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A comparison of stability and clinical outcomes in single-radius versus multi-radius femoral design for total knee arthroplasty
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We compared the intraoperative varus-valgus stability from 0° to 90° of flexion and postoperative clinical outcomes in patients receiving TKA via either a single-radius femoral design (50 TKA, SR group) or multi-radius femoral design (50 TKA, MR group). We measured stabilities at 0°, 30°, 60° and 90° of flexion using a navigation system. The clinical outcomes including HSS scores, WOMAC scores and VAS score during stair climbing were compared after a minimum of 2-year follow-up. The single-radius femoral designs in TKA showed better intra-operative stability at 30° of flexion (7.6 vs. 8.3) compared with the multi-radius femoral design, but not at other angles. However, the clinical outcomes revealed no other significant differences in terms of HSS scores, WOMAC scores and VAS score between two groups.
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Fracture mechanisms and fracture pattern in men and women aged 50 years and older: a study of a 12-year population-based injury register, Umea, Sweden
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In a study of a 12-year population-based injury register, Umea, Sweden, we analyzed the fracture mechanisms and fracture pattern in men and women 50 years and older. Low-energy trauma was responsible for the major and costliest part of the fracture panorama, but the pattern differs between age groups. INTRODUCTION: Osteoporosis-related fracture is a major health problem: the number of hip fractures is expected to double to 2030. While osteoporosis is one of many risk factors, trauma is almost always involved. Therefore, we analyzed injury mechanisms in patients aged over 50. METHODS: We registered injury mechanism, cause, diagnosis in all trauma patients at Umea University hospital, Sweden. This population-based register (1993-2004) comprises a total of 113,668 injuries (29,189 fractures). Patients >or=50 years contributed to 13,279 fractures. RESULTS: Low-energy trauma (fall <1 m) caused 53% of all fractures >or=50 years and older. In those over 75 low-energy trauma caused >80%. The seasonal variation of fractures was maximally 25%. With increasing age, proximal fractures became more common, in both upper and lower extremities. Proximal locations predominate in older age groups. CONCLUSIONS: Low-energy trauma was responsible for the largest and costliest part of the fracture panorama. In fact, almost all fractures in middle-aged and old people were caused by low-energy mechanisms; thus, most fractures in these patients have a fragility component, and the contribution of osteoporosis-related fractures is more important than previously thought. A better understanding of injury mechanisms also in low-energy trauma is a prerequisite for preventive interventions
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Evaluation and management of leg problems in the runner
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Stress fractures, the medial tibial syndrome (shin splints), Achilles tendinitis, chronic compartment syndromes, the popliteal artery entrapment syndrome, and deep venous thrombosis are discussed. Attention is directed to the pathogenesis, diagnosis, treatment, and prognosis for these conditions.
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Obesity, overweight and patterns of osteoarthritis: the Ulm Osteoarthritis Study
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The objective of this study was to assess the association between obesity and osteoarthritis (OA) of the knee, hip, and hand. OA patterns were studied in 809 patients with knee or hip joint replacement due to OA. Patients with OA were categorized as having bilateral or generalized OA according to the presence of radiographic OA in the contralateral joint or different finger joints, and as normal weight, overweight, or obese according to their body mass index (BMI). Odds ratios (OR) and 95% confidence intervals (CI) for relative weight and OA patterns were estimated with multivariable logistic regression. Eighty-five percent of participants had bilateral OA, 26% had generalized OA, and 31% were obese. Obesity (BMI >/= 30 kg/m(2); OR = 8.1; 95% CI: 2.4-28) and overweight (BMI >/= 25 kg/m(2); OR = 5.9; 95% CI: 2.0-18) were strongly associated with bilateral knee OA. No association between obesity and bilateral hip OA (OR = 0.7; 95% CI: 0.3-1.7) nor generalized OA (OR = 1.1; 95% CI: 0.6-2.1) was observed. Obesity seems to be a mechanical rather than a systemic risk factor for OA with the knee joint being especially susceptible
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Floppy eyelid syndrome: a modified surgical technique
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PURPOSE: To describe and present the results of a modified surgical technique to repair floppy eyelids. METHODS: A case series of 5 patients who were treated with the modified technique is presented. This technique uses the relaxed skin tension lines to tighten the lids in an aesthetically minded reconstruction. RESULTS: All patients had relief of symptoms and good cosmetic and functional results. Average follow-up was 39 months. Complications were minor and easily treated. CONCLUSIONS: This modified surgical technique provides excellent long-term structural integrity of the wound with a potentially more acceptable camouflaged scar.
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Efficacy of adductor canal block following knee surgery: A systematic review
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Background and Goal of Study: Knee surgery is associated with significant postoperative pain. Adductor canal block (ACB), predominantly a sensory block involving the saphenous nerve, nerve to vastus medialis and the articular branch of obturator nerve1 , reduces postoperative pain after knee surgery but there is conflicting evidence regarding its efficacy. This systematic review examines current evidence regarding the efficacy of ACB for knee surgery. Materials and methods: Randomised controlled trials (RCTs) on MEDLINE and EMBASE with no year or language restrictions were sought using the following keywords and text words: adductor canal, subsartorial and saphenous nerve block. Bibliographies and published abstracts from 2000-13 were also reviewed. Full manuscripts were rated for quality using the Jadad scale. We included RCTs comparing ACB using the local anaesthetics bupivacaine or ropivacaine, with or without epinephrine versus saline as control. RevMan statistical sof tware utilised inverse variance, random effect to calculate mean difference (MD) with 95% confidence intervals (CI) for continuous variables, odds ratio and Mantel-Haenszel method for dichotomous variables. Primary outcome was 24 hr opioid consumption. Secondary outcomes were pain scores at 0, 2, 4, 6 and 24 hrs at rest postoperatively and incidence of postoperative nausea and vomiting (PONV). Results and discussion: Six RCTs published between 2008-13, Jadad scale 2-5, were identified and 289 patients met the inclusion criteria. Three trials used ACB for arthroscopic surgery and three studied ACB for total knee arthroplasty. Four trials used single shot ACB and two trials used intermittent boluses via a catheter. There was no statistical significance noticed in 24 hour opioid consumption (MD -4.83; 95% CI -11.80, 2.15; P=0.17) or in postoperative pain scores at 0, 2 and 4 hrs at rest. In contrast, there was statistical significance in favour of ACB at 6 hrs (P=0.02) and 24 hrs (P=0.006) at rest. There was no difference in the incidence of PONV. Conclusion: This systematic review suggests that the benefit of ACB for knee surgery for postoperative analgesia is inconclusive but this may be due to small sample sizes or performance bias. We recommend larger RCTs in order to confirm or refute the findings
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Treatment of distal biceps tendon rupture: why, when, how? Analysis of literature and our experience
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INTRODUCTION: The rupture of the distal biceps tendon is a relatively uncommon lesion. Even if conservative treatment may be an option in low demanding patients, young and active subjects may benefit from an early surgical reinsertion. Many techniques and fixation devices have been described, but in the literature, there are no clinical evidences that show the superiority of any of these. In this article, we report an analysis of the "state of the art" and our case series of surgical reinsertion with the double approach transosseous technique.
MATERIALS AND METHODS: Between 2003 and 2013, 26 patients underwent surgical reinsertion, either for acute or for chronic lesions of distal biceps tendon. We evaluated 21 acute cases treated with double approach using DASH and SECEC Elbow Scores. The mean follow-up was 22 months. Range of motion, supination and flexion strength were also recorded.
RESULTS: Mean final ROM was 6-132degree in F/E and 89-0-87degree in P/S; flexion and supination strength were 96 and 88 % compared to the opposite side. The main complications were two cases of heterotopic ossifications: one asymptomatic fracture of the proximal radius and one temporary neurapraxia of the radial nerve.
CONCLUSIONS: Analysing the literature and our outcomes, we underline the importance of timing for surgery, in young and compliant patients, with a valid rehabilitation protocol for excellent results. The choice of surgical technique remains controversial, and we believe that the double approach transosseous reinsertion is a safe, costless and relatively non-invasive technique, offering satisfactory results when performed early.
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Outcomes After the Operative Treatment of Bucket-Handle Meniscal Tears in Children and Adolescents
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Background: Bucket-handle meniscal tears (BHMTs), which we define as vertical longitudinal tears of the meniscus with displacement of the torn inner fragment toward the intercondylar notch region, are a well-recognized tear pattern. Optimizing the management of BHMTs in younger patients is important, as preserving meniscal tissue may limit future joint degeneration. Purpose/Hypothesis: The purpose of this study was to review the patient demographics, clinical presentation, operative details, outcomes, and risk factors for a reoperation associated with operatively treated BHMTs in a pediatric population. We hypothesized that the repair of BHMTs in adolescents would yield a higher reoperation rate than meniscectomy in our population. Study Design: Case-series; Level of evidence, 4. Methods: A departmental database was queried to identify all patients 19 years or younger who presented with a BHMT and underwent surgery between October 2002 and February 2013. Clinical, radiological, and surgical data were retrospectively collected, and risk factors for a reoperation and persistent pain were assessed in all patients with longer than or equal to 6 months of follow-up. Results: A total of 280 BHMTs were treated arthroscopically by 1 of 8 sports medicine fellowshipâ??trained surgeons. The mean age at surgery was 15.5 ± 2.5 years (range, 2.1-19.2 years), and most patients were male (177/280; 63%). Most injuries occurred during sports (203/248; 82%) and involved the medial meniscus (157/280; 56%). Concurrent anterior cruciate ligament (ACL) surgery was performed in 103 cases (37%). Meniscal repair was performed in 181 cases (65%) and was more common in younger patients (P =.01) and for the lateral meniscus (P <.001). Among 185 (66%) cases with longer than or equal to 6 months of adequate follow-up data (which included 126 meniscal repairs [68%]), a meniscus-related reoperation occurred in 45 (24%) cases. A reoperation related to the original BHMT injury or surgery was more common after meniscal repair than after meniscectomy (40/126 [32%] vs 5/59 [8%], respectively) (P =.001) and less common with concurrent ACL surgery (P =.07), although this was not statistically significant. Among patients injured during sports and with adequate follow-up, all but 1 patient (176/177; 99%) returned to sports; a slower rate of return was seen in those undergoing meniscal repair (P =.002) and concurrent ACL surgery (P <.001). At final follow-up, 170 of 185 patients (92%) were pain free. For the 15 patients with persistent pain at final follow-up, no identifiable risk factors for persistent pain were identified. Conclusion: Most BHMTs in younger patients occurred in males and during sports and affected the medial meniscus. Concurrent ACL surgery was indicated in approximately one-third of cases and was associated with a lower reoperation rate and slower return to sports. Two-thirds of patients underwent meniscal repair, over two-thirds of whom did not require a reoperation during the study period, despite the high activity levels in this age group.
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Single injection of high volume of autologous pure PRP provides a significant improvement in knee osteoarthritis: A prospective routine care study
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Background: Evidence is growing regarding the ability of platelet-rich plasma (PRP) injections to enhance functional capacity and alleviate pain in knee osteoarthritis (OA). However, heterogeneity in common practice regarding PRP preparation and biological content makes the initiation of this activity in a hospital complex. The aim of this study was to document the efficacy of a single PRP injection to treat knee OA and validate a routine care procedure. Methods: Fifty-seven patients with symptomatic knee OA received a single injection of large volume of very pure PRP. They were assessed at baseline and after one, three and six months, by measuring Knee Injury and Osteoarthritis Score (KOOS), Observed Pain after a 50-foot walk test and Visual Analog Scale (VAS) assessments. Magnetic Resonance Imaging (MRI) analysis was performed at baseline and six months after the procedure. The objective was to recover 50% of responders three months after the procedure using OMERACT-OARSI criteria. Results: A single administration of high volume pure PRP provided significant clinical benefit for 84.2% of the responders, three months after the procedure. The KOOS total score significantly increased from 43.5 ± 14.3 to 66.4 ± 21.7 six months after the procedure (p < 0.001). Pain also significantly decreased from 37.5 ± 25.1 to 12.9 ± 20.9 (p < 0.001). No difference was observed on MRI parameters. Conclusion: A single injection of large volume of very pure PRP is associated with significant functional improvement and pain relief, allowing initiation of daily PRP injection within our hospital.
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Septic arthritis
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This article describes the aetiology, diagnosis and treatment of pyogenic septic arthritis. The epidemiology is described and the at-risk groups delineated. The difficulties with current diagnostic methods are highlighted and controversies regarding optimal management raised. A list of pivotal articles is included
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Cost-effectiveness and economic impact of the KineSpring® Knee Implant System in the treatment of knee osteoarthritis in the United Kingdom
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Knee osteoarthritis (OA) is a condition affecting 8.5 million individuals in the United Kingdom (UK). Although many treatment options are available, there is a need for a less-invasive treatment for individuals with mild to moderate knee OA. The purpose of the present study was to determine whether the KineSpring System is a more effective treatment for knee OA when compared to other standard treatments, taking into consideration cost-utility ratios. Data was collected for the UK population breakdown. A literature search provided data on conservative and surgical treatment costs and functional outcome scores. The KineSpring System outcome scores were obtained from two trials. Quality-adjusted life years (QALYs) gained and cost-utility ratios were calculated for each treatment option, assuming a lifetime durability as well as 10-year durability. Assuming lifetime durability, the cost-utility ratios of surgical treatment, total knee arthroplasty (TKA), the KineSpring System, and conservative treatments, compared to no treatment are £1,303±22/QALY, £821±175/QALY, £796±73/QALY and £11,096±1188/QALY, respectively. Assuming a treatment durability of 10 years, the cost-utility ratio of surgical treatment, TKA, the KineSpring System, and conservative treatments, compared to no treatment are £4,153±95 per QALY, £2,698±768 per QALY, £2,848±345 per QALY, and £10,624±1528 per QALY, respectively. This study demonstrates that the KineSpring System is a cost-effective treatment for knee OA and is comparable to current standard-of-care treatments. Further research is needed to assess the long-term outcomes associated with the KineSpring System.
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Occurrence and incidence of the second hip fracture
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During a 16-year period, 256 second hip fractures were found in 3898 persons 40 years of age and older who had a previous hip fracture. Ninety-two percent of the second fractures were contralateral, and 68% of these were the same type as the first. Thus, 62% of the femoral neck and 72% of the trochanteric fractures were preceded by a contralateral fracture of the same type. The mean interval between fractures was 3.3 years, and there was no significant difference between genders or among fracture types. The risk of the first fracture was 1.6 per 1000 men per year and 3.6 per 1000 women, and for the second fracture 15 per 1000 men per year and 22 per 1000 women. This increase was highly significant for both genders, especially for men
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Exercise in knee osteoarthritis--preliminary findings: Exercise-induced pain and health status differs between drop-outs and retainers
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BACKGROUND: Exercise effectiveness is related to adherence, compliance and drop-out. The aim of this study is to investigate if exercise-induced pain and health status are related to these outcomes during two exercise programs in knee osteoarthritis patients.
METHODS: Symptomatic knee osteoarthritis patients were randomly allocated to a walking or strengthening program (N=19/group). At baseline, patients were categorized according to their health status. Exercise adherence and compliance were calculated and drop-out rate was registered. For exercise-induced pain, patients rated their pain on an 11-point numeric rating scale (NRS) before and after each training session. Before each session the maximal perceived pain of the last 24h (NRSmax24) was assessed. Patients rated their global self-perceived effect (GPE) on a 7-point ordinal scale after the intervention period.
RESULTS: 53% of the participants felt they improved after the program, 6 patients dropped out. The mean adherence and compliance rates were higher than .83 in both groups. Worse health and higher exercise-induced pain were seen in drop-outs. NRSmax24 during the first 3 weeks did not significantly increase compared to baseline, but correlated negatively with adherence during the home sessions (-.56, p<.05). Lower adherence during supervised sessions was significantly related with higher pre-exercise pain scores (rho=-.35, p<.05).
CONCLUSION: Patients who drop-out show a worse health condition and higher exercise-induced pain levels compared to patients that retained the program.
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Treatment of posttraumatic varus ankle deformity with supramalleolar osteotomy
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Supramalleolar osteotomies for correction of posttraumatic varus arthritis in early and mid-stages provide good functional and clinical outcomes. However, the biomechanical behavior of the ankle joint differs from the knee, and therefore correction of the distal TAS angle alone may not provide a physiologic load transfer across the ankle joint. Osseous balancing of an arthritic varus ankle joint may require not only correction of the articular surface angle in the frontal plane but may include a biplanar correction to improve the talar coverage and a fibular osteotomy to restore ankle joint congruency.
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Sialolithiasis. Ultrastructural morphology and bacterial etiology
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Twenty-five salivary calculi, most of them formed in the submandibular gland, were subjected to scanning electron microscopic study to determine their microstructure and investigate possible bacterial colonization. Hydroxyapatite was the most common crystalline component, with up to 7 different forms of crystallization. Amorphous arrangements were also observed, though no pyramidal crystals were present. Whicklokite and calcium oxalate followed in order of decreasing presence. The findings of main interest were 'casts', occupied (or with signs of having been occupied) by germs identifiable as a result of cast shape (enterococci, staphylococci and streptococci). It cannot be affirmed that these germs contribute to initial stone formation, for neither microorganisms nor casts were found in the nucleus; however, they could promote calculus growth by modifying local pH or by releasing enzymes that favor hydroxyapatite formation. Non-bacterian spheroid bodies previously described by other authors were also visualized. These may correspond to mucinous aggregates or to mucoproteic subtances of bacterial origin. The modification of saliva or the adoption of measures against local infection might help to limit the incidence and magnitude of sialolithiasis
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Midterm clinical results of osteochondral autograft transplantation for advanced stage Freiberg disease
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PURPOSE: We aimed to evaluate the midterm clinical results of osteochondral autograft transplantation (OAT) for advanced stage Freiberg disease.
METHODS: This study included consecutive patients who underwent OAT for advanced stage Freiberg disease and were followed postoperatively for more than five years. In all cases, the autograft was harvested from the ipsilateral knee joint. Clinical evaluation was performed based on the American Orthopaedic Foot and Ankle Society Lesser Metatarsophalangeal-Interphalangeal Scale (AOFAS) score and visual analogue scale (VAS) score, which were done pre-operatively and at the most recent follow-up. Radiological evaluation was performed at two years after the operation. Furthermore, the most recent six patients underwent magnetic resonance imaging (MRI) five years after the operation to assess the configuration of the articular surface.
RESULTS: A total of 13 patients (all female; mean age 16.7 years; range 10-38 years) were included and followed up for a mean duration of 67.2 months (range 60-100 months). The mean AOFAS significantly improved from a score of 66.9 +/- 5.3 (range 59-77) to 93.0 +/- 7.6 (range 82-100) (p < 0.0001). Likewise, the mean VAS significantly improved from a score of 72.7 +/- 10.3 (range 60-90) to 7.8 +/- 7.2 (range 0-20) (p < 0.0001). Radiographs at two years after the operation revealed no osteoarthritic change in all cases. MRI at five years after the operation showed consolidation of the transplanted autograft and smooth configuration of the articular surface in the six cases.
CONCLUSIONS: OAT may be effective for advanced stage Freiberg disease. Further studies are necessary before this technique can become the standard operative treatment.
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Transcranial direct current stimulation of SMA modulates anticipatory postural adjustments without affecting the primary movement
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Recent works provide evidences that anticipatory postural adjustments (APAs) are programmed with the prime mover recruitment as a shared posturo-focal command. However the ability of the CNS to adjust APAs to changes in the postural context implies that the postural and voluntary components should take different pathways before reaching the representation of single muscles in the primary motor cortex. Here we test if such bifurcation takes place at the level of the supplementary motor area (SMA).TDCS was applied over the SMA in 14 subjects, who produced a brisk index-finger flexion. This activity is preceded by inhibitory APAs, carved in the tonic activity of Biceps Brachii and Anterior Deltoid, and by an excitatory APA in Triceps Brachii. Subjects performed a series of 30 flexions before, during and after 20. min of tDCS in CATHODAL, ANODAL or SHAM configuration. The inhibitory APA in Biceps and the excitatory APA in Triceps were both greater in ANODAL than in SHAM and CATHODAL configurations, while no difference was found among the latter two (ANODAL vs. SHAM: biceps +26.5%, triceps +66%; ANODAL vs. CATHODAL: biceps +20.5%, triceps: +63.4%; for both muscles, ANOVA p<. 0.02, Tukey p<. 0.05). Instead, the APA in anterior deltoid was unchanged in all configurations. No changes were observed in prime mover recruitment and index-finger kinematics. Results show that the SMA is involved in modulating APAs amplitude. Moreover, the differential effect of tDCS observed on postural and voluntary commands suggests that these two components of the motor program are already separated before entering SMA.
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Bone mass, muscle function and fracture of the proximal femur
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The epidemiology and pathogenesis of hip fractures are reviewed. There is evidence that physical inactivity and concomitant muscle weakness are important determinants of the risk of hip fracture
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Condylocephalic nails versus extramedullary implants for extracapsular hip fractures
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BACKGROUND: Two types of implants used for the surgical fixation of extracapsular hip fractures are condylocephalic nails (intramedullary nails that are inserted up through the femoral canal from above the knee and across the fracture) and extramedullary implants. OBJECTIVES: To compare condylocephalic nails (e.g. Ender and Harris nails) with extramedullary implants (e.g. fixed nail plates and sliding hip screws) for the treatment of extracapsular (trochanteric and subtrochanteric) hip fracture in adults. SEARCH STRATEGY: We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (September 2004), the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 3, 2004), MEDLINE (1966 to September week 1 2004), EMBASE, the UK National Research Register, orthopaedic journals, conference proceedings and reference lists of articles. SELECTION CRITERIA: Randomised or quasi-randomised trials comparing condylocephalic nails with extramedullary implants. DATA COLLECTION AND ANALYSIS: We independently assessed trial quality and extracted data. Ender nails and Harris nail data were presented separately. Results from fixed nail plates and sliding hip screws were subgrouped. MAIN RESULTS: Eleven trials involving 1667 people with predominantly trochanteric fractures were included. Ten compared Ender nails with either a fixed nail plate or a sliding hip screw. One compared the Harris condylocephalic nail with a sliding hip screw.The only advantages of condylocephalic nails were a reduced deep wound sepsis rate (0.9% versus 4.2%; relative risk 0.28, 95% confidence interval 0.11 to 0.62), length of surgery and operative blood loss. However, there was an increased risk of reoperation (20.9% versus 5.5%; relative risk 3.72, 95% confidence interval 2.54 to 5.44) and later fracture of the femur when compared with extramedullary implants. There was an increased risk of cut-out of the implant from the femoral head for Ender nails compared with the sliding hip screw, but not for fixed nail plates. Backing out of the nail was a frequent complication (30%) of Ender nails and often resulted in revision surgery.Ender nails had an increased risk of shortening of the leg and external rotation deformity and potentially a poorer return to previous walking ability. An increase in residual pain, predominantly knee pain, was also evident in patients undergoing condylocephalic nailing. There was no apparent difference in mortality between the condylocephalic nail and extramedullary implant groups. AUTHORS' CONCLUSIONS: Any advantages in intra-operative outcomes of condylocephalic nails are outweighed by the increase in fracture healing complications, reoperation rate, residual pain and limb deformity when compared with an extramedullary implant, particularly a sliding hip screw. The use of condylocephalic nails (in particular Ender nails), for trochanteric fracture is no longer appropriate. CONDYLOCEPHALIC NAILS VERSUS EXTRAMEDULLARY IMPLANTS FOR EXTRACAPSULAR HIP FRACTURES: A hip fracture is a break near the top of the thigh bone (femur). Those located further away from the hip joint are termed extracapsular. Such fractures may be surgically fixed using metal implants. Two types of implant are compared here. Condylocephalic nails, such as Ender nails, are inserted near the knee, and pushed up through the bone marrow of the femur and across the fracture site. Extramedullary implants consist of a screw or rod, inserted in the upper part of the femur to bridge the fracture, connected to a plate secured to the femur. This review found that, despite quicker surgery, Ender nails were associated with an increased risk of complications and reoperation when compared with extramedullary implants in common use
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Uncemented porous tantalum acetabular components: Early follow-up and failures in 613 primary total hip arthroplasties
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Uncemented tantalum acetabular components were introduced in 1997. The purpose was to determine the 2- to 10-year results with this implant material in primary total hip arthroplasty. Our registry identified all primary total hip cases with porous tantalum cups implanted from 1997 to 2004. Clinical outcomes and radiographs were studied. 613 cases were identified. Seventeen percent of patients were lost to follow-up. Twenty-five reoperations were performed (4.4%). Acetabular cup removal occurred in 6 cases (1.2%). No cups were revised for aseptic loosening. Incomplete radiolucent lines were found on 9.3% of initial postoperative radiographs. At 2. years, 67% had resolved. Zero new radiolucent lines were detected. Two- to 10-year results of porous tantalum acetabular components for primary total hip arthroplasty demonstrate high rates of initial stability and apparent ingrowth. © 2014 Elsevier Inc.
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Doxycycline plus ivermectin versus ivermectin alone for treatment of patients with onchocerciasis
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BACKGROUND: Onchocerciasis, also known as "river blindness," is a parasitic disease that is caused by infection from the filarial nematode (roundworm), Onchocerca volvulus. Nematodes are transmitted from person to person by blackflies of the Simulium genus, which usually breed in fast flowing streams and rivers. The disease is the second leading infectious cause of blindness in endemic areas.Ivermectin (a microfilaricide) is widely distributed to endemic populations for prevention and treatment of onchocerciasis. Doxycycline, an antibiotic, targets Wolbachia organisms that are crucial to the survival of adult onchocerca (macrofilaricide). Combined treatment with both drugs is believed to cause direct microfilarial death by ivermectin and indirect macrofilarial death by doxycycline. Long-term reduction in the numbers of microfilaria in the skin and eyes and in the numbers of adult worms in the body has the potential to reduce the transmission and occurrence of onchocercal eye disease. OBJECTIVES: The primary aim of this review was to assess the effectiveness of doxycycline plus ivermectin versus ivermectin alone for prevention and treatment of onchocerciasis. The secondary aim was to assess the effectiveness of doxycycline plus ivermectin versus ivermectin alone for prevention and treatment of onchocercal ocular lesions in communities co-endemic for onchocerciasis and Loa loa (loiasis) infection. SEARCH METHODS: We searched CENTRAL (which contains the Cochrane Eyes and Vision Trials Register) (Issue 7, 2015), Ovid MEDLINE, Ovid MEDLINE In-Process and Other Non-Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE (January 1946 to July 2015), EMBASE (January 1980 to July 2015), PubMed (1948 to July 2015), Latin American and Caribbean Health Sciences Literature Database (LILACS) (1982 to July 2015), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com) (last searched 1 July 2014), ClinicalTrials.gov (www.clinicaltrials.gov) and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We did not use any date or language restrictions in the electronic search for trials. We last searched the electronic databases on 15 July 2015. SELECTION CRITERIA: We included randomized controlled trials (RCTs) that had compared doxycycline plus ivermectin versus ivermectin alone. Participants with or without one or more characteristic signs of ocular onchocerciasis resided in communities where onchocerciasis was endemic. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed trial eligibility and extracted data. We used standard methodological procedures as expected by Cochrane. MAIN RESULTS: We identified three RCTs including a total of 466 participants with a diagnosis of onchocerciasis. All trials compared doxycycline plus ivermectin versus ivermectin alone. One study investigated improvement in visual impairment at six-month follow-up; the other two studies measured microfilarial loads in skin snips to assess sustained effects of treatment at follow-up of 21 months or longer. The studies were conducted at various centers across three countries (Cameroon, Ghana, and Liberia). We judged all studies to be at overall high risk of bias because of inadequate randomization and lack of masking (one study), missing data (two studies), and selective outcome reporting (three studies).Only one study measured visual outcomes. This study reported uncertainty about the difference in the proportion of participants with improvement in visual impairment at six-month follow-up for doxycycline plus ivermectin compared with ivermectin alone (risk ratio (RR) 1.06, 95% confidence interval (95% CI) 0.80 to 1.39; 240 participants; very low-quality evidence). No participant in either group showed improvement in optic atrophy, chorioretinitis, or sclerosing keratitis at six-month follow-up. More participants in the doxycycline plus ivermectin group than in the ivermectin alone group showed improvement in iridocyclitis (RR 1.24, 95% CI 0.69 to 2.22) and punctate keratitis (RR 1.43, 95% CI 1.02 to 2.00) at six-month follow-up; however, we graded these results as very low quality.Two studies reported that a six-week course of doxycycline may result in Wolbachia depletion and macrofilaricidal and sterilizing activities in female Onchocerca worms; however, no analysis was possible because data were missing and incomplete (graded evidence as very low quality). Adverse events were reported in 16 of 135 (12%) participants in one of these studies and included itching, headaches, body pains, and vertigo; no difference between treatment groups was reported for any adverse event. The second study reported that one (1.3%) participant in the doxycycline plus ivermectin group had bloody diarrhea after treatment was initiated. AUTHORS' CONCLUSIONS: Available evidence on the effectiveness of doxycycline plus ivermectin compared with ivermectin alone in preventing and treating onchocerciasis is unclear. Limited evidence of very low quality from two studies indicates that a six-week course of doxycycline followed by ivermectin may result in more frequent macrofilaricidal and microfilaricidal activity and sterilization of female adult Onchocerca compared with ivermectin alone; however, effects on vision-related outcomes are uncertain. Future studies should consider the effectiveness of treatments in preventing visual acuity and visual field loss and their effects on anterior and posterior segment lesions, particularly chorioretinitis. These studies should report outcomes in a uniform and consistent manner at follow-up of three years or longer to allow detection of meaningful changes in vision-related outcomes.
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Bone Health in Duchenne Muscular Dystrophy- a case controlled study of Risedronate use - Risedronate in DMD
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INTERVENTION: Trade Name: Actonel Once a week 5mg film coated tablets Product Name: Risedronate sodium Product Code: Risedronate Pharmaceutical Form: Filmâ?coated tablet Trade Name: Calcichew D3 Forte Product Name: Calcichew D3 Forte Product Code: Calcichew D3 Forte Pharmaceutical Form: Chewable tablet CONDITION: Bone Health in Duchenne Muscular Dystrophyâ? a randomised controlled study of Risedronate use PRIMARY OUTCOME: Main Objective: ; (1)To prospectively determine, using a randomized controlled trial, the effects of a targeted intervention on improving BMD in this population using oral bisphosphonate and calcium and Vitamin D supplementation (Calcichew D3 Forte) versus Calcium and Vitamin D supplementation with Calcichew D3 Forte alone.; Primary end point(s): Primary Outcome:; Efficacy of bisphosphonates and Calcium and Vitamin D supplementation with Calcichew D3 Forte, compared with Calcium and Vitamin D supplementation (Calchichew D3 Forte) alone ; ; a. Change /% change in areal/volumetric BMD Z score of lumbar spine following intervention over 12 months is the primary endpoint. Criteria for success of treatment will be an increase of 0.5SD in lumbar spine Z score as measured by DXA scan. The doctor reporting the DXA scans (MMcK) will be blinded to what treatment each patient is receiving. Our study is large enough to detect a difference of 0.8SD in lumbar spine DXA score between treatment and control groups.; ; ; b. Change /% change in areal/volumetric BMD Z score of lateral distal femoral head, distal third of radius, total body excluding head as measured by DXA; ; Our power calculation is based on the primary end point of lumbar spine BMD Zâ?score changes. Because stratified randomization has only a minor effect on power for a superiority trials such as this standard twoâ?group comparison power calculations were used; Based on a twoâ?sided significance level of 5% and a power of 80%, a trial with 25 patients in each group would be able to detect a difference in BMD lumbar spine Zâ?score changes of 0.81 standard deviations (SD) or greater after 12months treatment.; This change in BMD lumbar spine Z score has been reported by previous groups using similar dose regime.; ; ; ; ; Secondary Objective: (2)To assess bone health in Irish population of children and young adults with DMD ; a) Baseline calcium and vitamin D status and optimize prior to onset of trial; b) Baseline bone mineral density in ambulant and nonambulant boys with DMD, using DXA scan and markers of bone formation and resorption. DXA performed up to six months prior to the onset of the trail will be used as a baseline measurement.; c) Determine the incidence of long bone and vertebral fractures and bone pain in this group and whether there is any correlation with disease severity/steroid use or genetic mutations.; (3) To establish guidelines on management of bone health in the DMD population to reduce fracture risk.; ; ; ; ; INCLUSION CRITERIA: 1.>/4 years old at time of initiation of study 2. Z score as measured by DXA >1.0 S.D. below the mean 3. boys only with DMD Are the trial subjects under 18? yes Number of subjects for this age range: F.1.2 Adults (18â?64 years) yes F.1.2.1 Number of subjects for this age range F.1.3 Elderly (>=65 years) no F.1.3.1 Number of subjects for this age range
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Urinary calculi in hypercalcemic states
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In this brief review of various hypercalcemic disorders and the likelihood of renal calculus formation, it is clearly evident that renal calculi occur much more often in hyperparathyroidism than in the other hypercalcemic states. Dystrophic calcification and nephrocalcinosis are common to all of the hypercalcemic disorders, including hyperparathyroidism, when the hypercalcemia is marked and the limit of solubility of calcium and phosphate in serum is approached. Interestingly, in sarcoidosis there are calcium oxalate crystals in variously distributed sarcoid granuloma, and the renal calculi are composed of calcium oxalate. By contrast, in hyperparathyroidism, the calculi composed of calcium phosphate predominate. This indicates a subtle and as yet undefined alteration in oxalate metabolism in sarcoidosis. An increase in urine pH occurs in hyperparathyroidism, and this enhances formation of crystalline calcium phosphate. However, the striking disparity between the frequency of calculus formation in hyperparathyroidism and that in other hypercalcemic disorders, several of which may be of relatively long duration, suggests that there indeed may be increased promoters of crystal formation in the urine of hyperparathyroid patients. [References: 45]
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Infected nonunion of tibia and femur treated by bone transport
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OBJECTIVE: The objective of this study was to evaluate the effectiveness of the treatment of infected nonunion of tibia and femur by bone transport.
MATERIAL AND METHODS: We retrospectively reviewed 110 patients with infected nonunion of tibia and femur treated by bone transport. Our study included 92 males and 18 females with a mean age of 38.90 years. The site of infected nonunion involved 72 tibias and 38 femurs. The mean length of the bone defects after radical debridement was 6.15 cm (range 3-13 cm).
RESULTS: The mean follow-up after removal of the apparatus was 23.12 months (14-46 months). Ten patients including seven patients with infected tibia nonunion and three patients with infected femur nonunion were lost to follow-up. All the patients achieved bone union, and no recurrence of infection was observed. The time of bone transport took a mean of 67.50 days (range 33 to 137 days), and the mean external fixation index was 1.48 months/cm (range 1.15-1.71 months/cm). According to Association for the Study and Application of the Method of Ilizarov (ASAMI) classification, bone results were excellent in 68, good in 28, fair in 12, and poor in 2; functional results were excellent in 37, good in 42, fair in 21, and no poor.
CONCLUSIONS: Our study and the current evidence suggested that Ilizarov methods in the treatment of infected nonunion of tibia and femur acquired satisfied results. Radical debridement is the key step to control bone infection.
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Proximal tibial bone density is preserved after unicompartmental knee arthroplasty knee
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Background: Bone mineral density (BMD) in the proximal tibia decreases after TKA and is believed to be a factor in implant migration and loosening. Unicompartmental knee arthroplasty (UKA) is a less invasive procedure preserving knee compartments unaffected by degeneration. Finite element studies have suggested UKA may preserve BMD and that implants of differing stiffnesses might differentially affect BMD but these notions have not been clinically confirmed. Questions/purposes: We therefore asked whether (1) proximal tibial BMD decreases after UKA, and (2) a cemented metal tibial component with a mobile polyethylene (PE) bearing would have greater BMD loss than a cemented PE tibial component. Methods: We prospectively followed 48 patients who underwent 50 UKAs using one of two implants: one with a cemented metal tibial baseplate and a mobile PE insert (n = 26) and one with a cemented all-PE tibial component (n = 24). In followup we assessed pain and function (Oxford Knee Score, SF-12, The Knee Society Score©) and radiographs. BMD changes were assessed using quantitative CT osteodensitometry performed postoperatively and at 1 and 2 years after the index procedure. Results: Mean cancellous BMD decreased 1.9% on the medial side and 1.1% on the lateral side. Mean cortical BMD was static, decreasing 0.4% on the medial side and increasing 0.5% on the lateral side. The greatest observed difference between implants for any region was 3.7%. There were no differences in pain or functional outcome scores. Conclusions: BMD was preserved 2 years after UKA with no major differences seen between implant types. © 2013 The Association of Bone and Joint Surgeons®.
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Prospective Results of Uncemented Tantalum Monoblock Tibia in Total Knee Arthroplasty. Minimum 5-Year Follow-up in Patients Younger Than 55 Years
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A significant increase in younger patients undergoing total knee arthroplasty raises the theoretical concern for revision secondary to micromotion and fixation failure with cemented components. We prospectively studied 100 consecutive tantalum monoblock uncemented tibial components and 312 concurrent cemented controls. Patients younger than 55 years with adequate bone stock were enrolled. This cementless patient group was younger and had higher preoperative functional status. Prostheses were posterior-substituting uncemented femoral and tibial components with a cemented patellar button. Knee Society pain and function scores and radiographs were obtained, and a cost analysis was performed. Knee Society scores were excellent and equivalent beyond 6 months. There was no significant difference in perioperative blood loss, complication rates, or cost. There was a significant decrease in operative time in the uncemented group. Radiographs revealed no failures of ingrowth at last follow-up. There were 3 uncemented group failures, but none were due to failure of fixation. The use of a porous tantalum tibia at minimum 5 years has yielded promising clinical and radiographic results in a younger patient population. (copyright) 2011 Elsevier Inc
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The effects of various physical non-operative modalities on the pain in osteoarthritis of the knee
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The purpose of this study was to evaluate the effect of various non-operative modalities of treatment (transcutaneous electrical nerve stimulation (TENS); neuromuscular electrical stimulation (NMES); insoles and bracing) on the pain of osteoarthritis (OA) of the knee. We conducted a systematic review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to identify the therapeutic options which are commonly adopted for the management of osteoarthritis (OA) of the knee. The outcome measurement tools used in the different studies were the visual analogue scale and The Western Ontario and McMaster Universities Arthritis Index pain index: all pain scores were converted to a 100-point scale. A total of 30 studies met our inclusion criteria: 13 on insoles, seven on TENS, six on NMES, and four on bracing. The standardised mean difference (SMD) in pain after treatment with TENS was 1.796, which represented a significant reduction in pain. The significant overall effect estimate for NMES on pain was similar to that of TENS, with a SMD of 1.924. The overall effect estimate of insoles on pain was a SMD of 0.992. The overall effect of bracing showed a significant reduction in pain of 1.34. Overall, all four non-operative modalities of treatment were found to have a significant effect on the reduction of pain in OA of the knee. This study shows that non-operative physical modalities of treatment are of benefit when treating OA of the knee. However, much of the literature reviewed evaluates studies with follow-up of less than six months: future work should aim to evaluate patients with longer follow-up.
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Reliability of using radius union scoring system among general practitioners, orthopedic residents and orthopedic surgeons for distal end radius fracture healing evaluation
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Background: Fractures of distal end of radius are common fractures in adults. They were commonly treated by general practitioners (GPs) in rural Thailand. Inadequate time for immobilization and casting may reach more complications such as failure to maintain reduction or stiffness. There has been no publication of objective tools for diagnosing of fracture union to date. Radius union scoring system (RUSS) may be a good diagnostic tool and easy to use. However, there is no study about the reliability between GPs and orthopedic surgeons. Objective: To study the reliability of using RUSS score between different evaluators-GPs and orthopedic surgeons. Material and Method: Anteroposterior and lateral view of plain wrist radiographs from 20 distal end radius fractured patients were used for reviewing. RUSS was used for rating of radiographs by 6 GPs, 6 orthopedic residents and 3 orthopedic surgeons. Interobserver reliability was determined and calculated. Results: This study found low level of interobserver between GPs and orthopedic surgeons (ICC = 0.39, 95% CI) and low level of interobserver reliability in inexperienced groups of physicians in this study (ICC = 0.37 and 0.48 in GPs and junior residentsâ?? group). Level of interobserver reliability has been associated with raterâ??s experience. Conclusion: Level of interobserver reliability between general practitioners and orthopedic surgeons was low due to experiences of the raters. RUSS may not be a proper tool for inexperienced physicians.
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Impact of obesity on disability, function, and physical activity: data from the Osteoarthritis Initiative
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OBJECTIVES: Older adults with obesity are at risk for osteoarthritis (OA) and are predisposed to functional decline and disability. We examined the association between obesity and disability, physical activity, and quality of life at 6 years.
METHOD: Using data from the longitudinal Osteoarthritis Initiative (OAI), we analysed older adults (age >= 60 years) with a body mass index (BMI) at baseline >= 18.5 kg/m(2) (n = 2378) using standard BMI categories. Outcomes were assessed at the 6-year follow-up and included: the Late-Life Function and Disability Index (LLDI), the 12-item Short Form Health Survey (SF-12), and the Physical Activity Scale for the Elderly (PASE). Linear regression predicted outcomes based on BMI category, adjusting for age, sex, race, education, smoking, cohort status, radiographic knee OA, co-morbidity scores, and baseline scores when available.
RESULTS: Follow-up data were available for 1727 (71.9%) participants (mean age 67.9 +/- 5.3 years; 61.6% female). At baseline, obese subjects compared to overweight and normal were on a greater number of medications (4.28 vs. 3.63 vs. 3.32), had lower gait speeds (1.22 vs. 1.32 vs. 1.36 m/s), higher Charlson scores (0.59 vs. 0.37 vs. 0.30), and higher Western Ontario and McMaster University OA Index (WOMAC) scores (right: 14.8 vs. 10.3 vs. 7.5; left: 14.4 vs. 9.9 vs. 7.5). SF-12 scores at 6 years were lower in obese patients than in overweight or normal [99.5 (95% CI 98.7-100.4) vs. 101.1 (95% CI 100.4-101.8) vs. 102.8 (95% CI 101.8-103.8)], as were PASE scores [115.1 (95% CI 110.3-119.8) vs. 126.2 (95% CI 122.2-130.2) vs. 131.4 (95% CI 125.8-137.0)]. The LLDI limitation component demonstrated differences in obese compared to overweight or normal [78.6 (95% CI 77.4-79.9) vs. 81.2 (95% CI 80.2-82.3) vs. 82.5 (95% CI 81.1-84.0)].
CONCLUSIONS: Obesity was associated with worse physical activity scores, lower quality of life, and higher risk of 6-year disability.
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Treatment of undisplaced femoral neck fractures in the elderly
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BACKGROUND: While the treatment for displaced femoral neck fractures in the elderly (Garden types III and IV) is quite clear, the procedure for impacted or undisplaced femoral neck fractures (Garden types I and II) is still a subject of controversy. Methods: Thirty-seven (all >80 years old) patients with undisplaced femoral neck fractures were treated with osteosynthesis by cannulated screws fixation. The clinical outcomes were followed up retrospectively for at least two years. RESULTS: The overall union rate was 94.59% (35 patients) at 6 months after primary internal fixation. The overall success rate was 83.78% (31 patients), and the overall failure rate was 16.22% (6 patients). CONCLUSIONS: Osteosynthesis with cannulated screws fixation is a simple, safe, economical, and reasonably effective procedure for the treatment of undisplaced femoral neck fractures in patients older than 80 years
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Development of an Osteoarthritis (OA) Care Plan to Improve Process and Quality of OA Treatment Decisions
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The investigators propose to prospectively randomize orthopedists, with their patients, to receive (or not) a realâ?time, webâ?based system intervention: the OA Care plan. The OA Care plan will include individualized, patientâ?centric information: (1) trended patientâ?reported OA pain and function, (2) tailored estimates of likely TJR benefits and risks based on a contemporary US cohort of 25,000 TJR patients (FORCEâ?TJR Registry), (3) evidenceâ?based information for nonâ?operative care, and (4) individual patient goals. Specific Aims include: Aim 1. Patients and their Caregivers/Trusted Others will refine the design, content, and usability of a realâ?time, webâ?based individual OA Care plan to guide TJR and nonâ?operative OA care decisions. Aim 2. Randomize 40 orthopedists, and their patients, to receive the OA Care plan at the time of orthopedic consultation (intervention) vs. usual care (control) and compare (a) OA care decision process and quality and (b) quality of OA care as measured by pain relief and functional gain in the two arms at 6 and 12 months after the decision, and assess the impact of decision quality on quality of OA care. Aim 3. Randomize 54 orthopedists, and their patients, to receive the OA Care plan plus peer, family, and primary care physician support (OA Care plan+Support; intervention) vs. the OA Care plan alone and compare the quality of OA care decision and quality of care (pain relief, functional gain) in the two arms. Based on the components of the Chronic Care Model, this technologyâ?delivered, individualized OA Care plan will enable patients and clinicians to make treatment decisions based on patient symptoms, goals, and comparative effectiveness evidence. The investigators hypothesize that OA Care plan users, as compared to usual care, will report greater decision quality for both TJR or nonâ?operative care, and better quality of care (less OA pain, greater function). Further, the investigators anticipate incremental effectiveness of the OA Care plan+Support (peer, family, and primary care support) on the same outcomes. Study results will guide future OA Care plan implementation to assure optimal healthcare for patients with advanced knee and hip OA. Finally, lessons learned from the evaluation of this automated patientâ?centric decision support system can be extended beyond OA and TJR to other elective surgical procedures to engage informed patients to make optimal individual decisions.
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A review of 100 cases of supracondylar fractures in children seen in Ibadan
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Supracondylar fracture of the humerus in children is one of the commonest fractures in children of school age all over the world. The experience of the mode of presentation, mechanism of injury and the different modalities of treatment in the University College Hospital, Ibadan is presented. The results suggest that severely displaced supracondylar fractures in this environment are better managed with open reduction and internal fixation
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Preoperative oral administration of fast-release morphine sulfate reduces postoperative piritramide consumption
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The aim of this prospective randomized placebo-controlled double-blind study was to investigate the effect of premedication with morphine sulfate on postoperative pain. Ninety-eight ASA I-III patients undergoing total replacement of the knee or hip joint were randomly assigned to one of two groups. Group 1 received 20 mg morphine sulfate p.o. approximately one hour before the start of surgery; group 2 received placebo. After surgery, piritramide was administered via patient-controlled analgesia over 24 hours. Piritramide consumption and pain scores (visual analog scale) were recorded. The duration of surgery (mean +/- SD) was comparable in the two groups (group 1: 145 +/- 42 min, group 2: 131 +/- 35 min). In group 1 the cumulative piritramide consumption during 24 hours postoperation was significantly less than in the placebo group (37.5 +/- 12.5 mg versus 46.8 +/- 22.1, t-test, p < 0.05), although similar pain scores were recorded (group 1: 4.8 +/- 1.8 and 3.6 +/- 1.7, group 2: 4.8 +/- 1.6 and 3.4 +/- 2.0, at 1 and 24 hours, respectively). These data show that the preoperative oral administration of morphine sulfate, regardless of its short half-life, can reduce postoperative consumption of opioids at similar pain levels
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Three-dimensional variations in the lower limb caused by the windlass mechanism
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BACKGROUND: The windlass mechanism was described as the effect caused by the extension of the first metatarsalphalangeal joint (1st MTPJ). Quantify the degrees of movement produced in the leg by means of the Bioval® sensor system, after performing two measurements in the 1st MTPJ, 45° extension and maximum extension. METHODS: Tests-post-test study with just one intervention group, performed in the Clinical Podiatry Area of the Faculty of Nursing, Physiotherapy and Podiatry of the University of Seville. Subjects were included as of age 20, with a value from 0° to 3° valgus, Helbing line, a value from 0° to +5° for the foot postural index, and a localisation axis for the normalised subtalar joint. Subjects with surgical operations of the first ray, fractures and surgical operations in the leg, pathologies in the first ray and rheumatic diseases were excluded. Measurement was performed with the Bioval® system by means of inserting four sensors in the bone structures involved in the windlass mechanism. RESULTS: With the 45° wedge we observed a direct correlation among the variables extension-plantar flexion 1st MTPJ and rotation of the femur. With maximal extension of the 1st MTPJ we obtained a direct relationship between the variable extension of the 1st MTPJ and the variables plantar flexion and prono-supination of the 1st metatarsal as well as with the variables tibia rotation and femur rotation. CONCLUSION: Kinematic analysis suggested that the higher the degree of extension the more movement will be generated. This reduces the level of impact the more distal the structure with respect to the 1st MTPJ, which has an impact on the entire leg. Because of the kinematic system used wasn't suitable, its impact wasn't exactly quantified.
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Localization of regional lymph nodes in melanomas of the head and neck
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Objectives: To study the efficacy of gamma-probe radiolocalization of the first draining (sentinel) lymph node (SLN) in stage NO melanoma of the head an neck and to evaluate its potential role in the staging and treatment of this disease. Design: Gamma-probe radiolocalization, a new alternative to blue-dye lymphatic mapping, uses a scintillation (gamma) probe to identify radiolabeled SLNs. In a consecutive sample clinical trial, gamma-probe radiolocalization of the SLN is compared with lymphoscintigraphy and blue- dye lymphatic mapping. Follow-ups ranged from 1.7 years to 4 years, with a mean follow-up of 2.5 years. Setting: Tertiary and private care teaching hospital. Patients: Between June 1993 and November 1995, 23 patients with stage NO intermediate-thickness melanoma of the head and neck were enrolled in this volunteer sample. Interventions: Twenty-four hours prior to surgery, a radioactive tracer was intradermally injected around the circumference of a primary melanoma. Twelve patients also had blue dye injected just prior to surgical resection. Using a handheld gamma probe, radiolabeled lymph nodes were identified and selectively removed with minimal dissection. In patients with nodes with histologic evidence of metastases, a regional lymphadenectomy was performed. Main Outcome Measures: The successful identification of radiolabeled SLNs, the correlation of SLN radiolabeling to lymphoscintigraphy and blue-dye mapping, and the long-term development of regional metastases. Results: Surgeons successfully resected the radiolabeled SLNs in 22 (96%) of 23 patients. The success rate of blue-dye lymphatic mapping was 8 (75%) of 12 patients and lymphoscintigraphy was 20 (91%) of 22 patients. One hundred percent of blue-stained lymph nodes were radiolabaled. The one patient in whom no SLN could be identified developed regional disease at 17 months. Conclusions: Gamma-probe radiolocalization and resection of the radiolabeled SLN is a simple and reliable method of staging regional lymph nodes and determining the need for elective lymphadenectomy.
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Seasonal variation in the incidence of hip fractures in Emilia-Romagna and Parma
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Though some reports suggest the existence of seasonal changes in hip fracture incidence, with a peak in winter months, other investigations have failed to confirm this finding. In this study we present data on the month-to-month variability of hip fractures in Emilia-Romagna, a region of Northern Italy with a population of approximately four million inhabitants, and in Parma, a province of Emilia-Romagna (population of approximately 400,000). Data on cervical and trochanteric fractures were obtained from two sources: a) records of all operative procedures in the five orthopaedic centres serving the area of the Parma province; and b) a computerised database of all hospital discharges from public and private hospitals of Emilia-Romagna. In both cases, the analysis gave similar results, with no evidence of a consistent seasonal pattern in hip fracture rates
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MDCT evaluation of pancreatic contour variations in head, neck, body and tail: surgical and radiological significance
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OBJECTIVE: The purpose of the study was to investigate the incidence of pancreatic contour variations on multidetector CT (MDCT) for abdominal examinations. METHODS: A retrospective analysis of 700 MDCT scans was performed in patients who underwent triple phase CT abdomen between October 2018 and January 2021. After excluding 176 patients, finally total of 524 patients were included in the study. For simplification, we classified the pancreatic contour variations as classified by Ross et al. and Omeri et al. Pancreatic head-neck variations was classified into Type I-anterior, Type II-posterior and Type III-horizontal variety. Pancreatic body-tail variation was divided into Type Ia-anterior projection; Ib-posterior projection and Type IIa-globular, IIb-lobulated, IIc-tapered, and IId-bifid pancreatic tail. RESULTS: The most common type of variation in the head was Type II (n?=?112, 21.3%) followed by Type III (n?=?37, 7%) and Type I (n?=?21, 4%). The most common type of variation in the body of pancreas was Type Ia (n?=?33, 6.2%) followed by Type Ib (n?=?13, 2.4%). In the tail region of pancreas, the most common variation was Type IIb (n?=?21, 4%) followed by Type IIa (n?=?19, 3.6%). CONCLUSION: Pancreatic contour variations are not very uncommon in daily practice. Knowledge of these variations is important for surgeons, radiologists and avoids misjudgement of normal pancreatic tissue as tumor or lymph node especially on unenhanced or single phase MDCT.
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Running Dose and Risk of Developing Lower-Extremity Osteoarthritis
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Whether or not running leads to the development of knee and hip osteoarthritis has been a much-debated topic and is often a question patients pose to their physicians. Recent literature adds to a growing body of evidence suggesting that lower-dose running may be protective against the development of osteoarthritis, whereas higher-dose running may increase one's risk of developing lower-extremity osteoarthritis. However, running dose remains challenging to define, leading to difficulty in providing firm recommendations to patients regarding the degree of running which may be safe. Furthermore, when counseling patients regarding their risk of developing lower-extremity osteoarthritis secondary to running, clinicians must consider many additional factors, such as the numerous health benefits from running and individual risk factors for developing osteoarthritis.
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Preoperative morphometric differences in the distal femur are based on skeletal size in Japanese patients undergoing total knee arthroplasty
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PURPOSE: The objectives of this study were to measure the morphometric parameters of preoperative distal femurs to determine the differences by diagnosis and gender after accounting for skeletal size. METHODS: One-hundred and seventy-nine Japanese patients who underwent total knee arthroplasty (TKA) (25 males and 154 females) were assessed. The anteroposterior length (AP), mediolateral width (ML), aspect ratio (AR), surgical epicondylar axis (SEA) to posterior condylar axis (PCA) angle, and Whiteside to SEA angle were measured on preoperative computed tomography scans. The AP/ML, AR/ML, SEA/PCA, and Whiteside/PCA relationships were evaluated and compared by patient diagnosis and gender. The results were also compared with the sizes of 10 currently available TKA implants in Japan. RESULTS: The mean AP, ML, AR, SEA/PCA angle, and Whiteside/PCA angle were 58.8 mm, 64.7 mm, 0.91, external rotation (ER) 3.5 degrees , and ER 1.6 degrees , respectively. AP and AR each were significantly correlated with ML (p < 0.001). AP, ML, and AR were not significantly different between patients diagnosed with osteoarthritis and rheumatoid arthritis. AP/ML and AR/ML were significantly correlated within each diagnosis (p < 0.001), but the analysis of covariance showed no significant differences between the diagnoses. AP and ML were significantly longer (p < 0.001) in males (63.6, 72.7 mm) than in females (58.1, 63.4 mm), while AR was smaller in males (0.88 vs. 0.92), with significant correlations for AP/ML (male: p < 0.010, female: p < 0.001) and AR/ML (male: p = 0.002, female: p < 0.001) in each gender. However, the analysis of covariance showed no significant differences between gender in the AP/ML and AR/MR correlations. The AP/ML ratio of our data was similar to the size variations of the 10 TKA implants, but the AR/ML ratio was quite different from almost all the implants. CONCLUSIONS: No differences in preoperative femur morphometry were found between patients with different diagnoses, but the gender difference in AR was related to the difference in skeletal size between males and females. LEVEL OF EVIDENCE: Case series with no comparison groups, Level IV
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Unipolar versus bipolar Exeter hip hemiarthroplasty: a prospective cohort study on 830 consecutive hips in patients with femoral neck fractures
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BACKGROUND: Hip replacement using a hemiarthroplasty (HA) is a common surgical procedure in elderly patients with fractures of the femoral neck. Data from the Swedish Hip Arthroplasty Register suggest that there is a higher risk for revision surgery with the bipolar HA compared with the unipolar HA. PURPOSE: In this study we analysed the reoperation and the dislocation rates for Exeter HAs in patients with a displaced femoral neck fracture, comparing the unipolar and bipolar prosthetic designs. Additionally, we compared the outcome for HAs performed as a primary intervention with those performed secondary to failed internal fixation. METHODS: We studied 830 consecutive Exeter HAs (427 unipolar and 403 bipolar) performed either as a primary operation for a displaced fracture of the femoral neck or as a secondary procedure after failed internal fixation of a fracture of the femoral neck. Cox regression analyses were performed to evaluate factors associated with reoperation and prosthetic dislocation. Age, gender, the surgeon's experience, indication for surgery (primary or secondary) and type of HA (unipolar or bipolar) were tested as independent variables in the model. RESULTS: The prosthetic design (uni- or bipolar) had no influence on the risk for reoperation or dislocation, nor had the age, gender or the surgeon's experience. The secondary HAs were associated with a significantly increased risk for reoperation (HR 2.6, CI 1.5-4.5) or dislocation (HR 3.3, CI 1.4-7.3) compared to the primary HAs. We found no difference in the risk for reoperation or dislocation when comparing Exeter unipolar and bipolar HAs, but special attention is called for to reduce the risk of prosthesis dislocation and reoperation after a secondary HA
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Does concomitant breast surgery add morbidity to abdominoplasty?
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BACKGROUND: Patients undergoing abdominoplasty often have breast concerns, as well as abdominal concerns, because pregnancy is often the etiologic factor in both. Although concerns about combination procedures have been raised recently, the specific issue of combining abdominoplasty and breast surgery has been scarcely addressed. OBJECTIVE: This study was designed to evaluate the morbidity of abdominoplasty alone versus that associated with abdominoplasty combined with breast surgery. METHODS: A retrospective review of 92 consecutive cases performed by a single surgeon in an outpatient setting was performed. Two groups of patients were identified, those who had abdominoplasty alone, and those who had abdominoplasty with associated breast surgery. Breast surgery included augmentation, mastopexy, augmentation/mastopexy, implant removal/exchange, and breast reduction. The groups were compared with respect to morbidity rates, and, additionally, operative time, body mass index, volume of liposate removed (all patients underwent some lipoplasty), and age were evaluated as potential contributing factors in morbidity. RESULTS: No significant difference in morbidity was seen between patients undergoing abdominoplasty alone and patients undergoing abdominoplasty with combined breast surgery. There were no deaths or hospital admissions with either group of patients. CONCLUSIONS: This study provides additional evidence that abdominoplasty and breast surgery can be combined safely.
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Metachondromatosis: more than just multiple osteochondromas
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INTRODUCTION: Metachondromatosis is a rare genetic disease of osteochondroma and enchondroma formation, caused by loss of function of the PTPN11 gene. It is distinct from other similar conditions such as multiple osteochondromas and hereditary multiple exostoses by the distribution and orientation of lesions, and pattern of inheritance. Lesions typically occur in hands, feet, femora, tibiae and the pelvis. Lesions are typically reported to regress in adulthood. METHODS: We reviewed the current literature on metachondromatosis, and present four new cases in a family with metachondromatosis. RESULTS: Long-term follow up data reveal spontaneous regression of lesions by skeletal maturity. Complications may include nerve palsy due to the mass effect of lesions, avascular necrosis of the femoral head and angular deformity of long bones. Histopathological analysis has demonstrated that lesions in metachondromatosis are a mix of osteochondromas and enchondromas; however, one case of chondrosarcoma has been reported. CONCLUSION: Lesions associated with metachondromatosis may cause a variety of complications due to mass effects; however, they are often asymptomatic, cause cosmetic concerns and, importantly, most regress spontaneously. Regular clinical review with selective imaging to monitor for such complications is appropriate, but uncomplicated lesions are unlikely to require surgical intervention.
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Automatic detection of landmarks for the analysis of a reduction of supracondylar fractures of the humerus
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An accurate identification of bone features is required by modern orthopedics to improve patient recovery. The analysis of landmarks enables the planning of a fracture reduction surgery, designing prostheses or fixation devices, and showing deformities accurately. The recognition of these features was previously performed manually. However, this long and tedious process provided insufficient accuracy. In this paper, we propose a geometrically-based algorithm that automatically detects the most significant landmarks of a humerus. By employing contralateral images of the upper limb, a side-to-side study of the landmarks is also conducted to analyze the goodness of supracondylar fracture reductions. We conclude that a reduction can be classified by only considering the detected landmarks. In addition, our technique does not require a prior training, thus becoming a reliable alternative to treat this kind of fractures.
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Subchondral Calcium Phosphate is Ineffective for Bone Marrow Edema Lesions in Adults With Advanced Osteoarthritis
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BACKGROUND: Injury to subchondral bone is associated with knee pain and osteoarthritis (OA). A percutaneous calcium phosphate injection is a novel approach in which subchondral bone marrow edema lesions are percutaneously injected with calcium phosphate. In theory, calcium phosphate provides structural support while it is gradually replaced by bone. However, little clinical evidence supports the efficacy of percutaneous calcium phosphate injections.
QUESTIONS/PURPOSES: We asked: (1) Does percutaneous calcium phosphate injection improve validated patient-reported outcome measures? (2) What proportion of patients experience failure of treatment (defined as a low score on the Tegner Lysholm Knee Scoring Scale)? (3) Is there a relationship between outcome and age, sex, BMI, and preoperative grade of OA?
METHODS: Between September 2012 and January 2014, we treated 33 patients with percutaneous calcium phosphate injections. Twenty-five satisfied our study inclusion criteria; of those, three patients were lost to followup and 22 (88%; 13 men, nine women) with a median age of 53.5 years (range, 38-70 years) were available for retrospective chart review and telephone evaluation at a minimum of 6 months (median, 12 months; range, 6-24 months). Our general indications for this procedure were the presence of subchondral bone marrow edema lesions observed on MR images involving weightbearing regions of the knee associated with localized pain on weightbearing and palpation and failure to respond to conservative therapy (> 3 months). Patients with pain secondary to extensive nondegenerative meniscal tears with a flipped displaced component at the level of bone marrow edema lesions, or with mechanical axis deviation greater than 8degree were excluded. All patients had Grades III or IV chondral lesions (modified Outerbridge grading system for chondromalacia) overlying MRI-identified subchondral bone marrow edema lesions. Percutaneous calcium phosphate injection was performed on the medial tibial condyle (15 patients), the medial femoral condyle (five patients), and the lateral femoral condyle (two patients). Concomitant partial meniscectomy was performed in 18 patients. Preoperative and postoperative scores from the Knee Injury and Arthritis Outcome Score (KOOS) and the Tegner Lysholm Knee Scoring Scale were analyzed.
RESULTS: For patients available for followup, the outcome scores improved after treatment. The KOOS improved from a mean of 39.5 +/- 21.8 to 71.3 +/- 23 (95% CI, 18.6-45.2; p < 0.001) and the Tegner and Lysholm score from 48 +/- 15.1 to 77.5 +/- 20.6 (95% CI, 18.8-40.2; p < 0.001). However, seven of the 22 patients had poor clinical outcomes as assessed by the Tegner Lysholm Knee Scoring Scale, whereas three had fair results, five had good results, and seven had excellent results. The postoperative Tegner Lysholm score was inversely related to the preoperative Kellgren-Lawrence OA grade (R(2) = 0.292; F (1.20) = 9.645; p = 0.006). We found no relationship between outcome scores and age, sex, or BMI.
CONCLUSIONS: In a study that would have been expected to present a best-case analysis (short-term followup, loss to followup of patients with potentially unsatisfactory results, and use of invasive cotreatments including arthroscopic debridements), we found that percutaneous calcium phosphate injection in patients with symptomatic bone marrow edema lesions of the knee and advanced OA yielded poor results in a concerning proportion of our patients. Based on these results, we advise against the use of percutaneous calcium phosphate injections for patients with advanced osteoarthritic changes.
LEVEL OF EVIDENCE: Level IV, therapeutic study.
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Dietary Supplement-Drug Interaction-Induced Serotonin Syndrome Progressing to Acute Compartment Syndrome
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BACKGROUND Dietary supplements have been associated with an increase in emergency intervention as a result of unexpected adverse events. Limited resources and information on significant drug-drug interactions with dietary supplements and prescription medications have contributed to associated complications and unexpected events. We present the case of a patient who consumed multiple prescription medications and dietary supplements which resulted in significant complications. CASE REPORT A 28-year-old man presented to the Emergency Department complaining of severe calf pain after exercising. In addition to his prescription medications, which included sertraline, he also consumed dietary supplements prior to his workout. He developed serotonin syndrome with rhabdomyolysis, which rapidly progressed to acute compartment syndrome. An emergency bilateral four-compartment double-incision lower extremity and forearm fasciotomy was performed, with complete recovery. CONCLUSIONS Drug-drug interactions involving dietary supplements are frequently overlooked in most healthcare settings, especially in the Emergency Department. Health care providers should be cognizant of the potential drug- drug interactions resulting in serotonin syndrome to prevent the progression to acute compartment syndrome and associated complications. Pharmacists play a key role in recognizing drug-dietary supplement interactions and adverse effects.
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Early Experience With Body Contouring Procedures in Patients With End-Stage Renal Disease Awaiting Renal Transplant
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INTRODUCTION: Patients with (end-stage renal disease) ESRD often have many medical comorbidities, posing a higher risk for any surgical procedure. Obese patients are asked to lose weight to become more acceptable renal transplant candidates. Unfortunately, this often results in a panniculus and excess ptotic skin with accompanying functional and aesthetic concerns. We report our early experience in body contouring procedures in patients with ESRD who underwent massive weight loss. METHODS: Three patients with ESRD on the renal transplant waitlist at UC Davis Medical Center opted for elective body contouring procedures before their transplant surgery. All 3 patients were determined by the transplant team to have a high-risk panniculus and were referred to plastic surgery for panniculectomy before renal transplant. Two of the patients had concurrent lower body lift with panniculectomy, and the third patient underwent modified upper body lift with gynecomastia surgery 7 months after the initial panniculectomy. RESULTS: The mean age of the group was 49 (range = 40-62) years, including 1 male and 2 female patients. The average body mass index of the group was 25.6 (range = 22.8-31.8), and all 3 patients had massive weight loss, with a mean BMI drop of 28.1 (range = 24.2-34.9). Postoperatively, only 1 patient experienced minor wound healing delay, which resolved 3 months after surgery with debridement in clinic and local wound care. CONCLUSIONS: In our early experience, we have seen that body contouring surgery in patients with ESRD awaiting renal transplant has an acceptable and manageable risk profile. By making minor modifications to preoperative, intraoperative, and postoperative routines, body contouring procedures can be safely performed in this patient population and can significantly decrease the functional and aesthetic problems caused by excess skin, resulting in improved body image and quality of life.
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Proximal femoral allograft: prognostic indicators
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Between 1972 and 1999, the Orthopedic Oncology Service treated 150 patients with resection and allograft transplantation of the proximal femur. Of the group, 121 patients had malignant tumors of the proximal femur and 29 had benign disorders. Four types of allografts were used: osteoarticular (46 patients), allograft-prosthesis (73), intercalary (20), and allograft-arthrodesis (5). Only 16% of the patients died of disease and 3% required amputation. The overall success rate for the series was 77% with the best results for the allograft prosthetic (82%) and intercalary procedures (87%). Graft infection (15 patients), allograft fracture (26 patients), and local recurrence (11 patients) most markedly affected outcome. With the exception of deaths of disease, no significant outcome difference occurred between the patients with malignant and benign disorders. In conclusion, allograft implantation especially for aggressive or malignant tumors of the proximal femur appears to be a competent system for therapy
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The sex-specific influence of quadriceps weakness on worsening patellofemoral and tibiofemoral cartilage damage: the MOST Study
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OBJECTIVE: Reports on quadriceps weakness as a risk factor for incident and progressive knee osteoarthritis are conflicting, potentially due to differing effects of muscle strength on patellofemoral and tibiofemoral compartments. This study aimed to examine the sex-specific relation of quadriceps strength to worsening patellofemoral and tibiofemoral cartilage damage over 84-months.
METHODS: The Multicenter Osteoarthritis Study (MOST) is a cohort study of individuals with or at risk for knee osteoarthritis. Maximal quadriceps strength was assessed at baseline. Cartilage damage was semi-quantitatively assessed by magnetic resonance images (MRIs) at baseline and 84-month follow-up using the Whole-Organ MRI Score (WORMS). Worsening patellofemoral and tibiofemoral cartilage damage was defined as any WORMS score increase in each subregion within medial and lateral compartments separately. Logistic regression with generalised estimating equations was used to assess the sex-specific relation of quadriceps strength to worsening cartilage damage.
RESULTS: 1,018 participants (mean age 61+/-8 years, and BMI 29.3+/-4.5 kg/m<sup>2</sup> ; 64% female) were included. Quadriceps weakness increased the risk of worsening lateral patellofemoral cartilage damage in women (risk ratio for lowest vs. highest quartile of strength: 1.50 (95% confidence interval: 1.03, 2.20); linear trend p=0.007) but not in men. There was generally no association between quadriceps weakness and worsening cartilage damage in the medial or lateral tibiofemoral compartment for either women or men.
CONCLUSION: Low quadriceps strength increased the risk of worsening cartilage damage in the lateral patellofemoral joint of women suggesting that optimising quadriceps strength may help prevent worsening of structural damage in the patellofemoral joint in women. This article is protected by copyright. All rights reserved.
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Osteochondral lesions of the knee reconstructed with mesenchymal stem cells - results
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BACKGROUND: We present the results of the treatment of osteochondral lesions with the modified sandwich technique with a collagen membrane. The aim of the study was to assess and compare clinical outcomes following the reconstruction of osteochondral lesions in two groups of patients treated with stem cells obtained from blood and with bone marrow concentrate. MATERIAL AND METHODS: The study group comprised 46 patients with MRI-confirmed osteochondral lesions of various aetiology. A group of 21 patients was treated with bone marrow concentrate and 25 patients were treated with mesenchymal cells obtained from peripheral blood. Patients were assessed with the use of KOOS, Lysholm and VAS scales at 6 months, and at 1 and 5 years following the reconstruction. RESULTS: We noted a significant improvement across all scales in 40 patients (86%). A poor outcome was noted in 6 patients. There was a statistically significant superiority of the group treated with stem cells obtained from blood. The analysis of MRI evidence in patients with good and excellent results showed satisfactory reconstruction of the cartilaginous surface and good regenerate integration. At 5 years, a slight decrease in mean clinical assessment scores was seen in both groups of patients. CONCLUSIONS: 1. The modified sandwich reconstruction is an effective modality in the treatment of severe osteochondral lesions of the knee. 2. Slightly poorer outcomes in the group treated with bone marrow concentrate may have resulted from the number of injected stem cells.
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What are the most important risk factors for a patient's developing intraoperative hypothermia?
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Anesthesiologists attempt to maintain perioperative normothermia for surgical patients. We surveyed clinical anesthesiologists and physician researchers and asked them to prioritize risk factors for a patient to develop intraoperative hypothermia. The questionnaire included 41 factors associated with changes in patient temperature identified during a computerized literature search. We asked respondents to estimate the relative importance of each risk factor on a 10-point scale. The survey was mailed to two groups: 1) 180 anesthesiologists (n = 84 respondents) randomly selected from the 1999 American Society of Anesthesiologists Members Directory and to 2) 24 physician researchers (n = 12 respondents) in thermoregulation. Researchers rated the following to be the most important risk factors for hypothermia (in sequence): neonates, a low ambient operating room temperature, burn injuries, general anesthesia with neuraxial anesthesia, geriatric patients, low temperature of the patient before induction, a thin body type, and large blood loss. The results for the clinician group were similar, because the median differences between the groups' results were two or fewer units for all items. The risk factors identified to be most important can now be further evaluated in clinical trials to develop a multivariate predictive tool for calculating a patient's a priori risk for developing hypothermia. IMPLICATIONS: Surveys of clinicians and physician researchers identified what they consider to be the most important risk factors for perioperative hypothermia (e.g., neonates, a low ambient operating room temperature, burn patients, and general anesthesia with neuraxial anesthesia)
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Return to an athletic lifestyle after osteochondral allograft transplantation of the knee
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BACKGROUND: Osteochondral allograft transplantation (OATS) is a treatment option that provides the ability to restore large areas of hyaline cartilage anatomy and structure without donor site morbidity and promising results have been reported in returning patients to some previous activities. However, no study has reported on the durability of return to activity in a setting where it is an occupational requirement.
HYPOTHESIS: Osteochondral allograft transplantation is less successful in returning patients to activity in a population in which physical fitness is a job requirement as opposed to a recreational goal.
STUDY DESIGN: Case series; Level of evidence, 4.
METHODS: A retrospective review was conducted of 38 consecutive OATS procedures performed at a single military institution by 1 of 4 sports medicine fellowship-trained orthopaedic surgeons. All patients were on active duty at the time of the index procedure, and data were collected on demographics, return to duty, Knee Injury and Osteoarthritis Outcome Score (KOOS), and ultimate effect on military duty. Success was defined as the ability to return to the preinjury military occupational specialty (MOS) with no duty-limiting restrictions.
RESULTS: The mean lesion size treated was 487.0 +/- 178.7 mm(2). The overall rate of return to full duty was 28.9% (11/38). An additional 28.9% (11/38) were able to return to limited activity with permanent duty modifications. An alarming 42.1% (16/38) were unable to return to military activity because of their operative knee. When analyzed for return to sport, only 5.3% (2/38) of patients were able to return to their preinjury level. Eleven patients underwent concomitant procedures. Statistical power was maintained by analyzing data in aggregate for cases with versus without concomitant procedures. When the 11 undergoing concomitant procedures were removed from the data set, the rate of return to full activity was 33.3% (9/27), with 22.3% (6/27) returning to limited activity and 44.4% (12/27) unable to return to activity. In this subset, 7.4% (2/27) were able to return to a preinjury level of sport. The KOOS values were significantly higher in the full activity group when compared with the limited and no activity groups (P < .01). Branch of service was a significant predictor of outcome, with Marine Corps and Navy service members more likely to return to full activity compared with Army and Air Force members. A MOS of combat arms was a significant predictor of a poor outcome. All patients demonstrated postoperative healing of their grafts as documented in their medical chart, and no patient in the series required revision for problems with graft incorporation.
CONCLUSION: Osteochondral allograft transplantation for the treatment of large chondral defects in the knee met with disappointing results in an active-duty population and was even less reliable in returning this population to preinjury sport levels. Branch of service and occupational type predicted the return to duty, but other traditional predictors of outcome such as rank and years of service did not. The presence of concomitant procedures did not have an effect on outcome with respect to activity or sport level with the numbers available for analysis.
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Reconstruction of composite leg defects post-war injury
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BACKGROUND: In a high conflict region, war injuries to the distal lower extremity are a major source of large composite defects involving bone and soft tissues. These defects are at the edge between using a single free flap [osteo-(+/-myo) cutaneous] vs double free flap reconstruction (bone and soft tissue). In this paper, we present our experience and outcomes in treating patients with leg war injury reconstructed using a single free fibula flap.
METHODS: Fifteen patients with distal leg composite defects secondary to war injuries were treated between January 2015 and March 2016. All patients were reconstructed using single barrel free fibula osteo-(+/-myo)cutaneous flap where single or double skin paddles were used according to the soft tissue defect requiring coverage.
RESULTS: There were no cases of total or partial flap loss. Complications were limited to three cases including traumatic fibula fracture, venous congestion with negative findings, and residual soft tissue defect requiring coverage. There were no cases of wound dehiscence or infection. Mean follow-up time was 418.8 days. Mean bone healing time was nine months after which patients were allowed full weight bearing.
CONCLUSION: A single barrel free fibula osteo-(+/-myo)cutaneous flap is a valid and reliable tool for reconstruction composite lower extremity defects post-war injury. Adequate planning of fibula flap soft tissue components (skin, muscle) rearrangement is essential for success in such challenging reconstructions.
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The use of benzodiazepines in the aged patient: Clinical and pharmacological considerations
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Benzodiazepines are widely used to treat anxiety and insomnia in elderly patients. The interest of this prescription is discussed in this article. The discussion is based on the pharmacological properties and adverse effects of benzodiazepines in the elderly subjects. The conclusions are that benzodiazepines should be rarely prescribed in elderly people; many patients treated by benzodiazepines should be withdrawn and other therapeutic strategies than benzodiazepines should be considered to treat anxiety and insomnia in the elderly patients
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Prevalence and risk factors for non-vertebral fractures in patients receiving oral glucocorticoids
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Introduction: Glucocorticoids taken orally increase the risk of fractures. It has been noted that a dose as low as 2.5 mg/day increases the risk of vertebral fracture. What is less clear is the possible influence of other risk factors for osteoporosis on the presence of non-vertebral fractures in patients taking glucocorticoids. Patients and Methods: A cross-sectional study, performed on 513 men and women from Spain, who were taking at least 7.5 mg/day of oral prednisone for a minimum of 3 months. A questionnaire was developed, through which information on risk factors was collected. Results: 28.3% of the patients who were taking glucocorticoids at a daily oral dose of 7.5 mg/ day for a minimum of 3 months had suffered at least one non-vertebral fracture. The risk increased with age, the number of months the glucocorticoids had been taken, the presence of falls in the last year and, above all, with a maternal history of hip fracture. Conclusions: In patients taking oral glucocorticoids for over 3 months at doses higher than 7.5 mg/day of prednisone or equivalent, the prevalence of non-vertebral fractures was 28.3%. Some risk factors associated with the presence of these fractures were identified. The duration of glucocorticoid use appears to be more strongly related to the presence of non-vertebral fractures than the daily dose. (copyright) 2012 Kowsar Corp
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The effect of calcitriol on endoplasmic reticulum stress response
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Calcitriol, the active form of vitamin D, is known for its anticancer properties including induction of apoptosis, inhibition of angiogenesis, and metastasis. Calcitriol also increases intracellular calcium triggering apoptosis in a calpain-dependent manner. Since the main storage unit for cellular calcium is endoplasmic reticulum (ER) and a decrease in ER calcium levels might induce ER stress associated cell death, we hypothesized that the cellular actions of calcitriol occur via ER stress. We have evaluated induction of ER stress by assessing BIP expression and XBP-1 splicing in breast cancer cell lines (MCF-7 and MDA-MB-231) and mammary epithelial cell line MCF10A. Our results suggest that cytotoxic concentrations of calcitriol induce an ER stress related response indicated as increased BIP levels and XBP-1 splicing not only in breast cancer cells but also in mammary epithelial cell line. However, vehicle treatment also induced a similar response de-emphasizing the importance of such effect. Calcitriol also failed to activate calpains, further weakening the idea of ER stress as the main mechanism for apoptotic effects of calcitriol. Taken together our results suggest an association between ER stress and vitamin D signaling. However present data indicates that ER stress by itself is not sufficient to explain anticancer properties of calcitriol.
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Circumferential abdominoplasty for sequential treatment after morbid obesity
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BACKGROUND: The severely obese patient, after considerable loss of weight, has large remaining skin folds. Classic transverse abdominoplasties leave bulges in the flanks. This article presents an alternative procedure, circumferential abdominoplasty, which involves the perimeter of the abdomen. METHODS: Average age of the patients was 39.5 years, consisting of 10 females and two males. Incisions were made like those of the classic transverse abdominoplasty, but were extended dorsally without tension on the suture-line. RESULTS: Pre and postoperative aspects revealed the huge impact achieved after resection of the excess panniculus, with improvement of body contour, posture, ambulation, social and psychological integration, hygiene and sexual performance. In some patients, seromas, partial dehiscences, flap infection and atelectasis were immediate complications. Hypertrophic scars and some remaining skin folds were late complications. CONCLUSION: The major disadvantage of the circumferential abdominoplasty is the resulting scar. However, this procedure should be taken into consideration as an option to achieve a more harmonious body contour. Complications are not enough to contraindicate the surgery, because the patients preferred better social and professional integration, as well as behavioral improvement due to enhancement in their self-confidence.
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Healing rate of transverse osteotomies of the olecranon used in reconstruction of distal humerus fractures
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To determine the rate of healing of the osteotomy, we studied the cases of 10 patients who had transverse osteotomy of the olecranon for surgical exposure of a complex distal humerus fracture. The average age of the patients was 48 years, and the average follow-up was 24 months. Nine of the fractures were complex supracondylar/intercondylar fractures. All of the humerus fractures were treated with bone plates and screws, and nine of the osteotomies of the ulna were reconstructed with a large lag screw and tension band wire. Smooth pins and a tension band wire were used in 1 patient with osteoporotic bone. Union of the ulnar osteotomy occurred in 7 patients, and 3 of the patients had a nonunion. The average time of healing of the distal humerus fractures was 3.5 months, and the average time of healing of the ulnar osteotomies was 5.2 months. Six of the patients developed a gap at the osteotomy site by displacement or resorption of it, and two of these progressed to a nonunion. The patients whose ulnar osteotomy healed had an average extension lag of 33 degrees, and the average flexion at their elbows was 122 degrees. The patients who had a fibrous nonunion of the ulnar osteotomy had an average extension lag of 27 degrees at the elbow, and all 3 patients had full flexion of the elbow joint. Because of the nonunion rate of 30% in our patients, we no longer use a transverse osteotomy of the olecranon to expose distal humerus fractures at surgery
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Autologous Chondrocyte Implantation Improves Knee-Specific Functional Outcomes and Health-Related Quality of Life in Adolescent Patients
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BACKGROUND: Existing studies of autologous chondrocyte implantation (ACI) in adolescent patients have primarily reported outcomes that have not been validated for cartilage repair and have failed to include measures of general health or health-related quality of life. PURPOSE: This study assesses validated knee-specific functional outcomes and health-related quality of life after ACI in adolescent patients. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Patients younger than 18 years who underwent ACI between 1999 and 2011 with a minimum 2-year clinical follow-up were identified from a prospectively collected database. A total of 37 patients were included in the analysis. Patient demographic data and pre- and postoperative functional outcomes scores were collected and chondral lesion characteristics were assessed. Primary outcome measures were the International Knee Documentation Committee (IKDC) subjective score and the Knee Injury and Osteoarthritis Outcome Score-Quality of Life (KOOS-QOL) subscore; secondary outcome measures were Short Form-12 (SF-12) and other KOOS subscores. In subgroup analyses, we assessed whether primary outcome results differed based on lesion location, concurrent meniscal allograft transplantation (MAT), and subsequent surgery after ACI. RESULTS: Study patients had a mean 4.6 ± 2.4 years of follow-up, a mean age of 16.7 ± 1.5 years, and a mean lesion size of 4.0 ± 2.2 cm2. The IKDC subjective score improved from 34.9 preoperatively to 64.6 postoperatively (mean improvement, 29.7 points [95% CI, 20.7 to 38.7 points]; P < .001) and the KOOS-QOL subscore improved from 24.3 to 55.3 (mean improvement, 31.0 points [95% CI, 21.3 to 40.7 points]; P < .001) at final follow-up. All other KOOS subscales and the SF-12 physical component score also showed significant improvements ( P < .008 in all cases), whereas the SF-12 mental component score showed no improvement ( P = .464). There was a 37.8% rate of subsequent surgery after ACI (most commonly, chondral debridement [54%], meniscectomy [11%], microfracture [9%], and loose body removal [9%]). Subgroup analysis showed no effect of lesion location, concurrent MAT, or subsequent surgery on improvement in IKDC subjective scores and KOOS-QOL subscores ( P > .05 in all cases). CONCLUSION: ACI is an effective treatment for adolescent patients with symptomatic, large chondral lesions, resulting in significant improvements in knee-specific functional outcome scores and health-related quality of life scores. Although patients must be cautioned on the relatively high reoperation rate (37.8%) and limitations in knee function even after ACI, all patients in this study exhibited improvements over preoperative knee function at the most recent follow-up regardless of ACI location, concurrent MAT, or subsequent surgery.
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T-condylar fractures of the distal humerus in children: report on three cases
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T-condylar fractures of the distal humerus are very rare in children. Because of their rarity, there is a lack of evidence in the literature on the best method to treat such fractures. We report the cases of three paediatric patients with T-condylar fracture of the distal humerus. A high degree of attention is needed in order not to miss the presence of intra-articular fracture, especially in the case of a low supracondylar fracture and in those with a history of high-energy trauma. Anatomic intra-articular fracture reduction is the key to success in managing this rare injury
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Increased serum and synovial levels of midkine are associated with radiological progression in primary knee osteoarthritis patients
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Background: Midkine is a heparin-binding growth factor that is believed to have functional antagonism, although it helps in tissue repair, it can also enhance inflammatory reactions resulting in more tissue injury. Aim of the work: This study aimed to determine serum and synovial fluid (SF) levels of midkine in patients with primary knee osteoarthritis (KOA) and to correlate these levels with patientsâ?? clinical and functional parameters as well as radiological progression of KOA. Patients and methods: Midkine was measured in the serum and 23 SF samples from 52KOA patients as well as in the serum from 20 healthy controls. In the patients, The Western Ontario McMaster scale (WOMAC) was recorded to assess functional status. Graded plain radiographs using Thomas score, and musculoskeletal ultrasound examination (MSUS) of both knees were performed at baseline and after 2 years to assess radiological progression. Results: The patients mean age was 51.5 ± 10.6 years and disease duration was 5.4 ± 4.7 years. Serum levels were significantly increased in KOA patients (80.8 ± 31.8 pg/mL) compared to the controls (65.6 ± 14.8 pg/mL). Patients with elevated serum and SF midkine had twofold increased risk of radiological progression with MSUS (RR2.4 and 2.6 respectively). However, there was no increased risk of radiological progression detected with plain radiography. Conclusion: Osteoarthritis patients have significantly elevated serum and synovial levels of midkine that were correlated with functional status assessed with WOMAC index and obviously associated with radiological progression on MSUS suggesting that it could be a useful marker to reflect OA severity and implies a possible role in the disease pathogenesis.
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Dry Arthroscopy of the Wrist: Surgical Technique
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Purpose: To present a method to perform arthroscopic exploration and instrumentation without infusing any fluid. Methods: The hand is suspended from a bow, with traction on all fingers. Portals are developed as in the classic (wet) wrist arthroscopic procedure except that no water is infused to distend the joint and create the optic cavity. For this procedure the joint must be dried; we use suction through the synoviotomes and neurosurgical patties to accomplish this. Results: We have performed more than 100 wrist arthroscopies using the dry technique without any undue difficulty. Conclusions: The dry technique is as effective as the classic procedure, without the cumbersome leakage of water or the risk of compartment syndrome. It allows some sophisticated arthroscopic procedures to be performed that would be impracticable with water. In addition from these benefits, if open surgery is performed after the arthroscopic exploration then the tissue planes are dry, making surgery much easier. The technique is believed to be inappropriate if thermal probes are used. A learning curve exists. © 2007 American Society for Surgery of the Hand.
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Long-term trends in the incidence of distal forearm fractures
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In this population-based descriptive study covering the 50-year period, 1945-94, there was a statistically significant increase in distal forearm fractures due to severe trauma in both women and men (p < 0.001) but no secular increase in fractures due to moderate trauma (approximately osteoporosis). Since fractures attributed to severe trauma comprised a greater proportion of the total in men (52%) than women (21%), an overall doubling of age-adjusted forearm fracture incidence in men between 1945 and 1994 was statistically significant (p < 0.001), but the 7% increase in age-adjusted rates among women was not (p = 0.90). While the epidemiological pattern of distal forearm fracture incidence in Rochester was similar to that seen elsewhere, the overall incidence rate of 287.4 per 100,000 person-years (95% CI 267.7-307.1) in 1985-94 was less than current rates in Sweden, presumably because the great increase in distal forearm fracture incidence seen, for example, in Malmo between 1953-57 and 1980-81 was not observed in Rochester. The trends in distal forearm fracture rates in Rochester men and women over the past 50 years are broadly consistent with trends in hip fracture incidence in this community over the same time span
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Novel quantitative assessment of metamorphopsia in maculopathy
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PURPOSE: Patients with macular disease often report experiencing metamorphopsia (visual distortion). Although typically measured with Amsler charts, more quantitative assessments of perceived distortion are desirable to effectively monitor the presence, progression, and remediation of visual impairment. METHODS: Participants with binocular (n = 33) and monocular (n = 50) maculopathy across seven disease groups, and control participants (n = 10) with no identifiable retinal disease completed a modified Amsler grid assessment (presented on a computer screen with eye tracking to ensure fixation compliance) and two novel assessments to measure metamorphopsia in the central 5 degrees of visual field. A total of 81% (67/83) of participants completed a hyperacuity task where they aligned eight dots in the shape of a square, and 64% (32/50) of participants with monocular distortion completed a spatial alignment task using dichoptic stimuli. Ten controls completed all tasks. RESULTS: Horizontal and vertical distortion magnitudes were calculated for each of the three assessments. Distortion magnitudes were significantly higher in patients than controls in all assessments. There was no significant difference in magnitude of distortion across different macular diseases. There were no significant correlations between overall magnitude of distortion among any of the three measures and no significant correlations in localized measures of distortion. CONCLUSIONS: Three alternative quantifications of monocular spatial distortion in the central visual field generated uncorrelated estimates of visual distortion. It is therefore unlikely that metamorphopsia is caused solely by retinal displacement, but instead involves additional top-down information, knowledge about the scene, and perhaps, cortical reorganization.
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The relationship between external knee moments and muscle co-activation in subjects with medial knee osteoarthritis
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PURPOSE: External knee moments are reliable to measure knee load but it does not take into account muscle activity. Considering that muscle co-activation increases compressive forces at the knee joint, identifying relationships between muscle co-activations and knee joint load would complement the investigation of the knee loading in subjects with knee osteoarthritis. The purpose of this study was to identify relationships between muscle co-activation and external knee moments during walking in subjects with medial knee osteoarthritis.
METHODS: 19 controls (11 males, aged 56.6+/-5, and BMI 25.2+/-3.3) and 25 subjects with medial knee osteoarthritis (12 males, aged 57.3+/-5.3, and BMI 28.2+/-4) were included in this study. Knee adduction and flexion moments, and co-activation (ratios and sums of quadriceps, hamstring, and gastrocnemius) were assessed during walking and compared between groups. The relationship between knee moments and co-activation was investigated in both groups.
FINDINGS: Subjects with knee osteoarthritis presented a moderate and strong correlation between co-activation (ratios and sums) and knee moments.
INTERPRETATION: Muscle co-activation should be used to measure the contribution of quadriceps, hamstring, and gastrocnemius on knee loading. This information would cooperate to develop a more comprehensive approach of knee loading in this population.
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Intra-articular fractures of the distal femur: a long-term follow-up study of surgically treated patients
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OBJECTIVE: To analyze the long-term (5-25 years) functional and radiologic results of surgically treated intra-articular fractures of the distal femur.
DESIGN: Retrospective study.
SETTING: University hospital.
PATIENTS AND METHODS: Sixty-seven surgically treated consecutive patients with 67 intra-articular distal femoral fractures were included in this study. All fractures were classified according to the AO classification. There were 36 men and 31 women. The mean age at time of accident was 45 years (range 16-94 years). There were 38 patients with isolated fractures and 29 with multiple fractures. Median hospital stay was 23 days (range 12-330 days). A 1-year follow-up was done in all 67 patients. Thirty-two of these patients were also seen for an additional long-term follow-up visit. Functional results of these 32 patients were graded using the Neer and HSS knee scores. Radiologic results were graded using the Ahlback score. Statistical analysis was performed by means of the SPSS data analysis program.
RESULTS: At 1-year follow-up in 40 of 65 patients (62%), the fracture was fully healed, in 22 patients (34%) a fixation callus still existed, and 1 patient had a nonunion. In 2 patients, an arthrodesis was performed. The mean knee range of motion was 111 degrees (range 10-145 degrees). After a mean follow-up of 14 years (range 5-25 years), the mean knee range of motion was 118 degrees (range 10-145 degrees). The Neer score showed good to excellent results in 84% of the patients, and the HSS knee score showed good to excellent results in 75% of the patients. Patients with isolated fractures scored significantly better functionally (Neer/HSS 90 points) compared with those with multiple fractures. The Ahlback score showed a moderate to severe development of secondary osteoarthritis in 36% of all patients. Seventy-two percent of these patients still scored a good to excellent functional result. Seven patients (10%) had local complications in the form of a deep wound infection. Five of these patients were treated successfully, whereas 2 had a chronic infection that subsequently led to an arthrodesis.
CONCLUSION: Surgical treatment of monocondylar and bicondylar femoral fractures shows good long-term results after open reduction and internal fixation. Knee function increases through time, though the range of motion does not increase after 1 year. The presence of secondary osteoarthritis does not mean less favorable functional results in most patients.
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What proportion of patients report long-term pain after total hip or knee replacement for osteoarthritis? A systematic review of prospective studies in unselected patients
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BACKGROUND: Total hip or knee replacement is highly successful when judged by prosthesis-related outcomes. However, some people experience long-term pain. OBJECTIVES: To review published studies in representative populations with total hip or knee replacement for the treatment of osteoarthritis reporting proportions of people by pain intensity. DATA SOURCES: MEDLINE and EMBASE databases searched to January 2011 with no language restrictions. Citations of key articles in ISI Web of Science and reference lists were checked. STUDY ELIGIBILITY CRITERIA, PARTICIPANTS AND INTERVENTIONS: Prospective studies of consecutive, unselected osteoarthritis patients representative of the primary total hip or knee replacement population, with intensities of patient-centred pain measured after 3 months to 5-year follow-up. STUDY APPRAISAL AND SYNTHESIS METHODS: Two authors screened titles and abstracts. Data extracted by one author were checked independently against original articles by a second. For each study, the authors summarised the proportions of people with different severities of pain in the operated joint. RESULTS: Searches identified 1308 articles of which 115 reported patient-centred pain outcomes. Fourteen articles describing 17 cohorts (6 with hip and 11 with knee replacement) presented appropriate data on pain intensity. The proportion of people with an unfavourable long-term pain outcome in studies ranged from about 7% to 23% after hip and 10% to 34% after knee replacement. In the best quality studies, an unfavourable pain outcome was reported in 9% or more of patients after hip and about 20% of patients after knee replacement. LIMITATIONS: Other studies reported mean values of pain outcomes. These and routine clinical studies are potential sources of relevant data. CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS: After hip and knee replacement, a significant proportion of people have painful joints. There is an urgent need to improve general awareness of this possibility and to address determinants of good and bad outcomes
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Prophylaxis of Infective Endocarditis: Prevention of the Perfect Storm
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Despite the availability of endocarditis prophylaxis guidelines for more than five decades, no prospective, randomised trial has ever been conducted to evaluate the efficacy and safety of this practice. This fact, in combination with mixed results from case-control investigations and other factors, has prompted a re-evaluation of the appropriateness of the guidelines. The update provided herein highlights recent revisions in guidelines promulgated by different countries. (copyright) 2007 Elsevier B.V. and the International Society of Chemotherapy
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Does the timing of reoperation influence the risk of graft infection?
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OBJECTIVE: This study compared the incidence and characteristics of graft infection in patients who underwent early vs late revisional surgery of lower extremity arterial bypass grafts. METHODS: Between 1992 and July 2005, 500 revisional procedures were performed on 198 lower extremity bypass grafts. Patients whose revisions were performed <30 days after the primary bypass were in the early revision (ER) group (n = 99), and those done >30 days after bypass were in the late revision (LR) group (n = 99). Infection was defined as cellulitis with graft exposure or purulence in continuity with a graft that required antibiotics and operation for infection control. Mean follow-up was 60 months (range, 2 to 60 months). Groups were compared using Student's t test. RESULTS: The ER group included 66 autogenous and 33 prosthetic grafts. The LR group consisted of 53 autogenous and 46 prosthetic grafts. Of the 500 revisional procedures performed, 17 graft infections occurred (3.4%). Twelve (70.6%) were prosthetic grafts and five (29.4%) were autogenous grafts (P = .004). Defining the infection rate per graft rather than per revisional procedure, the ER group had a significantly higher graft infection rate at 11% (11/99) compared with 6.1% in the LR group (6/99; P = .012). The risk of infection for prosthetic grafts was significantly higher within the ER group at 27.3% (9/33) compared with autogenous grafts at 3.1% (2/66; P = .0001). Infection developed in three vein grafts and three prosthetic grafts in the LR group (P = NS). For prosthetic graft revisions only, infection risk was 27.3% (9/33) in the ER group and 6.5% (3/46) in the LR group (P = .005). The most common cultured pathogen was methicillin resistant Staphylococcus aureus (ER, 6/11 vs LR, 3/6; P = NS). Within the ER group, the prevalence of Pseudomonas aeruginosa was significantly higher at 27.3% (3/11) compared with 0% (0/6) in the LR group (P = .04). CONCLUSIONS: Early revision of lower extremity arterial bypass grafts has a significantly higher risk of graft infection compared with revision >1 month after surgery. Infection will develop in approximately 25% (9/33) of prosthetic grafts that are reoperated on early. If feasible, reoperation should be delayed >1 month for prosthetic grafts needing revision. Endovascular or extra-anatomic interventions should be considered if early revision is mandated in this group
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Randomized phase III trial of bleomycin, vindesine, mitomycin-C, and cisplatin (BEMP) versus cisplatin (P) in disseminated squamous-cell carcinoma of the uterine cervix: an EORTC Gynecological Cancer Cooperative Group study
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PURPOSE: Three previous mitomycin-cisplatin-based chemotherapy trials conducted within the EORTC Gynecological Cancer Cooperative Group (GCCG) in patients with disseminated squamous-cell carcinoma of the uterine cervix (SCCUC) suggested that with such regimens a higher overall response rate and a higher complete response rate could be obtained compared to what might have been expected from cisplatin alone. In that respect the combination of bleomycin, vindesine (Eldesine), mitomycin C and cisplatin (BEMP) was the most promising. In the present study BEMP has been compared with the best single agent, cisplatin (P) in the expectation that improved response rates might translate into a better survival.
PATIENTS AND METHODS: Eligible patients were those with SCCUC and disseminated measurable disease outside previously irradiated areas, aged < or = 75 years, with a WHO performance status < or = 2 and adequate bone marrow, renal, hepatic and pulmonary function, who gave consent according to regulations followed in individual institutions. Patients were randomized to BEMP: E 3 mg/m2 day 1, P 50 mg/m2 day 1, B 15 mg (24-hour infusion) day 2-4 and M 8 mg/m2 (at alternate cycles), or P 50 mg/m2. The first four cycles were given every 3 weeks (induction phase). Subsequent cycles were given every four weeks (maintenance phase), during which B was deleted from BEMP (MEP). Patients failing on P could be treated with BEM. Of the 287 patients entered, 235 were eligible and 201 evaluable for response.
RESULTS: BEMP induced a significantly higher response rate than P (42% vs. 25%, P = 0.006). There was no difference in complete response rate (11% vs. 7%). BEMP was significantly more toxic than P (+/- BEM), both with respect to hematologic and nonhematologic toxicities. After a median follow-up of 6.1 years, survival curves were not significantly different. Median progression-free survival and overall survival were 5.3 and 10.1 months with BEMP and 4.5 and 9.3 months with P (+/- BEM), respectively. In a multivariate analysis of prognostic factors for survival, a lower age (P = 0.003), a lower performance status (P = 0.0001) and a short (<1 year) interval since diagnosis (P = 0.0152) were all associated with an increased risk of dying. For progression-free survival, lower age, prior radiotherapy, locoregional involvement and no prior surgery were associated with a high risk. Treatment with BEMP or P had no significant impact on survival, but for progression-free survival there was a trend in favor of BEMP (P = 0.0893). Adjusting for prognostic factors did not change the effect of treatment.
CONCLUSIONS: Combination chemotherapy with BEMP produces more toxicity and more responses compared with cisplatin alone in patients with disseminated SCCUC, but this does not translate into a better survival. Therefore, in the palliative setting single-agent cisplatin should remain the standard therapy for these patients.
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Medial compartment knee replacement-a Caribbean perspective
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Objective: To show the feasibility of medial compartment knee replacement (MCKR) in the Caribbean population. Design and Methods: Four patients ages 41-59 years received MCKR based on a presentation of medial compartment osteoarthritis. Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score and range of movement of the knee were recorded preoperatively and three months postoperatively. Component sizes and postoperative complications were documented. Results: The four patients (3 females and 1 male) received MCKR of which two were right and two were left. Mean WOMAC scores preoperatively was 66 and postoperatively was 36. Reduction in mean subscores were seen with a reduction in pain from 13.5 to 10.0, stiffness from 4.5 to 3.0 and physical activity from 48 to 23. Improvement of average knee flexion was seen from preoperatively 91.3(degrees) to postoperatively 102.5(degrees). No significant varus or valgus deformity was found preoperatively and postoperatively. No complications were recorded up to three months postoperatively. Conclusion: Medial compartment knee replacement is a suitable option for selected patients with medial compartment disease. However, long term follow-up on outcomes is needed in the Caribbean
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Predictive values of calcaneal quantitative ultrasound and dual energy X ray absorptiometry for non-vertebral fracture in older men: results from the MrOS study (Hong Kong)
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Calcaneal QUS is comparable to DXA in predicting non-vertebral fractures in older Chinese men. INTRODUCTION: The predictive values of calcaneal quantitative ultrasound (QUS) and dual-energy X-ray absorptiometry (DXA) for non-vertebral fractures in older Chinese men were examined. METHODS: One thousand nine hundred twenty-one Chinese men aged 65-92 years had calcaneal QUS and axial DXA bone mineral density (BMD) measurements. The incidence of non-vertebral fractures was documented. Cox regression and receiver operating curve (ROC) analysis were used to examine the associations of QUS parameters and BMD with the incidence of non-vertebral fractures. RESULTS: The duration of follow-up was (mean +/- SD) 6.5 +/- 1.7 years. One hundred thirty-one non-vertebral fractures were recorded, 71 of which were major fragility fractures. Broadband ultrasound attenuation (BUA) and quantitative ultrasound index (QUI) were significantly associated with non-vertebral fractures and major fragility fractures, with age and fracture history-adjusted hazard ratio (95% CI) of 1.23 (1.03, 1.47) and 1.32 (1.10, 1.59) per standard deviation reduction, respectively, for non-vertebral fractures; 1.32 (1.04, 1.68) and 1.43 (1.11, 1.84), respectively, for major fragility fractures. Age and fracture history-adjusted areas under ROC curves of hip or spine BMDs were significantly greater than that of BUA or QUI in predicting major fragility fractures, but not in predicting all non-vertebral fractures. The addition of BUA or QUI had no effect on AUCs of total hip BMD alone. CONCLUSIONS: The ability of calcaneal QUS to predict non-vertebral fractures was comparable to that of axial BMD by DXA, but was inferior to BMD in predicting major fragility fractures in older Chinese men
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Recurrent Desmoid Tumor with Intra-Abdominal Extension After Abdominoplasty: A Rare Presentation
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BACKGROUND Desmoid tumors are fibrous neoplasms that originate from the musculoaponeurotic structures in the body. Abdominal wall desmoid tumors are rare, but they can be locally aggressive, with high incidence of recurrence. These tumors are more common in young, fertile women. They frequently occur during or after pregnancy. CASE REPORT We present the case of a 63-year-old post-menopausal woman with a desmoid tumor of the anterior abdominal wall. She had no relevant family history. During abdominoplasty, an incidental mass was excised and biopsied, and was identified as a desmoid tumor with free margins. One year later, the patient presented with vague abdominal discomfort and feeling of heaviness. An incision was made through the previous abdominoplasty scar to maintain the aesthetic outcome. A large mass, arising from the abdominal wall and extending intra-abdominally, was excised and was determined to be a recurrent desmoid tumor. CONCLUSIONS Recurrent anterior abdominal wall desmoid tumors in post-menopausal women are rare and locally aggressive, with a high risk of recurrence. During abdominal wall repair in abdominoplasty, desmoid tumor filaments might seed deep intra-abdominally. Therefore, it is necessary to take adequate safe margins before abdominal wall repair. Post-operatively, surgeons should keep a high index of suspicion for tumor recurrence.
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Medical care of elderly patients with hip fractures
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Medical morbidity associated with hip fractures in the elderly population is considerable. The all-cause mortality rate is 24% at 12 months. The functional limitations of survivors can be pronounced. As the American population ages, hip fractures will substantially affect the utilization of hospital resources. Several issues, including preoperative clearance and related surgical timing, deep venous thrombosis prophylaxis, delirium, nutrition, and urinary tract management, are important in the care of these patients. A close partnership between orthopedic surgeons and clinicians provides the best strategy of care for the subset of patients with multisystemic complications
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Clinical phenotype and musculoskeletal characteristics of patients with aggrecan deficiency
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Aggrecan is a proteoglycan within the physeal and articular cartilage. Aggrecan deficiency, due to heterozygous mutations in the ACAN gene, causes dominantly inherited short stature and, in many patients, early-onset osteoarthritis and degenerative disc disease. We aimed to further characterize this phenotypic spectrum with an emphasis on musculoskeletal health. Twenty-two individuals from nine families were enrolled. Histories and examinations focused on joint health, gait analysis, joint specific patient reported outcomes, and imaging studies were performed. All patients had dominantly inherited short stature, with the exception of a de novo mutation. Short stature was worse in adults versus children (median height -3.05 SD vs. -2.25 SD). ACAN mutations were not always associated with bone age advancement (median advancement +1.1?years, range 0 to +2?years). Children had subtle disproportionality and clinically silent joint disease-25% with osteochondritis dissecans (OD). Adults had a high prevalence of joint symptomatology-decline in knee function, disability from spinal complaints, and lower physical activity on outcome measures. Osteoarthritis (OA) and OD was detected in 90% of adults, and orthopedic surgeries were reported in 60%. Aggrecan deficiency leads to short stature with progressive decline in height SD, mild skeletal dysplasia, and increasing prevalence of joint pathology over time. Optimal musculoskeletal health and quality of life can be attained with timely identification of pathology and intervention.
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Effects of local anesthesia with bupivacaine plus epinephrine on blepharoptosis and levator palpebrae muscle function
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PURPOSE: To evaluate the effect of local anesthesia with bupivacaine plus epinephrine on the extent of blepharoptosis and levator palpebrae muscle function. METHODS: : In this prospective interventional case series, patients with blepharoptosis who were candidates for aponeurotic surgery were included. After initial preparations in the operating room, a total of 1 ml of a mixture of bupivacaine 0.5% plus epinephrine 1:100,000 were injected into the upper eyelid. The margin reflex distance 1 (MRD1) and the extent of levator muscle function were measured before and 2, 5, 10, and 15 minutes after injection. RESULTS: A total of 36 eyes including 21 men (58.3%) and 15 women (41.7%) with an average age of 41.81 +/- 23.09 (17-83 years) were studied. There were 21 eyes with myogenic and 15 eyes with aponeurotic blepharoptosis. The mean MRD1 was 1.18 +/- 1.06 mm before injection and -0.02 +/- 0.85, 0.52 +/- 0.98, 0.98 +/- 1.05, and 1.02 +/- 1.06 mm at 2, 5, 10, and 15 minutes after injections, respectively. The changes in the MRD1 measurements were statistically significant at all time points. The MRD1 values decreased during the first 2 minutes after injection in 88.8% of eyes, but returned to initial value after 15 minutes in 84.3%. The change in the levator muscle function measurements was statistically significant at 2 and 5 minutes after injections; however, the differences were clinically negligible. CONCLUSIONS: : The local anesthesia of the eyelid with 1 ml bupivacaine plus epinephrine causes a temporary increase of blepharoptosis within the first few minutes with minimal effect on levator muscle function measurements.
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Foot pressure pattern, hindfoot deformities, and their associations with foot pain in individuals with advanced medial knee osteoarthritis
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This survey clarified foot pressure patterns and hindfoot deformities in individuals with advanced knee osteoarthritis (OA) and analyzed their associations with foot pain. Sixty-four individuals with unilateral knee OA who underwent total knee arthroplasty (TKA) were divided into the following groups: no foot pain (n=26; men:women, 4:22; mean age, 73.7 years), foot pain resolved after TKA (12; 2:10; 75.8), and foot pain remaining after TKA (26; 4:22; 74.7). Elderly individuals without pain or deformity in either knee (54; 10:44; 74.3) were controls. Navicular height ratio of the medial longitudinal arch, leg-heel angle, and partial foot pressure as the percentage of body weight (%PFP) were calculated.%PFPs of the medial and lateral heel regions before TKA were significantly lower for the no foot pain group than for controls. One year after TKA, %PFP improved significantly. In the foot pain resolved group, before TKA, the leg-heel angle was significantly higher, and%PFPs of the medial and lateral heel regions and navicular height ratio before TKA were significantly lower than those of controls. One year after TKA, all parameters improved significantly. In the foot pain remaining group, similar abnormalities were observed before TKA; however, significant improvement was only observed for%PFP of the medial heel region 1year after TKA. More than half of the patients with advanced knee OA had foot pain. This improved in approximately one-third, 1year after TKA. Hindfoot deformities are probably associated with foot pain in individuals with advanced knee OA.
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High-risk chief complaints III: abdomen and extremities
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Abdominal and extremity complaints are a frequent reason for presentation to the emergency department. Although these are common complaints, several abdominal and extremity disease entities may be missed or may be subject to delayed diagnosis. This article provides an overview of the diagnosis and management of several high-risk abdominal and extremity complaints, including appendicitis, abdominal aortic aneurysm, mesenteric ischemia, bowel obstruction, retained foreign body, hand and finger lacerations, fractures, and compartment syndrome. Each section focuses primarily on the pitfalls in diagnosis by highlighting the limitations of history, physical examination findings, and diagnostic testing and provides specific risk management strategies. [References: 71]
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Regenerative treatment of osteochondral lesions of distal tibial plafond
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OBJECTIVES: Osteochondral lesions of the distal tibial plafond (OLTP) are rare and far less common than osteochondral lesions of the talus. Literature data do not report clinical records with significant number of cases and follow-up. The aim of our study was to evaluate clinical and MRI outcomes following arthroscopic treatment of distal tibia osteochondral lesions and to report our results with treating these rare lesions. METHODS: Between October 2010 and November 2011, a consecutive series of 27 patients, 15 males and 12 females, were treated arthroscopically with the one-step BMDCT for OLTPs. Exclusion criteria were: age < 18 or > 50 years, patients with severe osteoarthritis (stage III according to Van Dijk classification), presence of kissing lesions of the ankle and patients with rheumatoid or hemophilic arthritis. All patients were evaluated through X-rays; MRI was performed preoperatively and at the final follow-up with MOCART score; clinical evaluation was assessed by AOFAS score at various follow-ups of 12, 24, 36, 60 and 72 months. RESULTS: No complications were observed post-surgery or during the rehabilitation period. The AOFAS score improved from 52.4 preoperatively to 80.6 at the mean final follow-up. All the patients were satisfied with the procedure. In 14 cases the MRI showed a complete filling of the osteochondral defect, in three patients a hypertrophic tissue was observed, and in the other two patients an incomplete repair of the lesion associated with a persistent slight subchondral edema was reported. A topographic study was also performed. CONCLUSIONS: Osteochondral lesions of the distal tibia represent a challenge for the orthopedic surgeon because of their difficulty diagnostic and rarities. The high incidence of good outcome in our series indicates that the one-step BMDCT could be a valid option for the treatment of this rare type of lesions. Further studies with a longer follow-up and more accurate imaging studies are necessary to confirm these results.
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Rothia aeria as a cause of sepsis in a native joint
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Rothia aeria is a recently described Gram-positive rod from the family Micrococcaceae. An elderly woman with rheumatoid arthritis and dental abscesses who was undergoing immunosuppression had R. aeria isolated from synovial fluid. This report characterizes this rare organism and contributes to the literature on its pathogenicity and likely oral source
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Patient selection for skin-tightening procedures
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Noninvasive skin-tightening devices have become increasingly popular over the last decade to improve skin laxity with minimal risk and recovery time. Proper patient selection improves patient outcomes and satisfaction. There are many devices available for tightening including monopolar radiofrequency, bipolar radiofrequency, fractional radiofrequency devices, infrared devices, combined light and bipolar radiofrequency devices, and intense focused ultrasound devices. There have been shortcomings with tightening devices including inconsistent clinical outcomes. The question arises, why are there inconsistent results and variability among patient outcomes? Variability could be related to different devices, treatment protocols, body area treated, and patient selection. Patient age, degree of laxity, history of smoking, ethnicity, body mass index, and individual patient pain threshold could all possibly contribute to patient response to tightening devices. The literature does not elucidate consistently, which variables are the most important in predicting best patient response. Included is a review of the literature discussing skin tightening and patient selection.
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Management of odontoid fractures in the elderly
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Odontoid fractures are frequent in patients over 70 years of age, and in patients over 80 years of age they form the majority of spinal fractures. In a retrospective analysis of 23 geriatric (> 70 years) patients with a fracture of the odontoid, we compared some of the clinical features to a contemporary series of patients younger than 70 years of age. Whereas in the younger patients high-energy trauma accounted for the majority of the fractures, low-energy falls were the underlying cause in 90% of the odontoid fractures in the elderly. In contrast to the younger age group, in elderly patients predominantly type II fractures (95%) were identified. Anterior and posterior displacement were recorded with equal frequency on the first postinjury radiograph in the younger age group, whereas in geriatric patients displacement was mainly posterior. The number of associated injuries was significantly higher in younger patients. There was no difference in the occurrence of neurological deficits (13%) between the two age groups, and neurological compromise was mainly related to posterior dislocation of the odontoid in both groups. The overall complication rate was significantly higher in elderly patients (52.2% vs 32.7%), with an associated in-hospital mortality of 34.8%. Loss of reduction and non-union after non-operative treatment, a complicated postoperative course and complications due to associated injuries accounted primarily for this high complication rate. Elderly patients with a fracture of the odontoid are a high-risk group with a high morbidity and mortality rate. An aggressive diagnostic approach to detect unstable fractures and application of a halo device or early primary internal stabilisation of these fractures is recommended
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Preoperative methylprednisolone increases plasma Pentraxin 3 early after total knee arthroplasty: a randomized, double-blind, placebo-controlled trial
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Preoperative glucocorticoid administration reduces the systemic inflammatory response. Pentraxin 3 (PTX3) is a novel inflammatory marker belonging to the humoral arm of innate immunity exerting a potentially protective host response. This study evaluated PTX3 and other complement marker changes after preoperative methylprednisolone (MP) early after total knee arthroplasty (TKA). Seventy patients were randomized (1 : 1) to preoperative intravenous (i.v.) MP 125 mg (group MP) or isotonic saline i.v. (group C). The outcomes included change in plasma PTX3, mannose-binding lectin (MBL), ficolins (ficolin-1, -2 and -3), complement components (C4 and C3), terminal complement complex (TCC) and C-reactive protein (CRP) concentrations. Blood samples were analysed at baseline and 2, 6, 24 and 48 h after surgery with complete sampling from 63 patients for analyses. MP resulted in an increase in circulating PTX3 compared to saline from baseline to 24 h postoperatively (P<0.001), while MP reduced the systemic inflammatory response (CRP) 24 and 48 h postoperatively (P<0.001). However, the small postoperative changes in MBL, ficolin-1, -2 and -3, C4, C3 and TCC concentrations did not differ between groups (P>0.05). In conclusion, preoperative MP 125 mg increased circulating PTX3 and reduced the general inflammatory response (CRP) early after TKA, but did not affect other complement markers.
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Moderators of Effects of Internet-Delivered Exercise and Pain Coping Skills Training for People With Knee Osteoarthritis: Exploratory Analysis of the IMPACT Randomized Controlled Trial
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BACKGROUND: Internet-delivered exercise, education, and pain coping skills training is effective for people with knee osteoarthritis, yet it is not clear whether this treatment is better suited to particular subgroups of patients.
OBJECTIVE: The aim was to explore demographic and clinical moderators of the effect of an internet-delivered intervention on changes in pain and physical function in people with knee osteoarthritis.
METHODS: Exploratory analysis of data from 148 people with knee osteoarthritis who participated in a randomized controlled trial comparing internet-delivered exercise, education, and pain coping skills training to internet-delivered education alone. Primary outcomes were changes in knee pain while walking (11-point Numerical Rating Scale) and physical function (Western Ontario and McMaster Universities Osteoarthritis Index function subscale) at 3 and 9 months. Separate regression models were fit with moderator variables (age, gender, expectations of outcomes, self-efficacy [pain], education, employment status, pain catastrophizing, body mass index) and study group as covariates, including an interaction between the two.
RESULTS: Participants in the intervention group who were currently employed had significantly greater reductions in pain at 3 months than similar participants in the control group (between-group difference: mean 2.38, 95% CI 1.52-3.23 Numerical Rating Scale units; interaction P=.02). Additionally, within the intervention group, pain at 3 months reduced by mean 0.53 (95% CI 0.28-0.78) Numerical Rating Scale units per unit increase in baseline self-efficacy for managing pain compared to mean 0.11 Numerical Rating Scale units (95% CI -0.13 to 0.35; interaction P=.02) for the control group.
CONCLUSIONS: People who were employed and had higher self-efficacy at baseline were more likely to experience greater improvements in pain at 3 months after an internet-delivered exercise, education, and pain coping skills training program. There was no evidence of a difference in the effect across gender, educational level, expectation of treatment outcome, or across age, body mass index, or tendency to catastrophize pain. Findings support the effectiveness of internet-delivered care for a wide range of people with knee osteoarthritis, but future confirmatory research is needed.
TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12614000243617; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=365812&isReview=true (Archived by WebCite at http://www.webcitation.org/6z466oTPs).
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The use of the McKeever metallic hemiarthroplasy for unicompartmental arthritis
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We reviewed the results of sixty-one McKeever unicompartmental arthroplasties performed by the senior one of us (T. P.) for osteoarthritis of the knee. The average follow-up was five years (range, two to thirteen years). Forty-four (72 per cent) of the arthroplasties were rated as good to excellent. The average postoperative range of motion in these knees was 110 degrees. Six knees were rated as fair and eleven knees, as poor. The poor results appeared to be caused by degenerative arthritis involving ipsilateral compartments that had not been resurfaced with an implant
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Treatment of focal degenerative cartilage defects with polymer-based autologous chondrocyte grafts: four-year clinical results
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INTRODUCTION: Second-generation autologous chondrocyte implantation with scaffolds stabilizing the grafts is a clinically effective procedure for cartilage repair. In this ongoing prospective observational case report study, we evaluated the effectiveness of BioSeed-C, a cell-based cartilage graft based on autologous chondrocytes embedded in fibrin and a stable resorbable polymer scaffold, for the treatment of clinical symptomatic focal degenerative defects of the knee. METHODS: Clinical outcome after 4-year clinical follow-up was assessed in 19 patients with preoperatively radiologically confirmed osteoarthritis and a Kellgren-Lawrence score of 2 or more. Clinical scoring was performed before implantation of the graft and 6, 12, and 48 months after implantation using the Lysholm score, the Knee injury and Osteoarthritis Outcome Score (KOOS), the International Knee Documentation Committee (IKDC) score, and the International Cartilage Repair Society (ICRS) score. Cartilage regeneration and articular resurfacing were assessed by magnetic resonance imaging (MRI) 4 years after implantation of the autologous cartilage graft. RESULTS: Significant improvement (P < 0.05) of the Lysholm and ICRS scores was observed as early as 6 months after implantation of BioSeed-C and remained stable during follow-up. The IKDC score showed significant improvement compared with the preoperative situation at 12 and 48 months (P < 0.05). The KOOS showed significant improvement in the subclasses pain, activities of daily living, and knee-related quality of life 6 months as well as 1 and 4 years after implantation of BioSeed-C in osteoarthritic defects (P < 0.05). MRI analysis showed moderate to complete defect filling with a normal to incidentally hyperintense signal in 16 out of 19 patients treated with BioSeed-C. Two patients without improvement in the clinical and MRI scores received a total knee endoprosthesis after 4 years. CONCLUSIONS: The results show that the good clinical outcome achieved 1 year after implantation of BioSeed-C remains stable over the course of a period of 4 years and suggest that implanting BioSeed-C is a promising treatment option for the repair of focal degenerative defects of the knee
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CSF circulation in subjects with the empty sella syndrome
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The etiology to the empty sella syndrome (ESS) is not known. Increased intracranial pressure (ICP) has been suggested to be one of the possible causes. In the present study the CSF circulation was analyzed in 48 subjects with ESS with gamma cisternography, pneumoencephalography (PEG) and computed tomography (CT). In 80% of the subjects the CSF circulation was retarded with convexity block which was combined with widened CSF transport pathways and basal cisterns. These findings were correlated with the clinical signs and symptoms, most of which seemed to be related to the imparied CSF circulation (i.e. impared memory, balance disturbances, cerebellar ataxia, papilledema, hypertension and pituitary disorders). Headache, psychiatric symptoms, visual field defects and obesity, however, were not related to the impaired CSF circulation. It is concluded that impaired CSF dynamics leading to intermittent increase of ICP has a major impact on the development of the ESS and that most of the patients' complaints are related to this disturbance. Thus it is important to obtain information of the CSF dynamics concurrent with the diagnosis of ESS. For this purpose PEG or CT may be used as the first examination. Moreover, the patient should be examined at least every second year for symptoms and signs of progressive impairments of the CSF circulation.
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Differences in gait pattern parameters between medial and anterior knee pain in patients with osteoarthritis of the knee
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BACKGROUND: Patients with osteoarthritis of the knee have unique spatiotemporal gait alterations. These gait changes have not yet been differentiated according to the location of knee pain. The purpose of this study was to compare the gait patterns of patients with symptomatic knee osteoarthritis that exhibit either anterior or medial joint pain.
METHODS: 240 Patients with knee osteoarthritis were evaluated at one therapy center. Patients were divided into two groups according to the location of greatest pain in their worse knee. Patients underwent a computerized spatiotemporal gait analysis. Differences in gait patterns between the two knee pain locations were also examined within each gender.
FINDINGS: Compared with patients with pain in the anterior knee compartment, those with pain in the medial knee compartment exhibited a significantly slower walking speed (P<0.01), shorter step length (P<0.01), lower single-limb-support phase (P<0.01). These differences are witnessed mainly between the females in each group, whereas males differed only in single-limb-support.
INTERPRETATION: The results of this study suggested underlying gait differences in the nature of medial and anterior knee pain. Furthermore, gender differences in gait may exist between patients with medial knee pain compared to patients with anterior knee pain.
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Change in brow position after upper blepharoplasty or levator advancement
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Brow position after blepharoplasty is somewhat controversial. Some authors insist that brow position remains unchanged after surgery. On the other hand, there is also an opinion that brow position changes after surgery.We evaluate the influence of upper blepharoplasty or correction of ptosis on brow position in East Asians. Sixty patients (120 eyes) who underwent upper blepharoplasty or levator advancement were evaluated for change in brow position. Marginal reflex distance 1, brow height from medial canthus, upper eyelid margin on midpupillary level, lateral canthus, and brow height from the center of the pupil were measured before surgery and 6 months after surgery. The distance between the upper lid margin and the brow was shortened after upper blepharoplasty or levator advancement, which could cause brow depression. Change in brow height was greater after levator advancement than after blepharoplasty. These findings might be helpful for the prediction of brow position after surgery. Our study also implies that the possibility of a change in postoperative brow position change should be explained to patients before surgery, particularly ptosis patients.
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The epidemiology of osteosarcoma
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Osteosarcoma derives from primitive bone-forming mesenchymal cells and is the most common primary bone malignancy. The incidence rates and 95% confidence intervals of osteosarcoma for all races and both sexes are 4.0 (3.5-4.6) for the range 0-14 years and 5.0 (4.6-5.6) for the range 0-19 years per year per million persons. Among childhood cancers, osteosarcoma occurs eighth in general incidence and in the following order: leukemia (30%), brain and other nervous system cancers (22.3%), neuroblastoma (7.3%), Wilms tumor (5.6%), Non-Hodgkin lymphoma (4.5%), rhabdomyosarcoma (3.1%), retinoblastoma (2.8%), osteosarcoma (2.4%), and Ewing sarcoma (1.4%). The incidence rates of childhood and adolescent osteosarcoma with 95% confidence intervals areas follows: Blacks, 6.8/year/million; Hispanics, 6.5/year/million; and Caucasians, 4.6/year/million. Osteosarcoma has a bimodal age distribution, having the first peak during adolescence and the second peak in older adulthood. The first peak is in the 10-14-year-old age group, coinciding with the pubertal growth spurt. This suggests a close relationship between the adolescent growth spurt and osteosarcoma. The second osteosarcoma peak is in adults older than 65 years of age; it is more likely to represent a second malignancy, frequently related to Paget's disease. The incidence of osteosarcoma has always been considered to be higher in males than in females, occurring at a rate of 5.4 per million persons per year in males vs. 4.0 per million in females, with a higher incidence in blacks (6.8 per million persons per year) and Hispanics (6.5 per million), than in whites (4.6 per million). Osteosarcoma commonly occurs in the long bones of the extremities near the metaphyseal growth plates. The most common sites are the femur (42%, with 75% of tumors in the distal femur), the tibia (19%, with 80% of tumors in the proximal tibia), and the humerus (10%, with 90% of tumors in the proximal humerus). Other likely locations are the skull or jaw (8%) and the pelvis (8%). Cancer deaths due to bone and joint malignant neoplasms represent 8.9% of all childhood and adolescent cancer deaths. Death rates for osteosarcoma have been declining by about 1.3% per year. The overall 5-year survival rate for osteosarcoma is 68%, without significant gender difference. The age of the patient is correlated with the survival, with the poorest survival among older patients. Complete surgical excision is important to ensure an optimum outcome. Tumor staging, presence of metastases, local recurrence, chemotherapy regimen, anatomic location, size of the tumor, and percentage of tumor cells destroyed after neoadjuvant chemotherapy have effects on the outcome.
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Bone mineral density at the hip in Norwegian women and men--prevalence of osteoporosis depends on chosen references: the Tromso Study
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This study describes bone mineral density (BMD) and the prevalence of osteoporosis in women and men between 30-89 years in an unselected population. BMD was measured in g/cm(2) at total hip and femoral neck by dual-energy-X-ray absorptiometry in 3,094 women and 2,132 men in the 2001 Tromso Study. BMD levels were significantly explained by age and declined progressively in both sexes from middle into old age, with highest decline in women. With osteoporosis defined as a T-score of two and a half standard deviation below the young adult mean BMD, the prevalence at the total hip in subjects above 70 years was 6.9% in men and 15.3% in women, respectively, using the Lunar reference material for T-score calculations. The prevalence increased significantly to 7.3% in men and 19.5% in women, when T-scores were calculated on basis of the young adult mean BMD (age group 30-39 years) in the study population. At the femoral neck, prevalence of osteoporosis increased from 13.5 to 18.5% in men, and from 20.4 to 35.2% in women above 70 years, respectively, depending on how T-scores were calculated. The study highlights the challenges with fixed diagnostic levels when measuring normally distributed physiologic parameters. Although BMD only partly explains fracture risk, future studies should evaluate which calculations give optimal fracture prediction
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A constrained liner cemented into a secure cementless acetabular shell
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BACKGROUND: Constrained acetabular components have been used to treat hips with recurrent instability following total hip arthroplasty and hips that demonstrate instability during revision surgery. In such hips, when a secure cementless acetabular shell is present, the surgeon can cement a constrained liner into the existing shell. The purpose of this study was to evaluate the clinical and radiographic outcome of this technique with use of a tripolar constrained liner that was cemented into a well-fixed cementless acetabular shell. METHODS: Between 1988 and 2000, constrained liners were cemented into thirty-one well-fixed cementless acetabular shells at three centers. The average age of the patients at the time of the index surgery was 72.1 years, and the indications for the procedure were recurrent hip instability in sixteen hips and intraoperative instability in fifteen hips. The patients were evaluated with respect to the clinical outcome and radiographic evidence of shell loosening and osteolysis. RESULTS: At an average duration of follow-up of 3.9 years, twenty-nine liners (94%) were securely fixed in the cementless shells and two constrained liners had failed. One liner failed because it separated from the cement, and one failed because of fracture of the capturing mechanism. Both hips were successfully revised with another cemented tripolar constrained liner. No acetabular component demonstrated radiographic evidence of progressive loosening or osteolysis. CONCLUSIONS: A constrained tripolar liner cemented into a secure, well-positioned cementless acetabular shell provides stability and durability at short-term follow-up. Careful attention to the preparation of the liner, the sizing of the component, and the cementing technique are likely to reduce the failure of this construct, which can be used for difficult cases of total hip instability
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Elective implant removal in symptomatic patients after internal fixation of proximal humerus fractures improves clinical outcome
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Background: Operative treatment is the standard for severely displaced proximal humerus fractures, but functional impairment can persist. Retaining of the implant can be a reason and in other fracture situations has proved to ameliorate patient satisfaction. The aim of this study was to analyse the functional outcome after locking plate removal in proximal humerus fractures. Methods: In a two-year period, all symptomatic patients with plate osteosynthesis for proximal humerus fracture and hardware removal were retrospectively evaluated clinically and radiologically pre- and post-implant removal. Evaluation included Constant score, height of plate position and possible impingement, as well as intraoperative complications. Results: Twenty patients met the inclusion criteria. The mean age was 56 ± 12 years. The plates were placed 6.9 ± 3 mm distal to the greater tubercle. The operation was performed in 35 ± 10 min and no intraoperative complications were reported. The Constant score improved significantly after implant removal from 71 to 76 (p = 0.008). Conclusion: Symptomatic patients after locked plate osteosynthesis for proximal humerus fractures showed statistically significant improvement of the Constant score after implant removal.
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Quadriceps strength and the time course of functional recovery after total knee arthroplasty
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STUDY DESIGN: Prospective study with repeated measures. OBJECTIVES: The overall goal of this investigation was to describe the time course of recovery of impairments and function after total knee arthroplasty (TKA), as well as to provide direction for rehabilitation efforts. We hypothesized that quadriceps strength would be more strongly correlated with functional performance than knee flexion range of motion (ROM) or pain at all time periods studied before and after TKA. BACKGROUND: TKA is a very common surgery, but very little is known regarding the influence of impairments on functional limitations in this population. METHODS AND MEASURES: Forty subjects who underwent unilateral TKA followed by rehabilitation, including 6 weeks of outpatient physical therapy, were studied. Testing occurred at 5 time periods: preoperatively, and at 1, 2, 3, and 6 months after surgery. Test measures included quadriceps strength, knee ROM, timed up-and-go test, timed stair-climbing test, bodily pain, and general health and knee function questionnaires. RESULTS: Subjects experienced significant worsening of knee ROM, quadriceps strength, and performance on functional tests 1 month after surgery. Quadriceps strength went through the greatest decline of all the physical measures assessed and never matched the strength of the uninvolved limb. All measures underwent significant improvements following the 1-month test. Quadriceps strength was the most highly correlated measure associated with functional performance at all testing sessions. CONCLUSIONS: Functional measures underwent an expected decline early after TKA, but recovery was more rapid than anticipated and long-term outcomes were better than previously reported in the literature. The high correlation between quadriceps strength and functional performance suggests that improved postoperative quadriceps strengthening could be important to enhance the potential benefits of TKA
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A randomized, controlled multicenter study evaluating focused ultrasound treatment for fat reduction in the flanks
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Introduction: Energy-based cosmetic devices offer an in-office treatment option, with minimal downtime, to non-invasively remove unwanted fat. We evaluated focused, pulsed ultrasound treatment to randomized flanks, compared to corresponding non-treated contralateral flanks. Material and Methods: Subjects were enrolled at three sites for a series of focused ultrasound treatments to a single flank, with the contralateral flank remaining untreated throughout the study. Success criteria included measureable fat thickness reduction on ultrasound imaging in the treated areas at 16Â weeks after the final treatment session, and correct identification of the post-treatment photo and treated flank in at least 80% of evaluated images, as assessed by two blinded evaluators. Results: The post-treatment flank photo and treated flank side were correctly identified in 82% and 93% of cases, respectively. All study subjects demonstrated significant fat reduction in their treated area, as measured by ultrasound and skin caliper. Subjects expressed a high satisfaction from treatment outcomes. There were no complications with treatment. Conclusion: A series of three ultrasound treatments resulted in significant fat reduction in treated flanks. Although treatment results are more modest than with liposuction, non-invasive ultrasound treatment may provide an attractive alternative for patients seeking an in-office, nonsurgical procedure for fat reduction.
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Anterior knee pain in the young athlete: diagnosis and treatment
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The underlying etiology of anterior knee pain has been extensively studied. Despite many possible causes, often times the diagnosis is elusive. The most common causes in the young athlete are osteosynchondroses, patellar peritendinitis and tendinosis, synovial impingement, malalignment, and patellar instability. Less common causes are osteochondritis dissecans and tumors. It is always important to rule out underlying hip pathology and infections. When a diagnosis cannot be established, the patient is usually labeled as having idiopathic anterior knee pain. A careful history and physical examination can point to the correct diagnosis in the majority of cases. For most of these conditions, treatment is typically nonoperative with surgery reserved for refractory pain for an established diagnosis.
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Repeat liposuction-curettage treatment of axillary hyperhidrosis is safe and effective
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BACKGROUND: Liposuction-curettage (LC) is an effective surgical therapy option for axillary hyperhidrosis, with less scarring compared with radical excision of axillary skin. Although this method has proven to be effective, the treatment of nonresponders to minimally invasive surgery has not been previously defined. Whether these patients benefit from a second surgical procedure has not been evaluated so far. OBJECTIVES: To investigate efficacy and side-effects of a second LC with an aggressive rasping cannula in patients with insufficient prior surgery. METHODS: Nineteen nonresponders to prior LC (13 female and six male) underwent a second LC with a rasping cannula. Gravimetry was performed before and 8 months after surgery. Side-effects, patient satisfaction, the surgeons' intraoperative evaluation and the Vancouver Scar Scale (VSS) before and after surgery were documented. RESULTS: Sweat rates showed a reduction of 69% in 17 (89%) patients. Two patients (11%) did not respond to surgery. Eighty-four per cent of all patients were completely satisfied or satisfied with postoperative results. No severe side-effects were observed. The surgeon reported slightly increased difficulties during dissection of dermis from subcutaneous fat in three patients. Assessment of scars showed an excellent aesthetic outcome (mean VSS 0.79 before vs. 1.1 after surgery). CONCLUSIONS: LC using an aggressive cannula is an effective therapy option for patients with insufficient response to prior LC surgery, with a low risk of side-effects.
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