODSAfter debridement, 20 patients with 20 complicated and refractory wounds hospitalized in our burn wards from May 2008 to June 2010 were randomly divided into treatment group (T, treated with negative-pressure from -19 kPa to -8 kPa, n = 10) and control group (C, covered with petrolatum gauze overlaid with saline gauze and dry gauze, n = 10) according to alternating method. On post treatment day (PTD) 4, 7, and 14, granulation tissues of wound surface in size of 4 mm â?« 3 mm â?« 2 mm were harvested for histopathological observation (including capillary growth, inflammatory cells, and collagen arrangement) with HE staining, and the numbers of vascular endothelial cells (VEC, with addition of rabbit anti-human coagulation factor VIII related antigen polyclonal antibody) and proliferation period cells (with addition of mouse anti-human Ki-67 monoclonal antibody) were counted by immunohistochemical staining. Data were processed with t test. Another 59 patients harboring 62 complicated and refractory wounds admitted to our burn ward at the same period were treated with the same mode of debridement, negative-pressure therapy, followed by timely skin or skin flap grafting.RESULTS(1) Granulation tissue in T group grew more rapidly than that in C group. More capillaries and less inflammatory cells were observed in T group on PTD 7 as compared with those in C group. Collagen in T group on PTD 14 was more regular in arrangement than that in C group. The number of VEC per 400 times visual field in T group on PTD 4, 7, and 14 was respectively higher than that in C group (108.7 â?? 11.2 vs. 31.0 â?? 3.6, 138.0 â?? 14.7 vs. 34.6 â?? 4.5, 68.7 â?? 6.9 vs. 55.1 â?? 6.5, with t values from 4.62 to 30.28, P values all equal to 0.01). The number of proliferation period cell per 400 times visual field in T group on PTD 4 and 7 was respectively higher than that in C group (88.9 â?? 5.9 vs. 16.6 â?? 3.3, 128.1 â?? 13.0 vs. 110.1 â?? 8.9, with t value respectively 19.89, 3.33, P values all below 0.05). The number of proliferation period cell per 400 times visual field in T group on PTD 14 was obviously lower than that in C group (26.7 â?? 5.1 vs. 59.7 â?? 4.5, t = -12.43, P = 0.01). (2) After being treated with above therapeutic mode, necrotic tissues were removed completely and granulation tissue grew rapidly in 62 complicated and refractory wounds with high survival rate of skin grafts or skin flaps with good repair effect.CONCLUSIONSNegative-pressure therapy can accelerate VEC formation and stimulate cell proliferation after debridement. Debridement, negative-pressure therapy, and timely skins/skin flaps grafting can effectively increase healing rate of complicated and refractory wounds.OBJECTIVETo observe therapeutic effect of negative-pressure treatment combined with tissue transplantation on complicated and refractory wounds after debridement.

Grafts and flaps

DoD SSI (Surgical Site Infections)

'Grafts' and 'flaps' are the terms used to describe pieces of tissue that are transferred from one part of the body to another during reconstructive procedures. A graft is a piece of tissue that is detached from its site (and, most importantly, blood supply) of origin, and transferred to a different site, where it relies on the local blood supply to survive. Skin is the most commonly grafted tissue, but a graft may be of any tissue (e.g. fascia, fat, tendon, nerve, vessel, bone, composite tissue). The recipient bed must consist of healthy, well-vascularized tissue. Grafts cannot survive on poorly vascularized, densely scarred or irradiated tissue, tendon denuded of paratenon, bone denuded of periosteum, or infected tissue. The process of a graft acquiring a blood supply from its new recipient bed is termed 'take'. A flap is a piece of tissue that has an integral blood supply. Flaps can be classified according to their site, geometry, composition or blood supply. Flaps can be used to cover poor recipient beds, joint contractures, to cover open fractures or joints, and to import blood supply in infected or irradiated wounds. Flaps can also be used to reconstruct specific structures, such as the thumb (toe transfer), breast (latissimus dorsi or free abdominal flap), mandible (fibular flap) and pharynx (jejunal flap). If there are several reconstructive options, the composition of the defect morbidity of the, donor site, patient preference and the surgeon's experience should be considered when choosing which flap to use. © 2006 Elsevier Ltd. All rights reserved.

Open intercondylar fractures of the distal humerus: Management using a mini-external fixator construct

The Treatment of Pediatric Supracondylar Humerus Fractures AUC

Intercondylar fractures of the distal humerus are a challenging entity to treat. Open reduction-internal fixation with plating is well accepted as the standard treatment for these fractures, because it allows early mobilization and prevents joint stiffness. However, this technique may be associated with inferior postoperative results and a higher risk of infection in open fractures. External fixation appears to be an interesting option in such cases, where the results of open reduction-internal fixation with plating may be suboptimal. We present a bilateral uniplanar mini-external fixator construct for the treatment of open intercondylar distal humeral fractures. We managed 8 cases with this external fixation technique, with 6 of 8 patients achieving good to excellent results as determined by Cassebaum's rating system

Osteochondral Autograft Transfer Technique for Glenoid Osteochondral Defect

Osteochondritis Dissecans 2020 Review

Glenoid osteochondral defects can be a significant source of pain and disability in an active population. Many treatments are available, but most joint-preserving procedures are limited to debridement, abrasion chondroplasty, or marrow-stimulation techniques, all of which depend on healthy underlying bone and none of which address underlying bony pathology. Osteochondral autograft transfer has been a successful form of treatment for lesions in the knee, elbow, and ankle, especially when subchondral bone is involved. We describe an arthroscopic method of treating glenoid osteochondral lesions with an osteochondral autograft transfer using a graft from the patient's ipsilateral knee. This technique addresses both cartilage and osseous pathology with minimal morbidity and provides a good biological restorative option for patients with isolated glenoid osteochondral defects.

Effect of clodronate treatment on risk of fracture: a systematic review and meta-analysis

MSTS 2018 - Femur Mets and MM

A systematic review and a meta-analysis of data of literature were performed to evaluate the efficacy of clodronate in the reduction of risk of fractures in patients with osteoporosis or tumour diseases. A systematic review was conducted to identify original articles, reviews, and any other literature report suitable for the purposes of the meta-analysis, limited to prospective randomized trials that included a placebo or an untreated control arm. The search has identified 18 trials, 13 of which in patients with cancer diseases (breast cancer and multiple myeloma were prevalent), 4 in patients with osteoporosis/low BMD, and 1 in elderly women living in community. A placebo control arm was used in 13 trials. Treatment and follow-up duration ranged from 3 months to 5 years. The meta-analysis showed that treatment with clodronate was associated with a reduction of the probability of new fractures compared with controls (OR = 0.572, 95% CI 0.465-0.704 for new vertebral fractures; OR = 0.668, 95% CI 0.494-0.905 for new non-vertebral fractures; and OR = 0.744, 95% CI 0.635-0.873 for new overall fractures in those articles where vertebral and non-vertebral new fractures were not considered separately). Similar findings were observed in the separate analysis in patients with cancer forms or osteoporosis. The results of the meta-analysis have demonstrated that clodronate is effective in reducing the risk of vertebral, non-vertebral, and overall fractures in patients with skeletal fragility.

Effects of cyclical etidronate therapy on bone loss in early postmenopausal women who are not undergoing hormonal replacement therapy

Management of Hip Fractures in the Elderly

This study was carried out to investigate the effectiveness and tolerability of cyclical etidronate therapy in the prevention of bone loss occurring in early postmenopausal women who are not undergoing hormone replacement therapy (HRT). A total of 109 Caucasian women aged 45-60 years were treated with etidronate 400 mg/day or placebo for 14 days followed by calcium supplementation 500 mg/day for 77 days. Ninety-one women completed the 2 years of the study. After 2 years, the estimated difference between the two groups as regards lumbar spine bone mineral density (BMD) was 2.53% (SEM 1.07%; p = 0.01); BMD of the hip and wrist were not significantly different between treatment groups. A clear reduction in bone turnover was obtained as evidenced by a significant decrease in serum alkaline phosphatase level and in urinary N-telopeptide/ creatinine ratio in the etidronate group; the difference between the two groups was -12% +/- 3.2% for serum alkaline phosphatase level (p = 0.019) and -22.9% +/- 13.7% for the urinary N-telopeptide/creatinine ratio (p = 0.047). There was no statistically significant difference between the two groups in terms of the serum osteocalcin levels and urinary hydroxyproline/ creatinine and calcium/creatinine ratios. Etidronate was generally well tolerated and its adverse event profile was similar to that of placebo. The results of this study indicate that cyclic etidronate therapy can prevent trabecular bone loss, with no deleterious effect on cortical bone, in the first 5 years of menopause and that it has a very high safety margin

Clinical usefulness of hindfoot assessment for total knee arthroplasty: persistent post-operative hindfoot pain and alignment in pre-existing severe knee deformity

OAK 3 - Non-arthroplasty tx of OAK

PURPOSE: The purpose of this study was to compare the hindfoot alignment and symptoms in patients with pre-existing moderate and severe knee deformities after total knee arthroplasty (TKA). METHODS: Eighty knees of 75 patients who underwent TKA for varus osteoarthritis were enrolled retrospectively and evaluated the following pre-operatively and at 2 years post-operatively: the American Orthopaedic Foot and Ankle Society ankle-hindfoot scale (pain and function scores), calcaneal pitch, and naviculocuboid overlap as an indicator of hindfoot alignment. The knees were divided into two groups according to the pre-operative hip-knee-ankle angle defined as the angle between the mechanical axis of the femur and the tibia: group M with genu varus of <=6degree, and group S with varus >6degree. RESULTS: The pain (p = 0.03) and function (p = 0.02) scores improved in group M; however, in group S, these measures did not change. The differences between the groups were not significant concerning the pre-operative calcaneal pitch and naviculocuboid overlap. The post-operative pitch (p = 0.03) and the overlap (p = 0.04) in group M was significantly greater and less than those in group S, respectively. Although the pitch (p < 0.01) and the overlap (p = 0.03) increased in group M, these did not change in group S. Post-operative hindfoot pain and valgus remained in patients in group S. CONCLUSIONS: For pre-existing moderate knee deformities, a relationship was observed between post-operative knee alignment and compensatory hindfoot alignment, whereas patients with severe deformities experienced persistent post-operative hindfoot pain and valgus alignment. It was concluded that evaluations and managements of residual symptoms after TKA including the hindfoot are important. These findings are clinically relevant that perioperative evaluation of the hindfoot should be required in knee surgery. To help improve the outcomes of TKA, clinicians may consider perioperative intervention in the insole and/or physical therapy of the foot and ankle. LEVEL OF EVIDENCE: Therapeutic study, Level III.

The role of shoulder fusion in the era of arthroplasty

The Treatment of Pediatric Supracondylar Humerus Fractures AUC

The indications, surgical techniques, results and complications of shoulder fusion are described. The indications are bacterial infection, paralytic disorders in infancy, combined deltoid and rotator cuff paralysis, post-traumatic brachial plexus lesions, inflammatory arthritis with severe rotator cuff involvement, failed arthroplasty, recurrent dislocation, after resection of tumours, irreparable rotator cuff tear painful arthritis in a patient whose activities require power but not movement, the immunocompromised patient, and tuberculosis. Satisfactory results are achieved in children with isolated shoulder paralysis, but in adults loss of glenohumeral movement is associated with about 50% loss of function. The best results are obtained in cases of isolated shoulder paralysis with a normal arm and hand distally. The most frequent complications are nonunion (5-20%), fracture of the ipsilateral humerus (10-15%) and infection (3-5%). Other causes of failure are functional limitation, fusion in malposition, functional involvement of the distal joints, acromioclavicular dislocation, suprascapular traction neuritis, failure or migration of an internal fixation device, epiphyseal problems, and the complications of using an allograft. Shoulder replacement is most likely to be chosen for most destructive shoulder disorders, but fusion is useful in certain cases

Pentavalent [99mTc]DMSA, [131I]MIBG, and [99mTc]MDP--an evaluation of three imaging techniques in patients with medullary carcinoma of the thyroid

MSTS 2018 - Femur Mets and MM

Nine patients with histologically proven medullary carcinoma of the thyroid (MCT) were imaged using pentavalent [99mTc]dimercaptosuccinic acid [(V)DMSA], [131I] metaiodobenzylguanidine (MIBG) and [99mTc]methylene diphosphonate (MDP). Technetium-99m (V)DMSA demonstrated most of the tumor sites in eight patients with proven metastases, with an overall sensitivity of 95% in lesion detection. Iodine-131 MIBG showed definite uptake in some of the tumor sites in three of the nine patients imaged, with equivocal uptake seen in a further one patient, with sensitivity of only 11% for lesion detection. Technetium-99m MDP demonstrated bony metastases only, in four of the patients imaged yielding a sensitivity of 61%. Technetium-99m (V)DMSA has been demonstrated in this study to be a useful imaging agent in patients with MCT, showing uptake in significantly more lesions and with better imaging qualities than [131I]MIBG, and with the ability to detect soft tissue as well as bony metastases.

Results of therapy and changing prognosis of multiple myeloma during the last 40 years in the region of North and Middle Moravia: Group of 562 patients

MSTS 2018 - Femur Mets and MM

Introduction: The aim of this study was the retrospective assessment of therapy results and the changing prognosis of multiple myeloma (MM) patients from the Middle and North Moravia region of the Czech Republic during the last 40 years. Patients and methods: The analyzed group of 562 patients was gathered in the years 1959-2000, mean age 63 (28-91) years, M/F ratio 1.1:1.0. Overall survival (OS) curves were plotted according to the method of Kaplan and Meier and compared using the log rank test (P < 0.05). Results: During the long assessed period, a significant change in prognosis and therapy response was achieved (P = 0.0000). The 'first turning point' (1963-1975) characterized by unsystematic melphalan and prednisone therapy (MP), led to significant improvement of OS (8-19 months, P = 0.0031) in comparison with the period of plain symptomatic therapy (1959-1963) and the increase in 3-year survival rate from 4 to 23% of patients. The 'second turning point' (1976-1980), characterized by introduction of the systematic conventional polychemotherapy (VMP, VMCP, VBAP, VCAP) and complex supportive treatment, was associated with subsequent improvement of therapeutic response (OS 40 months, P = 0.0000; 3- or 10-year survival was seen in 55 and 5.5% of patients). Nevertheless, the results of the next 20 years (regimens VB(C)MCP, VAD, Cy-VAD and CIDEX) are a little disappointing with insignificant progress. In the whole group of 295 patients from the years 1976 to 1995, divided into 5-year periods, remission (Râ?¤25% of the initial M-protein level) was achieved in 10-24% of cases, the OS median was 32-44 months, and 5 (respectively 10)-year survival improved from 25 to 36% and from 5.5 to 16.5% of patients. The 'third turning point' represented years 1996-2000 marked with the introduction of high dose (HD)-therapy with ASCT support leading in a group of 31 patients (â?¤ 65 years) to remission in 71%, to complete remission in 32% and to significant improvement of OS (P = 0.0037) and 5-year survival in 91% of the patients. The improvement of therapy results in this 'third turning point' was demonstrated in comparison with the 1976-1995 group with conventional therapy with a group of patients from 1996 to 2000 (both conventional and HD therapy with ASCT), characterized by 36% of remissions and 5-year survival of 57% of the patients (P = 0.030). HD therapy with ASCT achieved in the years 1996-2000 had better therapy results (R-71%, 5-year survival 91%) than that achieved in two comparable groups of patients (1991-1995 and 1996-2000), fulfilling all criteria of HD therapy with ASCT but treated with conventional therapy only (R - 24 and 32%, 5-year survival 46 and 68% of the patients). Conclusion: The retrospective analysis showed that the meaningful change in overall prognosis of MM patients achieved in Moravia is in accord with worldwide trends in the course of 1959-2000 years, which was achieved due to the gradual application of the modern innovated systems of complex therapy.

The Ottawa panel clinical practice guidelines for the management of knee osteoarthritis. Part three: aerobic exercise programs

OAK 3 - Non-arthroplasty tx of OAK

OBJECTIVES: To identify effective aerobic exercise programs and provide clinicians and patients with updated, high-quality recommendations concerning traditional land-based exercises for knee osteoarthritis. METHODS: A systematic search and adapted selection criteria included comparative controlled trials with strengthening exercise programs for patients with knee osteoarthritis. A panel of experts reached consensus on the recommendations using a Delphi survey. A hierarchical alphabetical grading system (A, B, C+, C, D, D+, or D-) was used, based on statistical significance ( P < 0.5) and clinical importance (15% improvement). RESULTS: The five high-quality studies included demonstrated that various aerobic training exercises are generally effective for improving knee osteoarthritis within a 12-week period. An aerobic exercise program demonstrated significant improvement for pain relief (Grade B), physical function (Grade B) and quality of life (Grade C+). Aerobic exercise in combination with strengthening exercises showed significant improvement for pain relief (3 Grade A) and physical function (2 Grade A, 2 Grade B). CONCLUSION: A short-term aerobic exercise program with/without muscle strengthening exercises is promising for reducing pain, improving physical function and quality of life for individuals with knee osteoarthritis.

Direct and indirect costs of non-vertebral fracture patients with osteoporosis in the US

Management of Hip Fractures in the Elderly

Osteoporosis is a condition marked by low bone mineral density and the deterioration of bone tissue. One of the main clinical and economic consequences of osteoporosis is skeletal fractures. To assess the healthcare and work loss costs of US patients with non-vertebral (NV) osteoporotic fractures. Privately insured (aged 18-64 years) and Medicare (aged >/=65 years) patients with osteoporosis (ICD-9-CM code: 733.0x) were identified during 1999-2006 using two claims databases. Patients with an NV fracture (femur, pelvis, lower leg, upper arm, forearm, rib or hip) were matched randomly on age, sex, employment status and geographic region to controls with osteoporosis and no fractures. Patient characteristics and annual healthcare costs were assessed over the year following the index fracture for privately insured (n = 4764) and Medicare (n = 48 742) beneficiaries (Medicare drug costs were estimated using multivariable models). Indirect (i.e. work loss) costs were calculated for a subset of privately insured, employed patients with available disability data (n = 1148). All costs were reported in $US, year 2006 values. In Medicare, mean incremental healthcare costs per NV fracture patient were $US13 387 ($US22 466 vs $US9079; p < 0.05). The most expensive patients had index fractures of the hip, multiple sites and femur (incremental costs of $US25 519, $US20 137 and $US19 403, respectively). Patients with NV non-hip (NVNH) fractures had incremental healthcare costs of $US7868 per patient ($US16 704 vs $US8836; p < 0.05). Aggregate annual incremental healthcare costs of NVNH patients in the Medicare research sample (n = 35 933) were $US282.7 million compared with $US204.1 million for hip fracture patients (n = 7997). Among the privately insured, mean incremental healthcare costs per NV fracture patient were $US5961 ($US11 636 vs $US5675; p < 0.05). The most expensive patients had index fractures of the hip, multiple sites and pelvis (incremental costs of $US13 801, $US9642 and $US8164, respectively). Annual incremental healthcare costs per NVNH patient were $US5381 ($US11 090 vs $US5709; p < 0.05). Aggregate annual incremental healthcare costs of NVNH patients in the privately insured sample (n = 4478) were $US24.1 million compared with $US3.5 million for hip fracture patients (n = 255). Mean incremental work loss costs per NV fracture employee were $US1956 ($US4349 vs $US2393; p < 0.05). Among patients with available disability data, work loss accounted for 29.5% of total costs per NV fracture employee. The cost burden of NV fracture patients to payers is substantial. Although hip fracture patients were more costly per patient in both Medicare and privately insured samples, NVNH fracture patients still had substantial incremental costs. Because NVNH patients accounted for a larger proportion of the fracture population, they were associated with greater aggregate incremental healthcare costs than hip fracture patients

Superficial soft tissue sarcomas (S-STS): a study of 367 patients from the French Sarcoma Group (FSG) database

MSTS 2022 - Metastatic Disease of the Humerus

AIM: The specific natural history of superficial soft tissue sarcomas (S-STS) has been rarely considered. We describe the clinical characteristics of a large series of S-STS (N=367) from the French Sarcoma Group (GSF-GETO) database and analyse the prognostic factors affecting outcome. METHODS: We performed univariate and multivariate analyses for overall survival (OS), metastasis-free survival (MFS) and local recurrence-free survival (LRFS). RESULTS: The median age was 59 years. Fifty-eight percent patients were female. Tumour locations were as follows: extremities, 55%; trunk wall, 35.4%; head and neck, 8% and unknown, 1.6%. Median tumour size was 3.0 cm. The most frequent tumour types were unclassified sarcoma (24.3%) and leiomyosarcoma (22.3%). Thirty-three percent of cases were grade 3. Median follow-up was 6.18 years. The 5-year OS, MFS and LRFS rates were 80.9%, 80.7% and 74.7%, respectively. Multivariate analysis retained histological type and wide resection for predicting LRFS and histological type and grade as prognostic factors of MFS. The factors influencing OS were age, histological type, grade and wide resection. STS with early invasion into but not through the underlying fascia had a significantly poorer MFS than with strict S-STS. CONCLUSION: S-STS represent a separate category characterised by a better outcome. Adequate surgery, i.e. wide resection, is essential in the management of S-STS.

International Multi-institutional Patterns of Contouring Practice and Clinical Target Volume Recommendations for Stereotactic Body Radiation Therapy for Non-Spine Bone Metastases

MSTS 2022 - Metastatic Disease of the Humerus

Purpose: Despite the increasing use of stereotactic body radiation therapy for non–spine bone metastases (NSBM), there is no established standard for target delineation. The objective of this study was to provide consensus recommendations on clinical target volume (CTV) delineation based on international expert contours. Methods and Materials: Eleven cases of NSBM were contoured by 9 international radiation oncologists. For each case, the gross tumor volume was provided on the simulation computed tomography scans with accompanying magnetic resonance imaging. Participants contoured the CTV and completed a clinical survey. Agreement between CTV contours were analyzed with simultaneous truth and performance level estimation using the kappa coefficient and the Dice similarity coefficient (DSC) and summarized to establish contouring recommendations. A direction-dependent analysis was applied to the consensus contours to quantify margins. Results: All CTV contours were completed. Six participants used a single-dose level, whereas 3 used a 2-dose level simultaneous integrated boost (SIB) technique. For the SIB cases, the largest volume receiving a stereotactic body radiation therapy (SBRT) dose was used for contour analysis. There was substantial agreement between contours across cases with a mean kappa of 0.72 (mean sensitivity 0.85, mean specificity 0.97). The mean DSC value was 0.77 (range, 0.67-0.87). Consensus CTV contouring recommendations were (1) an intraosseous CTV margin of 5 to 10 mm should be strongly considered within contiguous bone; (2) an extraosseous margin of 5 to 10 mm should be strongly considered where there is soft tissue disease or cortical bone disruption; (3) CTVs should be manually cropped to respect anatomic barriers to spread (eg, peritoneal cavity, pleura, uninvolved joint space and cortical bone). Conclusions: CTV contouring recommendations for NSBM-SBRT were established based on analysis of international expert consensus contours with a high level of agreement. These principles may provide guidance to treating physicians and inform future study until prospective clinical data can provide further refinement.

Outcomes Following Tourniquet and Non-Tourniquet Assisted Total Knee Arthroplasty

OAK 3 - Non-arthroplasty tx of OAK

The overall goal of this study is to determine the effects of intraoperative tourniquet use during total knee arthroplasty (TKA), compared to TKA without the use of a tourniquet (NOTQT), for strength and functional recovery following simultaneous bilateral TKA. During the procedure, each patient will receive tourniquet�assisted TKA (TQT) on one lower extremity while the contralateral lower extremity undergoes TKA without the use of a tourniquet (NOTQT), except for briefly during component cementation. Tourniquets are commonly used in TKA to improve visualization of the surgical field and limit blood loss. However, studies suggest that tourniquet use may be associated with higher rates of medical complications and poor functional outcomes, including increased swelling, decreased muscle strength and altered neuromuscular activity. We will measure strength, voluntary muscle activation, and other functional outcomes for each lower extremity at 4 time points (preop; inpatient (24�72 hrs after surgery); 3 weeks; and 3 months following TKA). We hypothesize that lower extremities in the NOTQT group will demonstrate improved strength and performance when compared to lower extremities in the TQT group.

Clinical Outcome of Revision Meniscal Allograft Transplantation: Minimum 2-Year Follow-up

Surgical Management of Osteoarthritis of the Knee CPG

PURPOSE: The purpose of this study was to assess the clinical and radiographic outcomes after revision meniscal allograft transplantation (RMAT). METHODS: Eleven patients underwent RMAT performed by the senior author (B.J.C.). These patients were studied prospectively and completed standardized outcome surveys (including International Knee Documentation Committee [IKDC], Cincinnati Knee-Rating System, Tegner score, Lysholm score, Short Form-12, Knee Injury and Osteoarthritis Outcome Score [KOOS], and overall satisfaction) preoperatively and annually thereafter for a minimum of 2 years. Radiographic analysis before surgery and at the most recent follow-up included anteroposterior, Rosenberg, lateral, and sunrise views graded by the Kellgren and Lawrence (K & L) scale. The status of the articular cartilage was graded intraoperatively using the Outerbridge classification. Two patients were lost to follow-up and one declined further participation. RESULTS: The average time to RMAT from the index procedure was 3.45 +/- 2.52 years, with a mean follow-up after RMAT of 3.83 +/- 1.3 years. One patient progressed to arthroplasty during follow-up and was not included in subjective outcome score follow-up. Clinical outcome scores that demonstrated significant improvements included IKDC (43 +/- 12 to 61 +/- 16; P = .03) and KOOS pain score (66 +/- 12 to 79 +/- 11; P = .047). Along with this, the subjective symptom rate significantly improved from 5.0 +/- 0.9 preoperatively to 6.7 +/- 1.8 postoperatively (P = .011). Radiographic (P = .7) and Outerbridge (P = .809) grading did not show progression. Seven of 8 patients would have surgery again, and satisfaction at final follow-up was 7.6 +/- 2.6. CONCLUSIONS: In this small series with short-term follow-up, RMAT resulted in high patient satisfaction and significant symptom reduction on validated outcome scores (IKDC and KOOS pain score), proving the original hypothesis that outcomes after RMAT would be improved compared with preoperative conditions. Identifiable causes of MAT failure may help predict response to RMAT. Because arthroplasty is still not favored in young active patients, a thorough discussion with the patient is necessary to best align their goals with those of the surgery when considering revision meniscus transplantation. LEVEL OF EVIDENCE: Level IV, therapeutic case series

Racial disparities in pre-operative pain, function and disease activity for patients with rheumatoid arthritis undergoing Total knee or Total hip Arthroplasty: A New York based study

OAK 3 - Non-arthroplasty tx of OAK

Background: Black and Hispanic patients with osteoarthritis have more pain and worse function than Whites at the time of arthroplasty. Whether this is true for patients with rheumatoid arthritis (RA) is unknown. Methods: This cross-sectional study used data on RA patients acquired between October 2013 and November 2018 prior to elective total knee (TKA) or hip arthroplasty (THA). Pain, function, and disease activity were assessed using the visual analogue scale (VAS), the Multidimensional Health Assessment Questionnaire (MDHAQ), and the Disease Activity Score (DAS28-ESR). We linked the cases to census tracts using geocoding to determine the community poverty level. Race, education, income, insurance and medications were collected via self-report. Using multivariable linear and logistic models we examined whether minority status predicted pain, function and RA disease activity at the time of arthroplasty. Results: Thirty seven (23%) of the 164 patients were Black or Hispanic (minorities). The MDHAQ and DAS28-ESR were not significantly worse while VAS pain score was significantly worse in minority patients (p = 0.03). There was no significant difference in education between the groups. Insurance varied significantly; 29% of minority patients had Medicaid vs. 0% of Whites (p < 0.0001). In the multivariable analyses minority status was not significantly associated with DAS28-ESR [p = 0.66], MDHAQ [p = 0.26], or VAS pain [p = 0.18]. Conclusions: For Black and/or Hispanic patients with RA undergoing THA or TKA at a high-volume specialty hospital, unlike Black or Hispanic patients with osteoarthritis (OA), there was no association with worse pain, function, or RA disease activity at the time of elective arthroplasty.

Antibiotic prophylaxis versus no prophylaxis for preventing infection after cesarean section

Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures

BACKGROUND: The single most important risk factor for postpartum maternal infection is cesarean section. Routine prophylaxis with antibiotics may reduce this risk and should be assessed in terms of benefits and harms. OBJECTIVES: To assess the effects of prophylactic antibiotics compared with no prophylactic antibiotics on infectious complications in women undergoing cesarean section. SEARCH STRATEGY: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (May 2009). SELECTION CRITERIA: Randomized controlled trials (RCTs) and quasi-RCTs comparing the effects of prophylactic antibiotics versus no treatment in women undergoing cesarean section. DATA COLLECTION AND ANALYSIS: Two authors independently assessed the studies for inclusion, assessed risk of bias and carried out data extraction. MAIN RESULTS: We identified 86 studies involving over 13,000 women. Prophylactic antibiotics in women undergoing cesarean section substantially reduced the incidence of febrile morbidity (average risk ratio (RR) 0.45; 95% confidence interval (CI) 0.39 to 0.51, 50 studies, 8141 women), wound infection (average RR 0.39; 95% CI 0.32 to 0.48, 77 studies, 11,961 women), endometritis (RR 0.38; 95% CI 0.34 to 0.42, 79 studies, 12,142 women) and serious maternal infectious complications (RR 0.31; 95% CI 0.19 to 0.48, 31 studies, 5047 women). No conclusions can be made about other maternal adverse effects from these studies (RR 2.43; 95% CI 1.00 to 5.90, 13 studies, 2131 women). None of the 86 studies reported infant adverse outcomes and in particular there was no assessment of infant oral thrush. There was no systematic collection of data on bacterial drug resistance. The findings were similar whether the cesarean section was elective or non elective, and whether the antibiotic was given before or after umbilical cord clamping. Overall, the methodological quality of the trials was unclear and in only a few studies was it obvious that potential other sources of bias had been adequately addressed. AUTHORS' CONCLUSIONS: Endometritis was reduced by two thirds to three quarters and a decrease in wound infection was also identified. However, there was incomplete information collected about potential adverse effects, including the effect of antibiotics on the baby, making the assessment of overall benefits and harms complicated. Prophylactic antibiotics given to all women undergoing elective or non-elective cesarean section is clearly beneficial for women but there is uncertainty about the consequences for the baby

Should bone scan be performed in Chinese prostate cancer patients at the time of diagnosis?

MSTS 2022 - Metastatic Disease of the Humerus

BACKGROUND: Prostate cancer (PCa) is increasingly being diagnosed in China. Early detection of bone metastases (BM) is critical in the management of patients with high-risk PCa. The aim of this study is to establish a screening model to determine if bone scan should be performed for BM in Chinese patients at the time when PCa is diagnosed. MATERIALS AND METHODS: The study included 488 patients who were diagnosed with PCa between 2009 and 2011 at a single center. All patients received bone scans using technetium (99m)Tc methylene diphosphonate at the initial staging. If the bone scan finding was equivocal, computed tomography or magnetic resonance imaging was performed to confirm the diagnosis. Age, prostate-specific antigen (PSA) at diagnosis, clinical stage assigned according to the TNM 2002 staging system and biopsy Gleason score were collected in all patients. Multivariate logistic regression analysis was performed to identify statistically significant covariates and then receiver operating characteristic (ROC) curves were generated to identify optimal cut-off values. Using these cut-off values, a formula was devised to calculate an index value for BM screening at diagnosis. The model was cross-validated using the leave-one-out method. RESULTS: Of the 488 patients, 65 patients (13.3%) had BM. The area under the ROC curve was 0.87 (95% confidence interval 0.83-0.94). The sensitivity of the cut-off point was 87.7% and the specificity was 73.1%. Bone scan is needed for all cT4 PCa patients, however, it is also advisable for cT1-T3 PCa patients who have a biopsy Gleason score <=3 + 4 and a PSA >132.1, and for cT1-T3 patients having a Gleason score of >=4 + 3 and PSA >44.5. CONCLUSIONS: The regression model may help determine if bone scan is needed to detect BM from PCa at the time of diagnosis. The model was generated upon a single center experience. Further validation is needed in future studies.

Continuing medical education article - Body contouring. Gynecomastia

Panniculectomy & Abdominoplasty CPG

The male patient's degree of breast sagging is the guideline that this author uses to determine the correct surgical approach to gynecomastia. When the patient has no sagging, a small infraareolar incision suffices. With significant sagging, alternative incisions are usually necessary for skin excision and areolar repositioning. Adjunctive lipoplasty is recommended to facilitate correction, improve results, and decrease morbidity and complications. Copyright © 2004 by The American Society for Aesthetic Plastic Surgery, Inc.

Periurethral injection of autologous fat for the treatment of sphincteric incontinence

Panniculectomy & Abdominoplasty CPG

A total of 15 women with stress incontinence and 6 men with post- prostatectomy sphincteric incontinence underwent periurethral injection of autologous fat while under local anesthesia. The fat was harvested from the abdominal wall by liposuction. Preoperative evaluation consisted of a micturition diary, questionnaire, semiquantitative pad test, cystoscopy and urodynamics. Sequential injections were performed at 1 to 3-month intervals. Results were assessed by subjective patient scores, pad tests and clinical evaluation performed at intervals. Followup was 12 to 30 months (mean 18). Only 1 man and none of the women with urethral hypermobility had lasting improvement. Of the 15 women 12 had intrinsic sphincteric deficiency (type 3 stress incontinence) and they were our most successful group. Of the 12 women 10 (83%) were improved (mean score of 8.8-7 before injection compared to 1.87 after injection) at 1 month following the initial injection. Of the 9 patients who continued with the treatment 7 (78%) noticed lasting improvement objectively and subjectively after 1 to 4 injections (mean 2.4). We believe that this technique shows sufficient promise as an alternative therapy for sphincteric incontinence to warrant continued clinical investigation.

Results after knee replacement with a posterior cruciate-substituting prosthesis

Surgical Management of Osteoarthritis of the Knee CPG

From 1979 to 1984, eighty patients (119 knees) were arbitrarily selected for treatment with knee arthroplasty in which a posterior cruciate-substituting replacement was used. The average age of the forty-nine women and thirty-one men was 66.9 years (range, twenty-two to eighty-four years). Sixty-one right and fifty-eight left knees were operated on, and bilateral replacement was performed in thirty-nine of the eighty patients. The diagnosis was osteoarthritis in fifty-eight patients (eighty-eight knees), rheumatoid arthritis in fourteen patients (twenty-two knees), osteonecrosis in three patients (four knees), and traumatic arthritis secondary to a fracture of the tibia or femur in five patients (five knees). The average preoperative score on The Hospital for Special Surgery knee-rating scale was 47.5 points, and the average range of motion preoperatively was 88 degrees (range, 30 to 140 degrees). Of the 119 knees, eighty-seven had a varus alignment (maximum, 35 degrees) before knee replacement. After follow-up of two to eight years, the average score on The Hospital for Special Surgery scale was 90 points, and the average range of motion was 107 degrees. Of the 119 knees, 83 per cent were rated as excellent; 15 per cent, as good; none, as fair; and 2 per cent, as poor. Radiolucencies of one millimeter were present in 76 per cent of the knees; of two millimeters, in 7 per cent; and of three millimeters, in 3 per cent. No statistically significant correlation between radiolucencies and the clinical result was found. The results in knees of patients who had rheumatoid arthritis were not as good as those in knees of patients who had other diagnoses (F = 11.44). Our experience suggested that the posterior cruciate-substituting design provides more motion than do the cruciate-sacrificing surface-replacement designs, with no deleterious effects. The rate of infection (1.6 per cent) after these procedures, which were carried out in a standard operating theater with vertical airflow, was equivalent to that in other published series in which rooms with laminar airflow were used. Patients who had a bilateral procedure did as well as those who had a unilateral replacement, but they required approximately 3.5 more units of blood

External fixation of distal radius fractures: Do benefits outweigh complications?

Distal Radius Fractures

Fractures of the distal radius are the most common bony injuries in the upper extremity, and many treatment methods have been described in the literature. External fixation remains a highly versatile method to treat many fracture types involving the distal radius. The primary indications for external fixation include reduction of unstable extra-articular fractures and most intra-articular fractures. The use of adjuvant pinning or "mini" open procedures can be used when external fixation inadequately reduces the joint line alone, especially with central depressions and highly comminuted injuries. The ease of use of the implants and successful track record make it an extremely versatile tool for treating complex fractures of the distal radius. © 2001 Lippincott Williams & Wilkins, Inc.

Endogenous parathyroid hormone is associated with reduced cartilage volume in vivo in a population-based sample of adult women

OAK 3 - Non-arthroplasty tx of OAK

OBJECTIVES: Animal and in vitro studies suggest that parathyroid hormone (PTH) may affect articular cartilage. However, little is known of the relationship between PTH and human joints in vivo. DESIGN: Longitudinal. SETTING: Barwon Statistical Division, Victoria, Australia. PARTICIPANTS: 101 asymptomatic women aged 35-49 years (2007-2009) and without clinical knee osteoarthritis, selected from the population-based Geelong Osteoporosis Study. RISK FACTORS: Blood samples obtained 10 years before (1994-1997) and stored at -80degreeC for random batch analyses. Serum intact PTH was quantified by chemiluminescent enzyme assay. Serum 25-hydroxyvitamin D (25(OH)D) was assayed using equilibrium radioimmunoassay. Models were adjusted for age, bone area and body mass index; further adjustment was made for 25(OH)D and calcium supplementation. OUTCOME: Knee cartilage volume, measured by MRI. RESULTS: A higher lnPTH was associated with reduced medial-but not lateral-cartilage volume (regression coefficient+/-SD, p value: -72.2+/-33.6 mm(3), p=0.03) after adjustment for age, body mass index and bone area. Further sinusoidal adjustment (-80.8+/-34.4 mm(3), p=0.02) and 25(OH)D with seasonal adjustment (-72.7+/-35.1 mm(3), p=0.04), calcium supplementation and prevalent osteophytes did not affect the results. CONCLUSIONS: A higher lnPTH might be detrimental to knee cartilage in vivo. Animal studies suggest that higher PTH concentrations reduce the healing ability of cartilage following minor injury. This may be apparent in the presence of increased loading, which occurs in the medial compartment, placing the medial cartilage at higher risk for injury.

Structural predictors of ten year knee cartilage volume loss

Surgical Management of Osteoarthritis of the Knee CPG

Background/Purpose: Cartilage volume loss is considered a key feature of knee osteoarthritis (OA) and increased loss over two years is associated with future knee replacement surgery. Previous studies have identified structural predictors of cartilage loss over 2-3 years including baseline cartilage volume, cartilage defects, bone marrow lesions (BMLs), meniscal pathology and bone area. These are now considered important risk factors for osteoarthritis progression. However no study has examined whether these features predict loss over longer timeframes. The aim of this study was to examine structural predictors of cartilage volume loss over ten years. Methods: 220 participants [mean age 45 (26-61); 57% female] were studied at baseline, two, and ten years. Approximately half were adult offspring of subjects who had a knee replacement performed for knee OA and the remaining were randomly selected controls that were initially matched by age and sex. Cartilage volume (tibial, patella), cartilage defects (tibial, femoral), BMLs (tibial, femoral, patella), meniscal extrusion (medial, lateral) and bone area (tibial) were measured using MRI. Predictors of ten year cartilage loss were examined using linear regression and all models were adjusted for age, sex, BMI, and offspring-control status. Interactions between offspring-control status and knee structures on cartilage loss were explored. Results:Cartilage change over ten years was -2.5% per annum (pa), -1.1% pa, and -2.1% pa for the medial and lateral tibial and patella sites respectively. BMLs predicted tibial (< =-433 mm(3) per 1 unit increase in BML size, P < 0.01) but not patella cartilage loss. Meniscal extrusion predicted lateral tibial cartilage loss (<=-872 mm(3) in those with a baseline extrusion versus those without, P < 0.01) but not medial tibial or patella cartilage loss. Cartilage volume at baseline predicted tibial and patella ten year cartilage loss (< = -0.26 to -0.41 mm(3) per unit increase in baseline volume, P< 0.01). There was interaction between offspring-control status for cartilage defects. Baseline defect score predicted lateral tibial cartilage loss in offspring (B=-242 mm(3) per unit increase in defect score, P<0.01); but, surprisingly defects appeared to be protective against medial and lateral tibial cartilage loss in controls (< = 276 to 327 mm(3) per unit increase in defect score, P<0.01). Both change in cartilage volume (r=-0.58 to -0.62, all P < 0.01) and progression of cartilage defects (r=-0.18 to -0.58, all P< 0.01) over two years predicted ten year tibial cartilage loss. Bone area did not predict ten year change in cartilage. Conclusion: Structural features which have been identified as risk factors for cartilage loss over 2-3 years appear to predict long-term cartilage changes with the most consistent data for BMLs. This was seen in a largely pre-radiographic cohort and indicates that bone marrow lesions, presence of meniscal extrusion; and to a lesser extent, cartilage volume and cartilage defects, may be used to identify individuals who will lose the most cartilage long-term. Additionally this study demonstrates that cartilage loss and cartilage defect progression over two years are reasonable predictors of long-term cartilage changes

Staying Active With Arthritis: RCT of Physical Activity for Older Adults With Osteoarthritis and Hypertension

OAK 3 - Non-arthroplasty tx of OAK

Over 9 million Americans have symptomatic osteoarthritis (OA) of the knee, a chronic disease associated with frequent joint pain, functional limitations, and quadriceps weakness that intrude upon everyday life. At least half of those with OA of the knee are diagnosed with hypertension or high blood pressure (HBP), one of the most prevalent risk factors for cardiovascular disease. Many other individuals with OA of the knee unknowingly have HBP and remain untreated. Our own work and that of others suggest that persons with OA of the knee experience reductions in BP when they participate in a regular regimen of physical activity. Even small decreases in systolic and diastolic BP found with physical activity are clinically significant, e.g., a 2 mm Hg decrease reduces the risk of stroke by 14% � 17%, and the risk of coronary heart disease is reduced by 6% � 9%. Yet, only 15% of persons with OA and 47% with HBP engage in regular physical activity. The purpose of this study is to investigate how the individually delivered, home�based, 6�month modified Staying Active with Arthritis (STAR) intervention, guided by self�efficacy theory and modified to address comorbid HBP, affects lower extremity exercise (flexibility, strengthening, and balance), fitness walking, functional status, BP, quadriceps strength, pain, fatigue, and health�related quality of life (HRQoL) in a convenience sample of 224 adults age 50 years or older with OA of the knee and HBP. Using a randomized controlled, 2�group design, we (1) hypothesize that at the end of the 6�month intervention period and 6 months after the intervention period ends those who receive the modified STAR intervention will be more likely to perform lower extremity exercise, participate in fitness walking, show improvements in objective functional status, and demonstrate reductions in BP than those who receive attention�control. Secondarily, we will (2) evaluate the impact of the modified STAR intervention, compared to attention�control, on subjective functional status, quadriceps strength, pain, fatigue, and HRQoL at both time points; (3) explore the impact of the modified STAR intervention, compared to attention�control, on self�efficacy and outcome expectancy at both time points; (4) explore the relationship between self�efficacy and outcome expectancy; and (5) explore the extent to which self�efficacy and outcome expectancy mediate the relationship between the modified STAR intervention and performance of lower extremity exercise and participation in fitness walking. Data will be analyzed using repeated measures modeling.

The technique of delivery of peri-operative analgesia does not affect the rehabilitation or outcomes following total knee arthroplasty

OAK 3 - Non-arthroplasty tx of OAK

Aims: This non-blinded randomised controlled trial compared the effect of patient-controlled epidural analgesia (PCEA) versus local infiltration analgesia (LIA) within an established enhanced recovery programme on the attainment of discharge criteria and recovery one year after total knee arthroplasty (TKA). The hypothesis was that LIA would increase the proportion of patients discharged from rehabilitation by the fourth post-operative day but would not affect outcomes at one year. Patients and Methods: A total of 242 patients were randomised; 20 were excluded due to failure of spinal anaesthesia leaving 109 patients in the PCEA group and 113 in the LIA group. Patients were reviewed at six weeks and one year post-operatively. Results: There was no difference in the proportion of patients discharged from rehabilitation by the fourth post-operative day, (77% in the PCEA group, 82% in the LIA group, p = 0.33), mean length of stay (four days in each group, p = 0.540), day of first mobilisation (p = 0.013) or pain (p = 0.278). There was no difference in mean Oxford Knee Scores (41 points in each group, p = 0.915) or the rate of complications in the two groups. Conclusion: Both techniques provided adequate pain relief, enabled early mobilisation and accelerated rehabilitation and good patient-reported outcomes up to one year post-operatively. PCEA and LIA are associated with similar clinical outcomes following TKA.

Barriers to accessing eye care services among visually impaired populations in rural Andhra Pradesh, South India

Upper Eyelid and Brow Surgery

PURPOSE: To understand the reasons why people in rural south India with visual impairment arising from various ocular diseases do not seek eye care. MATERIALS AND METHODS: A total of 5,573 persons above the age of 15 were interviewed and examined in the South Indian state of Andhra Pradesh covering the districts of Adilabad, West Godavari and Mahaboobnagar. A pre-tested structured questionnaire on barriers to eye care was administered by trained field investigators. RESULTS: Of the eligible subjects, 1234 (22.1%, N=5573)) presented with distant visual acuity < 20/60 or equivalent visual field loss in the better eye. Of these, 898 (72.7%, N=1234) subjects had not sought treatment despite noticing a decrease in vision citing personal, economic and social reasons. The analysis also showed that the odds of seeking treatment was significantly higher for literates [odds ratio (OR) 1.91, 95% confidence interval (CI) 1.38 to 2.65], for those who would be defined as blind by visual acuity category (OR 1.35, 95% CI 0.96 to 1.90) and for those with cataract and other causes of visual impairment (OR 1.50, 95% CI 1.11 to 2.03). Barriers to seeking treatment among those who had not sought treatment despite noticing a decrease in vision over the past five years were personal in 52% of the respondents, economic in 37% and social in 21%. CONCLUSION: Routine planning for eye care services in rural areas of India must address the barriers to eye care perceived by communities to increase the utilization of services.

Scar Perception: A Comparison of African American and White Self-identified Patients

Panniculectomy & Abdominoplasty CPG

Scars can have significant morbidity and negatively impact psychological, functional, and cosmetic outcomes as well as the overall quality-of-life, especially among ethnic minorities. The objective of this study was to evaluate African American and White patients' perception of their scars' impact on symptoms, appearance, psychosocial health, career, and sexual well-being, using validated assessment tools. METHOD: A total of 675 abdominoplasty and breast surgery patients from four providers completed the SCAR-Q, and Career/Sexual Well-Being scales via phone or email. A higher score on both assessments indicates a more positive patient perception. RESULTS: Of the 675 respondents, 77.0% were White, and 23.0% were African American. White patients scored significantly higher on the SCAR-Q (232?±?79 versus 203?±?116), appearance (66?±?26 versus 55?±?29), and Career/Sexual Well-Being (16?±?2 versus 15?±?5) scales than African American patients (P < 0.001, P < 0.001, P < 0.001, respectively). There was no significant correlation between duration after surgery and symptoms or appearance scores for African American patients (P = 0.11, P = 0.37). There was no significant correlation between patient age and SCAR-Q score or time after surgery and psychosocial scores. CONCLUSIONS: African American patients are more likely to have lower perceptions of their scarring appearance, symptoms, psychosocial impact, career impact, and sexual well-being impact than White patients. Scar appearance and symptoms are less likely to improve over time for African American patients. This study highlights the need to address patient ethnicity when considering further follow-up, counseling, or other measures to enhance scar perception.

Posterior deltoid-to-triceps tendon transfer to restore active elbow extension in patients with tetraplegia

The Treatment of Pediatric Supracondylar Humerus Fractures AUC

Tetraplegia, paralysis of all 4 limbs, is usually the result of cervical spinal cord injury. Recovery of independence is the primary goal of people with tetraplegia; this requires reconstruction of upper extremity function. Active elbow extension, necessary for a wide range of activities of daily living, is usually surgically reconstructible. The posterior deltoid-to-triceps tendon transfer was developed to restore active elbow extension; good functional results and high levels of patient satisfaction have been reported for this operation. (copyright) 2009 Lippincott Williams & Wilkins, Inc

Rapid and Efficient Production of Human Functional Mast Cells through a Three-Dimensional Culture of Adipose Tissue-Derived Stromal Vascular Cells

Panniculectomy & Abdominoplasty CPG

Mast cells (MC) are innate immune cells involved in many physiological and pathological processes. However, studies of MC function and biology are hampered by the difficulties to obtain human primary MC. To solve this problem, we established a new method to produce easily and rapidly high numbers of MC for in vitro studies using human adipose tissue, which is an abundant and easy access tissue. Stromal vascular fraction of adipose tissue, obtained from human abdominal dermolipectomy, was cultured as spheroids in serum free medium supplemented in stem cell factor. Using this method, we generated, within 3 wk, a highly pure population of connective tissue-type MC expressing MC typical peptidases (tryptase, chymase, and carboxypeptidase-A3) with a yield increasing over time. Stem cell factor was required for this culture, but unlike MC derived from CD34(+) cells, this culture did not depend on IL-3 and -6. MC obtained with this method degranulated following FceRI cross-linking or stimulation by C5a, compound 48/80, and substance P. Interestingly, activation by anti-IgE of both white adipose tissue-MC and MC obtained from peripheral blood-derived CD34(+) pluripotent progenitor cells induced the production of PGs as well as proinflammatory cytokines (TNF-a, Il-6, and GM-CSF). In conclusion, we developed a new time saving and reproducible method to produce highly pure and functional human MC in 3 wk from human adipose tissue.

Advantages of patellar resurfacing in total knee arthroplasty. Two-year results of a prospective randomized study

Surgical Management of Osteoarthritis of the Knee CPG

Complications of patellar resurfacing in total knee arthroplasty have rekindled the interest of many surgeons in patellar retention. In a prospective study 20 randomly selected patients of 40 underwent patellar resurfacing in combination with their total knee arthroplasty. The other 20 patients were left with an unresurfaced patella. Within 24 months of follow-up, the advantages of patellar resurfacing could be seen according to the Knee Society Score. Especially in advanced osteoarthritis of the knee joint, the patients achieved better scores in climbing stairs and in function. The superior functional results are arguments for patellar resurfacing, at least in knees with advanced osteoarthritis

"Sounds a Bit Crazy, But It Was Almost More Personal:" A Qualitative Study of Patient and Clinician Experiences of Physical Therapist-Prescribed Exercise For Knee Osteoarthritis Via Skype

OAK 3 - Non-arthroplasty tx of OAK

OBJECTIVE: To explore the experience of patients and physical therapists with Skype for exercise management of knee osteoarthritis (OA). METHODS: This was a qualitative study. The Donabedian model for quality assessment in health care (structure, process, and outcomes) informed semistructured individual interview questions. The study involved 12 purposively sampled patients with knee OA who received physical therapist-prescribed exercise over Skype, and all therapists (n = 8) who delivered the intervention in a clinical trial were interviewed about their experiences. Interviews were audio recorded and transcribed. Two investigators undertook coding and analysis using a thematic approach. RESULTS: Six themes arose from both patients and therapists. The themes were Structure: technology (easy to use, variable quality, set-up assistance helpful) and patient convenience (time efficient, flexible, increased access); Process: empowerment to self-manage (facilitated by home environment and therapists focusing on effective treatment) and positive therapeutic relationships (personal undivided attention from therapists, supportive friendly interactions); and Outcomes: satisfaction with care (satisfying, enjoyable, patients would recommend, therapists felt Skype more useful as adjunct to usual practice) and patient benefits (reduced pain, improved function, improved confidence and self-efficacy). A seventh theme arose from therapists regarding process: adjusting routine treatment (need to modify habits, discomfort without hands-on, supported by research environment). CONCLUSION: Patients and physical therapists described mostly positive experiences using Skype as a service delivery model for physical therapist-supervised exercise management of moderate knee OA. Such a model is feasible and acceptable and has the potential to increase access to supervised exercise management for people with knee OA, either individually or in combination with traditional in-clinic visits.

Changes in surgical loads and economic burden of hip and knee replacements in the US: 1997-2004

Surgical Management of Osteoarthritis of the Knee CPG

OBJECTIVE: A major component of the economic burden associated with the treatment of arthritis relates to surgical joint replacements of the hips/knees. The purpose of this study was to describe the recent trend of hip/knee replacements and the associated economic burden. METHODS: The Nationwide Inpatient Survey from 1997 to 2004 was analyzed. The International Classification of Diseases, Ninth Revision, Clinical Modification procedure coding was used to identify joint replacement cases. RESULTS: During 2004, approximately 225,900 (95% confidence interval [95% CI] 201,782-250,018) primary hip replacements and 431,485 (95% CI 397,454-465,516) primary knee replacements were performed. This was a 37% increase in primary hip replacements and a 53% increase in primary knee replacements compared with 2000. The number of primary replacement procedures increased equally for males and females; however, the number of procedures increased excessively among persons age 45-64 years. While Medicare remained the major source of payment (55.4% for primary hip replacements, 59.3% for primary knee replacements), private insurance payment experienced a steeper increase. In 2004, the national bill of hospital charges for hip/knee replacements was $26.0 billion, the hospital cost was $9.1 billion, and the amount of reimbursement was $7.2 billion (28% of hospital charges or 79% of hospital cost). Nearly 600,000 hip replacements and 1.4 million knee replacements will be performed in the year 2015. CONCLUSION: The number of joint replacement procedures performed is growing faster than ever. The health care community should consider and prepare for this upcoming demand of surgical loads and its associated economical burden

Antimicrobial susceptibility of coagulase-negative staphylococci on tissue allografts and isolates from orthopedic patients

Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures

Allograft infection occurs at a rate not different from that of similar procedures with large allografts or sterilized prosthetic devices and is usually caused by coagulase-negative staphylococci (CNS). CNS are feared for their limited antimicrobial susceptibility. We aimed at investigating this risk. CNS were isolated from 260 of 1461 allograft tissue grafts and compared with 384 consecutive clinical isolates from a general orthopedic population (258 patients). The CNS were identified and examined for their susceptibility to nine antibiotics used in routine practice. Staphylococcus epidermidis was the most commonly identified (35%) and the most resistant species of the allograft isolates. Comparing the overall antibiotic susceptibility patterns, clinical pathogens were significantly more resistant to six of the nine antibiotics (p < 0.01), namely penicillin, oxacillin, erythromycin, clindamycin, ofloxacin, and gentamicin. In conclusion, massive allograft infection is a well-known life-threatening surgical risk. However, we did demonstrate that allograft-related in contrast to orthopedic clinics-related CNS, are susceptible to commonly used first and second line antibiotics

Cost-effectiveness in fall prevention for older women

HipFx Supplemental Cost Analysis

Aims: The aim of this study was to estimate the cost-effectiveness of implementing an exercise-based fall prevention programme for home-dwelling women in the !80-year age group in Norway. Methods: The impact of the home-based individual exercise programme on the number of falls is based on a New Zealand study. On the basis of the cost estimates and the estimated reduction in the number of falls obtained with the chosen programme, we calculated the incremental costs and the incremental effect of the exercise programme as compared with no prevention. The calculation of the average healthcare cost of falling was based on assumptions regarding the distribution of fall injuries reported in the literature, four constructed representative case histories, assumptions regarding healthcare provision associated with the treatment of the specified cases, and estimated unit costs from Norwegian cost data. We calculated the average healthcare costs per fall for the first year. Results: We found that the reduction in healthcare costs per individual for treating fall-related injuries was 1.85 times higher than the cost of implementing a fall prevention programme. Conclusions: The reduction in healthcare costs more than offset the cost of the prevention programme for women aged !80 years living at home, which indicates that health authorities should increase their focus on prevention. The main intention of this article is to stipulate costs connected to falls among the elderly in a transparent way and visualize the whole cost picture. Cost-effectiveness analysis is a health policy tool that makes politicians and other makers of health policy conscious of this complexity. (copyright) 2009 the Nordic Societies of Public Health

Arthroplasty of the hip and knee in juvenile rheumatoid arthritis

Surgical Management of Osteoarthritis of the Knee CPG

The primary reason for total hip and total knee replacement in patients with juvenile rheumatoid arthritis is marked functional impairment. Secondary reasons are severe disabling pain and deformity. By the time a patient is ready for arthroplasty, alternatives to surgery have already been considered; synovectomies, soft-tissue releases, and osteotomies have already been performed, or the destructive process is too advanced for any form of therapy to have a considerable effect

Prognostic impact of chronological age on efficacy of immune checkpoint inhibitors in non-small-cell lung cancer: Real-world data from 86 173 patients

MSTS 2022 - Metastatic Disease of the Humerus

Immune checkpoint inhibitors (ICIs) have become standard pharmacological therapies in patients with non-small-cell lung cancer (NSCLC). Because elderly patients with NSCLC are often excluded from clinical trials as a result of lower functional capacity or comorbidities, the prognostic impact of chronological age on the efficacy of ICIs is unclear. The National Cancer Database was queried for stage IV NSCLC patients between 2014 and 2015. Associations between ICI therapy and clinical characteristics were assessed using chi-squared tests. Kaplan–Meier curves were compared using the log-rank test. A Cox proportional hazards model was used to identify clinical characteristics predictive of overall survival (OS). This study included 24 136 patients with stage IV NSCLC aged =75 years and 62 037 patients with stage IV NSCLC aged <75 years. Patients aged =75 years treated with ICIs had significantly longer OS than those not treated with ICIs (hazard ratio [HR] 0.61, 95% confidence interval [CI] 0.58–0.64, p < 0.0001). The corresponding HR in patients aged <75 years was 0.67 (95% CI 0.65–0.68, p < 0.0001). Cox modeling confirmed the survival benefit of ICI therapy in patients aged =75 years (HR for patients not receiving ICIs 1.63 [95% CI: 1.55–1.71], p < 0.0001). The corresponding HR in patients aged <75 years was 1.47 (95% CI 1.43–1.51, p < 0.0001). Chronological age does not appear to negatively impact the survival benefit of ICI therapy in patients with stage IV NSCLC according to this large real-world database analysis.

Quality differences between private for-profit, private non-profit and public hospitals in Norway: A retrospective national register-based study of acute readmission rates following total hip and knee arthroplasties

OAK 3 - Non-arthroplasty tx of OAK

Objectives To compare the quality of care - using unplanned acute hospital readmissions as a quality measure - among patients treated at private for-profit hospitals (PFPs), private non-profit hospitals (PNPs) and public hospitals (PUBs) in Norway. Design A retrospective comparative study using the Norwegian Patient Register. Readmissions were evaluated by logistic regressions both using adjustment for various patient-level and other covariates, and a two-stage model using distance as an instrumental variable. Setting The Norwegian healthcare system. Population All publicly financed patients having primary total hip (37 897 patients) or primary total knee arthroplasty (25 802 patients) at one of the three hospital types from 2009 to 2014. Primary outcome measure 30-day unplanned acute hospital readmission rate. Results We found highest readmission rates among PUBs and lowest among PFPs, for both procedures. However, the patients were on average more than 2 years younger at PFPs. PFPs also treated the least severe patients, while PUBs treated the most severe. Using adjustment for various patient-level and other covariates, compared to PUBs, both PFPs and PNPs had lower odds of readmission following both procedures. However, using the instrumental variable method, the only significant difference found was a lower odds of readmission at PNPs among hip patients when compared with PUBs. No patients in our data set were readmitted to PFPs, those originally treated at PFPs were readmitted to either PNPs or PUBs, and PUBs received most of the readmitted patients across hospital types. Conclusions Quality differences between hospital types were small; however, PNPs had significantly lower readmission rates compared with PUBs among patients having total hip arthroplasty. PUBs received the larger part of the readmitted patients across hospital types and thus play an essential role in the care of more complex patients and for readmissions, regardless of any quality differences.

Sentinel lymph node detection and microstaging in vulvar carcinoma

MSTS 2018 - Femur Mets and MM

OBJECTIVE: To determine the efficacy of using complementary techniques for detecting sentinel lymph nodes (SLNs) in vulvar carcinoma and to evaluate the utility of microstaging techniques. STUDY DESIGN: Patients with invasive vulvar carcinoma underwent sentinel lymph node detection (SLND) using preoperative lymphoscintigraphy, intraoperative isosulfan blue dye injection and an intraoperative hand-held gamma-detecting probe. Eleven patients were included and a total of 16 groins evaluated. Sentinel nodes identified were excised, bisected and examined in surgical pathology using hematoxylin and eosin (H&E) staining. Pathologically negative SLNs were subjected to additional microstaging via serial sectioning and immunohistochemical staining for cytokeratin. Surgical management of the vulvar cancer and extent of inguinal-femoral lymphadenectomy were individualized based on clinicopathologic parameters, including depth of invasion, location of the tumor and patient performance status. RESULTS: Lymphoscintigraphy, dye and gamma-detector methods led to the total detection of 16, 19 and 17 SLNs, respectively. In two cases the isosulfan blue dye assisted in the isolation of an additional sentinel node over that of the gamma probe. Each method individually identified SLNs in 10/11 patients (91%). A total of 19 sentinel nodes were isolated. One SLN (5%) was positive for metastatic disease using H&E staining. Of the 18 negative SLNs, 2 (11%) had micrometastases (< 0.2 mm) upon serial sectioning and immunohistochemical staining. CONCLUSION: Combined-modality mapping enhances detection of SLNs in vulvar carcinoma. Histologic microstaging improves the detection of micrometastases within SLNs.

Free tissue coverage of chronic traumatic wounds of the lower leg

DoD SSI (Surgical Site Infections)

Thirty-eight consecutive patients who underwent 42 free flaps for chronic wounds of the lower leg were identified over an 11-year period. All wounds were open for a minimum of 1 month (mean, 40 months; median, 8 months; range, 1 month to 30 years). The average age was 37 years (range, 7 to 68 years), there were 31 male patients and seven female patients, and the average follow-up time was 30 months (range, 12 to 72 months). The original injury was an open fracture in 28 patients, wound dehiscence after open reduction and internal fixation of a closed fracture in nine patients, and a shrapnel wound in one patient. A total of 23 patients had osteomyelitis, which was classified as local (involving less than 50 percent of the bone diameter) in 15 patients and as diffuse (involving greater than 50 percent of the bone diameter or infected nonunion) in eight patients. The wounds were treated with sequential debridement, antibiotics, and flap coverage. Ancillary procedures included antibiotic beads in 18 patients, saucerization in 16, Ilizarov bone transport in three, calcanectomy in two, and fibular resection and ankle fusion in one. Thirty-four of 42 flaps survived, four having undergone a repeat free flap. There were three failures out of 25 flaps (12 percent) among those with a normal angiogram and five failures out of 15 flaps (33 percent) among those with an abnormal angiogram (p > 0.05). The failure rate of those with osteomyelitis was six of 26 (23 percent) versus two of 26 (13 percent) for those without osteomyelitis (p > 0.05). Successful reconstruction (bone healed, patient ambulatory and infection-free) was achieved in 33 of 38 patients (87 percent). The failure of reconstruction for those patients with osteomyelitis was four of 23 (22 percent) versus one of 15 (7 percent) for others (p > 0.05). The failure rate of flaps in patients with diffuse osteomyelitis was three of eight (38 percent) versus two of 30 for others (7 percent, p = 0.053). The presence of diffuse osteomyelitis was associated with a lower rate of successful limb reconstruction. An abnormal angiogram and the presence of osteomyelitis both were associated with a lower rate of successful limb reconstruction, but this was not significant, probably because of the small size of the cohort.