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Functional evaluation in cruciate-retaining-type TKA: anatomical relationship between tibial osteotomy level and PCL attachment

OAK 3 - Non-arthroplasty tx of OAK

INTRODUCTION: The level and morphology of posterior cruciate ligament (PCL) attachment vary greatly among individuals, and the function of the PCL after tibial osteotomy performed during total knee arthroplasty (TKA) surgery remains unclear. Therefore, we evaluated the resection amount of PCL attachment and the function of the residual PCL in cruciate-retaining (CR)-type TKA. METHODS: We examined 76 patients with knee osteoarthritis who had undergone CR-type TKA. The level of the tibial PCL attachment was measured by preoperative MRI and the amount resected into the tibial PCL attachment from the osteotomy level as well as the longitudinal diameter of the residual PCL by postoperative radiography. The relationships between these and joint gap tension value at flexion or amount of tibial posterior transfer by postoperative stress radiography were examined. RESULTS: The longitudinal diameter of the PCL attachment and the attachment level varied widely among patients. There were 39 patients (51%) with tibial osteotomy level caudal to the PCL attachment. Flexion gap tension in patients with residual PCL (residual PCL group) was slightly higher than those without residual PCL (fully-resected group). There was no correlation between amount of PCL residual and joint gap tension at the flexion position. Even in those without residual PCL, no correlation was observed between the resected amount and flexion joint gap tension value. Comparison of amount of posterior transfer by postoperative stress radiography between those with and without residual PCL revealed no significant difference. CONCLUSIONS: It was confirmed that the level and morphology of the PCL attachment vary greatly among individuals and the amount of PCL resected at tibial osteotomy during TKA surgery varies depending on the patient. The tension due to flexion position tended to decrease if the tibial osteotomy line was caudal to the PCL attachment; however, the amount of tibial posterior transfer due to stress was not changed.

Iliotibial band autograft versus bone-patella-tendon-bone autograft, a possible alternative for ACL reconstruction: a 15-year prospective randomized controlled trial

OAK 3 - Non-arthroplasty tx of OAK

PURPOSE: The long-term results after using the iliotibial band autograft (ITB) in anterior cruciate ligament (ACL) reconstruction are not fully known. If equal in quality to conventional methods, the ITB graft could be a useful alternative as a primary graft, in revision surgery or multi-ligament reconstruction. The purpose is to assess whether the ITB autograft is a long-term reliable alternative to the bone-patella-tendon-bone (BPTB) autograft, using a prospective randomized controlled trial design. METHODS: From 1995 to 1996, sixty patients scheduled for primary ACL reconstruction were included in a prospective randomized controlled trial. Three senior knee surgeons, experienced in both types of ACL surgery, performed all the operations. A standardized and supervised rehabilitation programme was used for both groups for 6 months. Thirty patients received the ITB reconstruction, and 30 received the BPTB reconstruction. Forty-nine participated at follow-up in 2010 (82%). Primary outcome was the failure rate after ACL reconstruction. Secondary outcomes were knee injury osteoarthritis outcome score (KOOS) [pain, symptoms, Sport/Rec, quality of life (QOL), daily living function], Tegner activity scale, anterior knee pain-score, Lysholm score, Rolimeter laxity, extension deficit, single hop and crossover hop for distance. RESULTS: At 15-year follow-up, no significant difference existed between the groups. Graft failure occurred in 4 ITB subjects (16%) and 3 BPTB subjects (13%). KOOS (Sport/Rec) for the ITB group was 75 and 73 for the BPTB group. The KOOS (QOL) was 72 and 68 for the ITB group and BPTB group, respectively. CONCLUSION: Similar graft failure rates and KOOS were found when comparing ITB- and BPTB-operated individuals, at 15-year follow-up. The ITB graft had equal long-term clinical results compared to the BPTB graft and is recommended as a reliable alternative autograft for ACL reconstruction. LEVEL OF EVIDENCE: Therapeutic studies, Level I.

In order to explain knee pain due to osteoarthritis, should we start looking for answers outside of the knee joint?

Surgical Management of Osteoarthritis of the Knee CPG

Purpose: To explain the variance in knee pain and perceived need for surgery (PNS) using psychological measurements of depression, anxiety and stress symptoms, physical activity, Body Mass Index (BMI) and Waist Circumference (WC) in obese and non-obese individuals with knee osteoarthritis (OA). Methods: Participants were a sample of 31 women and men between 50 and 80 years old diagnosed with knee OA, based upon radiographic examination evaluated by an orthopedic surgeon, were pre-selected. Three different methods of radiographic examination (Kellgren and Lawrence, Ahlback and Cooke) were used to detect differences between groups. Depression was assessed using the Beck Depression Inventory (BDI). The BDI is a 21-item self-report instrument intended to assess the existence and severity of symptoms of depression. Depression, Anxiety and Stress Scale (DASS) was also used. The DASS is a 42-item self-report questionnaire divided in three scales designed to measure the negative emotional states of depression, anxiety and stress. Physical Activity (PA) was assessed using Metabolic Equivalents (METs) values of common physical activities classified as light, moderate and vigorous intensity activity based on guidelines for exercise testing and prescription of the American College of Sports Medicine (ACSM). Knee pain and PNS were assessed using a visual analog scale (VAS) after performance testes, such as 6 Minute Walk Test, Timed Up and Go, stairs climbing test and peak of oxygen consumption, had been performed. Participants were asked to score by pointing on a 10 cm line (0-10) their perceived level of knee pain. Likewise for PNS, participants were asked to indicate under the same scale their perceived need for surgery. Results: Participants were divided according to their BMI into two groups: obese and morbid obese individuals (BMI = 30 kg/m2; (greater-than or equal to) 35 kg/ m2) or group A (N = 15) and healthy weight and overweight individuals (BMI = 18.5-24.9 kg/m(2); BMI = 25-29.9 kg/m(2)) or group B (N = 16). An independent t-test between groups did not show any significant difference in radiographic OA, indicating that both groups had similar levels of knee OA severity. Our two correlation analysis between knee pain and radiographic OA and between PNS and radiographic OA did not show any significant correlation. Multiple Regression Analysis, from a sample of 31individuals, indicated that BDI had the highest correlation with PNS (r = .71; p < .0001) and the coefficient of determination (R2) of the model was R2 = .62 (p < .0001). Our second Multiple Regression Analysis used a sample of 46 individuals including group A (N = 15), group B (N = 16) and healthy controls (N = 15). While excessive weight measured by BMI and Waist Circumference showed strong and significant correlations (r = .64; p < .0001) and (r = .69; p < .0001) with knee pain, our results indicated again that BDI had the highest correlation with knee pain (r = .77; p < .0001) and the coefficient of determination of the model was R2 = .75 (p < .0001). Conclusion: Notwithstanding the importance of radiographic findings to diagnose knee OA, our study did not show any significant correlation between radiographic OA and knee pain and PNS. Knee pain, due to OA, is the predominant symptom of OA and is the general reason why people decide to undergo total knee replacement surgery. Our study emphasizes the relevance of a more comprehensive understanding of pain complaints to improve our ability to identify individuals with knee OA and to apply rational treatment strategies, thereby offering a relevant target for intervention

Vitamin D and vitamin D analogues for preventing fractures associated with involutional and post-menopausal osteoporosis

Management of Hip Fractures in the Elderly

BACKGROUND: Vitamin D and related compounds have been used to prevent osteoporotic fractures in older people. OBJECTIVES: To determine the effects of vitamin D or related compounds, with or without calcium, for preventing fractures in older people. SEARCH STRATEGY: We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, the Cochrane Central Register of Controlled Trials (The Cochrane Library 2007, Issue 3), MEDLINE, EMBASE, CINAHL, and reference lists of articles. Most recent search: October 2007. SELECTION CRITERIA: Randomised or quasi-randomised trials comparing vitamin D or related compounds, alone or with calcium, against placebo, no intervention, or calcium alone, reporting fracture outcomes in older people. DATA COLLECTION AND ANALYSIS: Two authors independently assessed trial quality, and extracted data. Data were pooled, where admissible, using the fixed-effect model, or random-effects model if heterogeneity between studies appeared high. MAIN RESULTS: Forty-five trials were included. Vitamin D alone appears unlikely to be effective in preventing hip fracture (nine trials, 24,749 participants, RR 1.15, 95% CI 0.99 to 1.33), vertebral fracture (five trials, 9138 participants, RR 0.90, 95% CI 0.42 to 1.92) or any new fracture (10 trials, 25,016 participants, RR 1.01, 95% CI 0.93 to 1.09).Vitamin D with calcium reduces hip fractures (eight trials, 46,658 participants, RR 0.84, 95% CI 0.73 to 0.96). Although subgroup analysis by residential status showed a significant reduction in hip fractures in people in institutional care, the difference between this and the community-dwelling subgroup was not significant (P = 0.15).Overall hypercalcaemia is significantly more common in people receiving vitamin D or an analogue, with or without calcium (18 trials, 11,346 participants, RR 2.35, 95% CI 1.59 to 3.47); this is especially true of calcitriol (four trials, 988 participants, RR 4.41, 95% CI 2.14 to 9.09). There is a modest increase in gastrointestinal symptoms (11 trials, 47,042 participants, RR 1.04, 95% CI 1.00 to 1.08, P = 0.04) and a small but significant increase in renal disease (11 trials, 46,537 participants, RR 1.16, 95% CI 1.02 to 1.33). AUTHORS' CONCLUSIONS: Frail older people confined to institutions may sustain fewer hip fractures if given vitamin D with calcium. Vitamin D alone is unlikely to prevent fracture. Overall there is a small but significant increase in gastrointestinal symptoms and renal disease associated with vitamin D or its analogues. Calcitriol is associated with an increased incidence of hypercalcaemia

Comparison of predebridement and debridement cultures in predicting postoperative infections in compound fractures

DoD SSI (Surgical Site Infections)

Introduction: Compound fractures are fractures which communicate to the external environment through a wound, exposing the bone. Bacterial contamination is reported to occur in 60-70% of the cases which may be responsible for the infectious complications in these patients. This study has aimed to predict the appropriate time of culture, its frequency and the type of specimen to be processed for determining the microbial flora of the fracture wound which will help in instituting rational antibiotic treatment for the patient. Aim: To compare predebridement and debridement cultures in causing postoperative infections in patients with compound fractures of long bones. Materials and Methods: This was a prospective study conducted at Madras Medical College for a period of six months involving 100 samples consisting of sequential swabs and tissue specimens sent to the Microbiology laboratory for investigation. Results: In the predebridement period, within six hours of injury, 15% of the cultures showed significant growth out of which Staphylococcus aureus was isolated in 53%. Among the debridement cultures 41% showed significant growth. Postoperative follow up was done for six weeks. Forty six percent of patients showed clinical signs of infection. Thirty nine percent of patients turned out to be culture positive confirming the presence of postoperative infection. It was noted that 53 percent of predebridement culture positive patients continued to have persistent infection in the postoperative period and 66% of the debridement culture positive patients developed postoperative infection. It was concluded that the sensitivity of predebridement cultures and debridement cultures were 21% and 69% respectively. Conclusion: It is therefore recommended that debridement culture with a higher sensitivity will provide guidance regarding the choice of antimicrobial therapy.

High false negative rate of Tc-99m MDP whole-body bone scintigraphy in detecting skeletal metastases for patients with hepatoma

MSTS 2018 - Femur Mets and MM

BACKGROUND/PURPOSE: Technetium-99m methylene diphosphonate (Tc-99m MDP) whole-body bone scintigraphy (BS) has been widely used for detecting bone metastases. The aim of this study is to investigate the diagnostic accuracy of BS in detecting skeletal metastases for hepatocellular carcinoma (HCC) patients. In addition, the anatomic distribution of the metastatic bone lesions and the prognoses of the HCC patients are also analyzed. METHODS: We retrospectively reviewed BS results of 179 consecutive HCC patients from January 2005 to December 2006 in our institution. The false negative (FN) rate, sensitivity, and specificity of BS were evaluated by patient-based and region-based analyses. RESULTS: A total of 59 patients (33.0%) were confirmed of bone metastases. A total of 25 of these 59 patients (46.3%) had at least one lesion categorized as BS FN, and the bone metastatic status for 10 patients (17.0%) was underestimated by BS. The most observed metastatic site was spine while the most observed sites with FN of BS were the lower extremity. In total, there were 122 metastatic regions and 33 regions (27.0%) were FN of BS. Patients without any metastases survived significantly longer than any of other groups with metastases. CONCLUSION: High FN rate of Tc-99m MDP BS in detecting metastatic bone lesions for HCC patients was observed. In our opinion, careful history taking, meticulous examination, and a high index of suspicion are important for HCC patients with unexplained progressive pain in the musculoskeletal system. Even with negative results from Tc-99m MDP BS, the possibility of skeletal metastases cannot be indiscriminately excluded.

Outcomes of 447SCORE((registered trademark)) highly congruent mobile-bearing total knee arthroplasties after 5-10years follow-up

Surgical Management of Osteoarthritis of the Knee CPG

Introduction: The goal of mobile-bearing total knee arthroplasties (TKA) with an anatomical trochlea is to reduce polyethylene wear, the risk of loosening, and patellofemoral complications. Rotating mobile-bearing

Total knee replacement after fractures about the knee

Surgical Management of Osteoarthritis of the Knee CPG

We reviewed 17 cases of posttraumatic arthritis after fractures about the knee. All patients underwent total knee replacement; one had a distal femoral osteotomy to correct a deformity prior to arthroplasty. Thirteen patients had a minimum one-year follow-up, with an average follow-up of 27 months (range, one to four years). Of these, eight were considered to have a successful clinical result. All five patients with unsuccessful results had major intraoperative and/or postoperative complications. In malunions of intra-articular fractures of the proximal tibia, the important technical consideration for planned total knee replacement is preoperative tilt of the tibial plateau in the antero-posterior (AP) and lateral radiographic views. Tibial plateau tilt should be recognized during preoperative planning, and intraoperative adjustments are required. In malunions of extra-articular fractures of the distal femur or proximal tibia, a varus or valgus deformity is an important consideration. Prearthroplasty osteotomy may be considered in a patient with a significant bony deformity above or below the joint line. Incisions should be carefully planned, especially when a previous lateral distal femoral approach has been performed. The results may resemble revision rather than primary arthroplasty

Clinical and economic burden of revision knee arthroplasty

OAK 3 - Non-arthroplasty tx of OAK

Surgery is indicated for symptomatic knee osteoarthritis (OA) when conservative measures are unsuccessful. High tibial osteotomy (HTO), unicompartmental knee arthroplasty (UKA), and total knee arthroplasty (TKA) are surgical options intended to relieve knee OA pain and dysfunction. The choice of surgical intervention is dependent on several factors such as disease location, patient age, comorbidities, and activity levels. Regardless of surgical treatment, complications such as infection, loosening or lysis, periprosthetic fracture, and postoperative pain are known risks and are indications for revision surgery. The clinical and economic implications for revision surgery are underappreciated. Over 55,000 revision surgeries were performed in 2010 in the US, with 48% of these revisions in patients under 65 years. Total costs associated with each revision TKA surgery have been estimated to be in excess of $49,000. The current annual economic burden of revision knee OA surgery is $2.7 billion for hospital charges alone. By 2030, assuming a 5-fold increase in the number of revision procedures, this economic burden will exceed $13 billion annually. It is appealing to envision a therapy that could delay or obviate the need for arthroplasty. From an actuarial standpoint, this would have the theoretical downstream effect of substantially reducing the number of revision procedures. Although no known therapies currently meet these criteria, such a breakthrough would have a tremendous impact in lessening the clinical and economic burden of knee OA revision surgery.

Neuromuscular Function of the Knee Joint Following Knee Injuries: Does It Ever Get Back to Normal? A Systematic Review with Meta-Analyses

Osteochondritis Dissecans 2020 Review

BACKGROUND: Neuromuscular deficits are common following knee injuries and may contribute to early-onset post-traumatic osteoarthritis, likely mediated through quadriceps dysfunction. OBJECTIVE: To identify how peri-articular neuromuscular function changes over time after knee injury and surgery. DESIGN: Systematic review with meta-analyses. DATA SOURCES: PubMed, Web of Science, Embase, Scopus, CENTRAL (Trials). ELIGIBILITY CRITERIA FOR SELECTING STUDIES: Moderate and high-quality studies comparing neuromuscular function of muscles crossing the knee joint between a knee-injured population (ligamentous, meniscal, osteochondral lesions) and healthy controls. Outcomes included normalized isokinetic strength, muscle size, voluntary activation, cortical and spinal-reflex excitability, and other torque related outcomes. RESULTS: A total of 46 studies of anterior cruciate ligament (ACL) and five of meniscal injury were included. For ACL injury, strength and voluntary activation deficits were evident (moderate to strong evidence). Cortical excitability was not affected at?<?6 months (moderate evidence) but decreased at 24+?months (moderate evidence). Spinal-reflex excitability did not change at?<?6 months (moderate evidence) but increased at 24+?months (strong evidence). We also found deficits in torque variability, rate of torque development, and electromechanical delay (very limited to moderate evidence). For meniscus injury, strength deficits were evident only in the short-term. No studies reported gastrocnemius, soleus or popliteus muscle outcomes for either injury. No studies were found for other ligamentous or chondral injuries. CONCLUSIONS: Neuromuscular deficits persist for years post-injury/surgery, though the majority of evidence is from ACL injured populations. Muscle strength deficits are accompanied by neural alterations and changes in control and timing of muscle force, but more studies are needed to fill the evidence gaps we have identified. Better characterisation and therapeutic strategies addressing these deficits could improve rehabilitation outcomes, and potentially prevent PTOA. TRIAL REGISTRATION NUMBER: PROSPERO CRD42019141850.

Adiponectin: is it a biomarker for assessing the disease severity in knee osteoarthritis patients?

OAK 3 - Non-arthroplasty tx of OAK

AIM: The results of previous studies regarding the role of adiponectin in the pathogenesis of osteoarthritis (OA) are controversial. The aim of this study is to investigate the relation of plasma adiponectin levels with clinical and radiological disease severity in knee OA patients. METHOD: Sixty patients with knee OA and 25 healthy controls were included in the study. Patients were divided into two subgroups: lean (Group 1, n = 30) and obese (Group 2, n = 30). Healthy controls were accepted as Group 3 (n = 25). Pain intensity was measured with a visual analogue scale (VAS), functional disability with Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and Quality of Life (QoL) with Short Form-36 (SF-36). Also all patients were radiologically evaluated and graded according to Kellgren-Lawrence (KL) scale. Plasma concentrations of adiponectin levels were measured by enzyme-linked immune-sorbent assay (ELISA). RESULTS: Serum adiponectin levels were higher in OA patient subgroups than those in the control group but the difference did not reach a significant level after adjustments for age, gender and body mass index (P = 0.078). There was a positive correlation between adiponectin concentration and KL grading scores. Additionally, there was a positive correlation between adiponectin levels and clinical variables (VAS and WOMAC total scores) in patient subgroups (r = 0.326 P = 0.012, r = 0.583 P < 0.001, respectively). SF-36 scores were inversely associated with adiponectin levels. CONCLUSION: Plasma adiponectin concentrations were associated with both clinical and radiological disease severity in knee OA patients. Thus, adiponectin hormone might be a potential clinically useful biomarker while assessing disease severity in the future.

A follow-up study on the effects of a milk supplement on bone mineral density of postmenopausal chinese women in Malaysia

Management of Hip Fractures in the Elderly

Background: A previous study on a randomized controlled trial in 173 postmenopausal Chinese women in Kuala Lumpur showed that milk supplementation was effective to reduce bone loss at the total body, lumbar spine, femoral neck and total hip compared to the control group on a usual diet (Chee et al. 2003). Objective: The objective was to determine whether the results were sustained after the conclusion of the study. Design: A follow-up study, 18 months after a randomized controlled trial of milk supplementation was concluded. A total of 139 participants were followed up 21 months after the study ended. Bone mineral density (BMD) was measured at the total body, lumbar spine, femoral neck and total hip by dual energy X-ray absorptiometry, and anthropometric measurements as well as changes in dietary habits were measured. Results: At the follow-up, the milk supplement group did not show significant bone loss from baseline at most sites (mean differences (plus or minus) SE) (total body 0.42(plus or minus)0.25%, femoral neck 0.44(plus or minus)0.58%, total hip -0.06(plus or minus)0.46%), unlike the control group (total body -1.07(plus or minus) 0.28% p<0.005, femoral neck -1.49(plus or minus)0.56% p<0.05, total hip -0.89(plus or minus)0.57% p<0.05). However, both the milk and control groups showed bone loss from baseline at the lumbar spine (milk -2.01%, control -3.29%, p>0.05). The calcium intake of the milk group remained significantly higher than the control group (milk 710 mg/day, control 466 mg/day, p<0.005) despite discontinuation of the milk supplement. Conclusions: The results showed that some of the beneficial effects of a milk supplement were still evident at follow-up and it was possible to motivate subjects to adopt a positive change in dietary calcium intake after intervention. The Journal of Nutrition, Health & Aging(copyright)

The fate of miniplates in facial trauma and orthognathic surgery: a retrospective study

Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures

The fate of 279 Champy miniplates used routinely as permanent implants over a 5-year-period in the management of maxillofacial trauma and orthognathic surgery has been analysed retrospectively. Trauma patients (62) and orthognathic patients (47) were analysed separately; in each group those patients who had plates removed were compared to the patients with retained plates. This study indicates that the morbidity of retaining plates is within acceptable limits and that the routine removal of plates at 3 months may be unnecessary

Primary chemotherapy and delayed surgery for nonmetastatic osteosarcoma of the extremities. Results in 164 patients preoperatively treated with high doses of methotrexate followed by cisplatin and doxorubicin

MSTS 2022 - Metastatic Disease of the Humerus

BACKGROUND: Neoadjuvant chemotherapy is the most accepted treatment for localized osteosarcoma. This has led to a great improvement in limb-sparing surgery and in disease-free survival. Patients with a good response to preoperative chemotherapy showed a higher disease-free survival rate. Current studies examine the possibility of patients whose limbs could be rescued with a poor necrosis and a reduction of the side effects related to aggressive treatments. METHODS: Between September 1986 and December 1989, 164 patients entered the second neoadjuvant study conducted at the Rizzoli Institute, Bologna, Italy, for non-metastatic osteosarcoma of the extremities. Preoperative chemotherapy consisted of two cycles of high-dose methotrexate intravenously (i.v.) followed by cisplatin intraarterially and doxorubicin i.v. After surgery, patients classified as good responders (> 90% tumor necrosis) received three more cycles of these drugs, whereas poor responders (< 90% tumor necrosis) had more chemotherapy, which included ifosfamide and etoposide in addition to the other three drugs. RESULTS: Limb salvage was performed in 83% of cases. At an average follow-up of 54 months (36-76), 109 patients (66%) were continuously disease-free, 2 died from doxorubicin cardiotoxicity, and 52 experienced metastases and 3 had local recurrence. In two of these three patients, metastases followed local recurrence. The 5-year actuarial continuously disease-free survival rate was 63%, with no differences between good and poor responders. Excluding 20 patients who had major protocol violations, the projected continuous disease-free survival rate was 71%. CONCLUSIONS: With an aggressive neoadjuvant chemotherapy, it is possible to cure more than 60% of nonmetastatic osteosarcoma of the extremities, avoiding amputation in most cases. Ifosfamide and etoposide seem to be effective in patients who did not respond to preoperative chemotherapy.

Knee joint vibration signal analysis with matching pursuit decomposition and dynamic weighted classifier fusion

OAK 3 - Non-arthroplasty tx of OAK

Analysis of knee joint vibration (VAG) signals can provide quantitative indices for detection of knee joint pathology at an early stage. In addition to the statistical features developed in the related previous studies, we extracted two separable features, that is, the number of atoms derived from the wavelet matching pursuit decomposition and the number of significant signal turns detected with the fixed threshold in the time domain. To perform a better classification over the data set of 89 VAG signals, we applied a novel classifier fusion system based on the dynamic weighted fusion (DWF) method to ameliorate the classification performance. For comparison, a single leastsquares support vector machine (LS-SVM) and the Bagging ensemble were used for the classification task as well. The results in terms of overall accuracy in percentage and area under the receiver operating characteristic curve obtained with the DWF-based classifier fusion method reached 88.76% and 0.9515, respectively, which demonstrated the effectiveness and superiority of the DWF method with two distinct features for the VAG signal analysis.

Supplemental calcium for the prevention of hip fracture: potential health-economic benefits

Management of Hip Fractures in the Elderly

We assessed the cost-effectiveness of daily calcium supplementation for the prevention of primary osteoporotic hip fractures. The assessment was based on our meta-analysis of the published relative-risk estimates from 3 double-masked, placebo-controlled, clinical trials and our analysis of raw data from the National Health and Nutrition Examination Survey 1988-1994 on the daily intake of calcium supplements by adults in the United States. These data were then used to estimate the preventable proportion of hip fractures. The 1995 National Hospital Discharge Survey database provided the number and demographic characteristics of patients discharged with a primary diagnosis of hip fracture, as well as their discharge destination. The 1990 itemized costs of hip fractures, as estimated by the US Congress Office of Technology Assessment, were inflated to 1995 dollars using the medical care component of the Consumer Price Index. Using these inflated itemized costs, we then estimated the weighted average expenditures, reflecting both the types of services associated with specific hospital-discharge destinations and the demographic characteristics of discharged patients. The cost of supplements containing 1200 mg/d of elemental calcium for the mean duration (34 months) of the 3 clinical trials was calculated on the basis of 1998 unit-price and market-share data for 6 representative products. For 1995, the data indicate that 290,327 patients aged > or =50 years were discharged from US hospitals with a primary diagnosis of hip fracture, at our estimated direct cost of $5.6 billion. Based on the risk reductions seen in the 3 trials, we estimated that 134,764 hip fractures and $2.6 billion in direct medical costs could have been avoided if individuals aged > or =50 years consumed approximately 1200 mg/d of supplemental calcium. Additional savings could be expected, because this intervention is also associated with significant reductions in the risk for all nonvertebral fractures. Comparing the cost of calcium with the expected medical savings from hip fractures avoided, it is cost-effective to give 34 months of calcium supplementation to women aged > or =75 years in the United States. If, as the published studies suggest, shorter periods of supplementation result in an equivalent reduction in the risk of hip fractures, calcium supplementation becomes cost-effective for all adults aged > or =65 years in the United States. The data support encouraging older adults to increase their intake of dietary calcium and to consider taking a daily calcium supplement. Even small increases in the usage rate of supplementation are predicted to yield significant savings and to reduce the morbidity and mortality associated with hip fracture at an advanced age

Reduction of metastatic rate by immunotherapy: A comparison of the immunogenic properties of metastasizing tumor cells versus tumor cells in the primary mass

MSTS 2018 - Femur Mets and MM

The vasculature of a poorly immunogenic, highly metastatic transplantable fibrosarcoma (T-241) maintained in the femoral muscle of C57BL/6J mice was perfused. This permitted collection of tumor cells which had invaded into the tumor vascular channels (ie, metastasizing tumor cells). Also collected as a separate population were tumor cells from the primary tumor mass. Immunization was carried out with these cell populations in conjunction with BCG and the effect on the growth of primary tumor and metastatic rate was evaluated following rechallenge with unfractionated tumor cells. The rate of tumor growth at the primary site was not affected by any of the immunization schedules. However, immunization with venous effluent cells (metastasizing tumor cells) and BCG was two times more effective in reducing the number of pulmonary metastases than immunization using tumor cells isolated from the primary tumor mass. Passively transferred spleen cells from donors immunized with the cell populations listed above had exactly the same effect, that is, no effect on the growth of the primary tumor, but a dramatic reduction in the metastatic rate when effluent tumor cells were used to immunize cell donors. The data point to an antigenic heterogeneity with this particular transplantable tumor.

Botulinum toxin A for the prevention of hip dislocation in cerebral palsy

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 the safety and effectiveness of Botulinum Toxin A in preventing hip dislocation in cerebral palsy. As a secondary objective, we intend to analyse the effect of botulinum toxin on adductor and iliopsoas spasticity, on patient function and on passive hip range of motion

Degree of osteoporosis affects the fracture site in older patients with proximal femur fractures

Management of Hip Fractures in the Elderly

Introduction: This study was performed to analyse the relationship between the existence and degree of osteoporosis with age, gender, fracture site and laterality in older patients having proximal fractures due to simple fall. Materials and Method: Records of 200 consecutive patients ((117 women, 83 men, mean age 74.5 years) who were at or older than 60 years of age and had proximal femoral fracture were retrospectively analyzed. Results: A signiScant difference was not found between the osteoporotic and non-osteoporotic groups with respect to age, gender, laterality and fracture site (p>0.05). The rate of intertrochanteric fracture was signiScantly higher in borderline/mild osteoporosis group than the rate in moderate/severe osteoporosis group (p<0.001). The grade of osteoporosis was not related to age, gender and laterality in the osteoporotic patients with proximal femur fractures (p>0.05). Conclusion: Older patients with borderline or mild osteoporosis are more prone to intertrochanteric fractures in the hip region. The risk of femoral neck fractures increases in patients with advanced osteoporosis

Parental age and risk of childhood cancer

MSTS 2022 - Metastatic Disease of the Humerus

Background: Few risk factors for childhood cancer are well-established. We investigated whether advancing parental age increases childhood cancer risk. Methods: We assessed the relationship between parental age and childhood cancer in a case-control study using pooled population-based data. Our pooling was based on linked cancer and birth registry records from New York, Washington, Minnesota, Texas, and California. Subjects included 17,672 cancer cases diagnosed at ages 0-14 years during 1980-2004 and 57,966 controls born during 1970-2004. Individuals with Down syndrome were excluded. Odds ratios and 95% confidence intervals were calculated by logistic regression for the association between parental age and childhood cancer after adjustment for sex, birth weight, gestational age, birth order, plurality, maternal race, birth year, and state. Results: Positive linear trends per 5-year maternal age increase were observed for childhood cancers overall (odds ratio = 1.08 [95% confidence interval = 1.06-1.10]) and 7 of the 10 most frequent diagnostic groups: leukemia (1.08 [1.05-1.11]), lymphoma (1.06 [1.01-1.12]), central nervous system tumors (1.07 [1.03-1.10]), neuroblastoma (1.09 [1.04-1.15]), Wilms' tumor (1.16 [1.09-1.22]), bone© 2009 by Lippincott Williams & Wilkins.

Risk factors for same-admission mortality after pathologic fracture secondary to metastatic cancer

DoD SSI (Surgical Site Infections)

PURPOSE: The skeleton is the third most common site of cancer metastases. Approximately 10 % of patients with bone metastases will develop a pathologic fracture, with significant associated morbidity and mortality. The purpose of this study was to identify risk factors for same-admission mortality after pathologic fractures secondary to metastatic cancer. METHODS: The Nationwide Inpatient Sample database was queried from 2002 to 2013 for hospitalized patients with diagnoses of pathologic fracture and a primary cancer at high risk for skeletal metastasis. Univariate and multivariate analyses were performed to determine risk factors associated with same-admission mortality after fracture. RESULTS: A total of 371,163 patients were identified. The spine was the most common site of pathologic fracture (68.0 %) followed by lower extremity (25.0 %) and upper extremity (8.7 %). The following factors were independently associated with increased mortality (p < 0.001): cancer of lung or unspecified location; fracture of upper or lower extremity; male gender; age >=65; non-Medicare insurance; coexisting congestive heart failure, chronic pulmonary disease, renal failure, or liver disease; and postoperative surgical site infection, acute myocardial infarction, pulmonary embolism, or pneumonia. Closed reductions were associated (p < 0.001) with increased mortality while open or percutaneous surgical treatments were protective (p < 0.001) against mortality. CONCLUSIONS: Pathologic fractures are a devastating consequence of metastatic bone disease, contributing significantly to morbidity and mortality. Numerous demographic and medical factors are associated with increased same-admission mortality. This data is useful for counseling patients with skeletal metastatic disease and should be taken into consideration when conducting routine skeletal surveillance in patients with metastatic cancer.

Clinical and radiographic comparison of a single LP-PRP injection, a single hyaluronic acid injection and daily NSAID administration with a 52-week follow-up: a randomized controlled trial

OAK 3 - Non-arthroplasty tx of OAK

BACKGROUND: Knee osteoarthritis (OA) is a disease with a high prevalence in the adult population. Nonsteroidal anti-inflammatory drugs (NSAID) or intra-articular injections [hyaluronic acid (HA) or platelet-rich plasma (PRP)] can provide clinical benefit. Magnetic resonance imaging (MRI) has proven to be useful for the evaluation of cartilage volume and thickness in knee osteoarthritis. The purpose of this study was to evaluate the benefit provided by PRP injection in comparison with hyaluronic acid and NSAID in knee OA patients and to compare the radiographic evolution at the 52-week follow-up. METHODS: One hundred and six patients were enrolled and randomized according to the Spanish Rheumatology Society knee osteoarthritis diagnosis criteria. Ninety-eight patients completed the study (33 received NSAID treatment, 32 a single hyaluronic acid injection and 33 a single PRP injection). Patients were prospectively evaluated at baseline, 26 and 52 weeks using the Western Ontario McMaster Universities osteoarthritis index (WOMAC) and the visual analogue scale (VAS), and at baseline and 52 weeks with X-ray and MRI. RESULTS: A 20% decrease in WOMAC pain and increase in physical function was found in 30 and 24%, respectively, of those patients who received PRP treatment, at the 52-week follow-up. WOMAC pain and VAS improved in the hyaluronic acid and NSAID groups. However, better results were obtained in the PRP group compared to hyaluronic acid and NSAIDs (P < 0.05). No differences in Kellgren-Lawrence or cartilage thickness progression were found. CONCLUSIONS: Leukocyte-poor platelet-rich plasma (LP-PRP) injections are better in terms of clinical improvement with respect to HA injections or oral NSAID treatment in knee osteoarthritis patients at the 52-week follow-up. Moreover, a single LP-PRP injection is effective. However, LP-PRP has no influence on cartilage progression. LEVEL OF EVIDENCE: Level II.

Expression of CC chemokine receptor 7 in tonsillar cancer predicts cervical nodal metastasis, systemic relapse and survival

MSTS 2018 - Femur Mets and MM

The aim of this study was to evaluate the expression of CC chemokine receptor 7 (CCR7) in squamous cell cancer of the tonsil with respect to patterns of spread, relapse-free, overall and disease-specific survival. Eighty-four patients with squamous cell cancer of the tonsil were identified. There was a male predominance of 3 : 1 and the median age at diagnosis was 53 (range 35-86) years. The median duration of follow-up was 33 (range 2-124) months. There was a significant association between CCR7 immunopositivity and synchronous cervical nodal metastasis in patients with tonsillar cancer (Spearman's correlation coefficient 0.564; P<0.001). Relapse-free (P=0.0175), overall (P=0.0136) and disease-specific (P=0.0062) survival rates were significantly lower in patients whose tumours expressed high levels of CCR7. On multivariate analysis, high-level CCR7 staining predicted relapse-free (hazard ratio 3.0, 95% confidence intervals 1.1-8.0, P=0.026) and disease-specific (hazard ratio 10.2, 95% confidence intervals 2.1-48.6, P=0.004) survival. Fifteen percent of patients with the highest level of tumour CCR7 immunopositivity relapsed with systemic metastases. These data demonstrated that CCR7 expression was associated with cervical nodal and systemic metastases from tonsillar cancers. High levels of CCR7 expression predicted a poor prognosis.

An Update on Cryopreservation of Adipose Tissue

Panniculectomy & Abdominoplasty CPG

Currently, fat transplantation occurs immediately after harvesting procedures. Because low rates of fat graft take are well reported in the literature, many patients require multiple surgical procedures for fat graft harvest. These subsequent procedures lead to increased cost, donor-site morbidity, and patient discomfort in the long term. The ability to preserve our patients' own adipose aspirate would allow us to counteract these shortcomings and ultimately improve the clinical outcome after fat grafting. Unfortunately, there is no optimal and practical adipose tissue cryopreservation protocol for use by the plastic surgeon at the present time. Because of this dilemma, the senior author (L.L.Q.P.) has investigated this concept in an effort to create a protocol that is both technically sound and clinically achievable to allow for the long-term preservation of adipose tissue. In this article, the authors aim to outline this effort, review current clinical applications that have been reported in the literature, and detail exciting future perspectives in the use of preserved lipoaspirates for repeated fat grafting procedures or in the form of cell-based therapy engineered for reconstructive endeavors for their patients.

Parathyroid hormone-related protein and ezrin are up-regulated in human lung cancer bone metastases

MSTS 2018 - Femur Mets and MM

Lung cancer often metastasizes to bone in patients with advanced disease. Identification of the factors involved in the interactions between lung cancer cells and bone will improve the prevention and treatment of bone metastases. We identified changes in metastasis-related gene expression of human HARA lung squamous carcinoma cells co-cultured with neonatal mouse calvariae using a pathway-specific microarray analysis. Nine genes were up-regulated and two genes down-regulated in HARA cells co-cultured with mouse calvariae. Five of the nine up-regulated genes, including caveolin 1, CD44, EphB2, ezrin, and Parathyroid hormone-related protein (PTHrP), and one down-regulated gene, SLPI, were further confirmed by Reverse transcription-polymerase chain reaction (RT-PCR). A mouse model was subsequently used to study the role of PTHrP and ezrin in bone metastasis in vivo. PTHrP (all three isoforms) and ezrin were up-regulated in HARA cells at sites of bone metastasis as detected by RT-PCR and immunohistochemistry. The PTHrP 141 mRNA isoform was increased by the greatest extent (13.9-fold) in bone metastases compared to PTHrP 139 and PTHrP 173 mRNA. We then generated a HARA cell line in which PTHrP expression was inducibly silenced by RNA interference. Silencing of PTHrP expression caused significant reduction of submembranous F-actin and decreased HARA cell invasion. Ezrin up-regulation was confirmed by Western blots on HARA cells co-cultured with adult mouse long bones. Further, Transforming growth factor beta (TGF-beta) was identified as one of the factors in the bone microenvironment that was responsible for the up-regulation of ezrin. The identification of PTHrP and ezrin as important regulators of lung cancer bone metastasis offers new mechanistic insights into the metastasis of lung cancer and provides potential targets for the prevention and treatment of lung cancer metastasis.

Common tongue conditions in primary care

Reconstruction After Skin Cancer

Although easily examined, abnormalities of the tongue can present a diagnostic and therapeutic dilemma for physicians. Recognition and diagnosis require a thorough history, including onset and duration, antecedent symptoms, and tobacco and alcohol use. Examination of tongue morphology and a careful assessment for lymphadenopathy are also important. Geographic tongue, fissured tongue, and hairy tongue are the most common tongue problems and do not require treatment. Median rhomboid glossitis is usually associated with a candidal infection and responds to topical antifungals. Atrophic glossitis is often linked to an underlying nutritional deficiency of iron, folic acid, vitamin B12, riboflavin, or niacin and resolves with correction of the underlying condition. Oral hairy leukoplakia, which can be a marker for underlying immunodeficiency, is caused by the Epstein-Barr virus and is treated with oral antivirals. Tongue growths usually require biopsy to differentiate benign lesions (e.g., granular cell tumors, fibromas, lymphoepithelial cysts) from premalignant leukoplakia or squamous cell carcinoma. Burning mouth syndrome often involves the tongue and has responded to treatment with alpha-lipoic acid, clonazepam, and cognitive behavior therapy in controlled trials. Several trials have also confirmed the effectiveness of surgical division of tongue-tie (ankyloglossia), in the context of optimizing the success of breastfeeding compared with education alone. Tongue lesions of unclear etiology may require biopsy or referral to an oral and maxillofacial surgeon, head and neck surgeon, or a dentist experienced in oral pathology. Copyright © 2010 American Academy of Family Physicians.

Biomechanical behavior of human crural fascia in anterior and posterior regions of the lower limb

DOD - Acute Comp Syndrome CPG

The present work focuses on the numerical modeling of the mechanical behavior of the crural fascia, the deep fascia enwrapping the lower limb muscles. This fascia has an important biomechanical role, due to its interaction with muscles during contraction and its association with pathological events, such as compartment syndrome. The mechanical response of the crural fascia is described by assuming a hyperelastic fiber-reinforced constitutive model, with families of fibers disposed according to the spatial disposition of the collagen network, as shown in histological analyses. A two-dimensional finite element model of a lower limb transversal section has been developed to analyze deformational behavior, with particular attention on interaction phenomena between crural fascia and enwrapped muscles. The constitutive model adopted for the crural fascia well fits experimental data taken along the proximalâ??distal and medialâ??lateral directions. The finite element analysis allows for interpreting the relation between change in volume and pressure of muscle compartments and the crural fascia deformation.

An unusual case of ewing sarcoma: A middle-aged woman with multiple recurrences over 36 years

MSTS 2022 - Metastatic Disease of the Humerus

Ewing sarcoma (EWS) is a primary bone tumor that most often occurs in the long bones of young patients. EWS is typically an aggressive tumor that is highly sensitive to radiation therapy; recurrences often occur, usually within a year of treatment. We present a case of EWS that first presented in a patient at the age of 40 with extraosseous disease. The patient was treated initially with radiation and surgery. Over the following 36-year period, the tumor recurred once and metastasized twice. The morphologic, immunohistochemical, and cytogenetic features of this tumor were typical of EWS, and the tumor was highly responsive to radiation therapy. The unusually prolonged course in this patient demonstrates significant heterogeneity in the biological behavior of EWS, and the importance of randomized trials in cancer therapy.

The impact of liposuction cannula size on adipocyte viability

Panniculectomy & Abdominoplasty CPG

PURPOSE: Autologous fat transfer ("fat grafting") is widely used in cosmetic and reconstructive surgery, but long-term outcomes remain inconsistent. Each step in the transfer process can cause mechanical damage to the graft tissue. In particular, liposuction breaks aspirated adipose tissue into distinct globules and subjects it to shear forces, both of which can impact subsequent fat graft viability. The optimal size of the liposuction cannula for use in fat grafting is not known. METHODS AND TECHNIQUES: Controlled lipoaspirate samples were collected from adult female patients undergoing elective liposuction of the abdomen and flanks with uniform aspiration pressure (-25 in Hg) and either a 3- or 5-mm standard blunt-tip liposuction cannula. Individual grafts of 1.00+/-(0.01) gram were prepared and injected into the bilateral flanks of nude mice with a 14-gauge catheter. After six weeks, these grafts were explanted and analyzed by weight and histology. RESULTS: At six weeks, fat lobules in the 5-mm group retained 25% more weight than those in the 3-mm group [mean (SD), 0.70 (0.07) vs 0.56 (0.09) g, n=24/group, P<0.01). Histologic analysis revealed more intact, nucleated adipocytes in the 5-mm group than in the 3-mm group [4.42 (0.92) vs 3.10 (0.56) on a 1-5 rating scale]. The 5-mm group exhibited both less infiltrate [1.58 (0.17) vs 3.13 (0.70)] and less fibrosis [1.67 (0.45) vs 3.13 (0.89)] than the 3-mm group. CONCLUSIONS: In this controlled model of fat grafting with either a 5- or 3-mm aspiration cannula, the use of a larger aspiration cannula led to improved graft retention and quality. This finding has important implications for clinical applications of fat grafting.

Vulnerable patients with a fractured neck of femur: nutritional status and support in hospital

Management of Hip Fractures in the Elderly

BACKGROUND AND AIM: Malnutrition has serious consequences for recovery and increases the risk of complications in hospital patients. Fractured neck of femur (NOF) patients may be particularly at risk because of their old age and frail state of health. We conducted an observational study to evaluate the nutritional state and the nutritional support, which was provided to this group during their stay in hospital. METHODS: Twenty-five consecutive people admitted to an orthopaedic ward with a fractured NOF at Charing Cross Hospital, London were recruited. Anthropometric measures, biochemical indices, 3 days dietary intake and dietetic referral rates were collected. RESULTS: Patients had a significantly lower body mass index (BMI) compared with the mean BMI for sex and age in an elderly UK population (21.97 +/- 1.06 versus 26.73 +/- 0.03 kg m(-2); P < 0.005). They took just 58.6% of their energy requirements in hospital (4219 +/- 319 versus 7199 +/- 202 kJ mean(-1) daily intake over 3 days in week 2). Using the hospitals own nutritional risk assessment tool 56% of patients were found to be at risk of malnutrition on admission, which increased to 68% after 2-3 weeks. Of these 64% were referred to a dietitian and were given nutritional supplements. Nutritional assessment revealed that their nutritional status worsened during stay. CONCLUSIONS: This group of patients with fractured NOF is likely to be malnourished on admission and to show a rapid deterioration in its nutrition status during admission. Energy needs were not met in up to 50% of patients. These results reinforce the need to screen, supplement and monitor fractured NOF patients

Comparison of self-reported knee injury and osteoarthritis outcome score to performance measures in patients after total knee arthroplasty

OAK 3 - Non-arthroplasty tx of OAK

OBJECTIVE: To characterize patient outcomes after total knee arthroplasty (TKA) by (1) examining changes in self�report measures (Knee Injury and Osteoarthritis Outcome Score [KOOS]) and performance measures over the first 6 months after TKA, (2) evaluating correlations between changes in KOOS self�report function (activities of daily living [ADL] subscale) and functional performance (6�minute walk [6MW]), and (3) exploring how changes in pain correlate with KOOS ADL and 6MW outcomes. DESIGN: Retrospective cohort evaluation. SETTING: Clinical research laboratory. PATIENTS (OR PARTICIPANTS): Thirty�nine patients scheduled for a unilateral, primary TKA for end�stage unilateral knee osteoarthritis. METHODS: Patients were evaluated 2 weeks before surgery and 1, 3, and 6 months after surgery. MAIN OUTCOME MEASUREMENTS: KOOS, 6MW, timed�up�and�go (TUG), and stair climbing tests (SCT), quadriceps strength. RESULTS: Three of 5 KOOS subscales significantly improved by 1 month after TKA. All 5 KOOS subscales significantly improved by 3 and 6 months after TKA. In contrast, performance measures (6MW, TUG, SCT, and quadriceps strength) all significantly declined from preoperative values by 1 month after TKA and significantly improved from preoperative values by 3 and 6 months after TKA; yet, improvements from preoperative values were not clinically meaningful. Pearson correlations between changes in the KOOS ADL subscale and 6MW from before surgery were not statistically significant at 1, 3, or 6 months after TKA. In addition, KOOS Pain was strongly correlated with KOOS ADL scores at all times, but KOOS Pain was not correlated with 6MW distance at any time. CONCLUSIONS: Patient self�report by using the KOOS did not reflect the magnitude of performance deficits present after surgery, especially 1 month after TKA. Self�report KOOS outcomes closely paralleled pain relief after surgery, whereas performance measures were not correlated with pain. These results emphasize the importance of including performance measures when tracking recovery after TKA as opposed to solely relying on self�reported measures.

[Application of the anatomic plate and trapezoid plate in comminuted intertrochanteric fracture combined with trochanteric coronal position fracture: a controlled clinical trial]

Management of Hip Fractures in the Elderly

OBJECTIVE: To investigate the therapeutic effect and operative characteristic of the anatomic plate and trapezoid plate for treament of the comminuted intertrochanteric fracture combined with trochanteric coronal position fracture.METHODS: From Jan. 1998 to Mar. 2007, 57 patients suffered from comminuted intertrochanteric fracture combined with trochanteric coronal position fracture were randomly divided into two groups, 21 patients in trapezoid plate group were treated with the trapezoid compression plate, included 11 males and 10 females with an average age of 41.8 years; and 36 patients in anatomic plate group were treated with the anatomic plate, included 17 males and 19 females with an average age of 42.1 years. All of the 57 fractures were A3 type according to AO classification. The functions of hip joints were evaluated according to the Harris hip functional standard score.RESULTS: All 57 patients were followed-up for 5 months to 9 years and 3 months with an average of 4.8 years. The healing time of the fractures was from 8 to 20 weeks with an average of 12.8 weeks. The results of Harris scoring showed the pain scores of the anatomic plate group were higher than that of the trapezoid plate group (P < 0.05). The function scores of the anatomic plate group were higher than that of the trapezoid plate group (P < 0.01). There were no statistically significant different in the deformity and ranges of joint scores between two groups (P > 0.05).CONCLUSION: In unstable comminuted intertrochanteric fracture combined with trochanteric coronal position fracture, the lateral wall of trochanteric is often destroyed. The anatomic plate and the trapeziod compression plate can provide effective internal fixation, while many othere internal fixation methods were limited in this kind of fracture. As compared with the anatomic plate fixation, the trapezoid compression plate fixation of comminuted intertrochanteric fracture combined with trochanteric coronal position fracture have several advantages, such as fewer complications, faster union of fracture and earlier recovery of joint functions

Assessment of a Prototype Apache Flight Eyewear

Upper Eyelid and Brow Surgery

BACKGROUND: Apache pilots needing refractive correction are issued modified HGU-4/P aviator spectacles. However, a recently published survey found field of view (FOV) dissatisfaction with the current spectacles when sighting in with a Helmet Display Unit (HDU). A current Air Force flight frame was modified in-lab and the purpose of this study was to evaluate the FOV with the current Apache flight frame vs. the modified flight frame. METHODS: Recruited were 21 Apache pilots to assess FOV under three conditions: 1) wearing the current Apache frame; 2) wearing the modified Apache frame; and 3) wearing no frame. The main outcome measure was total FOV of four quadrants tested: superior left (45 degrees ); superior right (135 degrees ); inferior right (225 degrees ); and inferior left (315 degrees ). RESULTS: No significant differences in FOV were seen between the two frames tested while wearing the current Apache helmet (P = 0.33) and the new Apache helmet (P = 0.64). However, there were significant differences in FOV between the no frame condition and the two frame conditions tested with both helmets (P < 0.001). DISCUSSION: No significant differences in FOV were seen between the two frames tested while wearing either Apache helmet. However, with both helmets there were significant differences in FOV between the no frame condition and the two frame conditions tested. This suggests that wearing no eyewear is still optimal in integrating the HDU device. With advances in contact lens technology, future research can study the viability of the latest generation of multifocal contact lenses with Apache aviators. Walsh DV, Jurek GM, McLean WE, Statz JK, Allen RL, Riggs DW. Assessment of a prototype Apache flight eyewear. Aerosp Med Hum Perform. 2016; 87(9):800-805.

Are patient-specific cutting blocks cost-effective for total knee arthroplasty?

Surgical Management of Osteoarthritis of the Knee CPG

BACKGROUND: Using patient-specific cutting blocks for TKA increases the cost to the hospital for these procedures, but it has been proposed they may reduce operative times and improve implant alignment, which could reduce the need for revision surgery. QUESTIONS/PURPOSES: We compared TKAs performed with patient-specific cutting blocks with those performed with traditional instrumentation to determine whether there was improved operating room time management and component coronal alignment to support use of this technology. METHODS: We retrospectively reviewed 57 patients undergoing primary TKAs using patient-specific custom cutting blocks for osteoarthritis and compared them with 57 matched patients undergoing TKAs with traditional instrumentation during the same period (January 2009 to September 2010). At baseline, the groups were comparable with respect to age, sex, and BMI. We collected data on operative time (total in-room time and tourniquet time) and measured component alignment on plain radiographs. RESULTS: On average, TKAs performed with patient-specific instrumentation had similar tourniquet times (61.0 versus 56.2 minutes) but patients were in the operating room 12.1 minutes less (137.2 versus 125.1 minutes) than those in the standard instrumentation group. We observed no difference in the femorotibial angle in the coronal plane between the two groups. CONCLUSIONS: Patient-specific instrumentation for TKA shows slight improvement in operating room time management but none in component alignment postoperatively. Therefore, routine use of this new technology may not be cost-effective in its current form. LEVEL OF EVIDENCE: Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence

Combined Lymphedema and Capillary Malformation of the Lower Extremity

Panniculectomy & Abdominoplasty CPG

UNLABELLED: Primary lymphedema and capillary malformation are independent vascular malformations that can cause overgrowth of the lower extremity. We report a series of patients who had both types of malformations affecting the same leg. The condition is unique but may be confused with other types of vascular malformation overgrowth conditions (eg, Klippel-Trenaunay and Parkes Weber). METHODS: Our Vascular Anomalies Center and Lymphedema Program databases were searched for patients with both capillary malformation and lymphedema. Diagnosis of lymphedema-capillary malformation was made by history, physical examination, and imaging studies. Because lymphedema-capillary malformation has phenotypical overlap with other conditions, only patients who had imaging confirming their diagnosis were included in the analysis. Clinical and radiological features, morbidity, and treatment were recorded. RESULTS: Eight patients (4 females and 4 males) had confirmed lymphedema-capillary malformation. Referring diagnosis was Klippel-Trenaunay syndrome (n = 4), diffuse capillary malformation with overgrowth (n = 3), or lymphatic malformation (n = 1). The condition was unilateral (n = 6) or bilateral (n = 2). Morbidity included infection (n = 6), difficulty fitting clothes (n = 6), bleeding or leaking vesicles (n = 5), leg length discrepancy (n = 4), and difficulty ambulating (n = 3). All patients were managed with compression regimens. Operative management was liposuction (n = 3), treatment of phlebectatic veins (n = 3), staged skin/subcutaneous excision (n = 1), and/or epiphysiodesis (n = 1). CONCLUSIONS: Lymphedema and capillary malformation can occur together in the same extremity. Both conditions independently cause limb overgrowth primarily because of subcutaneous adipose deposition. Compression garments and suction-assisted lipectomy can improve the condition. Lymphedema-capillary malformation should not be confused with other vascular malformation overgrowth diseases that have different morbidities and treatments.

Vitamin D and vitamin D analogues for preventing fractures associated with involutional and post-menopausal osteoporosis

Management of Hip Fractures in the Elderly

BACKGROUND: Due to their known effects on bone metabolism, vitamin D and related compounds have been proposed for the prevention of osteoporosis and fractures. OBJECTIVES: To determine the effects of supplementation with Vitamin D or a Vitamin D analogue in the prevention of fractures of the axial and appendicular skeleton in elderly men or women with involutional or post-menopausal osteoporosis. SEARCH STRATEGY: We searched MEDLINE, EMBASE, CINAHL, LILACS, CABNAR, BIOSIS, HEALTHSTAR, Current Contents, The Cochrane Database of Systematic Reviews, the Cochrane Musculoskeletal Injuries Group trials register, and bibliographies of identified trials and reviews. Date of the most recent search: September 2000. SELECTION CRITERIA: Any randomised or quasi-randomised trial which compared vitamin D or a vitamin D analogue, either alone or in combination with calcium supplementation, with a placebo, no intervention, or the administration of calcium supplements, with eligible fracture outcomes, in elderly men or women with involutional or post-menopausal osteoporosis. DATA COLLECTION AND ANALYSIS: Two reviewers independently assessed trial quality, by use of a nine item scale, and extracted data. Additional information was sought from trialists. Where possible the data were pooled. Pooling of data, where it was admissible, used pooled relative risk and fixed effects model. MAIN RESULTS: Almost all estimates of treatment effects are based on single studies. Administration of vitamin D3 alone without calcium co-supplementation was not associated with any reduction in incidence of hip fracture (relative risk (RR) 1.20, 95% confidence interval (CI) 0.83, 1.75) or other non-vertebral fracture. Administration of vitamin D3 with calcium co-supplementation to frail elderly people in sheltered accommodation was associated with a reduction in incidence of hip fracture (RR 0.74, 95% CI 0.60, 0.91). In healthy younger, ambulant participants the effect on hip fracture is unknown (RR 0.36, 95% CI 0.01, 8.78), although there appears to be a significant overall effect on non-vertebral fracture incidence in this group ( RR 0.46, 95% CI 0.23,0.90). Calcitriol (1,25 dihdyroxy vitamin D) was effective in reducing the incidence of vertebral deformity (RR 0.49, 95% CI 0.25, 0.95). Calcitriol was more effective than calcium in reducing the frequency of new vertebral deformities during the third year of treatment (RR 0.28, 95% CI 0.15, 0.52). 1-alpha-hydroxy vitamin D was effective in reducing the incidence of non-vertebral fractures in a single small study of elderly people whose mobility was impaired by neurological disease (RR 0.12, 95% CI 0.02, 0.95). No statistically significant effects were found for other comparisons of vitamin D or its analogues against each other, with and without calcium supplementation. REVIEWER'S CONCLUSIONS: Uncertainty remains about the efficacy of regimens which include vitamin D or its analogues in fracture prevention. Particularly if co-supplementation of calcium is required, significant cost differences are likely to exist between regimens. Further large randomised trials are currently being conducted to clarify the effectiveness of community fracture prevention programmes employing vitamin D supplementation

Osteotomy for treating knee osteoarthritis

OAK 3 - Non-arthroplasty tx of OAK

BACKGROUND: Patients with unicompartmental osteoarthritis of the knee can be treated with an osteotomy. The goal of an osteotomy is to unload the diseased compartment of the knee. This is the second update of the original review published in The Cochrane Library, Issue 1, 2005. OBJECTIVES: To assess the benefits and harms of an osteotomy for treating patients with knee osteoarthritis, including the following main outcomes scores: treatment failure, pain and function scores, health-related quality of life, serious adverse events, mortality and reoperation rate. SEARCH METHODS: The Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE (Current Contents, HealthSTAR) were searched until November 2013 for this second update. SELECTION CRITERIA: Randomised and controlled clinical trials comparing an osteotomy with other treatments for patients with unicompartmental osteoarthritis of the knee. DATA COLLECTION AND ANALYSIS: Two review authors independently selected trials, extracted data and assessed risk of bias using the domains recommended in the 'Risk of bias' tool of The Cochrane Collaboration. The quality of the results was analysed by performing overall grading of evidence by outcome using the GRADE (Grades of Recommendation, Assessment, Development and Evaluation) approach. MAIN RESULTS: Eight new studies were included in this update, for a total of 21 included studies involving 1065 people.In four studies, the randomised sequence was adequately generated and clearly described. In eight studies, allocation concealment was adequately generated and described. In four studies, the blinding procedures were sufficient. In six studies, incomplete outcome data were not adequately addressed. Furthermore, in 11 studies, the selective outcome reporting item was unclear because no study protocol was provided.Follow-up of studies comparing different osteotomy techniques was too short to measure treatment failure, which implicates revision to a knee arthroplasty.Four studies evaluated a closing wedge high tibial osteotomy (CW-HTO) with another high tibial osteotomy (aHTO). Based on these studies, the CW-HTO group had 1.8% (95% confidence interval (CI) -7.7% to 4.2%; low-quality evidence) more pain compared with the aHTO group; this finding was not statistically significant. Pooled function in the CW-HTO group was 0.5% (95% CI -3.8% to 2.8%; low-quality evidence) higher compared with the aHTO group; this finding was not statistically significant. No data on health-related quality of life and mortality were presented.Serious adverse events were reported in only four studies and were not significantly different (low-quality evidence) between groups. The reoperation rate were scored as early hardware removal because of pain and pin track infection due to the external fixator. Risk of reoperation was 2.6 (95% CI 1.5 to 4.5; low-quality evidence) times higher in the aHTO group compared with the CW-HTO group, and this finding was statistically significant.The quality of evidence for most outcomes comparing different osteotomy techniques was downgraded to low because of the numbers of available studies, the numbers of participants and limitations in design.Two studies compared high tibial osteotomy versus unicompartmental knee replacement. Treatment failure and pain and function scores were not different between groups after a mean follow-up of 7.5 years. The osteotomy group reported more adverse events when compared with the unicompartmental knee replacement group, but the difference was not statistically significant. No data on health-related quality of life and mortality were presented.No study compared an osteotomy versus conservative treatment.Ten included studies compared differences in perioperative or postoperative conditions after high tibial osteotomy. In most of these studies, no statistically significant differences in outcomes were noted between groups. AUTHORS' CONCLUSIONS: The conclusion of this update did not change: Valgus high tibial osteotomy reduces pain and improves knee function in patients with medial compartmental osteoarthritis of the knee. However, this conclusion is based on within-group comparisons, not on non-operative controls. No evidence suggests differences between different osteotomy techniques. No evidence shows whether an osteotomy is more effective than alternative surgical treatment such as unicompartmental knee replacement or non-operative treatment. So far, the results of this updated review do not justify a conclusion on benefit of specific high tibial osteotomy technique for knee osteoarthritis.

Uncemented STAR total ankle prostheses. Three to eight-year follow-up of fifty-one consecutive ankles

Surgical Management of Osteoarthritis of the Knee CPG

BACKGROUND: The feasibility of replacing the ankle joint has been a matter of speculation for a long time. In recent years, the designs of ankle prostheses have been improved, and three designs, all used without bone cement, currently dominate the market. However, documentation of the clinical results of the use of these prostheses is sparse. We reviewed the intermediate-term results of fifty-one consecutive Scandinavian Total Ankle Replacements (STAR). METHODS: Between 1993 and 1999, fifty-one consecutive ankles were replaced with an uncemented, hydroxyapatite-coated STAR total ankle prosthesis. Clinical examination for the present study was performed by one surgeon who had not taken part in the operations. Standardized radiographs were used. Complications and failures were recorded, and patient satisfaction and functional outcome scores were determined for all patients with an unrevised implant. RESULTS: Twelve ankles had to be revised. Seven were revised because of loosening of at least one of the components; two, because of fracture of the meniscus; and three, for other reasons. A component was exchanged in seven of the twelve revisions, whereas the ankle was successfully fused in the other five. An additional eight ankles had radiographic signs of loosening. The thirty-nine unrevised ankles (thirty-seven patients) were examined after thirty-six to ninety-seven months (median, fifty-two months). The patient was satisfied with the result after thirty-one of the ankle replacements, somewhat satisfied after two, and not satisfied after six. The median Kofoed score increased from 39 points before the surgery to 70 points at the time of the follow-up examination. A median follow-up score of 74 points was recorded when the system described by Mazur et al. and the AOFAS (American Orthopaedic Foot and Ankle Society) system were used. The median range of motion was approximately the same preoperatively and postoperatively. The estimated five-year survival rate, with revision for any reason as the end point, was 0.70. When radiographic loosening of either component was used as the end point, the estimated five-year radiographic survival rate was significantly better for the last thirty-one ankles treated in the series (p = 0.032). CONCLUSIONS: Total ankle replacement may be a realistic alternative to arthrodesis, provided that the components are correctly positioned and are of the correct size. However, the risks of loosening and failure are still higher than are such risks after total hip or total knee replacement

Bone reconstruction with a free vascularized fibular graft after giant cell tumour resection

Distal Radius Fractures

Free vascularized fibular transfers were used in six patients with extensive bony defects after excision of a giant cell tumour of the distal end of the radius. The results have been satisfactory.

Lung cancer screening results in the National Cancer Institute New York study

Reconstruction After Skin Cancer

METHODSThree major medical centers participated in the study, recruiting approximately 10,000 cigarette smoking men older than 45 years of age at each center: Memorial Sloan-Kettering Cancer Center (MSKCC) in New York, NY, Johns Hopkins Hospital in Baltimore, MD, and The Mayo Clinic in Rochester, MN. At MSKCC, the men were divided randomly into two groups: a dual screen group received four monthly sputum cytology examinations in addition to annual posteroanterior and lateral chest X-rays and an X-ray only group received annual chest X-rays but no sputum examinations. The men suspected of lung carcinoma because of radiologic or sputum cytology findings were referred immediately for evaluation, and those with operable lung carcinoma were recommended for surgery and treated with intent to cure.RESULTSThe men who entered into the study remained in the screening program for 5- 8 years, depending on their date of enrollment, and were followed for 2 years after screening. Follow-up was completed on more than 99%. There were 53 of the 10,040 men in the study who were found to have lung carcinoma on initial examination (prevalence): 23 were in the X-ray only group; of 30 found in the dual screen group, 9 (all with squamous cell carcinoma) were detected by cytology alone. During the entire study and the 2-year follow-up period, 354 of the 10,040 men developed lung carcinoma, equally divided between the dual screen and X-ray only groups. Nearly two-thirds (190 men) had lesions that were detected by screening, and over 50% (100 men) were in Stage I. Excluding oat cell carcinoma, during the screening period 175 of 250 carcinomas (70%) were detected by screening. In contrast, during the 2-year post-screening period, 61 lung carcinomas were diagnosed of which only 12 (20%) were Stage I. Chest X-ray was most effective in detecting peripheral adenocarcinomas of the lung, which were the most common cell type. Cytology was most effective in detecting early epidermoid carcinomas of major bronchi. The epidermoid carcinomas grew slowly, metastasized late, and after becoming visible by X-ray could be treated equally effectively as in the earlier occult stage. Forty percent of all the lung carcinomas were detected in Stage I, and at least two-thirds of the patients with Stage I lung carcinoma treated by complete resection did not die of their disease. Overall 5-year survival of all patients with lung carcinoma who had enrolled in the detection program was 35%, compared with 13% for the United States as a whole during this same time period.CONCLUSIONSSputum cytology and the chest X-ray complemented each other as lung carcinoma detection techniques. The chest X-ray best detected peripheral adenocarcinomas of the lung, which are the most common type of lung carcinoma. Sputum cytology detected epidermoid carcinomas arising in major bronchi, but these are slow growing tumors that can be resected and cured after becoming visible by chest X-ray. Thus, for subjects at risk of lung carcinoma who could be followed by annual chest X-rays, sputum cytology did not improve survival, but for high risk subjects who had only a single screening examination, sputum cytology increased the number of early lung carcinomas detected. The design of the current study did not permit evaluation of chest X-ray screening versus nonscreening for prevention of death from lung carcinoma. However, the large proportion of Stage I lung carcinomas and the high survival rate of patients in this study compared with Surveillance, Epidemiology, and End Results program data strongly suggested that screening for lung carcinoma in high risk populations is a valuable public health measure.BACKGROUNDAnecdotal reports of radiologically occult early stage lung carcinomas detected by sputum cytology suggested that screening by cytology might lead to earlier diagnosis, more effective surgical therapy, and lower death rates from lung carcinoma. Thus, a randomized study was undertaken to evaluate sputum cytology as a lung carcinoma screening technique supplementing the chest X-ray.

Analysis of symmetry between lower limbs during gait of older women with bilateral knee osteoarthritis

OAK 3 - Non-arthroplasty tx of OAK

Background: Osteoarthritis (OA) is a common condition in older adults, with high epidemiological, clinical, and economic burden worldwide. In clinical practice, patients with knee OA often walk with abnormal gait patterns because of pain, stiffness and/or mobility dysfunctions. Therefore, assessing the symmetry of the lower limbs might improve the rehabilitation treatment and prescription of walking devices. Aims: To compare the symmetry of step length and single support phase between lower limbs during gait of older women with bilateral knee OA and asymptomatic controls, and to verify if there is difference between these two groups in relation to velocity, cadence, step length and single support phase. Methods: This cross-sectional study included a convenience sample of 66 community-dwelling older women aged � 65 years with a medical diagnosis of symptomatic bilateral knee OA (n = 33) and asymptomatic controls (n = 33), matched by age and body mass index. All gait parameters were obtained using the GAITRite® system. Results: Mean age of the sample was 72.6 ± 4.0 years. Participants with OA walked with lower velocity (p = 0.001), cadence (p = 0.009) and step length bilaterally (both p = 0.001). No significant difference was found between groups in the symmetry of step length between lower limbs, single support phase and symmetry of single support phase between lower limbs. Conclusion: Older women with bilateral knee OA walk with lower velocity, cadence and step length, but have the same symmetry in the step length and single support phase between lower limbs as asymptomatic older women.

Multicomponent training program with weight-bearing exercises elicits favorable bone density, muscle strength, and balance adaptations in older women

Management of Hip Fractures in the Elderly

Physical exercise is advised as a preventive and therapeutic strategy against aging-induced bone weakness. In this study we examined the effects of 8-month multicomponent training with weight-bearing exercises on different risk factors of falling, including muscle strength, balance, agility, and bone mineral density (BMD) in older women. Participants were randomly assigned to either an exercise-training group (ET, n = 30) or a control group (CON, n = 30). Twenty-seven subjects in the ET group and 22 in the CON group completed the study. Training was performed twice a week and was designed to load bones with intermittent and multidirectional compressive forces and to improve physical function. Outcome measures included lumbar spine and proximal femoral BMD (by dual X-ray absorptiometry), muscle strength, balance, handgrip strength, walking performance, fat mass, and anthropometric data. Potential confounding variables included dietary intake, accelerometer-based physical activity, and molecularly defined lactase nonpersistence. After 8 months, the ET group decreased percent fat mass and improved handgrip strength, postural sway, strength on knee flexion at 180 degrees /s, and BMD at the femoral neck (+2.8%). Both groups decreased waist circumference and improved dynamic balance, chair stand performance, strength on knee extension for the right leg at 180 degrees /s, and knee flexion for both legs at 60 degrees /s. No associations were found between lactase nonpersistence and BMD changes. Data suggest that 8 months of moderate-impact weight-bearing and multicomponent exercises reduces the potential risk factors for falls and related fractures in older women

Gamma and other cephalocondylic intramedullary nails versus extramedullary implants for extracapsular hip fractures in adults

Management of Hip Fractures in the Elderly

BACKGROUND: Two types of implants used for the surgical fixation of extracapsular hip fractures are cephalocondylic intramedullary nails, which are inserted into the femoral canal proximally to distally across the fracture, and extramedullary implants (e.g. the sliding hip screw). OBJECTIVES: To compare cephalocondylic intramedullary nails with extramedullary implants for extracapsular hip fractures in adults. SEARCH STRATEGY: We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (April 2010), The Cochrane Central Register of Controlled Trials (The Cochrane Library 2010, Issue 1), MEDLINE (1950 to March 2010), EMBASE (1980 to 2010 Week 13), and other sources. SELECTION CRITERIA: All randomised and quasi-randomised controlled trials comparing cephalocondylic nails with extramedullary implants for extracapsular hip fractures. DATA COLLECTION AND ANALYSIS: Both authors independently assessed trial quality and extracted data. Wherever appropriate, results were pooled. MAIN RESULTS: We included 43 trials containing predominantly older people with mainly trochanteric fractures. Twenty-two trials (3749 participants) compared the Gamma nail with the sliding hip screw (SHS). The Gamma nail was associated with increased risk of operative and later fracture of the femur and increased reoperation rate. There were no major differences between implants in wound infection, mortality or medical complications.Five trials (623 participants) compared the intramedullary hip screw (IMHS) with the SHS. Fracture fixation complications were more common in the IMHS group. Results for post-operative complications, mortality and functional outcomes were similar in both groups.Three trials (394 participants) showed no difference in fracture fixation complications, reoperation, wound infection and length of hospital stay for proximal femoral nail (PFN) versus the SHS.None of the 10 trials (1491 participants) of other nail versus extramedullary implant comparisons for trochanteric fractures provided sufficient evidence to establish definite differences between the implants under test.Two trials (65 participants) found intramedullary nails were associated with fewer fracture fixation complications than fixed nail plates for unstable fractures at the level of the lesser trochanter.Two trials (124 participants) found a tendency to less fracture healing complications with the intramedullary nails compared with fixed nail plates for subtrochanteric fractures. AUTHORS' CONCLUSIONS: With its lower complication rate in comparison with intramedullary nails, and absence of functional outcome data to the contrary, the SHS appears superior for trochanteric fractures. Further studies are required to confirm whether more recently developed designs of intramedullary nail avoid the complications of previous nails. Intramedullary nails may have advantages over fixed angle plates for subtrochanteric and some unstable trochanteric fractures, but further studies are required. CEPHALOCONDYLIC INTRAMEDULLARY NAILS VERSUS EXTRAMEDULLARY IMPLANTS FOR EXTRACAPSULAR HIP FRACTURES IN ADULTS: Fractures of the thigh bone (femur) just below the hip joint capsule (extracapsular hip fractures) may be surgically fixed using a variety of implants. One particular type of implant is the sliding hip screw, which consists of a screw that is inserted into the upper part of the (femur) to bridge (fix) the fracture. This screw can move within a metal barrel connected to a plate that is screwed to the outside of the femur. Implants of this sort of design are called 'extramedullary'. Intramedullary implants are nails inserted from the top of the femur into the inner cavity of the femur bone ('the medulla') and held in place with screws. This review compared these two types of implants in predominantly older populations.The main results were for the comparisons of various types of intramedullary nails with the sliding hip screw. Twenty-two trials, involving 3749 participants, tested the Gamma nail. Five trials, involving 623 participants, tested the intramedullary hip screw (IMHS). Three trials, involving 394 participants, tested the proximal femoral nail. Other trials involved newer varieties of intramedullary nails. Most older trials showed a tendency for the nails to be associated with an increased risk of fracture of the thigh bone both during and after the operation. More recent trials testing newer varieties of nails seemed to avoid this specific problem to some extent. The review found that using intramedullary nails resulted in one extra reoperation in every 50 people. Mortality and, where data were available, other long-term outcomes were similar between the implants.The review concluded that current evidence supports the continued use of the sliding hip screw for fixing the more common types of extracapsular hip fractures. This may not be the case for some of the more recently developed designs of intramedullary nails or for specific fracture types, but further research is required to confirm this

The impact of morbid obesity on patient outcomes after total knee arthroplasty

Surgical Management of Osteoarthritis of the Knee CPG

Five hundred fifty patients who underwent primary total knee arthroplasty between 1987 and 2004 with a primary diagnosis of osteoarthritis and 1-year outcome data (Western Ontario and McMaster Osteoarthritis Index [WOMAC]) were evaluated. Patients were stratified into body mass index categories based on the World Health Organization classification of obesity. Patients were dichotomized into a class III morbidly obese group and a non-morbidly obese group. Independent t test and multivariable linear regression were used to determine if a difference existed in the 1-year WOMAC outcome between morbidly obese patients and all other patients. Although 1-year outcomes were worse for morbidly obese patients (P < .05), they showed greater improvement in function compared with non-morbidly obese patients. Morbid obesity does not affect 1-year outcomes in patients who have had a total knee arthroplasty

Total knee arthroplasty after lower extremity amputation: a review of 13 cases

Surgical Management of Osteoarthritis of the Knee CPG

Below knee amputation protects the ipsilateral knee from osteoarthritis and overloads the contralateral knee predisposing it to symptomatic osteoarthritis. We retrospectively reviewed 13 primary total knee arthroplasty (TKAs) in 12 patients with a prior lower extremity amputation. Twelve TKAs were performed on the contralateral side of the amputated limb while only one TKA was performed on the ipsilateral side. The average clinical follow-up was 6.8 +/- 4.8 years. Knee Society Scores improved from 30.4 +/- 11.8 to 88.5 +/- 4.2 after TKA with a prior contralateral amputation. Three (23.1%) patients with TKA after contralateral amputation had aseptic loosening of the tibial component. Patients experience clinically significant improvement with TKA after lower extremity amputation. Augmentation of tibial fixation with a stem may be advisable during TKA after contralateral amputation

Research Paper Differences in tumour characteristics of Hepatocellular Carcinoma between patients with and without Cirrhosis: A population-based study

MSTS 2022 - Metastatic Disease of the Humerus

Background: Liver cirrhosis is a major risk factor for hepatocellular carcinoma (HCC). However, 10%-20% of patients with HCC do not have cirrhosis. The aim of this study was to explore the potential differences in tumour characteristics of HCC between patients with and without cirrhosis. Methods: In this study, we identified total 10,849 patients with HCC diagnosed between 2010 and 2016, from the SEER database. The degree of fibrosis was categorized as "no cirrhosis"(Ishak score 0-4) or "cirrhosis"(Ishak score 5-6). Among all patients with HCC, patients with no cirrhosis and with cirrhosis accounted for 1800 (16.6%) and 9049 (83.4%), respectively. Results: Significant negative correlations were observed between no cirrhosis/cirrhosis and pathological grade (r =-0.074, P <0.001), tumour size (r =-0.186, P <0.001), N stage (r =-0.024, P =0.025), M stage (r =-0.036, P <0.001), liver metastasis (r =-0.024, P =0.014), and lung metastasis (r =-0.027, P =0.006). Logistic multivariate regression analysis showed that, compared with cirrhosis, no cirrhosis is an independent risk predictor of pathological grade [odds ratio (OR), 0.685; 95% confidence interval (CI), 0.571-0.822; P < 0.001], tumour size (OR, 0.392; 95% CI, 0.351-0.437; P < 0.001), N stage (OR, 0.704; 95% CI, 0.561-0.883; P < 0.001), and M stage (OR, 0.671; 95% CI, 0.561-0.804; P < 0.001). Conclusions: Compared with cirrhosis, no cirrhosis is significantly associated with worse pathological grade, larger tumour size, and more lymph node and distant metastases. Patients without cirrhosis that are otherwise neglected in HCC clinical practice require intensive focus in future studies.

Anti-infective therapy with an Er:YAG laser: influence on peri-implant healing

Dental Implant Infection

In addition to conventional treatment modalities (mechanical and chemical), the use of lasers has been increasingly proposed for the treatment of periodontal and peri-implant infections (i.e., cleaning and detoxification of implant surfaces). Preliminary results from basic studies have pointed to the high potential of the Erbium-doped: Yttrium, Aluminum and Garnet (Er:YAG) laser. Furthermore, preliminary clinical data indicate that treatment with this kind of laser may positively influence peri-implant healing. The aim of this research update is to evaluate, based on the currently available evidence, the use of an Er:YAG laser for the treatment of peri-implant infections and to indicate its potential as a new treatment modality.

Calcaneal ultrasound attenuation in older African-American and Caucasian-American women

Management of Hip Fractures in the Elderly

The lower fracture rates among African-American women relative to Caucasian women may reflect their higher bone mass. However, bone mass is not the only determinant of bone strength: the quality and microarchitecture of the bone are also important. Quantitative ultrasound is believed to measure properties of bone strength that are independent of bone mass. To test the hypothesis that there are racial differences in quantitative ultrasound measures of bone, we recruited 154 African-American women age > or = 65 years. A random sample of 300 Caucasian women participating in the Study of Osteoporotic Fractures in Pittsburgh, Pennsylvania, was chosen for comparison. The Walker Sonix UBA 575+ was used to measure calcaneal broadband ultrasonic attenuation (BUA). Duplicate BUA measurements were obtained with a reproducibility of 5%. We measured bone mineral density (BMD) of the hip and calcaneus using single (calcaneus) or dual (hip) energy X-ray absorptiometry. The correlation between BUA and calcaneal BMD was similar in Caucasians (r = 0.66, p < 0.001) and African-Americans (r = 0.58, p < 0.001). Age-adjusted BUA (dB/MHz) was higher among the African-American women than Caucasian women (69.1 and 66.2, respectively), but these differences were not statistically significant, (p = 0.12). Adjustment for calcaneal BMD completely attenuated the racial differences in BUA. BMD at the femoral neck and calcaneus was higher among the African-American women, even after adjusting for age, height and weight. In conclusion, our results suggest that racial differences in rates of fracture cannot be explained by differences in bone quality as assessed by ultrasound attenuation

Analysis of medial flexion gap after medial release for varus deformity by navigation-guided TKA

Surgical Management of Osteoarthritis of the Knee CPG

The goal of this study was to analyze medial flexion gaps after medial release for varus deformity by navigation-guided total knee arthroplasty (TKA). In each patient, a preoperative standing anteroposterior (AP) radiograph of the lower extremity and an AP valgus stress radiograph of the knee were used to measure preoperative mechanical axis angle and valgus stress angle, respectively. The correlation between preoperative varus deformities and medial flexion gap increases as measured by navigation was examined. Patients were assigned to 2 groups: group A (25 knees), in which the difference between the lateral flexion gap (LFG) and the medial flexion gap (MFG) (LFG-MFG) was (less-than or equal to)1 mm; and group B (73 knees), with an LFG-MFG of >1 mm. Mean preoperative mechanical axis angles in groups A and B were 13.21(degrees)(plus or minus)5.01(degrees) varus (range, 3.7(degrees)-23.6(degrees)) and 10.05(degrees)(plus or minus)3.70(degrees) varus (range, 1.9(degrees)-23.7(degrees)), respectively. Mean preoperative valgus stress angles in groups A and B were 1.72(degrees)(plus or minus)0.89(degrees) valgus (range, 0.1(degrees)-4.0(degrees)) and 4.84(degrees)(plus or minus)2.61(degrees) valgus (range, 0.1(degrees)-11.7(degrees)), respectively. A significant difference was observed between the groups in terms of mechanical axis angle (P=.002) and valgus stress angle (P<.001). Furthermore, valgus stress angle was found to be more strongly correlated with medial flexion gap increase than mechanical axis angle. The cutoff values of mechanical axis angle and valgus stress angle in group A were 13.4(degrees) and 2.45(degrees), respectively. This study shows that preoperative valgus stress angle measurements can be used to predict the extent of medial release for varus deformity

Does the liposuction method influence the phenotypic characteristic of human adipose-derived stem cells?

Panniculectomy & Abdominoplasty CPG

Adipose-derived stem cells (ASCs) possess a high differentiation and proliferation potential. However, the phenotypic characterization of ASCs is still difficult. Until now, there is no extensive analysis of ASCs markers depending on different liposuction methods. Therefore, the aim of the present study was to analyse 242 surface markers and determine the differences in the phenotypic pattern between ASCs obtained during mechanical and ultrasound-assisted liposuction. ASCs were isolated from healthy donors, due to mechanical and ultrasound-assisted liposuction and cultured in standard medium to the second passage. Differentiation potential and markers expression was evaluated to confirm the mesenchymal nature of cells. Then, the BD LyoplateTM Human Cell Surface Marker Screening Panel was used. Results shown that both population of ASCs are characterized by high expression of markers specific for ASCs: cluster of differentiation (CD)9, CD10, CD34, CD44, CD49d, CD54, CD55, CD59, CD71 and low expression of CD11a, CD11c and CD144. Moreover, we have noticed significant differences in antigen expression in 58 markers from the 242 studied. Presented study shows for the first time that different liposuction methods are not a significant factor which can influence the expression of human ASCs surface markers.

Fracture of the humerus caused by a slingshot projectile

The Treatment of Pediatric Supracondylar Humerus Fractures AUC

Unconventional and 'non-lethal' weapons are being used in crowd control regularly nowadays. The use of these arms is not risk-free. The paramilitary forces in 2010 used the old fashioned slingshots for crowd control in Kashmir. A young male suffered from a fracture of the distal humerus due to a marble from a slingshot. He was managed by debridement and plaster splintage. Use of apparently innocuous weapons for crowd control is not without risk, as the projectiles fired from them can achieve high velocities and cause significant damage

Quantitative MRI measures of cartilage predict knee replacement: a case-control study from the Osteoarthritis Initiative

Surgical Management of Osteoarthritis of the Knee CPG

OBJECTIVE: Knee osteoarthritis commonly requires joint replacement, substantially reduces quality of life and increases healthcare utilisation and costs. This study aimed to identify whether quantitative measures of articular cartilage structure predict knee replacement, and to establish their utility as outcomes in clinical trials of disease-modifying therapy. METHODS: A nested case-control study was performed in Osteoarthritis Initiative participants, a multicentre observational cohort of 4796 participants with or at risk of knee osteoarthritis. 127 knees were replaced between baseline and 4 years follow-up, and one control knee per case matched for baseline radiographic disease stage (Kellgren-Lawrence grade; KLG), gender and age. Quantitative cartilage measures were obtained from 3 T magnetic resonance images at the exam before knee replacement, and longitudinal change during the previous 12 months when available (n=110). RESULTS: Cartilage thickness loss in the central and total medial femorotibial compartment (primary and secondary predictor variables) was significantly greater in case than control knees (AUC=0.59/0.58). Differences in cartilage loss were greater at earlier than later radiographic disease stages (p<0.01 for interaction with KLG). Cartilage thickness loss in the central tibia was the most predictive longitudinal measure (AUC=0.64). Denuded bone areas in the medial femur were the most predictive and discriminatory cross-sectional measure between case and control knees (AUC=0.66). CONCLUSIONS: This study demonstrates the predictive value of quantitative, MRI-based measures of cartilage for the clinically relevant endpoint of knee replacement, providing support for their utility in clinical trials to evaluate the effectiveness of structure-modifying intervention

Case series and literature review: popliteal artery injury following total knee replacement

Surgical Management of Osteoarthritis of the Knee CPG

We present a case series and literature review of injury to the popliteal vessels during total knee replacement (TKR). This is rare but may be limb-threatening with devastating consequences for the patient. An individual surgeon will see few cases. Over a 28-month period 3913 elective TKRs were performed at three hospitals in East Anglia, United Kingdom. We present nine cases (0.23%) of popliteal artery injury following TKR. All required further investigation and intervention. The range of pathology included intra-operative haemorrhage (3 cases), thrombosis (2 cases), pseudo-aneurysm (3 cases) and arteriovenous fistula (1 case). Definitive treatment of the arterial injury was by primary repair (4 cases), interposition graft (2 cases), bypass graft (2 cases), endovascular stenting (1 case) and primary above-knee amputation (AKA; 1 case). There was morbidity in four patients: two AKAs, one case of foot-drop, and one unsightly fasciotomy scar. There was no mortality. Compared to other published studies (totalling 141 cases) complications resulting from direct arterial injury were significantly more common in our series. Incidence remains steady. More careful surgical technique may be the most effective preventative measure. Ongoing awareness is therefore essential for early diagnosis and management of this rare but serious complication

Preservation of oral health-related quality of life and salivary flow rates after inverse-planned intensity- modulated radiotherapy (IMRT) for head-and-neck cancer

Dental Implant Infection

PURPOSE: To assess whether comprehensive bilateral neck intensity-modulated radiotherapy (IMRT) for head-and-neck cancer results in preserving of oral health-related quality of life and sparing of salivary flow in the first year after therapy., METHODS AND MATERIALS: Twenty-three patients with head-and-neck cancer (primary sites: nasopharynx [5], oral cavity [12], oropharynx [3], and all others [3]) were accrued to a Phase I-II trial. Inverse planning was carried out with the following treatment goals: at least 1 spared parotid gland (defined as the volume of parotid gland outside the planning target volume [PTV]) to receive a median dose of less than 20 Gy; spinal cord, maximum 45 Gy; PTV(1) to receive a median dose of 50 Gy; PTV(2) to receive a median dose of 60 Gy (postoperative setting, n = 15) or 66-70 Gy (definitive radiotherapy setting, n = 8). Treatment was delivered with 6 and 15 MV photons using a "step-and-shoot" technique on a Varian 2300 EX linac with 120-leaf Millenium MLC. Unstimulated and stimulated whole-mouth salivary flow rates were measured, and patients completed the University of Washington instrument (UWQOL) and a separate xerostomia questionnaire (XQOL) in follow-up., RESULTS: Early functional outcome end point data are available at the 1-, 3-, and 12-month follow-up time points for 22, 22, and 18 patients, respectively. The combined mean parotid dose was 30.0 Gy (95% confidence interval: 26.9-33.1). The differences from baseline in mean overall UWQOL scores at 1, 3, and 12 months postradiotherapy were -0.24, 0.32, and 4.28, not significantly different from zero (p = 0.89, p = 0.87, p = 0.13). None of the UWQOL individual domain scores related to oral health (pain, eating-chewing, eating-swallowing, and speech) at 1, 3, or 12 months were significantly different from baseline. Both unstimulated and stimulated whole-mouth flow was variably preserved. Unstimulated salivary flow at 1 and 12 months was inversely correlated with combined mean parotid dose (p = 0.014, p = 0.0007), whereas stimulated salivary flow rates at 3 and 12 months were also correlated with combined mean parotid dose (p = 0.025, p = 0.0016). Combined maximum parotid dose was correlated with unstimulated flow rate at 12 months (p = 0.02, r = -0.56) and stimulated flow rate at 1 and 12 months (p = 0.036, r = -0.45; p = 0.0042, r = -0.66). The proportion of patients reporting total XQOL scores of 0 or 1 (no or mild xerostomia) did not diminish significantly from baseline at 1, 3, or 12 months (p = 0.72, p = 0.51, p = 1.0). Unstimulated and stimulated flow at 1 month was inversely correlated with total XQOL score at 12 months (p = 0.025, p = 0.029)., CONCLUSIONS: Oral health-related quality of life (HRQOL) was highly preserved in the initial 12 months after IMRT, as assessed with separate, validated instruments for xerostomia-specific quality of life and oral HRQOL. In general, patients with better-preserved unstimulated salivary flow rates tended to report lower xerostomia scores. Whole-mouth salivary flow rates post IMRT were inversely correlated with combined mean parotid doses. Longer follow-up is required to assess to what extent HRQOL is favorably maintained.

Prostate cancer update

MSTS 2018 - Femur Mets and MM

Research has yielded important insights into the impact of radical prostatectomy in patients with localized prostate cancer. Other recent research has focused on the role of nutrition in prostate cancer development and progression, improved prognostication for patients with both early and advanced prostate cancer, efficacy of adjuvant and neoadjuvant hormonal therapy, and development of novel agents. In addition, the role of bisphosphonates in patients with bone metastasis was established. © 2003 Lippincott Williams & Wilkins.

Managing the open calcaneal fracture: A systematic review

DoD SSI (Surgical Site Infections)

INTRODUCTION: Open fractures of the calcaneus are rare. They are mostly caused by high-energy trauma. There are several treatment options for calcaneal fractures. However, treatment of open calcaneal fractures might need a different approach, as open calcaneal fractures are associated with high rates of complications. The purpose of this study was to provide a literature overview on the management of open calcaneal fractures, and deduct a more standardized treatment algorithm. MATERIAL AND METHODS: A literature review was conducted in the databases of PubMed, EMBASE and the Cochrane Library for articles describing the management of open calcaneal fractures. Excluded were studies with less than 10 patients, studies describing combat injuries and reviews. Only articles published from 1998 to 2017 were included and there were no language restrictions. RESULTS: A total of 18 articles were included with 616 open calcaneal fractures in 598 patients. Most wounds were Gustilo grade III and most fractures were Sanders type III. Definitive surgery was performed after a mean of 9.8days and in most cases in the form of ORIF via ELA. The complication rate was 21% and the mean AOFAS score was 73.7 points. CONCLUSION: The complication rates of open calcaneal fractures are high and increase with the severity of the wound. A treatment algorithm is suggested. However, to produce a more evidence-based protocol and achieve consensus for treatment, additional research should be done, preferably in the form of a prospective multicenter database.

Use of submentoplasty to enhance cervical recontouring in face-lift surgery

Panniculectomy & Abdominoplasty CPG

A number of surgical techniques for recontouring the aging neck are available. Using liposuction and direct lipectomy, the surgeon can sculpt the jowl and submental contour. Posterior tightening of the ptotic platysma refines the submental area, while incisional or excisional techniques, along with midline plication, remove anterior banding. Despite these maneuvers, recurrent submental and cervical ptosis is noted in some patients. These individuals can benefit from a secondary submentoplasty, a submental tuck-up face-lift operation, usually within 6 to 18 months after their initial surgery. We have identified several reliable causes for a secondary submentoplasty. Submentoplasty as a planned second-stage surgery in certain patients allows achievement of more dramatic and long-lasting rejuvenation of the neck.

Celebrex Short Versus Long Therapy In Osteoarthritis Of The Knee

OAK 3 - Non-arthroplasty tx of OAK

This is a phase III, multicentre, randomized, double blind, parallel�group, pilot study designed to compare a long term (12 weeks) versus a short term (2 weeks) treatment with celecoxib 200 mg/die in treatment and prevention of new flare in patients with osteoarthritis of the knee.

Ewing's sarcoma: Experience with 12 cases

MSTS 2018 - Femur Mets and MM

Twelve patients with localized Ewing's sarcoma were treated between 1980-1990 at the Istanbul School of Medicine, Department of Pediatric Oncology-Hematology, Oncology Research and Treatment Center and Our Children Leukemia Foundation. There were 8 boys and 4 girls, with a mean age of 8.1 (range 3-17) years. The tumors were in the femur in 3 patients, in the humerus and rib in 2 patients each and in the tibia, radius, vertebra, clavicula and pelvis in 1 patient each. Chemotherapy alone was applied in 2 patients, 1 patient had chemotherapy and radiotherapy. The remaining 9 cases were treated with chemotherapy and radiotherapy (during the chemotherapy). The chemotherapy protocols were: VAC (n = 5), VACA (n = 3), IVAD (n = 3) and T.9 (n = 1). One patient died from the disease itself. Remissions were achieved in the other 11 patients. After 5 to 95 months (mean: 22 months) 7 patients had relapsed (4 had local and 3 had distant metastases). Three patients were not able to be followed, 3 died due to additional problems (infection, cardiotoxicity). The best prognosis was achieved when Ewing's sarcoma initiated in the long bones, with less than 100 ml tumor volumes and patients were under 5 years old. There were no significant differences among chemotherapy protocols.

Factors Associated With Surgical Outcomes in Congenital Ptosis: A 10-Year Study of 319 Cases

Upper Eyelid and Brow Surgery

PURPOSE: To evaluate the 10-year results of surgery for congenital ptosis and identify factors associated with excellent outcomes and recurrence. DESIGN: Retrospective, interventional case series. METHODS: A retrospective analysis was conducted of 319 patients who underwent surgical correction at a tertiary medical center for congenital ptosis. The main outcome measures were postoperative surgical outcomes and recurrence rates. Excellent lid height was assessed as a marginal reflex distance (MRD) greater than 3 mm. Recurrence was defined as a lid height less than 50% of the initial postoperative lid height. RESULTS: The overall surgical success rate was 97.2%. On multivariate analysis, 3 factors were significantly associated with a greater probability of achieving excellent lid height: treatment using levator muscle resection (LMR) (adjusted odds ratio [OR], 1.76; P = .04), better preoperative MRD (adjusted OR, 2.21; P < .001), and absence of Marcus Gunn (jaw-winking) syndrome (adjusted OR, 0.12; P = .01). For recurrence, 7 significant risk factors were identified: children less than 1 year old (adjusted OR, 4.92; P = .02), poorer preoperative MRD (adjusted OR, 0.64; P = .04), poorer postoperative MRD (adjusted OR, 0.32; P < .001), treatment with frontalis suspension (FS) (adjusted OR, 5.86; P < .001), wound infection (adjusted OR, 9.45; P = .02), postoperative entropion (adjusted OR, 11.25; P = .003), and conjunctival prolapse (adjusted OR, 7.10; P = .03). Kaplan-Meier analysis showed that the 1-, 5-, and 10-year recurrence-free rates were 97.3% +/- 1.2%, 80.5% +/- 4.4%, and 76.7% +/- 5.6%, respectively, for the LMR group and 90.9% +/- 3.1%, 42.9% +/- 8.1%, and 20.8% +/- 10.1%, respectively, for the FS group (P < .001, log-rank test). CONCLUSIONS: Surgical treatment of congenital ptosis had a high success rate. Identifying the risk factors and taking appropriate measures may result in better surgical outcomes and less recurrence. Our retrospective study showed that the likelihood of achieving excellent outcomes with lower recurrence rates was higher with LMR than with FS. However, a prospective randomized study is necessary to clarify their efficacy.

The Oxford unicompartmental knee prosthesis: a 2-14 year follow-up

Surgical Management of Osteoarthritis of the Knee CPG

Our medium- and long-term results obtained with the Oxford unicompartmental knee prosthesis for unicompartmental knee osteoarthrosis are presented. Ninety-seven prostheses were evaluated (87 medial, 10 lateral) in 86 patients, with the Hospital for Special Surgery knee score after 2-14 years (mean follow-up: 6 years 9 months). Five prostheses were lost to follow-up. Eight patients died, not related to surgery; none had undergone a revision. Fourteen revisions (of which one bilateral UKP), 11 medial and three lateral, were performed. The mean HSS score of the 69 UKPs was 178.8 (80% excellent, 10% good, 4% fair, 6% poor). These findings confirm the good results reported in other studies, regarding proper patient selection and a consistent operative technique

Review of knee arthroscopic practice and coding at a major metropolitan centre

OAK 3 - Non-arthroplasty tx of OAK

BACKGROUND: Arthroscopic knee surgery has been a topic of significant controversy in recent orthopaedic literature. Multiple studies have used administrative (Victorian Admitted Episodes Dataset and Centre for Health Record Linkage) data to identify trends in practice. This study explored the usage and reporting of arthroscopic knee surgery by conducting a detailed audit at a major Victorian public hospital. METHODS: A database of orthopaedic procedures at St Vincent's Hospital Melbourne was used to retrospectively identify cases of knee arthroscopy from 1 December 2011 to 1 April 2014. Procedures were categorized as diagnostic or interventional, and native and prosthetic joints were analysed separately. Procedure codes were reviewed by comparing a registrar, auditor and hospital coders for agreement. RESULTS: Of the 401 cases for analysis, 375 were conducted in native knees and 26 in prosthetic joints. Of native knees, 369 (98.4%) were considered interventional. The majority of these were conducted for meniscal pathology (n = 263, 70.1%), osteoarthritis (OA) (n = 25, 6.7%) and infection (n = 28, 7.6%). Comparison of codes assigned by different parties were found to be between 57% (k = 0.324) and 70% (k = 0.572) agreement, but not statistically significant. CONCLUSIONS: In this study, the most common indication for arthroscopy was meniscal pathology. Arthroscopy was rarely performed for OA in the absence of meniscal pathology. Diagnostic arthroscopy was rarely performed in the native knee, and fair to moderate agreement existed between parties in assigning Medicare Benefits Schedule procedure codes.

Surgical management of bisphosphonate induced osteonecrosis of the jaws

MSTS 2018 - Femur Mets and MM

Recent literature contains numerous articles on osteonecrosis of the jaws (ONJ) associated with bisphosphonate treatment (BPT), with most advocating a conservative approach to management. A prospective study was designed to review the surgical management of cases of ONJ that did not respond to conservative management. Forty patients, referred with ONJ that did not respond to conservative management, were treated surgically and followed up for 6 months to 4 years. Four patients were taking i.v. BPT as part of their bone cancer management and 16 were taking oral BPT for osteoporosis. The surgical management of ONJ involved antibiotic therapy, surgical debridement of all necrotic bone and tension-free primary closure. All 40 cases healed uneventfully with no wound breakdown during follow-up. Most of the literature supports the conservative management of ONJ, but the condition leaves the patient debilitated. Many cases do not respond to conservative management and the infection and bone destruction is progressive. The conservative management of ONJ is to be supported, but this prospective study has shown that those cases that do not respond may be managed surgically. It should be recognized that while the results of this paper are encouraging, some cases will be resistant to all treatments. © 2009 International Association of Oral and Maxillofacial Surgeons.

Ilizarov bone transport combined with antibiotic cement spacer for infected tibial nonunion

DoD SSI (Surgical Site Infections)

Purpose: To evaluate the curative effect of Ilizarov bone transport combined with antibiotic cement spacer for infected tibial nonunion with bone defect. Methods: We retrospectively reviewed the outcomes of 58 patients with infected tibial nonunion from January 2008 to March 2011 at our institution. Patients were treated with complete debridement, radical sequestrectomy, antibiotic cement spacer implantation, bone transport using the Ilizarov external fixator, and soft tissue reconstruction. Clinical efficacy was assessed using Paley’s grading system and patient satisfaction at the last follow-up. Results: Follow-up ranged from 24 to 63 months (average, 31.6 months). Mean size of the tibial defect was 9.2 cm (range, 6-15 cm). The soft tissue defect was closed successfully in all cases. Patients eventually achieved union with a mean bone union index of 1.2 months/cm at an average of 10.6 months (range, 8-31 months). In terms of Paley grade, 30 patients had excellent results, 23 good, and 5 fair. Functional results were excellent in 28 patients, good in 18, and fair in 12. Thirty-five patients felt extremely satisfied, 18 satisfied, and 5 acceptable with the functional outcome. Complications included pin site infection in 18 cases, limb length discrepancy less than 1.5 cm in 10, knee stiffness in 5, equinus deformity in 4, infectious recurrence in 1 and pin breakage in 1. There was no refracture at the reconstruction site. Conclusion: Ilizarov bone transport combined with antibiotic cement spacer is a versatile and effective method for treatment of infected tibial nonunion.

Patterns of Extrathoracic Metastases in Different Histological Types of Lung Cancer

MSTS 2022 - Metastatic Disease of the Humerus

Lung cancer is the leading cause of cancer-related deaths mainly attributable to metastasis, especially extrathoracic metastasis. This large-cohort research is aimed to explore metastatic profiles in different histological types of lung cancer, as well as to assess clinicopathological and survival significance of diverse metastatic lesions. Lung cancer cases were extracted and enrolled from the Surveillance, Epidemiology, and End Results (SEER) database. ?2-tests were conducted to make comparisons of metastatic distribution among different histological types and odds ratios were calculated to analyze co-occurrence relationships between different metastatic lesions. Kaplan–Meier methods were performed to analyze survival outcomes according to different metastatic sites and Cox regression models were conducted to identify independent prognostic factors. In total, we included 159,241 lung cancer cases with detailed metastatic status and complete follow-up information. In order to understand their metastatic patterns, we elucidated the following points in this research: (1) Comparing the frequencies of different metastatic lesions in different histological types. The frequency of bone metastasis was highest in adenocarcinoma, squamous cell carcinoma, LCLC and NSCLC/NOS, while liver was the most common metastatic site in SCLC. (2) Elaborating the tendency of combined metastases. Bi-site metastases occurred more common than tri-site and tetra-site metastases. And several metastatic sites, such as bone and liver, intended to co-metastasize preferentially. (3) Clarifying the prognostic significance of single-site and bi-site metastases. All single-site metastases were independent prognostic factors and co-metastases ended up with even worse survival outcomes. Thus, our findings would be beneficial for research design and clinical practice.

An intramedullary nail with multifunctional interlocking for all types of fracture in both femurs

Distal Radius Fractures

OBJECTIVE: A femoral compound interlocking intramedullary nail (FCIIN) was designed to treat all types of fractures between the trochanter and epicondyle of both femurs. It could substitute for femoral interlocking intramedullary nails (FIIN) at five points. METHODS: According to the morphological characteristics of the femoral medullary canal, the nail is designed to accommodate a 1250 mm radius of radian and a 135degree neck-shaft angle. Three interlocking holes of 6.5 mm diameter are located at the proximal end of the FCIIN, making crossing of the screws possible. The hole is designed to be vertical (90degree) or oblique (45degree upper or lower). At the tip of the proximal interlocking screws, whose root diameter gradually increases from 3.5 mm to 6.5 mm, a self-tapping cancellous screw is placed. There are two types of distal interlocking screws. One is a fine thread and the other a bolt screw. Two interlocking holes and a recess 4.5 mm in diameter are located at the distal end of the FCIIN. Under biomechanical destructive testing, the proximal interlocking screw device has satisfactory strength and reasonable structure. A total of 47 patients (31 males and 16 females, with an average age of 39.83 years) with femoral fractures were assessed in this study. Fourteen cases were diagnosed as intertrochanteric, 7 as subtrochanteric, 18 as femoral shaft, and 8 as supracondylar fractures. All 47 patients were treated with the FCIIN. RESULTS: Of the 47 patients, anatomic reduction was achieved in 34, good reduction in 11, and forced line reduction in 2 cases. Reduction was excellent or good in 95.87% of the fractures. The removal time of the FCIIN was 12 to 21 months (average, 16.9 months). One patient with an intertrochanteric fracture who had a fixation failure combined with non-union achieved healing with an external fixator at 18 months. Failure to insert the distal interlocking screws occurred in 5 patients but did not affect bone healing. CONCLUSION: The FCIIN is a useful device in the treatment of a variety of femoral fractures.

Renal disease in hematological malignancies

MSTS 2018 - Femur Mets and MM

Hematological malignancies can affect the kidneys in different ways. There may be direct invasion by the tumor cells, or the malignancy may act indirectly via immunologically mediated mechanisms. Primary renal lymphoma (PRL) without evidence of extrarenal spread has also been reported. The existence of this entity, however, has been questioned, because the kidneys do not normally contain lymphoid tissue. Renal involvement is rare in leukemias, and in some leukemias, renal dysfunction is usually found during the blastic crisis. Renal infiltration of leukemic cells has been recognized in some patients. In addition, some types of hematological neoplasia are associated with severe hypercalcemia that can lead to nephrocalcinosis. Renal involvement is one of the major manifestations of multiple myeloma (MM) and is an important cause of renal failure in the elderly. Renal failure occurs in more than 50 of MM patients, and is usually caused by the so-called myeloma kidney. Tumor lysis syndrome (TLS) is an oncological emergency characterized by a combination of metabolic disorders observed at the start of treatment of hematological malignancies. TLS may also be associated with the advancement of aggressive lymphomas and leukemias. The syndrome is frequently associated with renal dysfunction. Bone marrow transplantation for treatment of selected hematological neoplasms can be complicated by renal failure resulting from a variety of causes. Early renal injury most often results from infection and its subsequent treatment. Late renal injury after bone marrow transplantation, characterized by a syndrome similar to the hemolytic uremic syndrome, is called bone marrow transplant (BMT) nephropathy. This article reviews the clinical and pathological features of renal injury in hematological malignancies. © 2011 The Hong Kong Society of Nephrology.

Osteonecrosis of the hip in Korean patients with systemic lupus erythematosus: risk factors and clinical outcome

AAHKS (2) Corticosteroids

OBJECTIVE: The objective of this paper is to identify the risk factors for development of symptomatic osteonecrosis (ON) and predictors of total hip replacement (THR) among systemic lupus erythematosus (SLE) patients in Korea. METHODS: The medical records of 1051 patients with SLE were reviewed, and 73 patients with symptomatic ON were identified. Among them, 64 patients were eligible for the analysis. Sixty-four age- and sex-matched SLE patients without apparent ON were included as disease controls. The risk factors for development of symptomatic ON were identified by logistic regression analyses. The predictors of THR were determined by Cox proportional hazards regression analyses. RESULTS: Among 64 patients with ON, 59 had ON of the hip and 36 underwent THR. Independent risk factors for development of symptomatic ON included Cushingoid body habitus (OR 21.792 (95% confidence interval (CI) 2.594-183.083)), use of cyclophosphamide (OR 2.779 (95% CI 1.106-6.981)) and azathioprine (OR 2.662 (95% CI 1.143-6.200)). In the Cox proportional hazards model, only advanced radiological stage of ON (Association for Research on Osseous Circulation (ARCO) stage) was a statistically significant predictor of THR. In subgroup analysis with stage I-III ON, multivariate Cox regression analysis showed neuropsychiatric SLE (NPSLE) (HR 6.295 (95% CI 2.178-18.192)) and cumulative prednisolone dose in the first six months after ON diagnosis>0.9g (HR 3.238 (95% CI 1.095-9.58)) to be independent predictors. CONCLUSIONS: Advanced ARCO stage at the onset of ON is an independent risk factor for THR in SLE patients with ON. In ARCO stage I-III ON, patients with NPSLE and those receiving>0.9g prednisolone during the first six months after the ON diagnosis are likely to require THR.

Treatment of intertrochanteric fractures in elderly highrisk patients: dynamic hip screw vs. external fixation

HipFx Supplemental Cost Analysis

INTRODUCTION: Although the use of a dynamic hip screw (DHS) is considered to be the preferred treatment for intertrochanteric fractures, the external fixation device could produce clinical outcomes comparable to the outcomes obtained with conventional treatment. Furthermore, because external fixation is minimally invasive, we expected a lower rate of morbidity. Therefore, we compared the two treatments in a clinical trial of elderly patients with intertrochanteric fracture. METHODS: 60 elderly high-risk patients with an average age of 78 years were treated for intertrochanteric fracture, resulting from a low energy trauma. Patients were randomly divided in two groups regarding to treatment. In Group A the patients were treated with DHS, while in Group B were treated with external fixator. RESULTS: The fixator was well accepted and no patient had significant difficulties while sitting or lying. The average intraoperative time was 73 min in Group A and 15 min in Group B (p<0.05). 27 patients of Group A need blood transfusion postoperatively and none in Group B (p<0.05). The mean duration of hospitalization in Group A and Group B was 8.4 and 2.2 days, respectively (p<0.05). 9 of patients Group B had pin-track infection grade 2 that all were treated by oral antibiotics. There were no differences in comorbidities, quality of reduction, screw cut out, bed sore and HHS between the two groups. CONCLUSION: Treatment with external fixator is an effective treatment for intertrochanteric fractures in elderly highrisk patients. The advantages include quick and simple application, minimal blood loss, less radiation exposure, adequate fixation, pain reduction, early discharge from hospital, low costs and favourable functional outcomes

Expression of miR-206 in Human Knee Articular Chondrocytes and Effects of miR-206 on Proliferation and Apoptosis of Articular Chondrocytes

OAK 3 - Non-arthroplasty tx of OAK

BACKGROUND: Increasing evidence has demonstrated that microRNAs regulate the development of cartilage and osteogenesis. Whether miR-206 participates in the development of human articular cartilage remains largely unknown. This study aimed to investigate the role of miR-206 in human chondrocytes. METHODS: Expression of miR-206 was initially assessed in human osteoarthritis (OA) tissues and articular chondrocytes through quantitative real-time polymerase chain reaction. The effects of miR-206 on proliferation and apoptosis of human chondrocytes were assessed by 3-[4,5-dimethylthiazol-2-yl]-2,5-diphenyltetrazolium bromide (MTT) and Annexin V-fluorescein isothiocyanate (FITC)/propidium iodide (PI) double staining assay. Then, the effects of miR-206 on type II collagen alpha 1 (Col2a1), aggrecan, runt-related transcription factor 2 (RUNX2) and matrix metalloproteinase13 (MMP13) were examined with quantitative real-time polymerase chain reaction and Western blot analysis. RESULTS: MiR-206 was significantly increased in human OA tissues and chondrocytes. MiR-206 significantly inhibited the proliferation of chondrocytes, but promoted apoptosis. Expression of Col2a1 and aggrecan were dramatically decreased, and the expression of RUNX2 and MMP13 were significantly increased when miR-206 was overexpressed. CONCLUSIONS: MiR-206 may participate in cartilage degradation in OA. Manipulation of the expression of miR-206 in human chondrocytes may be a novel therapeutic strategy for the treatment of OA.

Antibiotics for acute orofacial infections

Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures

By virtue of their activity against common and microbial pathogens, three antibiotic groups have real or potential application in the routine management of acute orofacial infections: beta-lactams (penicillins and cephalosporins), macrolides (erythromycin and congeners) and the lincosamides (clindamycin). The beta-lactam agents, principally the penicillins, remain drugs of choice. The macrolides have gained a resurgence in popularity due to their low toxicity, improved pharmacokinetics with azithromycin and clarithromycin, and the ability to penetrate into white blood cells to attack intracellular microorganisms. Clindamycin may be useful in penicillin-allergic patients and when directed by culture and sensitivity tests

Biotechnology in the treatment of delayed unions and non-unions of the femur

Surgical Management of Osteoarthritis of the Knee CPG

Introduction Delayed unions or non-unions after treatment of femur fractures derive from inadequate reduction and stabilization of the fracture, insufficient blood supply to broken bone, bone loss or inappropriate postoperative management. The treatment of this condition is always problematic and there is high incidence of complications. Materials and methods We report the experience obtained from March 2010 to February 2013, in surgical treatment of femur fractures. We treated 10 patients, 7 with delayed union and 3 with clear signs of non-union of fracture. Treatment consists in new reduction and internal fixation, an autologous bone graft from controlateral femur with RIA (reamer/irrigator/aspirator) system, associated with the use of BMP-7 (bone morphogenetic protein-7). Results Mean follow-up was 16 months. Patients underwent clinical and radiographic evaluation by periodic checks. Consolidation occurred in all patients, except one case of septic non-union. There were no complications in donor site of autologous graft. The only complication observed was a case of knee stiffness treated with mobilization in narcosis. Discussion Delayed union or non-union of femur may be a consequence of inadequate treatment or post-operative management, but is often result of bone loss or avascular necrosis of fragments due to trauma's high energy. Therefore is important in treatment of this condition to ensure early mechanical stability associated to biological stimuli. Conclusions Early treatment with the technique described above (new fixation with autologous bone graft and BMP) in our opinion shows clear advantages in determining the healing of these diseases, avoiding other problems to patients

Is single-dose prophylactic gentamicin associated with acute kidney injury in patients undergoing cardiac surgery? A matched-pair analysis

Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures

OBJECTIVE: Although aminoglycoside treatment has been associated with nephrotoxic effects, single-dose gentamicin has been considered safe in surgery. However, the effect of a single-dose prophylactic aminoglycoside on the risk of acute kidney injury among patients undergoing cardiac surgery remains uncertain. METHODS: A population-based cohort study with matched-pair analysis of 2892 consecutive patients undergoing cardiac surgery at Aarhus University Hospital, Denmark, was performed. Two different prophylactic antibiotic regimens were used during the study period. The patients exposed to a single dose of prophylactic gentamicin were compared with those had not received gentamicin. Statistical analysis for matched data was performed. The data were retrieved from the Western Denmark Heart Registry. RESULTS: Matching resulted in 668 patient pairs. Patients receiving gentamicin had higher maximum serum creatinine during the first postoperative 72 hours (median, 96 vs 90 mmol/L; P=.0002). Also, a greater fraction of patients receiving gentamicin developed acute kidney injury according to the Acute Kidney Injury Network criteria (22% vs 17%; P=.02). The hospital length of stay was shorter in the control group (5.0 vs 5.6 days; P<.0001). No difference was found in the incidence of patients requiring postoperative dialysis, 30-day and 1-year mortality, or the incidence of sternal infection between the 2 groups. CONCLUSIONS: A single-dose prophylactic aminoglycoside in adult cardiac surgery patients was associated with an increased risk of acute kidney injury but not with a greater frequency of postoperative dialysis or mortality. No differences in the incidence of sternal infections between groups were observed

Oral melphalan, prednisone, and thalidomide for newly diagnosed patients with myeloma

MSTS 2022 - Metastatic Disease of the Humerus

BACKGROUND: Thalidomide is an immunomodulatory drug with strong antimyeloma activity. It is an effective treatment for multiple myeloma at disease recurrence and at diagnosis, both as a single agent and in combination with steroids or chemotherapy. No data are available on the association of thalidomide with oral melphalan and prednisone, still considered the standard treatment for elderly patients. METHODS: The feasibility and efficacy of the combination of melphalan, prednisone, and thalidomide (MPT) have been valuated in 49 newly diagnosed patients with multiple myeloma. RESULTS: According to European Bone Marrow Transplantation/ International Bone Marrow Transplantation Registry (EBMT/IBMTR) criteria, 18% of patients achieved immunofixation-negative complete disease remission (CR), 6% achieved immunofixation-positive near CR, 4% achieved a very good partial response, and 45% achieved a partial response, with a 50-89% reduction in monoclonal paraprotein. Six percent did not respond and 10% showed progressive disease. The median time to maximum response was 4 months. The Kaplan-Meier estimates of event-free survival and overall survival at 2 years were 64% and 91%, respectively. The major acute adverse events (National Cancer Institute Common Toxicity Criteria Grade III-IV) included thrombosis (20%), infections (12%), constipation (6%), and hematologic (22%) and neurologic (8%) toxicities. One patient died of pulmonary thromboembolism. CONCLUSIONS: These data suggested that MPT induced rapid and durable tumor responses with CR rates similar to those observed after autologous transplantation. Administration of prophylactic anticoagulant was required to prevent thromboembolism. MPT merits further investigation in randomized clinical trials.

Penile enhancement procedures with simultaneous penile prosthesis placement

Panniculectomy & Abdominoplasty CPG

Here we present an overview of various techniques performed concomitantly during penile prosthesis surgery to enhance penile length and girth. We report on the technique of ventral phalloplasty and its outcomes along with augmentation corporoplasty, suprapubic lipectomy, suspensory ligament release, and girth enhancement procedures. For the serious implanter, outcomes can be improved by combining the use of techniques for each scar incision. These adjuvant procedures are a key addition in the armamentarium for the serious implant surgeon.

GP referral of patients with osteoarthritis for consideration of total joint replacement: a longitudinal study

Surgical Management of Osteoarthritis of the Knee CPG

BACKGROUND: Individuals with hip or knee osteoarthritis (OA) are referred to orthopaedic surgeons if considered by their GP as potential candidates for total joint replacement (TJR). It is not clear which patients end up having this surgery. AIM: The aim of the study was to investigate symptom variation in individuals with OA newly referred by GPs to an orthopaedic surgeon for consideration for TJR, and to determine the predictors of having this procedure. DESIGN AND SETTING: A longitudinal study of patients at a regional orthopaedic centre with follow-up at 3, 6, and 12 months by postal questionnaire. METHOD: GP referrals of patients with OA to orthopaedic surgeons were consecutively sampled. Of the 431 eligible patients, 257 (59.6%) were recruited. Validated measurement tools were used to measure pain, physical functioning, severity of OA, and health-related quality of life. RESULTS: Over half the participants were in constant pain, taking pain medication more than once per day. Only 67 of 134 (50%) hip and 40 of 123 (33%) knee patients had a TJR within 12 months. Those who had a replacement had been diagnosed with OAfora shorter time, reported more frequent pain, were more likely to use a walking stick, and had worse pain, stiffness, and physical functioning. CONCLUSION: Many individuals considered for TJR ultimately may not have surgery, and more effective strategies of management need to be developed between primary and secondary care to achieve better outcomes and to improve quality of care

Microbiology in endodontics: an online study guide

Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures

The Editorial Board of the Journal of Endodontics has developed a literature-based study guide of topical areas related to endodontics. This study guide is intended to give the reader a focused review of the essential endodontic literature and does not cite all possible articles related to each topic. Although citing all articles would be comprehensive, it would defeat the idea of a study guide. This section will present the topical areas of microorganisms involved in primary infection; microorganisms involved with failing endodontics, culturing, bacteremia, and endodontics; leaving teeth open; antibiotics; actinomycosis; sterilization of instruments and sterilization of gutta-percha, microorganisms in periradicular lesions; biofilms; and fungi, viruses, and prions

Ankle arthroplasty for rheumatoid arthritis and osteoarthritis: prospective long-term study of cemented replacements

Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures

We performed 52 cemented ankle arthroplasties for painful osteoarthritis (OA) (25) or rheumatoid arthritis (RA) (27) using an ankle prosthesis with a near-anatomical design. We assessed the patients radiologically and clinically for up to 14 years using an ankle scoring system. The preoperative median scores were 29 for the OA group and 25 for the RA group and at ten years were 93.5 and 83, respectively. Six ankles in the OA group and five in the RA group required revision or arthrodesis. Survivorship analysis of the two groups showed no significant differences with 72.7% survival for the OA group and 75.5% for the RA group at 14 years

Estimating the excess costs for patients with incident fractures, prevalent fractures, and nonfracture osteoporosis

HipFx Supplemental Cost Analysis

SUMMARY: Based on a population age 50+, significant excess costs relative to matched controls exist for patients with incident fractures that are similar in relative magnitude to other chronic diseases such as stroke or heart disease. Prevalent fractures also have significant excess costs that are similar in relative magnitude to asthma/chronic obstructive pulmonary disease. INTRODUCTION: Cost of illness studies for osteoporosis that only include incident fractures may ignore the long-term cost of prevalent fractures and primary preventive care. We estimated the excess costs for patients with incident fractures, prevalent fractures, and nonfracture osteoporosis relative to matched controls. METHODS: Men and women age 50+ were selected from administrative records in the province of Manitoba, Canada for the fiscal year 2007-2008. Three types of cases were identified: (1) patients with incident fractures in the current year (2007-2008), (2) patients with prevalent fractures in previous years (1995-2007), and (3) nonfracture osteoporosis patients identified by specific pharmacotherapy or low bone mineral density. Excess resource utilization and costs were estimated by subtracting control means from case means. RESULTS: Seventy-three percent of provincial population age 50+ (52 % of all men and 91 % of all women) were included (121,937 cases, 162,171 controls). There were 3,776 cases with incident fracture (1,273 men and 2,503 women), 43,406 cases with prevalent fractures (15,784 men and 27,622 women) and 74,755 nonfracture osteoporosis cases (7,705 men and 67,050 women). All incident fractures had significant excess costs. Incident hip fractures had the highest excess cost: men $44,963 (95 % CI: $38,498-51,428) and women $45,715 (95 % CI: $36,998-54,433). Prevalent fractures (other than miscellaneous or wrist fractures) also had significant excess costs. No significant excess costs existed for nonfracture osteoporosis. CONCLUSION: Significant excess costs exist for patients with incident fractures and with prevalent hip, vertebral, humerus, multiple, and traumatic fractures. Ignoring prevalent fractures underestimate the true cost of osteoporosis

Current status and research progress of minimally invasive surgery for flail chest (Review)

DoD SSI (Surgical Site Infections)

Chest trauma accounts for ~13.5% of all traumas, and direct death from chest trauma accounts for 20.25% of all traumatic deaths. Chest trauma is the second cause of death from trauma. Frequent rib fractures, especially in patients with flail chest, often cause severe pain, chest wall softening, abnormal breathing and severe lung contusion and laceration, usually requiring thoracic surgery. In recent years, the open reduction and internal fixation treatment of rib fractures with flail chest has achieved satisfactory results, and some surgical indications have reached consensus. A number of scholars and medical centers have demonstrated the practicality and cost.effectiveness of rib fixation in flail chest, including the small incidence of pulmonary complications, the short ICU mechanical ventilation time, and the reduction of digestive tract inhibition. Open reduction and internal fixation of rib fractures involves multiple ribs. Conventional rib fractures require a large incision to achieve satisfactory exposure. Chest wall muscles, blood vessels and nerves (long thoracic and thoracodorsal nerves) are injured, resulting in a high infection rate of the incision and postoperative dysfunctions, such as limited upper limb, shoulder and back function, and long time numbness on the affected side of the chest. Therefore, the damage of muscles and nerves caused by conventional surgical methods limits the development of such surgical technique. Although the video.assisted thoracoscopic technique has become a necessary technical means for the treatment of thoracic trauma and has been applied to thoracic exploration and hemostasis, there is no report on the application of open reduction and internal fixation for rib fracture. The difficulty lies in the tightly combined bony thorax and the soft tissue of the chest wall. Therefore, experts have explored a variety of minimally invasive surgical methods for the flail chest. The current status and research progress of minimally invasive surgery for thoracic surgery are reviewed.

The aponeurotic approach to congenital ptosis

Upper Eyelid and Brow Surgery

Using a surgical technique directed at the levator aponeurosis, we successfully corrected 228 cases of congenital ptosis. The advantages of this approach are: normal anatomic planes and structures of the eyelid are maintained; basic and reflex tear secretion, goblet cells, or meibomian glands remain undisturbed, allowing maintenance of the three-layered tear film; any aponeurotic defects may be explored and repaired relatively easily; all elevating structures are preserved (aponeurosis rather than muscular levator is removed, Mueller's muscle is left intact, Whitnall's ligament is not violated); posterior sutures, which may irritate the cornea, are avoided; no tarsus or conjunctiva are removed.

Complications of the 'treatment' of tonsillar infection by traditional healers in Nigeria

Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures

Traditional healers in Nigeria attempt to treat tonsillar infections either by performing uvulectomy with a sickle knife or by digital rupture of the tonsil. These procedures result in various complications, including haemorrhage, septicaemia, cellulitis of the neck, peritonsillar and parapharyngeal abscess, upper airway obstruction, and pharyngo-laryngocele with pneumothorax. These complications are illustrated with case reports. The danger of encouraging traditional healers to practise unsupervised and unscientific medicine is stressed

Use of antidepressant medications and risk of fracture in older women

Management of Hip Fractures in the Elderly

Use of antidepressant medications has been associated with increased risk of fracture, but prior studies have been limited by incomplete control of confounders or a limited number of fractures. Use of antidepressant medications by 8,217 community-dwelling women aged 69 and older from a population-based prospective cohort study at four US clinical centers was assessed by interview at four examinations over a 10-year period, beginning in 1992-1994. Use was coded as a time-dependent variable. Incident fractures occurring after the initial medication assessment until July 2007 were confirmed by radiographic reports. Potential confounders were included in multivariable models and updated at each follow-up visit. Compared to nonusers of antidepressant medications, women using SSRIs experienced a higher risk of nonspine fracture in age-adjusted models (HR = 1.36, 95% CI 1.11-1.67) and in multivariable models controlling for potential confounders (HR = 1.30, 95% CI 1.04-1.62). SSRI use was not associated with an increased risk of first hip fracture (HR = 1.01, 95% CI 0.71-1.44) but was associated with an increased risk of wrist fracture (HR = 1.54, 95% CI 1.01-2.36). TCA use was associated with an increased risk of nonspine fracture in age-adjusted models, but in multivariable models this risk was attenuated. SSRI use was associated with a higher risk of any nonspine fracture, but not hip fracture, in this cohort of older women. TCA use was associated with a higher risk of nonspine fracture, but this association was in part explained by confounding factors. (copyright) 2011 Springer Science+Business Media, LLC

Expression of matrix metalloproteinases and components of the endocannabinoid system in the knee joint are associated with biphasic pain progression in a rat model of osteoarthritis

OAK 3 - Non-arthroplasty tx of OAK

Matrix metalloproteinases (MMPs) are considered important in articular cartilage breakdown during osteoarthritis (OA). Similarly, the endocannabinoid system (ECS) is implicated in joint function and modulation of nociceptive processing. Functional interplay between ECS and MMPs has been recently indicated. Here, we tested if changes in the expression of selected MMPs and major ECS elements temporally correlate with the intensity of OA-related pain. Knee OA was induced in male Wistar rats by intra-articular sodium monoiodoacetate injection. OA-like pain behavior was tested using the dynamic weight bearing. Joint tissue samples at different time points after OA induction were subjected to gene (quantitative polymerase chain reaction) and protein (Western blot) expression analyses. Monoiodoacetate-induced nocifensive responses in rats showed a biphasic progression pattern. The alterations in expression of selected MMPs elegantly corresponded to the two-stage development of OA pain. The most substantial changes in the expression of the ECS system were revealed at a later stage of OA progression. Alterations within ECS are involved in the process of adaptation to persistent painful stimuli. The accumulation of MMPs in osteoarthritic cartilage may have a role in the biphasic progression of OA-related pain. Temporal association of changes in ECS and MMPs expression shows a potential therapeutic approach that utilizes the concept of combining indirect ECS-mediated MMP inhibition and ECS modulation of pain transduction.

Bisphosphonate use and the risk of breast cancer: A meta-analysis of published literature

Management of Hip Fractures in the Elderly

Bisphosphonates are widely used in clinical practice to prevent and treat osteoporosis and cancer-induced bone loss. Recently, analysis of results of several published observational studies found that women who used bisphosphonates had a significant reduction in the risk of breast cancer compared with nonusers. However, the findings were inconsistent. We systematically searched MEDLINE and EMBASE databases through June 1, 2011. The eligibility determination and the data extraction were conducted independently by 2 of the authors. A random-effect model was used to obtain the pooled estimates of effect. We identified 2 cohort studies and 2 case-control studies that were eligible for analysis, which involved 15,363 patients with breast cancer and 84,931 bisphosphonate users. The results of our meta-analysis revealed that women who received bisphosphonates have a 15% risk reduction of any breast cancer (pooled risk ratio [RR], 0.85 [95% confidence interval {CI}, 0.74-0.98]; P =.03) and a 32% risk reduction of invasive breast cancer (pooled RR, 0.68 [95% CI, 0.59-0.80]; P <.001) compared with nonusers. In addition, there was a significant dose-response relationship between the duration of bisphosphonate use and breast cancer risk. A significantly protective effect of bisphosphonates was observed in patients who used bisphosphonates for more than 1 year before the diagnosis of breast cancer compared with nonusers. The bisphosphonate users had a risk reduction of breast cancer by 8% (pooled RR, 0.92 [95% CI, 0.87-0.96]; P =.001) for each additional year of the duration of bisphosphonate use. The use of bisphosphonates may have a beneficial effect on breast cancer risk. (copyright) 2012 Elsevier Inc

Revision total knee arthroplasty after failed high tibial osteotomy

Surgical Management of Osteoarthritis of the Knee CPG

Eleven patients (12 knees) who underwent revision total knee arthroplasty after failed high tibial osteotomy are reviewed. All patients were evaluated clinically and radiographically before osteotomy and arthroplasty, and in the follow-up period. The time from osteotomy until arthroplasty ranged from 9 months to 9 years, 6 months (average: 4 years, 5 months). The average follow-up period after arthroplasty was 6 years, 11 months (range: 1 year, 6 months to 13 years). On the basis of the Japan Orthopaedic Association osteoarthritic knee scoring system, the results of total knee arthroplasty after osteotomy were found to be comparable with the results after primary arthroplasty. Patients were divided into two groups according to the time from osteotomy to arthroplasty, alignment of the leg before arthroplasty, and the reason for requiring revision arthroplasty. Group 1 included 6 patients with 6 knees who underwent arthroplasty within 3 years after osteotomy. The main reason for revision arthroplasty in Group 1 was pain due to the recurrence of a varus deformity. Group 2 included 5 patients (6 knees) who underwent revision arthroplasty more than 5 years after osteotomy. The main reason for revision arthroplasty in Group 2 was pain or hydrarthrosis due to the progression to bi-compartmental or tri-compartmental osteoarthritis. There was no significant difference in the clinical results between the two groups. Concerning patellar height, LT/LP of Group 1 was significantly lower than that of Group 2. There were no significant differences in the radiographic findings among the two study groups and the control group of 71 patients (110 knees) who underwent primary total knee arthroplasty, except for alignment before arthroplasty. Using the Japan Orthopaedic Association osteoarthritic knee scoring system, previous osteotomy does not seem to affect the outcome of total knee arthroplasty. With refinement of the technique of high tibial osteotomy, revision total knee arthroplasty after 3 years or less would be avoidable, however, revision total knee arthroplasty due to osteoarthritic deterioration over time would be inevitable

Post-operative analysis and indication of total joint replacement for the aged

Surgical Management of Osteoarthritis of the Knee CPG

Recently, the advances made in materials and surgical techniques lowered further the age limit for the indication of total joint replacements. But none of the literature gives the upper age limit. This paper concerns the analyses of the clinical course, laboratory data and complications before and during the follow-up period of patients on whom total joint replacements were performed. The upper age limit for these operations is discussed

A face lift approach for sentinel node biopsy in head and neck melanoma patients

Reconstruction After Skin Cancer

BACKGROUND: Management of head and neck melanoma has changed dramatically with the use of sentinel node biopsy for staging. Nodal dissection may now be delayed or deferred based on the results of the sentinel node biopsy. The authors suggest using a face lift incision to access the nodal basins for sentinel node biopsy in head and neck melanoma. METHODS: A face lift incision was used successfully for sentinel node biopsy in 21 patients. The diagnosis of melanoma, histologic subtype, and depth of penetration were established by biopsy with permanent sections. All patients underwent lymphoscintigraphy on the morning of their surgery. If the scan showed multiple nodes at various levels of the neck or parotid, the patient was selected for a face lift incision for biopsy. RESULTS: The study comprised 14 men and seven women between the ages of 26 and 82 years (mean age, 55 years). The sites of melanoma included the temple in six patients, cheek in five, neck in four, and ear and scalp in two patients each. The average Clark's level and Breslow depth were 3.67 and 1.76 mm, respectively. The average number of basins involved was 2.14; the average number of nodes was 3.33, with an average of 1.56 nodes per basin. Follow-up ranged from 2 to 53 months (average, 26 months). Only two patients had sentinel nodes that were positive for metastatic melanoma. One complication, a transient paresis of the right marginal mandibular nerve, was observed. CONCLUSIONS: Using a face lift incision for sentinel node biopsy in head and neck melanoma is a safe, reliable technique. It provides excellent access to multiple nodal basins, well-concealed incisions, wide exposure for delayed therapeutic nodal dissection, and local and regional flap options for reconstructing the excision site.

Primary total knee arthroplasty in patients with fixed valgus deformity

Surgical Management of Osteoarthritis of the Knee CPG

Ninety-nine knees in 81 patients evaluated from two to ten years and having enough valgus deformity to require specific soft-tissue release were studied. They were also compared to a control group of 40 knees in 31 patients with no angular deformity greater than 5 degrees, who were matched for age and diagnosis. All procedures were performed using a minimally constrained, posterior-cruciate-ligament-sparing prosthesis. Pre- and postoperative axial alignment was measured on weight-bearing long-standing roentgenographs. Analysis included examination for lucent lines in postoperative fluoroscopically positioned roentgenographs and clinical data summarized using the 100-point scoring systems developed by The Knee Society. Knees were classified as having Type I, II, or III valgus deformities: Type I was defined as valgus deformity secondary to bone loss in the lateral compartment and soft-tissue contracture with medial soft tissues intact; Type II was defined as obvious attenuation of the medial capsular ligament complex; and Type III was defined as severe valgus deformity with valgus malpositioning of the proximal tibial joint line after overcorrected proximal tibial osteotomy. Only cases of Type I and Type II were represented in the 99 knees reported. Type I patients were treated with lateral soft-tissue release, and Type II patients were treated with medial capsular ligament tightening (i.e., ligament reconstruction procedures on the medial side). The Knee Society postoperative knee score was 87.6 (+/- 10.6) and mean postoperative functional score was 52.3. Alignment was well corrected and knee scores for the Type I and II groups were almost identical as were the functional scores. The results were grouped as 72% excellent, 18% good, 7% fair, and 2% poor. Notably, the control group was 39 of 40 patients excellent, and only one poor. Ligament stability was satisfactorily established by lateral release in Type I and with the combined medial plication in the Type II patients. The ligament-tightening procedures were on the average 40 minutes longer than those for the Type I or the control groups. The controversial nature of the simultaneous ligament reconstruction method is recognized, but good experience is reported

Current state of unloading braces for knee osteoarthritis

OAK 3 - Non-arthroplasty tx of OAK

PURPOSE: Unicompartmental knee osteoarthritis (OA) is often treated with the prescription of an unloading knee brace to decrease pain and stiffness. Braces have been shown to improve the quality of life by applying an external moment to offset increased compressive tibiofemoral contact loads, but evidence regarding mechanical efficacy at the joint is controversial. Thus, the purpose of this study was to review the current state of unloading braces on knee mechanics, clinical impact, and long-term disease progression. METHODS: A literature search was performed through the PubMed MEDLINE database for the search terms "osteoarthritis," "knee," "brace," and derivatives of the keyword "unload." Articles published since January 1, 1980 were reviewed for their relevance. Evidence for the effectiveness of unloading braces for disease management both biomechanically and clinically was considered. RESULTS: While significant research has been done to show improvement in OA symptoms with the use of an unloading brace, current literature suggests a debate regarding the effectiveness of these braces for biomechanical change. Clinical findings reveal overall improvements in parameters such as pain, instability, and quality of life. CONCLUSION: Although clinical evidence supports brace use to improve pain and functional ability, current biomechanical evidence suggests that unloading of the affected knee compartment does not significantly hinder disease progression. Level of evidence: Iii.

Pregabalin and pain after total knee arthroplasty: a double-blind, randomized, placebo-controlled, multidose trial

AAHKS (4) Acetaminophen

BACKGROUND: Pregabalin may reduce postoperative pain and opioid use. Higher doses may be more effective, but may cause sedation and confusion. This prospective, randomized, blinded, placebo-controlled study tested the hypothesis that pregabalin reduces pain at 2 weeks after total knee arthroplasty, but increases drowsiness and confusion. METHODS: Patients (30 per group) received capsules containing pregabalin (0, 50, 100, or 150 mg); two capsules before surgery, one capsule twice a day until postoperative day (POD) 14, one on POD15, and one on POD16. Multimodal analgesia included femoral nerve block, epidural analgesia, oxycodone-paracetamol, and meloxicam. The primary outcome was pain with flexion (POD14). RESULTS: Pregabalin did not reduce pain at rest, with ambulation, or with flexion at 2 weeks (P=0.69, 0.23, and 0.90, respectively). Pregabalin increased POD1 drowsiness (34.5, 37.9, 55.2, and 58.6% in the 0, 50, 100, and 150 mg arms, respectively; P=0.030), but did not increase confusion (0, 3.5, 0, and 3.5%, respectively; P=0.75). Pregabalin had no effect on acute or chronic pain, opioid consumption, or analgesic side-effects. Pregabalin reduced POD14 patient satisfaction [1-10 scale, median (first quartile, third quartile): 9 (8, 10), 8 (7, 10), 8 (5, 9), and 8 (6, 9.3), respectively; P=0.023). Protocol compliance was 63% by POD14 (50.0, 70.0, 76.7, and 56.7% compliance, respectively), with no effect of dose on compliance. Per-protocol analysis of compliant patients showed no effect of pregabalin on pain scores. CONCLUSIONS: Pregabalin had no beneficial effects, but increased sedation and decreased patient satisfaction. This study does not support routine perioperative pregabalin for total knee arthroplasty patients. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov: http://www.clinicaltrials.gov/ct2/show/study/NCT01333956.

The clinical implications of blood adiponectin in cardiometabolic disorders

Panniculectomy & Abdominoplasty CPG

Adipose tissue is now accepted by the scientific and medical community to be a genuine endocrine organ, in addition to its classical role as an energy store. Adiponectin is one of the many adipocytokines that are secreted almost exclusively by adipose tissue. Alteration in blood adiponectin concentrations has been linked to many human diseases in numerous cross-sectional and prospective studies. In this review, we describe briefly the biological effects of adiponectin as revealed by basic scientific investigations. We also summarize the principles of blood adiponectin assays. Overall, lower blood adiponectin concentration is found in subjects with obesity, type 2 diabetes mellitus, dyslipidemia, and hypertension. These medical conditions are components of the metabolic syndrome and major risk factors for accelerated atherosclerosis. Plasma adiponectin levels are also expected to be lower in subjects with cardiovascular diseases, such as coronary artery disease, ischemic stroke and peripheral artery disease. Congestive heart failure (CHF) and cardiac arrhythmia are common end points in cardiovascular diseases. Surprisingly, higher blood adiponectin levels are frequently reported to predict mortality associated with CHF. Few human data regarding adiponectin and cardiac arrhythmia are available. Higher blood adiponectin level has been documented only in atrial fibrillation. We also summarize data on the role of the high molecular weight (HMW) isoforms of adiponectin and the effects of clinical treatment on the levels of total or HMW adiponectin. Whether adiponectin is a risk marker or a risk factor for the diseases reviewed in this article, and in many other human diseases, and their detailed pathogenic links awaits further investigation. ©2009 Elsevier & Formosan Medical Association.

Physical exercise after knee arthroplasty: A systematic review of controlled trials

OAK 3 - Non-arthroplasty tx of OAK

Total knee arthroplasty TKA is the gold standard treatment for end-stage knee osteoarthritis. Most patients report successful long-term outcomes and reduced pain after TKA, but recovery is variable and the majority of patients continue to demonstrate lower extremity muscle weakness and functional deficits compared to age-matched control subjects. Given the potential positive influence of postoperative rehabilitation and the lack of established standards for prescribing exercise paradigms after TKA, the purpose of this study was to systematically review randomized, controlled studies to determine the effectiveness of postoperative outpatient care on short- and long-term functional recovery. Nineteen studies were identified as highly relevant for the review and four categories of postoperative intervention were discussed: 1) strengthening exercises; 2) aquatic therapy; 3) balance training; and 4) clinical environment. Optimal outpatient physical therapy protocols should include: strengthening and intensive functional exercises given through land-based or aquatic programs, the intensity of which is increased based on patient progress. Due to the highly individualized characteristics of these types of exercises, outpatient physical therapy performed in a clinic under the supervision of a trained physical therapist may provide the best long-term outcomes after the surgery. Supervised or remotely supervised therapy may be effective at reducing some of the impairments following TKA, but several studies without direct oversight produced poor results. Most studies did not accurately describe the "usual care" or control groups and information about the dose, frequency, intensity and duration of the rehabilitation protocols were lacking from several studies.

Complications of volar locking plates used to treat distal radius fractures

Distal Radius Fractures

About 10 years after volar locking plates were introduced to treat acute distal radius fractures, several papers have reported short-term complications. The aim of this paper was to report our complication rate over a 2-year period and to compare it to the literature. We found similar complication rates despite different classification systems. Because of the prospective nature of our study, we were able to demonstrate that extra-articular and/or intra-articular scores exceeding 8 points on a 12-points scale were statistically associated with more complications, irrespective of the patient's overall health and age.

L-brachioplasty: an adaptable technique for moderate to severe excess skin and fat of the arms

Panniculectomy & Abdominoplasty CPG

The L-brachioplasty is an L-shaped pattern of excision with the long limb from the elbow to the axilla and the short limb extending at right angles through the axilla and along the lateral chest. The width of the excisions through the arm, axilla and chest is based on preoperative assessment through anatomical point locations followed by pinch and gathering maneuvers. The following modifications have improved aesthetics and reduced complications: 1) improved geometric design, 2) anchor fixation of the posterior V-shaped advancement flap to the deltopectoral fascia, 3) excision site liposuction (ESL), and 4) and barbed suture closure. The free hand markings are followed by measuring equal anterior and posterior incision distances. The subcutaneous fat within the excision site is completely suctioned. After the perimeter is incised, the skin resection begins full thickness from the chest and through the axilla and then the skin only through proximal to distal arm skin. An anchor suture advances the posterior triangular flap to the deltopectoral fascia. A long-lasting absorbable barbed suture is passed through as a running horizontal mattress, starting from the center of the wound. A second continuous rapidly absorbing barbed intradermal suture completes the closure. Over the past 30 arms, only one seroma was aspirated on one occasion. There have been no lymphoceles. Appreciable swelling is over within a month. Incision dehiscence was limited to less than one centimeter in five patients. Tip necrosis of the V advancement flap occurred in three arms, leaving small wounds in the axilla to heal secondarily. Minor secondary skin reduction is rare. There were no contractures across the axilla. The women appreciated the reduced hair and axillary hollow. In most cases the skin laxity was corrected and the contour from the arm across the axilla to the lateral chest was excellent. No patient expressed regret over their scar.

Intra-articular injection of warmed lidocaine improves intraoperative anaesthetic and postoperative analgesic conditions

Surgical Management of Osteoarthritis of the Knee CPG

BACKGROUND: Although local anaesthesia for knee arthroscopy is a well-documented procedure, arthroscopy under local anaesthesia is often interrupted because of intolerable discomfort and pain. Warming local anaesthetic solutions may increase its anaesthetic effect. We tested whether intra-articular injection of warmed lidocaine solution could improve intraoperative anaesthetic and postoperative analgesic conditions. METHODS: Patients in the warmed group received 20 ml warmed (40 degrees C) lidocaine 1% intra-articularly 20 min before surgery. The patients in the control group received 20 ml room-temperature (25 degrees C) lidocaine 1% intra-articularly 20 min before surgery. During surgery, the patients reported pain on a visual analogue scale (VAS). RESULTS: The median VAS pain score was 1.5 (range, 0.0-3.0) in the warmed lidocaine group and 5.0 (4.0-8.0) in the control group (P<0.001). The median intra- and postoperative analgesic requirements in the control group were significantly greater than that in the warmed group. CONCLUSION: Warmed lidocaine injected intra-articularly provides improved intraoperative anaesthetic and postoperative analgesic conditions for patients undergoing knee arthroscopy

The Tibial Tubercle-Trochlear Groove Distance Is Greater in Patients With Patellofemoral Pain: Implications for the Origin of Pain and Clinical Interventions

OAK 3 - Non-arthroplasty tx of OAK

BACKGROUND: The distance between the tibial tubercle (TT) and trochlear groove (TT-TG distance) is known to be greater in patients with patellar instability. However, the potential role and prevalence of pathological TT-TG distances in a large cohort of skeletally mature patients with isolated patellofemoral pain (PFP) are not clear. PURPOSE: To determine if the mean TT-TG distance is greater in patients with PFP, who lack a history of patellar dislocations, knee trauma, or osteoarthritis, relative to healthy controls. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: A total of 50 knees (38 patients) with PFP and 60 knees (56 controls) without PFP formed the basis of this study. Magnetic resonance imaging was used to determine the TT-TG distance from 3-dimensional static scans. RESULTS: The cohort with PFP demonstrated a significantly greater mean TT-TG distance relative to asymptomatic controls (13.0 vs 10.8 mm, respectively; P = .001). Among the cohort with PFP, 15 knees (30%) demonstrated TT-TG distances >=15 mm, and 3 knees (6%) demonstrated TT-TG distances >=20 mm. CONCLUSION: Most adult patients with isolated PFP have elevated TT-TG distances compared with controls, which likely contributes to the force imbalance surrounding the knee.

Predictors of Local Recurrence in Patients With Myxofibrosarcoma

MSTS 2022 - Metastatic Disease of the Humerus

OBJECTIVES: Myxofibrosarcoma (MFS) is reported to have a higher risk of local recurrence (LR) following definitive surgical excision relative to other soft tissue sarcomas. We reviewed our clinical experience treating MFS to investigate predictors of LR. MATERIALS AND METHODS: We retrospectively reviewed treatment outcomes for MFS patients treated at our institution between 1999 and 2015. A total of 52 patients were identified. Median age was 65 years (range, 21 to 86 y). Site of disease was: upper extremity (27%), lower extremity (46%), trunk (15%), pelvic (8%), and head and neck (4%). Patients had low, intermediate, high-grade, and unknown grade in: 23%, 8%, 67%, and 2% of tumors, respectively. Tumors were categorized as <=5 cm (35%), >5 cm (56%), or unknown size (9%). In total, 71% received radiotherapy: 19% preoperative, 50% postoperative, and 2% both. All patients underwent surgery. Margins were negative in 71%, close/positive in 21%, and unknown in 8%. In total, 27% of patients received chemotherapy. Univariate Cox regression analysis was utilized to determine associations between clinical and treatment factors with LR. RESULTS: Median follow-up time was 2.9 years (range, 0.4 to 14.3 y). The 3-year actuarial LR, distant metastasis, and overall survival were: 31%, 15%, and 87%, respectively. Predictors of LR were patient age greater than or equal to the median of 65 years (hazard ratio, 13.46, 95% confidence interval, 1.71-106.18, P=0.013), and having close/positive tumor margins (hazard ratio, 3.4, 95% confidence interval, 1-11.53, P=0.049). CONCLUSIONS: In this institutional series of MFS older age and positive/close margins were significantly associated with a higher risk of LR.

Intra-articular giant synovial osteochondroma: case reports of the ankle and knee joint

Osteochondritis Dissecans 2020 Review

Two cases of giant intra-articular osteochondromas (knee and ankle joint) are reported; pathologically they are rare representations of synovial chondromatosis. A 17-year-old man presented with a tumorous mass which had been localized in his left ankle for many years, increasing in volume during the last months. The lesion was removed by posteromedial ankle arthrotomy. The second case was observed in a 39-year-old woman with a slow-growing mass in her right knee joint. The lesion was removed from the Hoffa fat pad by open anteromedial arthrotomy.

Is knee osteoarthritis a symmetrical disease? Analysis of a 12 year prospective cohort study

OAK 3 - Non-arthroplasty tx of OAK

BACKGROUND: The aim of this study was to document the development of bilateral knee osteoarthritis over a 12 year period using a middle-aged population-based cohort with knee pain at inclusion. METHODS: One hundred and forty three patients aged 35 to 54 were recruited from a population based cohort of 279 subjects who had knee pain at baseline and assessed with clinical and radiographic data, with 5 and 12 year follow up. The data was analysed with regard to the development and progression of uni- and bilateral knee osteoarthritis over 12 years. A definition of KL = 1 was used to define radiographic disease. RESULTS: 24 of the 30 (80%) patients with unilateral disease at baseline developed bilateral disease after 12 years. At baseline 37 patients (26%) had bilateral disease, whereas that number increased to 65 (52%) at 5 years and 100 (70%) at the 12 year follow up. The most common pattern was medial compartment involvement in both knees. Six patients had lateral compartment disease in one knee and medial in the other whereas only two had lateral compartment disease bilaterally. CONCLUSIONS: Bilateral knee osteoarthritis is very common with time, as the majority of sufferers will eventually develop radiographic disease in both knees. Clinicians need to be aware of the 'joint at risk' and researchers need to remember to account for both knees when assessing the relationship between physical function, pain and structural disease. The other knee should not be used for comparison, even if it appears to be normal at baseline.