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Retrograde intramedullary nailing of supracondylar femoral fractures: design and development of a new implant

Management of Hip Fractures in the Elderly

Since 1992 we have developed an implant in which the distal (condylar) screws have a diagonal configuration so that the screws can be closer to the distal end of the nail, allowing more distal fractures to be fixed. It also utilises the denser bone of the posterior condyles for more secure fixation in osteoporotic patients. The new implant was used for 24 extra-articular fractures from September 1994 to September 1997, and for 14 articular fractures from February 1995 to December 2000. There was no significant difficulty with obtaining fixation in very distal fractures and in osteoporotic bone. Early weightbearing was encouraged in those with extra-articular fractures. All fractures united within 3 months except one which required a bone graft (but no revision of implant) at 6 months. Average knee flexion at final followup was 101 degrees for extra-articular fractures and 106 degrees for articular fractures. Complications included quadriceps adhesions requiring further surgery in two patients who had open fractures, and malunion in one patient who had an early design of the implant and a 4.5mm condylar screw broke. Nine patients required late removal of condylar screws due to local soft tissue irritation

Management of Galeazzi's fracture dislocation. (A follow up study of 20 patients)

Distal Radius Fractures

A follow up study of 21 Galeazzi's fractures with evaluation of various therapeutic procedures is presented. Closed reduction should be attempted in all new cases, and in successful cases, control radiographs must be done after 3 wk to detect any redisplacement, and appropriate treatment undertaken. Open reduction remains the method of choice in all old cases or in failed closed reduction. Supplementing the open reduction with autogenous cancellous bone graft promotes union. Excision of the lower end of the ulna is useful in the mangement of old cases.

Diathermocoagulation in cutting mode and large flap dissection

Panniculectomy & Abdominoplasty CPG

BACKGROUND: The aim of this study was to determine the overall complication rate associated with the use of diathermocoagulation in cutting mode for flap dissection. METHODS: Because of the high rate of complications generally associated with abdominoplasty, a large flap, abdominoplasty, or abdominal dermolipectomy model was chosen. A retrospective review was conducted regarding 647 abdominoplasty procedures, 320 of which were performed with the monopolar diathermocoagulation in the cutting mode and 327 of which were performed with a steel scalpel. The two groups were similar regarding morphologic characteristics, prescriptions, and procedures. In both cases, hemostasis was performed with punctual monopolar coagulation current. Analysis was performed regarding the frequency of major general complications (e.g., deep vein thrombosis and pulmonary embolism), major surgical complications (e.g., acute hemorrhage), and "minor" complications (e.g., postoperative secondary collections or delayed wound healing). RESULTS: In the electrosurgery group, the incidence of noninfectious collections was significantly higher, as was the production of the drains. No difference was seen in terms of reintervention for acute hematoma, postoperative infectious collections, blood loss, hospital stay, or thromboembolic complications. Operations took significantly longer with the steel scalpel. The follow-up was significantly longer in the diathermocoagulation group. CONCLUSIONS: Monopolar diathermocoagulation has already proven its place in the general work of every surgeon. Moreover, this technique remains superior in terms of the rapidity with which surgery can be performed when dissecting large areas. Nevertheless, the higher rate of surgical complications leads to a longer follow-up period that, in part, runs counter to this advantage.

Impaired perceptual memory of locations across gaze-shifts in patients with unilateral spatial neglect

Upper Eyelid and Brow Surgery

Right hemisphere lesions often lead to severe disorders in spatial awareness and behavior, such as left hemispatial neglect. Neglect involves not only pathological biases in attention and exploration but also deficits in internal representations of space and spatial working memory. Here we designed a new paradigm to test whether one potential component may involve a failure to maintain an updated representation of visual locations across delays when a gaze-shift intervenes. Right hemisphere patients with varying severity of left spatial neglect had to encode a single target location and retain it across an interval of 2 or 3 sec, during which the target was transiently removed, before a subsequent probe appeared for a same/different location judgment. During the delay, gaze could have to shift to either side of the remembered location, or no gaze-shift was required. Patients showed a dramatic loss of memory for target location after shifting gaze to its right (toward their "intact" ipsilesional side), but not after leftward gaze-shifts. Such impairment arose even when the target initially appeared in the right visual field, before being updated leftward due to right gaze, and even when gaze returned to the screen center before the memory probe was presented. These findings indicate that location information may be permanently degraded when the target has to be remapped leftward in gaze-centric representations. Across patients, the location-memory deficit induced by rightward gaze-shifts correlated with left neglect severity on several clinical tests. This paradoxical memory deficit, with worse performance following gaze-shifts to the "intact" side of space, may reflect losses in gaze-centric representations of space that normally remap a remembered location dynamically relative to current gaze. Right gaze-shifts may remap remembered locations leftward, into damaged representations, whereas left gaze-shifts will require remapping rightward, into intact representations. Our findings accord with physiological data on normal remapping mechanisms in the primate brain but demonstrate for the first time their impact on perceptual spatial memory when damaged, while providing new insights into possible components that may contribute to the neglect syndrome.

Prognostic factors and survival according to tumor subtype in newly diagnosed breast cancer with liver metastases: A competing risk analysis

MSTS 2022 - Metastatic Disease of the Humerus

Population-based study for predicting the prognosis for breast cancer liver metastasis (BCLM) is lacking at present. Therefore, the present study aimed to evaluate newly diagnosed BCLM patients of different tumor subtypes and assess potential prognostic factors for predicting the survival for BCLM patients. Specifically, data were collected from the Surveillance, Epidemiology and End Results program from 2010 to 2014, and were assessed, including the data of patients with BCLM. Differences in the overall survival (OS) among patients was compared via Kaplan-Meier analysis. Other prognostic factors of OS were determined using the Cox proportional hazard model. In addition, the breast cancer-specific mortality was assessed using the Fine and Gray's competing risk model. A nomogram was also constructed on the basis of the Cox model for predicting the prognosis of BCLM cases. A total of 2,098 cases that had a median OS of 20.0 months were included. The distribution of tumor subtypes was as follows: 42.2% with human epidermal growth factor receptor 2 (Her2; -)/hormone receptor (HR; +), 12.8% with Her2(+)/HR(-), 19.1% with Her2(+)/HR(+) and 13.5% with triple negative breast cancer (TNBC). Kaplan-Meier analysis revealed that older age (>64 years), unmarried status, larger tumor, higher grade, no surgery, metastases at other sites, and TNBC subtype were associated with shorter OS. Additionally, multivariate analysis revealed that older age (>64 years), unmarried status, no surgery, bone metastasis, brain metastasis and TNBC subtype were significantly associated with worse prognosis. Thus, age at diagnosis, marital status, surgery, bone metastasis, brain metastasis and tumor subtype were confirmed as independent prognosis factors from a competing risk model. We also constructed a nomogram, which had the concordance index of internal validation of 0.685 (0.650-0.720). This paper had carried out the population-based prognosis prediction for BCLM cases. The survival of BCLM differed depending on the tumor subtype. More independent prognosis factors were age at the time of diagnosis, surgery, marital status, bone metastasis, as well as brain metastasis, in addition to tumor subtype. Notably, the as-constructed nomogram might serve as an efficient approach to predict the prognosis for individual patients.

The cost utility of autologous chondrocytes implantation using ChondroCelect(registered trademark) in symptomatic knee cartilage lesions in Belgium

Surgical Management of Osteoarthritis of the Knee CPG

Background: Knee cartilage lesions increase the risk of developing osteoarthritis (OA), and may eventually result in a total knee replacement (TKR). There is currently no consensus on the optimal treatment of cartilage lesions. ChondroCelect(registered trademark) (CC) is a cell-based therapy approved for use in autologous chondrocytes implantation (ACI) to treat symptomatic cartilage defects of the femoral condyle. Its capacity to safely restore good-quality cartilage was demonstrated in a randomized controlled trial (RCT) versus the surgical procedure microfracture (MFX). Objective: This study investigated the cost utility of CC used in ACI compared with MFX to treat symptomatic knee cartilage lesions in Belgium. Methods: A decision tree model comparing CC with MFX over a 40-year horizon was developed in TreeAge Pro(trademark). The key timepoints of the model were (i) clinical assessment 5 years after initial intervention (success or no success, with or without re-operation); (ii) development of OA at 15 years (yes/no); (iii) need for TKR at 20 years (yes/no); and (iv) need for prosthesis revision at 35 years (yes/no). Clinical data provided by the RCT of CC versus MFX were the clinical success (response) rate based on the Knee injury and Osteoarthritis Outcome Score (KOOS) at 36 months (82.9% vs 62.0%; p = 0.048) and the proportion of good structural repair/presence of hyaline cartilage based on International Cartilage Repair Society (ICRS II) visual item at 12 months (44.9% vs 23.2%; p= 0.023). Utility scores by surgery outcome were derived from the SF-36 questionnaire responses collected in the RCT. Conservative assumptions related to the incidences of OA, TKR and prosthesis revision relied on a literature search. A patient chart review (n = 82) provided follow-up costs by surgery outcome. National tariffs were applied to direct medical resources used (healthcare payer perspective, year 2008 costs). Annual discounting was applied to costs (3%) and effects (1.5%) as recommended by the Belgian pharmacoeconomic guidelines. Results: The incremental cost perQALYgained forCCcompared withMFXwas 16 229, with a difference in costs of 20 802 and 1.282 QALYs gained. Sensitivity analyses indicated that the key model drivers were the proportion of patients with hyaline cartilage and the correlation between hyaline cartilage formation and later avoidance of OA. Probabilistic sensitivity analyses showed robustness of the results, with 80% of the simulations below the usual UK National Institute for Health and Clinical Excellence (NICE) threshold of 22 000 per QALY. Conclusions: Assuming a good correlation between high-quality cartilage repair and avoidance of OA at a later stage, the benefits of the cell therapy CC over MFX in terms of

Relevance of calcitonin cut-off in the follow-up of medullary thyroid carcinoma for conventional imaging and 18-fluorine-fluorodihydroxyphenylalanine PET

MSTS 2018 - Femur Mets and MM

AIM: The American thyroid association (ATA) recommends that additional imaging procedures supplement cervical ultrasonography (US) in any patient with a basal calcitonin value above 150 pg/ml in the follow-up of medullary thyroid carcinoma (MTC). The aim of the present study was to reaffirm or challenge this cut-off for 18-Fluorine-Fluorodihydroxyphenylalanine positron emission tomography (18F-DOPA PET) and conventional imaging ultrasonography (US), computed tomography (CT), magnetic resonance imaging (MRI)). MATERIALS AND METHODS: Thirty-nine patients (18 females, 21 males), mean age 62 years, range from 35 to 86, followed-up for MTC were included in the present retrospective study. In our patients 64 18F-DOPA scans, 28 neck US, 28 CT and 8 MRI were performed. For all cases basal calcitonin values were available. Sensitivity and specificity of 18F-DOPA PET and conventional imaging (US, CT, MRI) related to calcitonin values were calculated. RESULTS: According to the calcitonin cut-off of 150 pg/ml, we found the following sensitivities and specificities: 79% and 80% for 18F-DOPA PET, 75% and 92% for US, 80% and 25% for CT, 50% and 75% for MRI. Taking the level of detectable calcitonin, we calculated the following sensitivities: 52% for 18F-DOPA PET, 46% for US, 79% for CT and 38% for MRI. CONCLUSION: We cannot confirm the calcitonin cut-off proposed by the ATA for the detection of MTC recurrences and contemporaneously we cannot state that 18F-DOPA PET has a very high sensitivity. For the neck region 18F-DOPA PET and US showed similar results. 18F-DOPA PET/CT seems to be the best imaging modality for whole-body tumor detection. Bone metastases are best detected by MRI.

Bilateral Distal Femoral Flexion Deformity After Total Knee Arthroplasty in a Patient with Rheumatoid Arthritis

Surgical Management of Osteoarthritis of the Knee CPG

Rheumatoid arthritis is an autoimmune systemic disease with predominant peripheral polyarthritis, often leading to severe joint destruction. This is a case report of an 81-year-old woman with long-standing severe rheumatoid arthritis requiring multiple orthopaedic operations for joint destruction since 2000. These operated joints improved her functional mobility until recently, when she found that her knees were fixed at around 70(degrees) of flexion with limited motion. There was chronic progressive flexion deformity of bilateral distal femurs, which was an extremely rare complication of total knee arthroplasty. (copyright) 2013, The Hong Kong Orthopaedic Association and Hong Kong College of Orthopaedic Surgeons

A randomized trial on the management of low-grade squamous intraepithelial lesion cytology interpretations

Reconstruction After Skin Cancer

STUDY DESIGNA total of 1572 women with a community-based LSIL interpretation were randomly assigned to immediate colposcopy, triage based on enrollment HPV DNA testing and liquid-based cytology at a colposcopy referral threshold of high-grade squamous intraepithelial lesion (HSIL), or conservative management based on repeat cytology at a referral threshold of HSIL. All arms included 2 years of semiannual follow-up and colposcopy at exit. Loop electrosurgical excision procedure was offered to women with histologic diagnoses of cervical intraepithelial neoplasia (CIN) grade 2 or 3 at any visit or persistent CIN grade 1 at exit. The main study end point was 2-year cumulative diagnosis of CIN grade 3.RESULTSThe 2-year cumulative diagnosis of CIN grade 3 was approximately 15% in all study arms. The HPV triage arm was closed early because more than 80% of women were HPV positive, precluding efficient triage. The immediate colposcopy strategy yielded 55.9% sensitivity for cumulative cases of CIN grade 3 diagnosed over 2 years. A conservative management strategy of repeat cytology at the HSIL threshold referred 18.8% of women while detecting 48.4% of cumulative CIN grade 3. At lower cytology thresholds, sensitivity would improve but would ultimately yield unacceptably high referral rates.CONCLUSIONLSIL cytology is best managed by colposcopy initially, because there was no useful triage strategy identified. Management of these patients, after colposcopy to rule out immediately overt CIN grade 2 or 3, needs to be determined.OBJECTIVEThis study was undertaken to compare alternative strategies for the initial management of low-grade squamous intraepithelial lesion (LSIL) cytology.

Graded Motor Imagery for Women at Risk for Developing Type I CRPS Following Closed Treatment of Distal Radius Fractures

Distal Radius Fractures

Distal radius fractures (DRF) account for nearly one�fifth of all fractures in older adults with women sustaining them at a rate of 5 to 1 relative to their male counterparts. The majority of DRF occur as a result of low impact injuries to the wrist with the hand being outstretched and are most often managed via closed treatment and cast immobilization The aftereffects of these injuries include pain, distal upper limb immobility, distal sensorimotor changes, hand weakness, edema, and type I complex CRPS development. Women, those sustaining low�force injuries, and those who undergo closed treatment and cast immobilization of the DRF, are at increased risk for developing type I CRPS. Given that alterations in the brain's somatosensory strip likely influence CRPS development, a newer intervention, graded motor imagery, is being used to restore the affected limbs cortical representation to its typical state. Beyond pain reduction, the implications of this type of approach also include restoring sensorimotor function to the affected limb. Evidence supports that these interventions can impact CRPS symptoms as well as motor function but only after they've developed. To date, there is no literature exploring how these techniques, specifically graded motor imagery, can be applied to prevent or mitigate the aforementioned aftereffects of DRF in women. To this end the investigators propose to pilot a 6�week randomized comparative effectiveness trial, where the modified graded motor imagery program + standard of care group is compared to a standard of care (SOC) control group. Immediately following cast immobilization, the intervention group and control group will each participate in one 1�hr and three 30�minute clinic�based sessions and 15 minute home programs three times daily. Blinded assessments will occur at baseline, 3 weeks, cast removal, and one and 3 months after cast removal and will include pain, sensorimotor, edema, and CRPS diagnostic outcomes. The project's aims are to: 1) determine the feasibility of recruiting, enrolling, treating, and following participants and 2) determine if those who participate in a GMI and SOC hand therapy program have differing pain, function, and counts of CRPS diagnoses when compared to those who receive only the SOC. The investigators hypothesize 1) that the project will be feasible to carry out on a larger scale and 2) that an early GMI will improve the pain, functional and upper limb sensorimotor outcomes of persons with closed treatment of DRF relative to a standard of care intervention.

A review of bone marrow lesions in the arthritic knee and description of a technique for treatment

Osteochondritis Dissecans 2020 Review

Introduction: Subchondral bone pathology includes a wide range of pathologies, such as osteoarthritis, spontaneous insufficiency fractures, osteonecrosis, transient bone marrow lesions syndromes, and trauma. They show typical magnetic resonance imaging (MRI) findings termed bone marrow lesions (BMLs). However, the etiology and evolution of BMLs in multiple conditions remains unclear. There is still no gold standard treatment protocol in treating BMLs in the knee, and a variety of treatment modalities have been tested in the hope that they might reduce pain and stop disease progression. Objectives: To review the treatment options for BMLs of the knee. Methods: A literature review was performed that included searches of PubMed, Cochrane, and Medline databases using the following keywords: Bone marrow lesions, sub chondroplasty, bone marrow concentrate, platelet-rich plasma (PRP), subchondral bone augmentation. Results: The use of novel biologic techniques to treat BMLs in the knee, such as PRP and Bone Marrow Cells, has yielded promising clinical outcomes. Conclusions: Future research of BMLs will be mandatory to address the different pathologies better and determining appropriate treatment strategies. There is still a need for high-quality RCTs studies and systematic reviews in the future to enhance further treatment strategy in preventing or treating BMLs of the knee.

In-vitro susceptibility of oral streptococci to pristinamycin

Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures

The inhibitory activity of pristinamycin against oral streptococci was compared with that of amoxycillin, erythromycin and vancomycin. Minimum inhibitory concentrations (MICs) of pristinamycin ranged from 0.03-1 mg/l (mode 0.25 mg/l), similar to those for amoxycillin. Erythromycin had a mode MIC of 0.06 mg/l and vancomycin, the least active, 1 mg/l. However, in killing curve experiments to compare the bactericidal activities of pristinamycin and erythromycin against several strains of oral streptococci, pristinamycin was substantially more active, consistently producing a rapid decrease in viable count during the first few hours of incubation. Pristinamycin may prove to be of value for the prophylaxis of post-dental extraction bacteraemia

Clinical, pathogenetic, and laboratory features of Capnocytophaga infections

Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures

Granulocytopenia and oral mucosal defects have been reported to be important predisposing factors to recently recognized cases of Capnocytophaga septicemia. The authors call attention to an apparent preponderance of these cases in the pediatric age group and emphasize laboratory features which they have found helpful in the diagnosis of Capnocytophaga infections. Thirteen patients with Capnocytophaga infections were seen during a seven-year period. Seven of these patients had Capnocytophaga bacteremia. Six of seven bacteremic patients were granulocytopenic, six had oral mucosal defects, and three died. Five of the seven bacteremic patients were younger than 20 years of age. This represents a disproportionate distribution of cases in the pediatric age group within the author's institution, because 43% of blood culture specimens submitted to their microbiology laboratory are obtained from pediatric patients. This observation is supported by a review of the reported cases of Capnocytophaga septicemia in which 7 of 12 patients were younger than 20 years of age. Because Capnocytophaga may superficially resemble the more commonly isolated Fusobacterium nucleatum, distinguishing features for laboratory identification are discussed

Analysis of NHSLA claims in hand and wrist surgery

Distal Radius Fractures

Claims for negligence are increasing in medical practice. We analysed data provided by the UK NHS Litigation Authority (NHSLA) on all hand and wrist surgery from 1995-2001. The numbers of claims increased from 13 to 40, but the number being successfully defended also increased from 2 to 13 during this period. Claims were most commonly attributed to errors at surgery (56%) or in outpatient clinics (24%). Strikingly the claims are clustered to a few common conditions, particularly the treatment of carpal tunnel syndrome (22%) and wrist fractures (48%). There were no claims related to complex hand surgery. We recommend better training for 'routine surgery', better description of distal radius fracture parameters at each clinic visit and better training in emergency departments (ED).

Changes in the antiangiogenic properties of articular cartilage in osteoarthritis

Management of Hip Fractures in the Elderly

Avascularity is important for the unique biomechanical properties of articular cartilage, and normal cartilage actively repels vascular invasion. This study investigated whether the antiangiogenic properties changed in the presence of osteoarthritis (OA) by culturing explants of human articular cartilage on the chorioallantoic membrane (CAM) of chick embryos and investigating the incidence of vascular invasion and the effects of exogenous vascular endothelial growth factor (VEGF) and matrix metalloproteinase-9 (MMP-9). The results were compared with those of non-OA cartilage obtained after femoral neck fractures. Altogether, 72% of OA samples but only 5% of non-OA samples were invaded by the CAM, indicating that changes in the antiangiogenic properties represented a fundamental difference between control and OA cartilage. Exogenous VEGF or MMP-9 increased the frequency of invasion to 70%-100%. Invasion most frequently occurred into cartilage matrix from which proteoglycans had been lost, the latter being detectable by sirius red staining of cartilage collagen. VEGF was synthesized by chondrocytes in proportion to the severity of degradation and might exacerbate the loss of resistance to invasion. These results indicate that loss of resistance to vascular invasion distinguishes OA cartilage from normal articular cartilage, which may be important in the pathogenesis of OA

Fluoroscopic radiation exposure: are we protecting ourselves adequately?

Distal Radius Fractures

BACKGROUND: While traditional intraoperative fluoroscopy protection relies on thyroid shields and aprons, recent data suggest that the surgeon's eyes and hands receive more exposure than previously appreciated. Using a distal radial fracture surgery model, we examined (1) radiation exposure to the eyes, thyroid, chest, groin, and hands of a surgeon mannequin; (2) the degree to which shielding equipment can decrease exposure; and (3) how exposure varies with fluoroscopy unit size. METHODS: An anthropomorphic model was fit with radiation-attenuating glasses, a thyroid shield, an apron, and gloves. "Exposed" thermoluminescent dosimeters overlaid the protective equipment at the eyes, thyroid, chest, groin, and index finger while "shielded" dosimeters were placed beneath the protective equipment. Fluoroscopy position and settings were standardized. The mini-c-arm milliampere-seconds were fixed based on the selection of the kilovolt peak (kVp). Three mini and three standard c-arms scanned a model of the patient's wrist continuously for fifteen minutes each. Ten dosimeter exposures were recorded for each c-arm. RESULTS: Hand exposure averaged 31 muSv/min (range, 22 to 48 muSv/min), which was 13.0 times higher than the other recorded exposures. Eye exposure averaged 4 muSv/min, 2.2 times higher than the mean thyroid, chest, and groin exposure. Gloves reduced hand exposure by 69.4%. Glasses decreased eye exposure by 65.6%. There was no significant difference in exposure between mini and standard fluoroscopy. CONCLUSIONS: Surgeons' hands receive the most radiation exposure during distal radial plate fixation under fluoroscopy. There was a small but insignificant difference in mean exposure between standard fluoroscopy and mini-fluoroscopy, but some standard units resulted in lower exposure than some mini-units. On the basis of these findings, we recommend routine protective equipment to mitigate exposure to surgeons' hands and eyes, in addition to the thyroid, chest, and groin, during fluoroscopy procedures.

Can a linear external fixator stand as a surgical alternative to open reduction in treating a high-grade supracondylar humerus fracture?

Pediatric Supracondylar Humerus Fracture 2020 Review

OBJECTIVE: High-grade pediatric supracondylar humerus fractures are commonly treated with closed reduction and internal fixation with percutaneous pinning. When this fails, open reduction followed by internal fixation is the widely accepted procedure of choice. Use of a lateral external fixator was recently described as an optional procedure, but evidence is scarce. METHODS: We investigated the outcomes of upper limbs treated by either open reduction with internal fixation or closed reduction and external fixation. RESULTS: Twenty-one patients completed the long-term follow-up; 11 underwent open reduction, and 10 underwent external fixation. Most patients in both groups reported excellent satisfaction. In both groups, the modified Disabilities of the Arm, Shoulder, and Hand score was extremely low and the average elbow range of motion was almost identical. Radiographic analysis consisting of Baumann's angle and the carrying angle revealed no statistical difference between the two groups. DISCUSSION: Optional treatment using a linear external fixator for complex nonreducible supracondylar humerus fractures yielded acceptable clinical and radiographic results, as with open reduction. Our sample size was small, but the promising results may assist in the implementation of an alternative surgical procedure, especially in more complicated cases involving flexion-type fractures or severe soft tissue damage and swelling.

High bone mass is associated with a greater prevalence of hip but not knee replacement

Surgical Management of Osteoarthritis of the Knee CPG

Introduction: Epidemiological studies have shown an inverse relationship between osteoarthritis (OA) and osteoporosis, implying that high bone mass may confer increased OA risk. We aimed to study clinical variables associated withOAin our High Bone Mass (HBM) population, recruited by systematically screening 335,115 DXA scans across England and Wales to identify index cases, and through them their family members. Material and Methods: HBM status in index cases was defined by DXA scan interpretation as (excluding known artefactual causes of elevated BMD measurement), an a) L1 Z-score of(greater-than or equal to)+3.2 and total hip Z-score(greater-than or equal to)+1.2 or b) total hip Z-score(greater-than or equal to)+3.2 and L1 Z-score(greater-than or equal to)+1.2. In relatives of known HBM index cases the definition of HBM was L1 Z-score plus total hip Z-score(greater-than or equal to)+3.2. Controls comprised unaffected relatives and spouses. Clinical indicators of OA (joint pain, joint replacement and NSAID use) were determined at structured interview; passive knee crepitus was assessed by doctor examination. Analyses used logistic regression adjusting for age, gender, smoking, alcohol use and BMI in Stata v11. Results: 339 HBM cases (mean age 61.7 years, 77 % female) and 188 controls (mean age 54.8 years, 46 % female) were included. Crude odds ratios suggested an increase in overall joint pain in HBMcases versus controls, which did not persist after adjustment. Adjusted NSAID use was more prevalent in HBM cases versus controls (OR 2.20 [1.09, 4.44], p=0.03, 95 % CIs shown). The prevalence of hip replacement was 6.5 % (cases) and 1.1 % (controls) with adjusted OR 5.04 [1.11-22.84], p=0.04. The prevalence of knee replacement was 6.8 % and 3.7 % in cases and controls respectively with adjusted OR 1.15 [0.44-2.99], p=0.77. In participants who were examined (n=404), the prevalence of moderate/severe knee crepitus was no different between cases and controls (OR 1.16 [0.70-1.90], p=0.57). Conclusion: HBM within this population was associated with increased prevalence of hip replacement surgery and NSAID use compared with unaffected family and spouse controls, suggesting a preferential effect of HBM on OA risk at the hip compared with the knee which warrants further exploration

Surgical treatments of cartilage defects of the knee: Systematic review of randomised controlled trials

OAK 3 - Non-arthroplasty tx of OAK

Background The aim of this systematic review was to identify high quality randomised controlled trials (RCTs) and to provide an update on the most appropriate surgical treatments for knee cartilage defects. Methods Two reviewers independently searched three databases for RCTs comparing at least two different treatment techniques for knee cartilage defects. The search strategy used terms mapped to relevant subject headings of MeSH terms. Strict inclusion and exclusion criteria were used to identify studies with patients aged between 18 and 55 years with articular cartilage defects sized between one and 15 cm2. Risk of bias was performed using a Coleman Methodology Score. Data extracted included patient demographics, defect characteristics, clinical outcomes, and failure rates. Results Ten articles were included (861 patients). Eight studies compared microfracture to other treatment; four to autologous chondrocyte implantation (ACI) or matrix-induced ACI (MACI); three to osteochondral autologous transplantation (OAT); and one to BST-Cargel. Two studies reported better results with OAT than with microfracture and one reported similar results. Two studies reported superior results with cartilage regenerative techniques than with microfracture, and two reported similar results. At 10 years significantly more failures occurred with microfracture compared to OAT and with OAT compared to ACI. Larger lesions (> 4.5 cm2) treated with cartilage regenerative techniques (ACI/MACI) had better outcomes than with microfracture. Conclusions Based on the evidence from this systematic review no single treatment can be recommended for the treatment of knee cartilage defects. This highlights the need for further RCTs, preferably patient-blinded, using an appropriate reference treatment or a placebo procedure.

Beyond the operating room: a look at legal liability in body contouring procedures

Panniculectomy & Abdominoplasty CPG

BACKGROUND: Malpractice claims affect the cost and quality of health care. OBJECTIVE: In this study, the authors examine legal litigation following body contouring surgery and identify factors influencing malpractice litigation outcomes. METHODS: The Westlaw legal database was searched for jury verdict and settlement reports related to body contouring procedures and medical malpractice. Cases included for analysis were examined for year of report, geographic location, patient demographics, procedure performed, alleged injury, causes of action, verdict, and indemnity payments. RESULTS: Of 113 cases, the most common injuries sustained were disfigurement (33.6%) and the necessitation of a revision procedure (33.6%). The most common cause of action cited was negligence (84.1%). Median plaintiff ages differed significantly (P = .003) between cases favoring the defendant (44.5 years) and those favoring the plaintiff (36 years). Of the alleged injuries, those cases citing an iatrogenic injury were 2.5 times more likely to result in either damages awarded or settlement (relative risk [RR], 2.5; 95% confidence interval [CI], 1.66-3.80). Cases that cited disfigurement were 87% more likely to result in damages awarded to the plaintiff (RR, 1.87; 95% CI, 1.08-3.26). CONCLUSIONS: Based on this study of body contouring litigation, younger plaintiff age and iatrogenic injury strongly favored plaintiffs in either awarded damages or a settlement. Disfigurement favored plaintiffs only in awarded damages. Our study emphasizes the need for adequate communication with the patient explaining realistic aesthetic results and risks of the procedure. In addition, iatrogenic organ injury must be handled expeditiously. Incorporating these recommendations into clinical practice may promote an improved physician-patient relationship while reducing litigatious health care costs.

Statistical analysis of perioperative and postoperative mortality of patients with prosthetic replacement of the hip joint

Management of Hip Fractures in the Elderly

From 1967 to 1975 a total of 1322 hip replacement operations in 1157 patients was carried out in the Orthopaedic Hospital, University of Heidelberg. The mortality rate, as evaluated by modern methods of medical statistics, was 5.7%. The risk of fatality must be one of the main factors influencing the surgeon when considering whether to offer hip replacement to an aged patient

Hypertrophic pyloric stenosis in infants following pertussis prophylaxis with erythromycin--Knoxville, Tennessee, 1999

Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures

In February 1999, pertussis was diagnosed in six neonates born at hospital A in Knoxville, Tennessee. Because a health-care worker at hospital A was most likely the source of exposure, the local health department recommended on February 25, 1999, that erythromycin be prescribed as postexposure prophylaxis for the approximately 200 infants born at hospital A during February 1-24, 1999. In March 1999, local pediatric surgeons noticed an increased number of cases of infantile hypertrophic pyloric stenosis (IHPS) in the area, with seven cases occurring during a 2-week period. All seven IHPS cases were in infants born in hospital A during February who were given erythromycin orally for prophylaxis following possible exposure to pertussis, although none had pertussis diagnosed. The Tennessee Department of Health and CDC investigated the cluster of IHPS cases and its possible association with use of erythromycin. This report summarizes the results of the investigation, which suggest a causal role of erythromycin in this cluster of IHPS cases

Prognostic value of serum markers of bone metabolism in untreated multiple myeloma patients

MSTS 2018 - Femur Mets and MM

Bone involvement is a central feature of multiple myeloma (MM). We investigated whether serum markers of osteoblastic and osteoclastic activity correlate with the presence of bone disease and survival in 313 MM patients enrolled in a phase III trial (E9486). Five markers were measured, including osteocalcin (OC), carboxy-terminal propeptide of type I collagen (PICP), bone alkaline phosphatase (BAP), carboxy-terminal telopeptide of type I collagen (ICTP) and tartrate-resistant acid phosphatase (TRAP). We analysed the relationship between serum levels of these markers and the presence of bone manifestations, and survival. Serum levels of ICTP and BAP correlated significantly with bone pain, lesions and fractures. Serum level of ICTP was also higher in stage II-III compared with stage I disease. The serum level of ICTP was significantly associated with shortened survival in the univariate analysis. The median survival times were 4.1 and 3.5 years for low and high ICTP respectively (P = 0.02). There was a strong relationship between ICTP and beta-2-micrgolobulin (B2M). ICTP stands out as a significant marker of bone disease. Incorporation of these markers into clinical trials assessing the use of bisphosphonates in MM is needed to determine whether they might serve as indicators of effectiveness of these agents.

Presence of gout is associated with increased osteoarthritis prevalence and severity

Surgical Management of Osteoarthritis of the Knee CPG

Background/Purpose: There is a pressing need to identify biomarkers of osteoarthritis (OA) presence/progression, and remediable risk factors that may promote OA therapeutic approaches. Uric acid (UA) in both soluble and crystalline forms is biologically active, and gout often occurs in a similar age group as OA. We tested whether subjects with gout or asymptomatic hyperuricemia (AH) have increased prevalence/severity of knee OA. Methods: Male subjects age 55-85 were consecutively recruited during primary care visits to an urban VA hospital. Subjects were interviewed and assessed for gout (ACR Clinical Criteria). Background medical histories and serum UA levels were obtained. Exclusion criteria included non-gout inflammatory arthritis, psoriasis, inflammatory bowel disease, hemodialysis, severe knee trauma or knee replacement. Enrolled subjects were categorized into 3 groups: gout, AH (no gout, UA >= 6.9 mg/dL), and controls (no gout, UA <= 6.8 mg/dL). On a 2nd visit subjects underwent OA assessment: knee pain history, WOMAC and RAPID3 surveys, musculoskeletal exam, weight-bearing bilateral knee X-ray, and knee/MTP ultrasound (US) to assess MSU crystal deposition. OA was diagnosed using ACR Clinical and Clinical/Radiographic criteria, and differences in summary statistics between groups were estimated using the Kruskal-Wallis and Chi-square tests. Images were read on a blinded basis (US by 2 independent reviewers, X-rays by a musculoskeletal radiologist). Results: Of 129 subjects screened, 119 were enrolled and 75 completed both visits: 25 gout, 25 AH, and 25 controls. Mean age/race were similar among all groups, but BMI was highest in the gout group. 68% of gout, 52% of AH and 28% of control subjects had knee OA by Clinical/Radiographic criteria (gout vs control, p=0.017). The unadjusted odds ratio for knee OA in gout vs control was 5.46 (95% CI [1.63, 18.36], p=0.040), and remained significant after BMI adjustment (OR 3.80, 95% CI: [1.06, 13.57, p=0.040]). Mean Kellgren-Lawrence grades were significantly higher in gout vs control for right (p=0.013) and left (p=0.049) knees. Bilateral knee OA was also more common in the gout group. WOMAC (knee pain, stiffness and functional limitation) and RAPID3 scores among gout subjects were higher compared to the other groups, but not statistically different. Crystal deposition detected by US was more common in subjects with vs without knee OA (40.5% vs 16.2%, p=0.020), but was not associated with OA in specific joints. Subjects with AH had knee OA prevalence/severity intermediate between control and gout patients. Conclusion: Our data suggest that presence of gout puts subjects at significantly higher risk for increased knee OA prevalence and severity. AH may independently convey knee OA risk but our sample size was inadequate for statistical confirmation. MSU crystal deposition as detected by US was also significantly higher in subjects with knee OA. Presence of gout or AH, as well as MSU crystal deposition on US, could potentially serve as useful biomarkers for knee OA risk, severity and progression. The possibility that gout and/or AH might contribute to OA risk suggests that UA management should be assessed as a potential intervention in OA patients

Interventions for treating proximal humeral fractures in adults

Pediatric Supracondylar Humerus Fracture 2020 Review

- Background Fracture of the proximal humerus, often termed shoulder fracture, is a common injury in older people. The management of these fractures varies widely. This is an update of a Cochrane Review first published in 2001 and last updated in 2012. Objectives To assess the effects (benefits and harms) of treatment and rehabilitation interventions for proximal humeral fractures in adults. Search methods We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, and other databases, conference proceedings and bibliographies of trial reports. The full search ended in November 2014. Selection criteria We considered all randomised controlled trials (RCTs) and quasi�randomised controlled trials pertinent to the management of proximal humeral fractures in adults. Data collection and analysis Both review authors performed independent study selection, risk of bias assessment and data extraction. Only limited meta�analysis was performed. Main results We included 31 heterogeneous RCTs (1941 participants). Most of the 18 separate treatment comparisons were tested by small single�centre trials. The main exception was the surgical versus non�surgical treatment comparison tested by eight trials. Except for a large multicentre trial, bias in these trials could not be ruled out. The quality of the evidence was either low or very low for all comparisons except the largest comparison. Nine trials evaluated non�surgical treatment in mainly minimally displaced fractures. Four trials compared early (usually one week) versus delayed (three or four weeks) mobilisation after fracture but only limited pooling was possible and most of the data were from one trial (86 participants). This found some evidence that early mobilisation resulted in better recovery and less pain in people with mainly minimally displaced fractures. There was evidence of little difference between the two groups in shoulder complications (2/127 early mobilisation versus 3/132 delayed mobilisation; 4 trials) and fracture displacement and non�union (2/52 versus 1/54; 2 trials). One quasi�randomised trial (28 participants) found the Gilchrist�type sling was generally more comfortable than the Desault�type sling (body bandage). One trial (48 participants) testing pulsed electromagnetic high�frequency energy provided no evidence. Two trials (62 participants) provided evidence indicating little difference in outcome between instruction for home exercises versus supervised physiotherapy. One trial (48 participants) reported, without presentable data, that home exercise alone gave better early and comparable long�term results than supervised exercise in a swimming pool plus home exercise. Eight trials, involving 567 older participants, evaluated surgical intervention for displaced fractures. There was high quality evidence of no clinically important difference in patient�reported shoulder and upper�limb function at one� or two�year follow�up between surgical (primarily locking plate fixation or hemiarthroplasty) and non�surgical treatment (sling immobilisation) for the majority of displaced proximal humeral fractures; and moderate quality evidence of no clinically important difference between the two groups in quality of life at two years (and at interim follow�ups at six and 12 months). There was moderate quality evidence of little difference between groups in mortality in the surgery group (17/248 versus 12/248; risk ratio (RR) 1.40 favouring non�surgical treatment, 95% confidence interval (CI) 0.69 to 2.83; P = 0.35; 6 trials); only one death was explicitly linked with the treatment. There was moderate quality evidence of a higher risk of additional surgery in the surgery group (34/262 versus 16/261; RR 2.06, 95% CI 1.18 to 3.60; P = 0.01; 7 trials). Although there was moderate evidence of a higher risk of adverse events after surgery, the 95% confidence intervals for adverse events also included the potential for a great r risk of adverse events after non�surgical treatment. Different methods of surgical management were tested in 12 trials. One trial (57 participants) comparing two types of locking plate versus a locking nail for treating two�part surgical neck fractures found some evidence of slightly better function after plate fixation but also of a higher rate of surgically�related complications. One trial (61 participants) comparing a locking plate versus minimally invasive fixation with distally inserted intramedullary K�wires found little difference between the two implants at two years. Compared with hemiarthroplasty, one trial (32 participants) found similar results with locking plate fixation in function and re�operation rates, whereas another trial (30 participants) reported all five re�operations occurred in the tension�band fixation group. One trial (62 participants) found better patient�rated (Quick DASH) and composite shoulder function scores at a minimum of two years follow�up and a lower incidence of re�operation and complications after reverse shoulder arthroplasty (RSA) compared with hemiarthroplasty. No important between�group differences were found in one trial (120 participants) comparing the deltoid�split approach versus deltopectoral approach for non�contact bridging plate fixation, and two trials (180 participants) comparing 'polyaxial' and 'monaxial' screws in locking plate fixation. One trial (68 participants) produced some preliminary evidence that tended to support the use of medial support locking screws in locking plate fixation. One trial (54 participants) found fewer adverse events, including re�operations, for the newer of two types of intramedullary nail. One trial (35 participants) found better functional results for one of two types of hemiarthroplasty. One trial (45 participants) found no important effects of tenodesis of the long head of the biceps for people undergoing hemiarthroplasty. Very limited evidence suggested similar outcomes from early versus later mobilisation after either surgical fixation (one trial: 64 participants) or hemiarthroplasty (one trial: 49 participants). Authors' conclusions There is high or moderate quality evidence that, compared with non�surgical treatment, surgery does not result in a better outcome at one and two years after injury for people with displaced proximal humeral fractures involving the humeral neck and is likely to result in a greater need for subsequent surgery. The evidence does not cover the treatment of two�part tuberosity fractures, fractures in young people, high energy trauma, nor the less common fractures such as fracture dislocations and head splitting fractures. There is insufficient evidence from RCTs to inform the choices between different non�surgical, surgical, or rehabilitation interventions for these fractures. Plain language summary Interventions for treating shoulder fractures in adults Background Fracture of the top end of the upper arm bone (proximal humerus) is a common injury in older people. It is often called a shoulder fracture. The bone typically fractures (breaks) just below the shoulder, usually after a fall. Most of these fractures occur without breaking the skin lying over the fracture. The injured arm is often supported in a sling until the fracture heals sufficiently to allow shoulder movement. More severe (displaced) fractures may be treated surgically. This may involve fixing the fracture fragments together by various means. Alternatively, the top of the fractured bone may be replaced (half 'shoulder' replacement: hemiarthroplasty). More rarely, the whole joint, thus including the joint socket, is replaced (total 'shoulder' replacement). Physiotherapy is often used to help restore function. Results of the search We searched medical databases up to November 2014 and included 31 randomised studies with a total of 1941 participants. Most of the 18 treatment comparisons were tested by one study only. The best evidence was from eight studies, one of which was a relatively large multicentre study these investigated whether surgery gave a better result than non�surgical treatment for displaced fractures. Key results Nine trials evaluated non�surgical treatment in usually less severe fractures. One trial found a type of arm sling was generally more comfortable than a type of body bandage. There was some evidence that early mobilisation (within one week), compared with delayed mobilisation (after three weeks), resulted in less pain and faster recovery in people with 'stable' fractures. Two studies provided weak evidence that many patients could generally achieve a satisfactory outcome when given sufficient instruction to pursue exercises on their own. Eight studies, involving 567 participants with displaced fractures, compared surgical versus non�surgical treatment. Pooled results from the five most recent trials showed that there were no important differences between the two approaches for patient�reported measures of function and quality of life at 6, 12 and 24 months. There was little difference between the two groups in mortality. Twice as many surgical group patients had additional or secondary surgery. More surgical group patients had adverse events. Twelve trials (744 participants) tested different methods of surgical treatment. There was weak evidence of some differences (e.g. in complications) between some interventions (e.g. different devices or different ways of using devices). There was very limited evidence suggesting similar outcomes for early versus delayed mobilisation after either surgical fixation or hemiarthroplasty. Quality of the evidence Most of the 31 studies had weaknesses that could affect the reliability of their results. We considered that the evidence was either of high or moderate quality for the results of the surgical versus non�surgical treatment comparison, which means that we are pretty certain these results are reliable. We considered that the evidence for other comparisons was of low or very low quality, which means we are unsure of these results. Conclusions Surgery does not result in a better outcome for the majority of people with displaced proximal humeral fractures and is likely to result in a greater need for subsequent surgery. Otherwise, there is not enough evidence to determine the best non�surgical or, when selected, surgical treatment for these fractures.

High complication rate after syndesmotic screw removal

DoD SSI (Surgical Site Infections)

PURPOSE: The aim of this study was to determine the rate of complications after routine syndesmotic screw removal. MATERIALS AND METHODS: All patients who underwent syndesmotic screw removal at our hospital between 2007 and 2012 were included in the study. Patient demographics, surgical characteristics, radiographic evaluation and complications were recorded from the patients' charts. Questionnaires were sent by postal mail to all patients, to measure patient satisfaction and pain (VAS scales). RESULTS: 161 patients were included in the trial. A wound infection was found in 8 (5%) patients. 3 were regarded as serious infections requiring hospitalisation and intravenous antibiotics, 2 of those required surgical revisions. 5 patients were treated by oral antibiotics. Staphylococcus aureus was identified as the causing organism in all (6/8) cases with a positive culture. The patients with postoperative infection reported more pain (5.3 vs. 2.3; p=0.02) and were less satisfied (4.7 vs. 7.6; p=0.014) with their ankle compared to those without infection (T-test for independent samples). CONCLUSION: There were 5% wound infections after routine syndesmotic screw removal. Routine antibiotic prophylaxis effective against S. aureus should be administered when removing syndesmotic screws. In our institution we now use one single dose Cefalotin of 2g intravenously 30-60min before screw removal.

Prophylactic oral antibiotics reduce reinfection rates following two-stage revision total knee arthroplasty

Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures

The purpose of this study was to compare the incidence of reinfection in patients who received oral antibiotic prophylaxis with those who did not following two-stage revision knee arthroplasty. Additional purposes included: (1) comparison of these findings to the infection rate in patients who underwent revision for aseptic reasons, and (2) characterisation of the organisms responsible for reinfection following revision procedures. Twenty-eight two-stage revision knee arthroplasty procedures were followed up by a mean of 33 days of oral antibiotics (range, 28-43 days), while the remaining 38 procedures received only 24-72 hours of in-patient antibiotics. The incidence of reinfection in each group within 12 months was compared. The reinfection rates were additionally compared to those of 237 patients who underwent revision for aseptic loosening over the same time period. Patients who were treated with postoperative antibiotic prophylaxis had a considerably lower reinfection rate, with one reinfection in the prophylaxis group (4%), compared to six reinfections in the no-prophylaxis group (16%). The reinfection rates remained higher compared to those found in patients who underwent revision knee arthroplasty for aseptic loosening (1 of 237 patients; 0.4%). Both high and low virulence organisms were identified in the patients who were subsequently reinfected. A minimum of 28 days of postoperative oral antibiotics appeared to decrease reinfection rates following two-stage revision knee arthroplasty. These results suggest that the use of oral antibiotic prophylaxis following re-implantation may be appropriate in all patients undergoing two-stage revision, even in the absence of any signs of active infection

Evidence-based guidelines for the management of hip fractures in older persons: an update

Management of Hip Fractures in the Elderly

OBJECTIVE: To update evidence-based guidelines for the treatment of proximal femoral fractures published in the Journal in 2003. DATA SOURCES: Systematic search of MEDLINE, CINAHL and EMBASE for articles published from October 2001 to June 2008, and the Cochrane Database of Systematic Reviews (most recent issue searched - Issue 2, 2008). STUDY SELECTION: Randomised controlled trials and meta-analyses of all aspects of acute-care hospital treatment and rehabilitation for proximal femoral fractures among participants aged 50 years or older with proximal femoral fractures not associated with metastatic disease or multiple trauma. DATA EXTRACTION: All studies were reviewed independently by two assessors, who recorded individual study results, and an assessment of study quality and treatment conclusions was made according to Cochrane Collaboration protocols. If necessary, a third review was performed to reach consensus. RESULTS: 128 new studies were identified and 81 met our inclusion criteria. Recommendations for time to surgery, thromboprophylaxis, anaesthesia, analgesia, prophylactic antibiotics, surgical fixation of fractures, nutritional status, mobilisation and rehabilitation have been updated. Also, recommendations regarding surgical wound closure, management of postoperative delirium, osteoporosis treatment and hip protectors have been added. The guidelines include the current National Health and Medical Research Council grades of recommendations for clinical guidelines. CONCLUSIONS: Significant changes in recommendations have been made, particularly in relation to surgery, rehabilitation and tertiary prevention. Hip fracture should be treated according to the most up-to-date evidence to achieve the best possible outcomes and optimal use of limited resources

Pediatric Knee Osteochondritis Dissecans Lesions

Osteochondritis Dissecans 2020 Review

Osteochondritis dissecans (OCD) can cause knee pain and dysfunction in children. The etiology of OCD remains unclear; theories on causes include inflammation, ischemia, ossification abnormalities, genetic factors, and repetitive microtrauma. Most OCD lesions in skeletally immature patients will heal with nonoperative treatment. The success of nonoperative treatment decreases once patients reach skeletal maturity. The goals of surgical treatment include maintenance of articular cartilage congruity, rigid fixation of unstable fragments, and repair of osteochondral defects with cells or tissues that can adequately replace lost or deficient cartilage. Unsalvageable OCD lesions can be treated with various surgical techniques.

Longitudinal Growth and pQCT Measures in Hutterite Children and Grandchildren Are Associated With Prevalence of Hip or Knee Replacement Resulting From Osteoarthritis in Parents and Grandparents

OAK 3 - Non-arthroplasty tx of OAK

BACKGROUND: Osteoarthritis (OA) is one of the leading causes of disability in the world. Several genes are associated with the development of OA, and previous studies have shown adult children of individuals with OA have higher areal bone mineral density (BMD). Because childhood is an important period of growth and bone development, and body composition is known to be associated with BMD, we speculated that there may be differences in growth and bone measures among young children with a genetic predisposition to OA. QUESTIONS/PURPOSES: (1) Do differences exist at baseline in anthropometric and peripheral quantitative CT (pQCT) measurements between children and grandchildren of individuals with OA and controls? (2) Do children and grandchildren of individuals with OA accrue bone longitudinally at a different rate than controls? METHODS: Longitudinal anthropometric (height, weight) and bone (cortical and trabecular volumetric BMD and cross-sectional area) measurements by pQCT were obtained at baseline and 18 and 36 months on children (n = 178) and grandchildren (n = 230) of 23 individuals with hip or knee arthroplasty resulting from OA and 23 sex-matched controls (16 females each). Grandchildren (age, 8-30 years) were further categorized as growing (premenarcheal or male < 14 years, n = 99) or mature (>= 2 years postmenarchal or males >= 18 years, n = 96). The remaining 35 grandchildren could not be categorized and were excluded. RESULTS: Mature granddaughters and grandsons of individuals with OA had greater trabecular volumetric BMD than controls (236 +/- 24 and 222 +/- 26 mg/cm, respectively, for granddaughters, difference of 14 [95% confidence interval {CI}, 1-28] mg/cm, p = 0.041 and 270 +/- 22 and 248 +/- 30 mg/cm, respectively, for grandsons, difference of 22 [95% CI, 1-42] mg/cm, p = 0.040). Greater trabecular volumetric BMD was observed in daughters of individuals with OA compared with daughters of controls (228 +/- 28 and 212 +/- 33 mg/cm, respectively, difference of 18 [95% CI, 3-30] mg/cm, respectively [p = 0.021]). Growing granddaughters and grandsons of controls had greater decreases in cortical volumetric BMD than grandchildren of individuals with OA (time-by-group [TG] based on mixed model [+/- standard error] -9.7 +/- 4.3 versus -0.8 +/- 4.4 mg/cm/year, respectively, for granddaughters, difference of 9.0 [95% CI, 2.4-15.5] mg/cm/year, p = 0.007 and -6.8 +/- 3.3 versus 4.5 +/- 3.4 mg/cm/year, respectively, for grandsons, difference of 11.3 [95% CI, 4.3-18.3] mg/cm/year, p = 0.002). Cortical volumetric BMD was maintained in sons of individuals with OA, but decreased in sons of controls (-0.0 +/- 1.5 versus -4.3 +/- 1.0 mg/cm/year, respectively, difference of 4.3 [95% CI, 0.7-7.8] mg/cm/year, p = 0.019 [TG]). There was a greater apparent decrease in cross-sectional area among daughters of individuals with OA than in controls (-4.6 +/- 0.9 versus -1.7 +/- 0.9 mm/year, respectively, difference of -2.9 [95% CI, -5.3 to -0.6] mm/year, p = 0.015 [TG]). CONCLUSIONS: Several anthropometric and bone differences exist between children and grandchildren of individuals with OA and controls. If these differences are confirmed in additional studies, it would be important to identify the mechanism so that preventive measures could be developed and implemented to slow or reduce OA development. CLINICAL RELEVANCE: Differences in growth and bone development may lead to increased loads on cartilage that may predispose offspring to the development of OA. If these differences are confirmed in additional studies, it would be important to identify the mechanism so that preventive measures could be developed and implemented to slow or reduce OA development.

Identifying Patient-Specific Pathology in Osteoarthritis Development Based on MicroCT Analysis of Subchondral Trabecular Bone

OAK 3 - Non-arthroplasty tx of OAK

The goal of this study was to identify alternative mechanisms of osteoarthritis pathology by analyzing subchondral bone. Femoral condyle samples were collected from post-menopausal female patients with knee osteoarthritis undegoing total knee arthroplasty. In the majority of patients, subchondral trabecular bone volume doubled under a region of the medial femoral condyle with full-thickness cartilage deterioration. However, in a subset of patients the bone volume in this region remained constant. This subset also had larger areas of vascular penetration in the calcified cartilage of the lateral condyle concurrent with increased vascular endothelial growth factor expression. Subtyping by subchondral bone characteristics identified a unique population, which lacked the sclerotic bone characteristic of late-stage osteoarthritis. Identification of subtypes within the osteoarthritis population allows investigation of alternate disease pathologies.

Bone transport with a unilateral external fixator for femoral infected nonunion after intramedullary nailing fixation: A case control study

DoD SSI (Surgical Site Infections)

This is a therapeutic study to evaluate the results of femoral infected nonunion using bone transport with an external fixator after debridement and irrigation. We retrospectively reviewed 15 patients with femoral infected nonunion after intramedullary nailing fixation of fractures from October 1999 to January 2010 in our institute. There were 7 males and 8 females with an average age of 32.5 years. First, the infection was eradicated completely, and the medullary canals were continuous irrigated for 2-3 weeks. After eradicating the infection tissues, the mean amount of bone defect was 8.7 cm (range, 4.0-16.0 cm). The unilateral consecutive distraction-compression osteosynthesis technique was applied after long-time medullary cavity-wound exclusion surgery. Enumeration data was described by frequency and measurement data by mean. Bone infections were controlled in all patients except 1 patient after the first debridement and irrigation. All patients have achieved bony union without recurrence of infection during the follow-up period, the mean external fixation index was 43.4 day/cm. According to the criteria recommended by Paley, the bone results were graded as excellent in 13 (86.7%) cases and good in 2 (13.3%) cases; the functional results were graded as excellent in 6 (40.0%) cases, good in 6 (40.0%) cases and fair in 3 (20.0%) cases. In management of femoral infectious nonunion which caused by intramedullary nailing fixation, the surgery of consecutive compression-distraction osteogenesis with unilateral external fixator achieves a highly effective treatment, and the method of debridement and irrigation is a compatible choice on the phase of infection-elimination.

Special Scientific Session of the International Skeletal Society, ISS 2011

Surgical Management of Osteoarthritis of the Knee CPG

The proceedings contain 21 papers. The topics discussed include: value of MDM2 and CDK4 immunohistochemistry in the differential diagnosis of low-grade osteosarcomas and other primary fibroosseous lesions of the bone; diagnostic accuracy and approach in the Ewing family of tumors using molecular and immunohistochemical techniques; macrophage MR imaging: evaluation for the non invasive in vivo monitoring ofantibiotic therapy in infectious arthritis; MR imaging findings of infection following knee arthroplasty: the positive predictive value of a lamellated synovitis; T2-weighted imaging and stimulated echo diffusion tensor imaging (DTI) in chronic exertional compartment syndrome (CECS) : a feasibility study; UTE MRI and bi-component measures of bone water content correlate with porosity; and high-resolution 3T MR neurography after cubital tunnel release and ulnar transposition

Bisphosphonate anticancer activity in multiple myeloma

MSTS 2018 - Femur Mets and MM

Bisphosphonates inhibit osteoclast-mediated bone resorption and have been used extensively to prevent skeletal-related events in patients with bone lesions from multiple myeloma (MM). In addition, in vitro and in vivo preclinical data suggest that bisphosphonates also have antimyeloma properties that may induce myeloma cell apoptosis, activate an anticancer immune response, inhibit angiogenesis, and reduce tumor burden, supporting an expanded role for bisphosphonates. Signals for improved survival in the clinic first emerged in retrospective analyses of MM patient subgroups in larger clinical trials. Recently, improved progression-free survival and overall survival with bisphosphonates have been reported in the overall populations of large-scale randomized clinical trials. Several ongoing clinical trials will help further define the role of bisphosphonates during antimyeloma therapy. Overall, bisphosphonates appear to be well tolerated in patients with MM; the most common adverse events are mild and can be easily managed. However, emphasis on renal monitoring and preventive dentistry are necessary to reduce the risk of potential adverse events, and have become the standard of care for patients with MM.

Comparison of piroxicam and naproxen in osteoarthritis of the foot

OAK 3 - Non-arthroplasty tx of OAK

Osteoarthritis is the most common joint disease and the second highest ranking cause of disability in the US. Osteoarthritis commonly affects the hands, wrists, spine, knees, and feet. One of the mainstays of treatment for osteoarthritis is the use of nonsteroidal anti�inflammatory drugs. While there have been controlled comparison studies of the various nonsteroidal anti�inflammatory drugs, these have been limited to osteoarthritis of the hands, spine, and hip. This study was a randomized, double�blind, parallel study of 8 weeks' duration comparing piroxicam (Feldene, 20 mg daily) to naproxen (Naprosyn, 1,000 mg daily) in the treatment of osteoarthritis of the foot in 45 patients. Both groups experienced significant pain relief and improvement of mobility.

Pathophysiology of polytrauma

DOD - Acute Comp Syndrome CPG

Immediate and early trauma deaths are determined by primary brain injuries, or significant blood loss (haemorrhagic shock), while late mortality is caused by secondary brain injuries and host defence failure. First hits (hypoxia, hypotension, organ and soft tissue injuries, fractures), as well as second hits (e.g. ischaemia/reperfusion injuries, compartment syndromes, operative interventions, infections), induce a host defence response. This is characterized by local and systemic release of pro-inflammatory cytokines, arachidonic acid metabolites, proteins of the contact phase and coagulation systems, complement factors and acute phase proteins, as well as hormonal mediators: it is defined as systemic inflammatory response syndrome (SIRS), according to clinical parameters. However, in parallel, anti-inflammatory mediators are produced (compensatory anti-inflammatory response syndrome (CARS). An imbalance of these dual immune responses seems to be responsible for organ dysfunction and increased susceptibility to infections. Endothelial cell damage, accumulation of leukocytes, disseminated intravascular coagulation (DIC) and microcirculatory disturbances lead finally to apoptosis and necrosis of parenchymal cells, with the development of multiple organ dysfunction syndrome (MODS), or multiple organ failure (MOF). Whereas most clinical trials with anti-inflammatory, anti-coagulant, or antioxidant strategies failed, the implementation of pre- and in-hospital trauma protocols and the principle of damage control procedures have reduced post-traumatic complications. However, the development of immunomonitoring will help in the selection of patients at risk of post-traumatic complications and, thereby, the choice of the most appropriate treatment protocols for severely injured patients. © 2005 Elsevier Ltd. All rights reserved.

Role of ozone therapy in the treatment of osteonecrosis of the jaws in multiple myeloma patients

MSTS 2018 - Femur Mets and MM

Current treatments for bisphosphonate-associated osteonecrosis of the jaw (ONJ) in multiple myeloma patients have limited efficacy. The biological effects of ozone indicate it may be therapeutic for ONJ. We, here, report the efficacy of a 15-day course of antibiotics, surgery and ozone therapy in 12 MM patients with ONJ.

Rupture of Flexor Pollicis Longus Tendon: A Complication of Volar Locking Plating of the Distal Radius

Distal Radius Fractures

We report an unusual case of complete rupture of the flexor pollicis longus tendon following volar locking plating for a distal radius fracture. We believe that the prominence of a distal locking screw head predisposed to the rupture of the tendon. We highlight that correctly attaching the distal locking screws to the plate is essential for obtaining the correct biomechanics of the device and preventing flexor tendon rupture.

Comparison of three different tourniquet application strategies for minimally invasive total knee arthroplasty: a prospective non-randomized clinical trial

Surgical Management of Osteoarthritis of the Knee CPG

INTRODUCTION: It is still controversial on the optimal timing of tourniquet used in total knee arthroplasty (TKA). Most previous studies focused on the comparison of different tourniquet application in controversial TKA, while the aim of our work was to compare three strategies of tourniquet application in minimally invasive TKA. MATERIALS AND METHODS: 90 patients were enrolled in this study. Based on the different tourniquet application strategies, they were divided into three groups. Group A: using tourniquet during the whole surgery; Group B: tourniquet inflated before incision and deflated after the hardening of the cement; Group C: using tourniquet during the cementation. Blood loss and serum levels of C-reactive protein, IL-6, creatine kinase and myoglobin were checked preoperatively. The HSS knee score, VAS pain score, range of motion (ROM), limb swelling and hospital stays were also recorded. RESULTS: The mean levels of Hb and Hct were lower in Group C (104.2 +/- 10.4 g/L, 31.8 +/- 3.2 %) than those in Groups A (111.4 +/- 14.4 g/L, p = 0.035; 34.1 +/- 4.1 %, p = 0.032) and B (112.8 +/- 14.3 g/L, p = 0.013; 34.5 +/- 3.7 %, p = 0.011) immediately after the surgery. Compared with Groups A and B, both serum inflammation and muscle damage markers were lower in Group C. There were no significant differences between the groups in terms of HSS knee score, ROM, estimated blood loss, swelling ratio, VAS pain score and hospital stays. CONCLUSIONS: Using a tourniquet full time in minimally invasive TKA causes less intraoperative blood loss and more excessive inflammation and muscle damage. However, the advantage of part-time using tourniquet did not show in early functional outcomes

Impaired expression of genes involved in reverse cholesterol transport in human osteoarthritic chondrocytes: Beneficial effect of LXR agonist treatment

Surgical Management of Osteoarthritis of the Knee CPG

Purpose: Osteoarthritis (OA) is a common age-related joint disease. As in other age-related degenerative diseases, such as those of the cardiovascular system, altered lipid metabolism has been implicated as a critical player in disease development. Increased serum cholesterol has been considered a risk factor for OA independent of obesity and also articular manifestations have been demonstrated in familial hypercholesterolemia patients. As excessive accumulation of free cholesterol is toxic for the cells, intracellular cholesterol accumulation is prevented by tight regulation of influx and efflux pathways. We have previously shown that chondrocytes are capable of internalizing lipoproteins, via LOX-1 (lectin-like oxidized low density lipoprotein receptor 1). Once cholesterol is accumulated in cells, its efflux is mediated through reverse cholesterol transport via nuclear factors LXRa and LXR(beta) (liver X receptors) and the ATP-binding-cassette transporter A1 (ABCA1) gene. ABCA1 serves as a lipid pump that effluxes cholesterol from cells to apolipoprotein A1 (ApoA1). As the accumulation of lipids in chondrocytes may signify a causal relationship to development and/or progression of OA, we investigated the expression of genes regulating reverse cholesterol transport, as ABCA1, ApoA1, LXRa and LXR(beta) in human chondrocytes. We also investigated the effect of a synthetic LXR agonist on apoptosis, ABCA1 and ApoA1 mRNA expression, lipid accumulation, as well as on COL2A1, AGC, MMP-3, MMP-13 and IL-6 expression levels. Methods: Articular cartilage samples were obtained from 27 patients with primary OA undergoing knee replacement surgery, while normal cartilage was obtained from 8 individuals undergoing fracture repair surgery, with no history of joint disease. Total cellular RNA was extracted from all samples and ABCA1, ApoA1, LXR(alpha) and LXR(beta) mRNA and protein expression levels were evaluated using real-time PCR and Western blot analysis respectively. The effect of the synthetic LXR agonist TO -901317 was studied after treatment of osteoarthritic chondrocytes and subsequent investigation of ABCA1, ApoA1, MMP-13, MMP-3 as well as COL2A1 and AGC mRNA expression levels. IL-6 was measured with ELISA. Cholesterol efflux was evaluated in osteoarthritic chondrocytes radiolabeled with [1,2(n)-(3)H] cholesterol after LXR treatment, while intracellular lipid accumulation was studied after Oil-red-O staining. Apoptosis was evaluated using flow cytometry. Results: We found that ApoA1 and ABCA1 mRNA and protein expression levels were significantly lower in osteoarthritic compared to normal cartilage (p<0.01 and p<0.001 respectively). In addition, LXR(alpha) and LXR(beta) mRNA expression levels were also found to be significantly lower in osteoarthritic cartilage (p<0.05 and p<0.01 respectively). Treatment of osteoarthritic chondrocytes with the LXR agonist TO-901317 resulted in: (i) significantly increased ApoA1 and ABCA1 mRNA expression levels (p<0.01), (ii) significant increase in cholesterol efflux (p<0.05) (iii) elimination of intracellular lipids deposits, which had been observed before agonist treatment (iv) significant reduction of MMP-3 and MMP-13 protein levels (p<0.001 and p<0.01, respectively), (v) significant increase by 2 and 6.6-fold in COL2A1 and AGC mRNA expression levels (p<0.05), (vi) significant decrease in IL-6 levels (p<0.01) and (vii) significant reduction of apoptosis (p<0.005). Conclusions: Our findings suggest that impaired expression of genes regulating cholesterol efflux may be a critical player in osteoarthritis, while the ability of the LXR agonist to facilitate cholesterol efflux, results in reduction of catabolic and inflammatory molecules and increase in anabolic genes' expression, suggesting its potential use for therapeutic intervention in osteoarthritis

New therapeutic approaches for metastatic thyroid carcinoma

MSTS 2018 - Femur Mets and MM

Treatment of metastatic differentiated thyroid cancer (DTC) includes the use of radioiodine and suppressive thyroid hormone treatment. A third of patients with distant metastases (who have radioiodine uptake, are younger than 40 years, have small metastases, and have well differentiated thyroid tumour) can be cured with radioiodine treatment. For other patients, there are no effective treatment modalities. However, the recent availability of molecularly targeted treatments has led to changes in the treatment strategy for DTC in patients with distant metastases, especially in those who are resistant to radioiodine treatment. © 2007 Elsevier Ltd. All rights reserved.

Prognostic risk factors that identify patients with clinical stage I nonseminomatous germ cell tumors at low risk and high risk for metastasis

MSTS 2018 - Femur Mets and MM

BACKGROUND: The purpose of this study was to develop a reliable model to identify clinical Stage I nonseminomatous germ cell tumors (NSGCTs) associated with low risk or high risk for occult retroperitoneal metastasis, so that the model could be used to customize the therapeutic approach for patients with these tumors. The model was to be based on pathohistologic parameters and immunohistochemical expression of proliferation markers, proteases, and adhesion molecules in the primary tumor. METHODS: One hundred forty-nine patients with clinical Stage I NSGCTs underwent retroperitoneal lymphadenectomy and were included in the study. Three to five paraffin embedded, formalin fixed tissue blocks were available from each patient and were analyzed for the following histopathologic features associated with pathologic Stage I or II disease: the presence or absence of vascular invasion (VI), the presence or absence of tunic invasion, and the percentage of each histologic type present in the primary tumor. Immunohistochemical expression of MIB-1, p53, bcl-2, cathepsin D, and E-cadherin was evaluated using a semiquantitative scoring system. Statistical analysis was performed with univariate and multivariate logistic regression models. RESULTS: The percentage of embryonal carcinoma (%EC, P < 0.001) and the presence of VI (P < 0.0001) and tunic invasion (P < 0.002) were the most significant independent risk factors associated with pathologic Stage II disease. A combination of %EC and VI allowed correct prediction of final pathologic stage for 88% of clinical Stage I patients. Cutoff values including both variables identified the correct pathologic stage for 131 of 149 patients (88%). Less than 45% EC and the absence of VI correctly identified pathologic Stage I disease in 91.5% of patients; more than 80% EC and the presence of VI correctly predicted pathologic Stage II in 88%. In univariate analysis, only p53 (P < 0.03) and E-cadherin (P < 0.001) expression were significantly different in the embryonal carcinoma component of pathologic Stage I and II NSGCT. To evaluate prospectively the clinical utility of the new derived cutoff points, the data were applied to 10 consecutive patients with clinical Stage I NSGCT who underwent retroperitoneal lymphadenectomy; pathologic Stage I and II were correctly predicted for 5 of 6 Stage I and 4 of 4 Stage II patients, respectively. CONCLUSIONS: %EC and the presence or absence of VI appear to be reliable prognosticators to identify patients at high risk and low risk for occult retroperitoneal disease. In cases of clinical Stage I NSGCT, p53, bcl-2, MIB-1, cathepsin D, and E-cadherin did not appear to be of prognostic significance. The authors recommend that all patients with clinical Stage I NSGCT have their primary orchiectomy specimens evaluated for %EC and the presence of VI to determine their risk for occult retroperitoneal metastasis.

Osteoporotic Fractures in the Brazilian Community-Dwelling Elderly: Prevalence and Risk Factors

Management of Hip Fractures in the Elderly

The risk of osteoporotic fractures is known to vary among populations. There are no studies analyzing concomitantly clinical, densitometric, and lab risk factors in miscigenated community-dwelling population of Brazil. A total of 1007 elderly subjects (600 women and 407 men) from Sao Paulo, were evaluated using a questionnaire that included risk factors for osteoporotic fractures. Bone mineral density (BMD) was measured by dual-energy X-ray absorptiometry at the hip and lumbar spine. Laboratory blood tests were also obtained. The prevalence of osteoporotic fractures was 13.2% (133 subjects), and the main fracture sites were distal forearm (6.0%), humerus (2.3%), femur (1.3%), and ribs (1.1%). Women had a higher prevalence (17.5%; 95% confidence interval [CI]: 14.6-20.6) than men (6.9%; 95% CI: 4.4-9.3) (p<0.001). After adjusting for significant variables, logistic regression revealed that female gender (odds ratio [OR]=2.7; 95% CI; 1.6-4.5; p<0.001), current smoking (OR=1.9; 95% CI: 1.2-3.3; p=0.013), and the femoral neck T-score (OR=0.7; 95% CI: 0.5-0.9; p=0.001) remain significant risk factors for osteoporotic fractures in the community-dwelling elderly. Our findings identified that female gender, current smoking, and low hip BMD are independent risk factors for osteoporotic fractures

Open pelvic fracture and fecal diversion

DoD SSI (Surgical Site Infections)

BACKGROUND: Mandatory fecal diversion has been advocated as an appropriate measure to prevent infection in the clinical setting of an open pelvic fracture. However, the efficacy of this practice has not been verified by prospective investigation and has received only inconsistent support from retrospective analyses. OBJECTIVE: To determine whether fecal diversion is associated with a substantially lower incidence of abdominopelvic infectious complications in patients with open pelvic fractures. DESIGN: Case-control study. SETTING: University-based tertiary care, level I trauma center. METHODS: The current study reviews our experience with 60 cases admitted from 1987 to 1993 to Harborview Medical Center, a regional level I trauma center. Data collected on each patient included age, sex, Injury Severity Score, Glasgow Coma Scale, initial heart rate and systolic blood pressure, location and severity of wound, fracture pattern, pelvic stability, time to open reduction internal fixation or external fixation, mortality, use of fecal diversion, and incidence and location of infection. Review of the literature produced an additional 186 patients amenable to analysis. RESULTS: Fecal diversion was performed in 19 patients, 5 (26%) of whom experienced subsequent abdominopelvic infectious morbidity. Of the remaining 41 patients, 7 patients (17%) experienced infectious complications. The 2 groups (diversion vs no diversion) were comparable with regard to relevant demographic and clinical characteristics of injury severity. Combining the present series with those reported by others gave a composite series of 246 patients. For the composite series, diversion was performed in 70% of patients. Infection developed in 27% of patients who underwent diversion vs 29% in patients who did not. In the present series, only mechanical instability was determined by stepwise logistic regression to be significantly associated with pelvic infection. This association was not altered by diversion status. CONCLUSIONS: Diversion of the fecal stream to protect open pelvic fractures is not associated with a lower incidence of abdominopelvic infectious complications. Diversion may offer protection to a select group of patients with extensive soft tissue injury or posterior wounds. Mechanical instability was independently associated with infection.

The Usability and Feasibility of Conjoint Analysis to Elicit Preferences for Distal Radius Fractures in Patients 55 Years and Older

Distal Radius Fractures

PURPOSE: Eliciting patient preferences is one part of the shared decision-making process-a process of decision making focused on the values and preferences of the patient. We evaluated the usability and feasibility of a point-of-care conjoint analysis tool for preference elicitation for shared decision making in the treatment of distal radius fractures in patients over the age of 55 years., METHODS: Twenty-seven patients 55 years of age or older with a displaced distal radius fracture were recruited from a hand and upper extremity clinic. A conjoint analysis tool was created describing the attributes of care (eg, return of grip strength) of surgical and nonsurgical treatment. This tool was administered to patients to determine their preferences for the treatment attributes when choosing between surgical and nonsurgical treatment. Patients completed a System Usability Scale (SUS) to evaluate usability, and time to complete the tool was measured to evaluate feasibility., RESULTS: Patients considered the conjoint analysis tool to be usable (SUS, 91.4; SD, 10.9). Mean time to complete the tool was 5.1 minutes (SD, 1.4 minutes). The most important attributes driving the decision for surgical treatment were return of grip strength at 1 year and time spent in a cast or brace. The most important attributes driving the decision for nonsurgical treatment were use of anesthesia during treatment and return of grip strength at 1 year., CONCLUSIONS: A point-of-care conjoint analysis tool for distal radius fractures in patients 55 years and older can be used to elicit patient preferences to inform the shared decision-making process. Further investigation evaluating the effect of preference elicitation on treatment choice, involvement in decision making, and patient-reported outcomes are needed., CLINICAL RELEVANCE: A conjoint analysis tool is a simple, structured process physicians can use during shared decision making to highlight trade-offs between treatment options and elicit patient preferences to inform treatment choices. Copyright © 2019 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.

Affective temperaments are associated with higher hopelessness and perceived disability in patients with open-angle glaucoma

Upper Eyelid and Brow Surgery

AIM: The aims of the study were to study: (i) affective temperaments in open-angle glaucoma (OAG) patients with some degree of functional visual impairment; (ii) psychological well-being and perceived disability, and their associations with affective temperaments; and (iii) associations between visual impairment, affective temperaments and psychological well-being. METHOD: Participants were 91 outpatients (39 women, and 52 men) with open-angle glaucoma (OAG) who were assessed for Visual Field Index, Mean Defect and Pattern Standard Deviation. Patients were also administered the Beck Hopelessness Scale, the TEMPS-A (Rome), the Gotland Male Depression Scale, the Emotional Well-being Scale, the Perceived Disability Questionnaire and the Suicidal History Self-Rating Screening Scale. RESULTS: Open-angle glaucoma patients (compared with a non-clinical sample of university students) had higher scores on the TEMP-A dysthimic and hyperthimic traits and lower scores on cyclothimic, irritability and anxiety traits. Such temperament variability was not linked to differences in severity of glaucoma. We did not find strong evidence supporting the fact that measures of visual impairment were linked to emotional well-being and depression. However, logistic regression analysis revealed that patients may have different patterns related to their illness according to specific temperaments. CONCLUSION: Patients with OAG may have different temperament profiles than non-clinical individuals. Such categorisation may be useful for predicting how they face the illness, for providing better care as well as for early recognition of mood disorders symptoms.

Infection as a complication of total knee-replacement arthroplasty. Risk factors and treatment in sixty-seven cases

Surgical Management of Osteoarthritis of the Knee CPG

Of 4171 total knee arthroplasties that were performed at our institution from 1973 to 1987, sixty-seven were followed by infection. The risk of infection was significantly increased in patients, particularly men, who had rheumatoid arthritis; in patients who had ulcers of the skin; and in patients who had had a previous operation on the knee. Infection was also associated with obesity, recurrent urinary-tract infection, and oral use of steroids, although the correlation was not statistically significant. Of the various treatment options that were studied, removal and delayed replacement of the knee prosthesis resulted in the best functional results

A comparison of the transtibial pullout technique and all-inside meniscal repair in medial meniscus posterior root tear: Prognostic factors and midterm clinical outcomes

Osteochondritis Dissecans 2020 Review

INTRODUCTION: There is a paucity of comparative clinical data between arthroscopic all-inside end-to-end meniscal root suture and transtibial pullout technique in medial meniscus posterior root tears (MMPRT). Therefore, this study aimed to compare treatment failure, mid-term clinical and radiological outcomes of all-inside meniscus root repair versus the transtibial pullout technique and to analyze prognostic factors of postoperative clinical and radiological outcomes. MATERIAL AND METHODS: Forty-four patients were included in two therapeutic group: arthroscopic all-inside meniscal suture (MS: 13 knees) and transtibial pullout technique (TP: 31 knees).Primary clinical outcomes at a minimum of 27.2 months postoperatively included Knee injury and Osteoarthritis Outcome Score (KOOS) and Lysholm Knee Questionnare (LKQ). Radiographic assessment of the knee was performed to determine osteoarthritis severity using the Kellgren-Lawrence (KL) grading system.In addition, pre and postoperative MRI scans and intraoperative arthroscopic findings were recorded and the correlations between these findings, as outcome predictors and postoperative patients reported subjective outcome were assessed. RESULTS: No significant differences in postoperative KOOS and LKQ scores were found between the MS and TP group (p = 0.38 and 0.17, respectively).During follow-up one patients (7.7%) in the MS group and two (6.5%) in the TP group underwent total knee arthroplasty. The difference did not reach the statistical significance (p = 0.88).No differences were observed in postoperative MRI findings such as meniscal extrusion, osteochondral defect, chondromalacia patella, and bone morrow edema (p = 0.25, 0.97, 0.97, and 0.88, respectively).A univariate model revealed that the presence of postoperative meniscal extrusion; osteochondral defect; chondromalacia patella; increased BMI; age (>40 years) and longer time lapse between clinical onset to surgery (>6 months) were predictors of poor clinical outcome. The presence of meniscal extrusion, osteochondral defect and chondropatia patella portended worst postoperative outcomes in a multiple linear regression model. CONCLUSIONS: It can be concluded that both techniques can reach good results when performed properly and if the injury pattern allows meniscal suture may be considered a treatment option for the management of MMPRT in well-selected patients.Patients with increased BMI, preoperative meniscal extrusion, chondromalacia patella, and osteochondral defect were at higher risk of poor clinical outcomes.

A single injection ultrasound-assisted femoral nerve block provides side effect-sparing analgesia when compared with intrathecal morphine in patients undergoing total knee arthroplasty

Surgical Management of Osteoarthritis of the Knee CPG

Postoperative pain after total knee arthroplasty (TKA) is severe, and achieving adequate analgesia remains a clinical challenge. We tested the hypothesis that, in patients having unilateral TKA under intrathecal (IT) anesthesia, the addition of a femoral nerve block would provide superior analgesia when compared with IT morphine and demonstrate fewer adverse side effects. In a single-blinded and controlled trial, 41 ASA I-III patients undergoing unilateral TKA were randomized into 2 groups. Both groups received 15 mg of IT hyperbaric bupivacaine for the surgical anesthetic. Group ITM received 250 microg of IT morphine and group FNB received an ultrasound-assisted femoral nerve block with 40 mL of 0.5% ropivacaine, 5 microg/mL of epinephrine, and 75 microg of clonidine. At 1, 2, 4, 6, 12, and 24 h postoperatively, we measured visual analog scales for pain, cumulative IV morphine consumption, hemodynamics, and side effects. There were no statistically significant differences in morphine consumption, pain at rest, or pain with movement. However, group FNB had fewer perioperative side effects including nausea, vomiting, and pruritus (P < 0.05 for each event). This corresponded to a decrease in patient satisfaction in group ITM, in which 20% of the patients rated their experience as "unsatisfactory" (P < 0.05). We conclude that, in comparison with IT morphine, a single injection femoral nerve block provides equivalent analgesia but with a significant reduction in side effects for patients having TKA under bupivacaine intrathecal anesthesia

Effects of l-Carnitine Supplementation on Serum Inflammatory Factors and Matrix Metalloproteinase Enzymes in Females with Knee Osteoarthritis: A Randomized, Double-Blind, Placebo-Controlled Pilot Study

OAK 3 - Non-arthroplasty tx of OAK

OBJECTIVE: Considering the importance of inflammation in the pathogenesis of osteoarthritis (OA) and induction of pain, this study was aimed to investigate the effect of L-carnitine supplementation on serum inflammatory mediators and OA-associated pain in females with knee OA. METHODS: In this clinical trial, 72 females with mild to moderate knee osteoarthritis started the study, divided into 2 groups to receive 750 mg/day L-carnitine (n = 36) or placebo (n = 36) for 8 weeks. Serum levels of Interleukine-1beta (IL-1beta), high-sensitivity C-reactive protein (hs-CRP), matrix metalloproteinases (MMPs)-1 and -13, and visual analog scale (VAS) for pain were assessed before and after supplementation. Data were analyzed by t test, Wilcoxon signed rank test, Mann-Whitney U test, and analysis of covariance. RESULTS: Only 69 patients (33 in the L-carnitine group and 36 in the placebo group) completed the study. L-Carnitine supplementation decreased serum IL-1beta and MMP-1 levels significantly (p = 0.001 and p = 0.021, respectively); however, serum hs-CRP and MMP-13 levels did not change significantly (p > 0.05). In the placebo group, serum IL-1beta levels increased significantly (p = 0.011), whereas other studied biomarkers did not change significantly. The mean VAS score decreased significantly in the L-carnitine and placebo groups by 52.67% and 21.82%, respectively (p < 0.001). Significant differences were only observed between the 2 groups in serum IL-1beta (p < 0.001) and MMP-1 (p = 0.006) levels and mean VAS score (p = 0.002) after adjusting for baseline values and covariates. CONCLUSION: Despite observed beneficial effects of short-term supplementation of L-carnitine in decreasing serum inflammatory mediators and improving pain in knee OA patients, further studies are needed to achieve concise conclusions.

A Functional Neuroimaging Study of Expectancy Effects on Pain Response in Patients With Knee Osteoarthritis

OAK 3 - Non-arthroplasty tx of OAK

Placebo treatments and healing rituals share much in common, such as the effects of expectancy, and have been used since the beginning of human history to treat pain. Previous mechanistic neuroimaging studies investigating the effects of expectancy on placebo analgesia have used young, healthy volunteers. Using functional magnetic resonance imaging (fMRI), we aimed to investigate the neural mechanisms by which expectancy evokes analgesia in older adults living with a chronic pain disorder and determine whether there are interactions with active treatment. In this fMRI study, we investigated the brain networks underlying expectancy in participants with chronic pain due to knee osteoarthritis (OA) after verum (genuine) and sham electroacupuncture treatment before and after experiencing calibrated experimental heat pain using a well tested expectancy manipulation model. We found that expectancy significantly and similarly modulates the pain experience in knee OA patients in both verum (n = 21, 11 female; mean +/- SD age 57 +/- 7 years) and sham (n = 22, 15 female; mean +/- SD age 59 +/- 7 years) acupuncture treatment groups. However, there were different patterns of changes in fMRI indices of brain activity associated with verum and sham treatment modalities specifically in the lateral prefrontal cortex. We also found that continuous electroacupuncture in knee OA patients can evoke significant regional coherence decreases in pain associated brain regions. Our results suggest that expectancy modulates the experience of pain in knee OA patients but may work through different pathways depending on the treatment modality and, we speculate, on pathophysiological states of the participants. PERSPECTIVE: To investigate the neural mechanisms underlying pain modulation, we used an expectancy manipulation model and fMRI to study response to heat pain stimuli before and after verum or sham acupuncture treatment in chronic pain patients. Both relieve pain and each is each associated with a distinct pattern of brain activation.

Endodontic failure--a problem from top to bottom

Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures

Endodontically treated teeth are susceptible to bacterial contamination through exposure to oral fluids. It is crucial, therefore, that restorations placed during and after root canal therapy protect the root canal from oral contamination. This paper highlights the clinical steps necessary to reduce the risk of contamination in root-filled teeth

Scurvy: Historically a plague of the sailor that remains a consideration in the modern intensive care unit

Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures

We report the case of the case of a 56 year old female with sepsis on a background of rheumatoid arthritis and steroid use manifesting with overt clinical features of scurvy. Ascorbic acid assays were able to demonstrate severe deficiency and confirm a diagnosis of scurvy. Clinical resolution of signs and symptoms following commencement of vitamin C replacement was rapid. The intensivist and dietitian need to consider this diagnosis even in the first world setting, particularly in the presence of sepsis, inflammatory conditions, steroid use and importantly malnutrition. (copyright) 2011 The Authors. Internal Medicine Journal (copyright) 2011 Royal Australasian College of Physicians

The long-term outcome of uncemented Low Contact Stress total knee replacement in patients with rheumatoid arthritis: results at a mean of 22 years

Surgical Management of Osteoarthritis of the Knee CPG

We reviewed the long-term clinical and radiological results of 63 uncemented Low Contact Stress (LCS) total knee replacements (TKRs) in 47 patients with rheumatoid arthritis. The mean age of the patients at the time of surgery was 69 years (53 to 81). At a mean follow-up of 22 years (20 to 25), 12 patients were alive (17 TKRs), 27 had died (36 TKRs), and eight (ten TKRs) were lost to follow-up. Revision was necessary in seven patients (seven TKRs, 11.1%) at a mean of 12.1 years (0 to 19) after surgery. In the surviving ten patients who had not undergone revision (15 TKRs), the mean Oxford knee score was 30.2 (16 to 41) at a mean follow-up of 19.5 years (15 to 24.7) and mean active flexion was 105 degrees (90 degrees to 150 degrees ). The survival rate was 88.9% at 20 years (56 of 63) and the Kaplan-Meier survival estimate, without revision, was 80.2% (95% confidence interval 37 to 100) at 25 years

Type 2 diabetes mellitus in nursing home patients: effects on bone turnover, bone mass, and fracture risk

Management of Hip Fractures in the Elderly

CONTEXT: Fractures are a major health burden in elderly institutionalized persons. Type 2 diabetes mellitus (DM) has a high prevalence in nursing home patients and has been associated with positive effects on bone mass in younger, community-dwelling elderly. OBJECTIVE: The objective of this study was to investigate whether type 2 DM affects bone mass, bone turnover, or prospective fracture rates in frail, elderly women living in nursing homes. DESIGN, SETTING, AND PARTICIPANTS: This study was a prospective cohort of 583 patients with type 2 DM and 1081 control (CTR) individuals above age 70 recruited from 95 nursing homes in Austria. Patients were enrolled and followed up by mobile study teams. MAIN OUTCOME MEASURES: We performed quantitative bone ultrasound measurements at the calcaneus, radius, and proximal third phalanx, measurements of quadriceps strength, and biochemical parameters of mineral metabolism and bone turnover. Patients were prospectively followed for hip and other nonvertebral fractures over 2 yr. RESULTS: Patients with type 2 DM had significantly higher age-, weight-, and mobility score-adjusted calcaneal stiffness (P < 0.0001), radial speed of sound (P < 0.005), and phalangeal speed of sound (P < 0.05) measurements when compared with CTRs. Mean serum PTH (-20.7%) and osteocalcin levels (-22.3%) were significantly lower (both P < 0.0001) in patients with treated type 2 DM despite comparable low serum 25-hydroxyvitamin D levels and slightly higher adjusted total serum calcium levels compared with CTRs. Important independent determinants of bone turnover in both patient groups were PTH, creatinine clearance, alanine aminotransferase, as well as glycosylated hemoglobin levels, together accounting for 30-40% of its variance. A total of 110 hip fractures occurred during the observation period, corresponding to a hip fracture rate of 3.1% (in CTRs) and 3.4% (in type 2 DM) per 100 patient years; this was not significantly different for CTRs and diabetics. CONCLUSIONS: Decreased PTH levels and higher levels of glycemia independently contribute to lower bone turnover in elderly nursing home patients with type 2 DM. Despite higher bone mass and lower bone turnover, hip fracture risk is comparable with women without DM

A technique for intraoperative construction of antibiotic spacers

Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures

A technique for intraoperatively creating an antibiotic spacer for two-stage treatment of infected total knee replacements is described. An intraoperative mold is made from the removed components and used to create antibiotic spacers with surface contours similar to those of the original total knee replacement. The spacers restore leg length and knee stability. This allows limited function during the interval before reimplantation of the new total knee replacement. It is a cost-effective and convenient technique for creating a suitably shaped and sized cement spacer for two-stage revision total knee replacement after infection. The clinical results of 12 consecutive patients using this technique with minimum of 2 years followup seem to be at least equal or better than results reported in previous studies. Level of Evidence: Prognostic study, Level II (retrospective study)

(v) Post-operative infection in total hip arthroplasty

Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures

The diagnosis of infection starts with a comprehensive history and thorough physical examination. First line investigations should include C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR). Elevation of one or both of these tests suggests infection and hip aspiration should be undertaken to confirm the diagnosis. Hip aspiration also allows identification of the infecting microorganism. Radionucleotide tests presently have a limited role but may be useful as first line investigations in patients with active inflammatory conditions. If there is still doubt regarding the diagnosis following these investigations then one should use clinical judgment and possibly proceed to intraoperative frozen section. Acute infections can sometimes be successfully treated with retention of the prosthesis but the gold standard treatment for chronic infections is two-stage reimplantation. (copyright) 2006

Wrist hemiarthroplasty for irreparable DRF in the elderly

Distal Radius Fractures

INTRODUCTION: The authors update their results of wrist hemiarthroplasty for irreparable distal radius fracture in the elderly, at a minimum of 2-year follow-up. MATERIALS AND METHODS: Between 2011 and 2018, 25 consecutive independent elderly patients (24 female, 27 wrists) were treated with wrist hemiarthroplasty for distal radius fracture at a single institution. The average age was 77 years (range 65-88). They all were independent at home. A total of 19 wrists were treated at the acute stage, and 8 secondary procedures. The average follow-up was 32 months (range 24-44). RESULTS: There was no dislocation, loosening, infection nor removal of the implants. We observed 3 CRPS. At final follow-up, the average VAS pain was 1/10, mean forearm pronation/supination arc was 150degree, and mean active flexion-extension arc was 60degree. Average wrist extension was 36degree. Mean grip strength was 68% of contralateral side. Mean Lyon wrist score was 74%. Mean Quick DASH score was 26%, and mean PRWE score was 25%. DISCUSSION: Our data suggest that treatment of acute irreparable distal radius fracture in the independent elderly patient with a bone-preserving primary wrist hemiarthroplasty may be a viable option. Longer-term follow-up are needed to confirm these preliminary data.

New study design evaluated the validity of measures to assess change after hip or knee arthroplasty

Surgical Management of Osteoarthritis of the Knee CPG

OBJECTIVE: We propose a study design to evaluate the ability of measures to assess physical function relatively independent of pain. We illustrate the design using data from patients scheduled for total hip (THA) or knee (TKA) arthroplasty. STUDY DESIGN AND SETTING: A repeated-measure study design was developed and applied to patients undergoing THA or TKA. A performance battery (PB) (walking, stair, and timed-up-and-go) was used as the gold standard measure for "physical function." Recent evidence indicates physical performance deteriorates 1 month after surgery compared to presurgical measures and patients with THA deteriorate to a greater extent than patients with TKA. Our design assessed whether the results from self-report measures (Western Ontario and McMaster Universities Osteoarthritis Index [WOMAC] and the Lower Extremity Functional Scale [LEFS]) of physical function were consistent with changes found using the PB. RESULTS: The performance measures demonstrated significant Occasion (pre- to 1 month postarthroplasty) and Group (hip vs. knee)-by-Occasion effects; the LEFS showed a significant Occasion effect; and the WOMAC PF showed neither. CONCLUSION: Our findings support the proposed design in that the PB was more sensitive to change than the self-report measures

The Effect of the Insall-Salvati Ratio on Outcome After Total Knee Arthroplasty

Surgical Management of Osteoarthritis of the Knee CPG

The effect of total knee arthroplasty (TKA) on the Insall-Salvati ratio (ISR) and the effect of the ISR on the outcome of TKA have not been clearly established. A retrospective review of 1055 primary TKAs performed in 1997 to 1998 was performed. Radiographic measurements were made preoperatively and postoperatively, and the ISR was calculated. Regression analysis was performed to determine the effects of these variables on range of motion (ROM), Knee Society Score, and stair, function, and pain scores. Total knee arthroplasty resulted in a decrease in the patella tendon length, as measured by the ISR in 50% of cases. Patella infera (ISR less than 0.8) developed postoperatively in 9.8% of TKAs and was twice as likely to occur in women as men. A decrease in the ISR was associated with diminished stair and function scores (P = .0004 and 0.0081, respectively). There was no effect of the ISR upon ROM, Knee Society Score, or pain scores. Optimal outcomes occurred in patients where the ISR was not decreased after TKA, with superior stair and function scores. (copyright) 2006 Elsevier Inc. All rights reserved

Disability due to knee pain and somatising tendency in Japanese adults

OAK 3 - Non-arthroplasty tx of OAK

BACKGROUND: Knee pain is common and related to knee osteoarthritis. However, there is a discrepancy between knee pain and radiographic osteoarthritis. In the general population, knee pain is associated with psychological and cognitive factors, which would be one explanation for the discrepancy. Limited evidence demonstrates that somatization is associated with knee pain. This study examined the association between disability due to knee pain and a high somatising tendency. METHODS: Japanese adults (aged 20-64 years) who had experienced knee pain in the past four weeks were included in this study (n = 14,695, 50% women). Data were extracted from a large internet survey. Somatising tendency was assessed using the Somatic Symptom Scale-8 (SSS-8). Disability due to knee pain was categorized into three levels: 1) knee pain without difficulty with activities of daily living (ADL), 2) knee pain with ADL difficulty but without requiring sick leave, and 3) knee pain requiring sick leave. The association between >= high somatising tendency (SSS-8 score >= 12) as well as very high somatising tendency (SSS-8 score >= 16) and disability due to knee pain was examined using logistic regression models adjusted for age, sex, body mass index, depressive symptoms, education level, regular exercise, chronicity of knee pain (>=3 months), osteoarthritis, rheumatoid arthritis, and fibromyalgia. RESULTS: Greater disability due to knee pain was associated with a higher odds ratio for >= high somatising tendency (adjusted odds ratio (aOR) = 2.36 [2.10-2.66] in group 2 vs. group 1, aOR = 3.23 [2.66-3.92] in group 3 vs. group 1). Stronger associations were found for a very high somatising tendency (aOR = 2.80 [2.42-3.23] in group 2 vs. group 1, aOR = 4.51 [3.64-5.58] in group 3 vs. group 1). CONCLUSIONS: Somatization may play a role in disability due to knee pain in the general adult population with knee pain, similar to the role of somatization in low back pain.

A four-year prospective study on microbial ecology of explanted prosthetic hips in 52 patients with "aseptic" prosthetic joint loosening

Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures

The bacteriology of explanted prosthetic hips and surrounding soft tissue was studied in 52 patients undergoing surgical revision for joint loosening. In a prospective four-year study, positive bacterial cultures were recorded in 34 (76%) patients. Coagulase-negative staphylococci were the predominant isolates, and 11 patients (33%) had more than three organisms isolated, 7 (20%) had two only, and 11 (33%) had one species. Among the 23 patients from whom specimens from all 11 predetermined anatomic sites were cultured, the highest frequency of positive cultures (52% and 47%) came from the shaft and capsular tissue, respectively. Organisms were less frequently recovered from the cement and acetabulum (13% and 4%, respectively). Using molecular typing in eight patients with paired isolates of the same species, clonal identity was found in four. An additional patient underwent a second revision for loosening 17 months after the first revision and the same clone of Staphylococcus epidermidis was isolated on both occasions

Reduction and osteosynthesis of subcapital fractures of the femoral neck: possible repercussions on post-fracture hemarthrosis of the hip

Management of Hip Fractures in the Elderly

Intracapsular hip pressure was measured in undisplace or less displaced subcapital fractures of the femoral neck before and after open reduction and internal fixation with three-flanged nails. After reduction and osteosynthesis, intracapsular pressure increased in three out of five cases. The result is discussed in relation to the possible role of intracapsular pressure sustained by hemarthrosis in the pathogenesis of post-traumatic vascularity of the femoral head