tag:blogger.com,1999:blog-61551321922358180102024-03-19T00:26:54.571-07:00Orthopaedic KnowledgeThis blog is dedicated to my students and orthopaedic residents who are eager to improve their orthopaedic knowledge.Dr. K.M. Liauhttp://www.blogger.com/profile/05374546719213574530noreply@blogger.comBlogger81125tag:blogger.com,1999:blog-6155132192235818010.post-1079101557151970182009-10-12T03:10:00.000-07:002009-10-12T03:12:04.585-07:00Osteomyelitis of Long Bones<div class="post-header"> <h1><span style="font-size:100%;">Osteomyelitis is defined as infection in bone. Osteomyelitis in long bones includes infections that differ from one another with regard to duration, etiology, pathogenesis, extent of bone involvement, and type of patient (which can be an infant, child, adult, or compromised or uncompromised host).</span></h1></div><!--end meta--> <p><strong>Etiology</strong><br />In hematogenous osteomyelitis, a single pathogenic organism is almost always recovered from the bone. In infants, Staphylococcus aureus, Streptococcus agalactiae, and Escherichia coli are most frequently isolated from blood or bone.</p> <p>However, in children over one year of age, Staphylococcus aureus, Streptococcus pyogenes, and Haemophilus influenzae are most commonly isolated. The incidence of Haemophilus influenza infection decreases after the age of four years.</p> <p>In adults, Staphylococcus aureus is the most common organism isolated. Multiple organisms are usually isolated from bone infected as a result of direct inoculation or contiguous focus infection. Staphylococcus aureus remains the most commonly isolated pathogen. However, gram-negative bacilli and anaerobic organisms are also frequently isolated.</p> <p><strong>Pathogenesis</strong></p> <p><strong>1. Source of Infection</strong></p> <p>Osteomyelitis can be caused by hematogenous spread, direct inoculation of microorganisms into bone, or a contiguous focus of infection. Hematogenous osteomyelitis usually involves the metaphysis of long bones in children because long bones of children have very active metabolic rates. The most common causes of direct-inoculation osteomyelitis are penetrating injuries and surgical contamination. Contiguous osteomyelitis commonly occurs in patients with severe vascular disease.</p> <p><strong>2. Host Factors</strong></p> <p>Host factors are primarily involved in the containment of the infection once it has been introduced adjacent to or into the bone. Host factors may predispose individuals to the development of osteomyelitis. Host deficiencies that lead to bacteremia favor the development of hematogenous osteomyelitis.</p> <p>Host deficiencies that are involved in the direct inoculation of organisms and/or contiguous spread of infection from an adjacent area of soft-tissue infection are primarily involved in the lack of containment of the initial infection.</p> <p>Some patients have an unusual susceptibility to acute skeletal infections when they have sickle cell anemia, chronic granulomatous disease, or diabetes mellitus. Many systemic and local factors influence the ability of the host to elicit an effective response to infection and treatment</p> <p><strong>Pathology</strong></p> <p><strong>1. Acute Osteomyelitis</strong></p> <p>Acute osteomyelitis presents as inflammation accompanied by edema, vascular congestion, and small-vessel thrombosis. In early acute disease, the vascular supply to the bone is decreased by infection extending into the surrounding soft tissue. When both the medullary and the periosteal blood supplies are compromised, large areas of dead bone (sequestra) may be formed in chronic phase.</p> <p>However, if treated promptly and aggressively with antibiotics and possibly with surgery, acute osteomyelitis can be arrested before dead bone presents.</p> <p><strong>2. Chronic Osteomyelitis</strong></p> <p>Pathologic features of chronic osteomyelitis are the presence of necrotic bone (sequestrum), the formation of new bone (involucrum), and the exudation of polymorphonuclear leukocytes joined by large numbers of lymphocytes, histiocytes, and occasionally plasma cells.</p> <p>New bone forms from the surviving fragments of periosteum and endosteum in the region of the infection. It forms an encasing sheath of live bone, known as an involucrum, surrounding the dead bone under the periosteum.</p> <p>The involucrum is irregular and is often perforated by openings through which pus may track into the surrounding soft tissues and eventually drain to the skin surfaces, forming a chronic sinus. The involucrum may gradually increase in density and thickness to form part or all of a new diaphysis.</p> <p>New bone increases in amount and density for weeks or months, according to the size of the bone and the extent and duration of the infection. Endosteal new bone may proliferate and obstruct the medullary canal. After host defense or operative removal of the sequestrum, the remaining cavity may fill with new bone, especially in children. However, in adults, the cavity may persist or the space may be filled with fibrous tissue, which may connect with the skin surface by means of a sinus tract.</p> <p style="text-align: center;"> </p><div id="attachment_4565" class="wp-caption aligncenter" style="width: 1034px;"><img class="size-large wp-image-4565" src="http://usmorthopedic.blog.com/files/2009/07/picture32-1024x771.png" alt="Views of the left wrist show a lobulated osteolytic lesion with well-defined borders and surrounding sclerosis in the distal radius. There were minimal expansion, mild periosteal reaction and soft tissue swelling." width="1024" height="771" /><p class="wp-caption-text">Views of the left wrist show a lobulated osteolytic lesion with well-defined borders and surrounding sclerosis in the distal radius. There were minimal expansion, mild periosteal reaction and soft tissue swelling.</p></div> <div id="attachment_4566" class="wp-caption aligncenter" style="width: 1009px;"><img class="size-large wp-image-4566" src="http://usmorthopedic.blog.com/files/2009/07/picture45-999x1024.png" alt="The red box encircles the sequestrum at lower part of tibia, the piece of necrotic tissue of tibial bone, that has become separated from the tibia" width="999" height="1024" /><p class="wp-caption-text">The red box encircles the sequestrum at lower part of tibia, the piece of necrotic tissue of tibial bone, that has become separated from the tibia</p></div> <p><strong>Signs and Symptoms</strong></p> <p>Children with hematogenous osteomyelitis may present with acute signs of infection including fever, irritability, lethargy, and local signs of inflammation. Children with hematogenous osteomyelitis usually have noninfected soft tissue enveloping the infected bone and are capable of mounting an effective response to the infection. The joint is usually spared from infection unless the metaphysis is intracapsular, as is found in the proximal part of the radius, humerus, or femur.</p> <p>Adults with primary or recurrent hematogenous osteomyelitis usually present with vague symptoms consisting of nonspecific pain and low-grade fever of one to three months’ duration. However, acute clinical presentations with fever, chills, swelling, and erythema over the involved bone or bones are occasionally seen.</p> <p>The source of bacteremia may be a trivial skin infection or a more serious infection such as acute or subacute bacterial endocarditis. Hematogenous osteomyelitis that involves either long bones or vertebrae is an important complication of injection drug abuse. Patients with contiguous osteomyelitis often present with localized bone and joint pain, erythema, swelling, and drainage around the area of trauma, surgery, or wound infection.</p> <p>Signs of bacteremia such as fever, chills, and night sweats may be present in the acute phase of osteomyelitis but are not seen in the chronic phase. Both hematogenous and contiguous focus osteomyelitis can progress to a chronic condition. Local bone loss, sequestrum formation, and bone sclerosis are common. Persistent drainage and/or sinus tracts are often found adjacent to the area of infection. The patient usually presents with chronic pain and drainage. If fever is present, it is low grade.</p>Dr. K.M. Liauhttp://www.blogger.com/profile/05374546719213574530noreply@blogger.com5tag:blogger.com,1999:blog-6155132192235818010.post-67199881723013470892009-10-12T03:04:00.001-07:002009-10-12T03:04:29.412-07:00External Fixation<p class="MsoNormal"><span>Case summary</span></p> <p class="MsoNormal">36 y/o, Malay gentleman</p> <p class="MsoNormal">Patient drove car with around 60km/h and was crashed with lorry from front. He was loss of consciousness and was sent to emergency department by ambulance. Multiple fractures and bleeding were noted. There was an open fracture of right leg, grade 3C in Gustillo classification. X-ray of the right leg was done.</p> <p class="MsoNormal">Plain x-ray of the right leg.</p> <p class="MsoNormal"><a rel="attachment wp-att-6702" href="http://usmorthopedic.blog.com/2009/10/12/external-fixation-2/pa060269/" mce_href="http://usmorthopedic.blog.com/2009/10/12/external-fixation-2/pa060269/"><img class="aligncenter size-medium wp-image-6702" src="http://usmorthopedic.blog.com/files/2009/10/pa060269-300x219.jpg" mce_src="http://usmorthopedic.blog.com/files/2009/10/pa060269-300x219.jpg" alt="AP view of tibial plateau #" width="300" height="219" /></a>This is an anterior-posterior view of distal 1/3 of right knee and proximal 2/3 of right leg. The x-ray showed that there is segmented fracture of tibial plateau, both condyles are split and the tibial shaft is wedged between them, there is intraarticular extended and was type 5 in Schatzker classification. There is no shortening, angulation or rotation of the bone was seen in this view.</p> <p class="MsoNormal"> </p><p class="MsoNormal"><a rel="attachment wp-att-6705" href="http://usmorthopedic.blog.com/2009/10/12/external-fixation-2/pa060272/" mce_href="http://usmorthopedic.blog.com/2009/10/12/external-fixation-2/pa060272/"><img class="aligncenter size-medium wp-image-6705" src="http://usmorthopedic.blog.com/files/2009/10/pa060272-300x217.jpg" mce_src="http://usmorthopedic.blog.com/files/2009/10/pa060272-300x217.jpg" alt="Lateral view of tibial plateau #" width="300" height="217" /></a>This is a lateral view of distal 1/3 of right knee and proximal 2/3 of right leg. The x-ray showed that there is segmented fracture of tibial plateau, There is 10 degree angulation of the tibial bone.There is no shortening or rotation of the bone was seen in this view.</p> <p class="MsoNormal"> </p><p class="MsoNormal">External fixation was done.</p> <p class="MsoNormal"><a rel="attachment wp-att-6703" href="http://usmorthopedic.blog.com/2009/10/12/external-fixation-2/pa060270/" mce_href="http://usmorthopedic.blog.com/2009/10/12/external-fixation-2/pa060270/"><img class="aligncenter size-medium wp-image-6703" src="http://usmorthopedic.blog.com/files/2009/10/pa060270-300x203.jpg" mce_src="http://usmorthopedic.blog.com/files/2009/10/pa060270-300x203.jpg" alt="AP view of x-ray after external fixation" width="300" height="203" /></a>This is an anterior-posterior view of distal 1/3 of right knee and proximal 2/3 of right leg. The x-ray showed that there is a interfragmentary screw fixing the fragmented tibial bone. Two pins were passed though th femur bone and another two pins were passed through the tibial bone. There is no angulation, shortening or rotation seen in this view.</p> <p class="MsoNormal"><a rel="attachment wp-att-6704" href="http://usmorthopedic.blog.com/2009/10/12/external-fixation-2/pa060271/" mce_href="http://usmorthopedic.blog.com/2009/10/12/external-fixation-2/pa060271/"><img class="aligncenter size-medium wp-image-6704" src="http://usmorthopedic.blog.com/files/2009/10/pa060271-300x206.jpg" mce_src="http://usmorthopedic.blog.com/files/2009/10/pa060271-300x206.jpg" alt="lateral view of x-ray after external fixation" width="300" height="206" /></a>This is a lateral view of distal 1/3 of right knee and proximal 2/3 of right leg. The x-ray showed that there is an interfragmentary screw on the fragments. there is no angulation, shortening and rotation of the bone was seen in this view.</p> <p class="MsoNormal"> </p><p class="MsoNormal"> </p> <p style="text-align: left; padding-left: 450px;" mce_style="text-align: left;padding-left: 450px"> </p><p style="text-align: left; padding-left: 450px;" mce_style="text-align: left;padding-left: 450px"> </p><p style="text-align: left; padding-left: 450px;" mce_style="text-align: left;padding-left: 450px"> </p><p style="text-align: left; padding-left: 450px;" mce_style="text-align: left;padding-left: 450px"> </p><p style="text-align: left; padding-left: 450px;" mce_style="text-align: left;padding-left: 450px"> </p><p style="text-align: left; padding-left: 450px;" mce_style="text-align: left;padding-left: 450px"> </p><p style="text-align: left; padding-left: 450px;" mce_style="text-align: left;padding-left: 450px"> </p><p style="text-align: left; padding-left: 450px;" mce_style="text-align: left;padding-left: 450px"> </p><p style="text-align: left; padding-left: 450px;" mce_style="text-align: left;padding-left: 450px"> </p><p style="text-align: left; padding-left: 450px;" mce_style="text-align: left;padding-left: 450px"> </p><p style="text-align: left; padding-left: 450px;" mce_style="text-align: left;padding-left: 450px"> </p><p style="text-align: left; padding-left: 450px;" mce_style="text-align: left;padding-left: 450px"> </p><p style="text-align: left; padding-left: 450px;" mce_style="text-align: left;padding-left: 450px"> </p><p style="text-align: left; padding-left: 450px;" mce_style="text-align: left;padding-left: 450px"> </p><p style="text-align: left; padding-left: 450px;" mce_style="text-align: left;padding-left: 450px"> </p><p style="text-align: left; padding-left: 450px;" mce_style="text-align: left;padding-left: 450px"> </p><p style="text-align: left; padding-left: 450px;" mce_style="text-align: left;padding-left: 450px"> </p><p style="text-align: left; padding-left: 450px;" mce_style="text-align: left;padding-left: 450px"> </p><p style="text-align: left; padding-left: 450px;" mce_style="text-align: left;padding-left: 450px"> </p><p style="text-align: left; padding-left: 450px;" mce_style="text-align: left;padding-left: 450px"> </p><p style="text-align: left; padding-left: 450px;" mce_style="text-align: left;padding-left: 450px"> </p><p style="text-align: left; padding-left: 450px;" mce_style="text-align: left;padding-left: 450px"> </p><p style="text-align: left; padding-left: 450px;" mce_style="text-align: left;padding-left: 450px"> </p><p style="text-align: left; padding-left: 450px;" mce_style="text-align: left;padding-left: 450px"> </p><p style="text-align: left; padding-left: 450px;" mce_style="text-align: left;padding-left: 450px"> </p><p style="text-align: left; padding-left: 450px;" mce_style="text-align: left;padding-left: 450px"> </p><p style="text-align: left; padding-left: 450px;" mce_style="text-align: left;padding-left: 450px"> </p><p style="text-align: left; padding-left: 450px;" mce_style="text-align: left;padding-left: 450px"> </p><p style="text-align: left; padding-left: 450px;" mce_style="text-align: left;padding-left: 450px"> </p><p style="text-align: left; padding-left: 450px;" mce_style="text-align: left;padding-left: 450px"> </p><p style="text-align: left; padding-left: 450px;" mce_style="text-align: left;padding-left: 450px"> </p><p style="text-align: left; padding-left: 450px;" mce_style="text-align: left;padding-left: 450px"> </p><p style="text-align: left; padding-left: 450px;" mce_style="text-align: left;padding-left: 450px"> </p><p style="text-align: left; padding-left: 450px;" mce_style="text-align: left;padding-left: 450px"> </p><p style="text-align: left; padding-left: 450px;" mce_style="text-align: left;padding-left: 450px"> </p><p style="text-align: left; padding-left: 450px;" mce_style="text-align: left;padding-left: 450px"> </p><p style="text-align: left; padding-left: 450px;" mce_style="text-align: left;padding-left: 450px"> </p><p style="text-align: left; padding-left: 450px;" mce_style="text-align: left;padding-left: 450px"> </p><p style="text-align: left;" mce_style="text-align: left">External fixation is a surgical treatment which is held by transfixing screws, pins or tensioned wires which are pass through the bone above and below of the fracture site. These are then connected to an external frame or rigid bar. While reducing the fracture in all three planes, hold it in the proper alignment (adjustment of the angulation), it also allow some degree of rigidity and stability. besides it also allow adjustment of length of the bone. External fixation is commonly apply to fracture of long bones (esp. femur, tibia and humerus) and pelvic, but it can also be used for fractures of almost any part of the skeleton (example bone of the hand). Insertion of wires and half pins must be with care, by the knowledge of 'safe corridors' is to avoid nerves or vessels injury.</p> <h4 style="text-align: left;" mce_style="text-align: left">Indications of external fixation include:</h4> <p>1. Fracture associated with severe soft tissue damage.</p> <p><a rel="attachment wp-att-6701" href="http://usmorthopedic.blog.com/2009/10/12/external-fixation-2/pa060267/" mce_href="http://usmorthopedic.blog.com/2009/10/12/external-fixation-2/pa060267/"><img class="aligncenter size-medium wp-image-6701" src="http://usmorthopedic.blog.com/files/2009/10/pa060267-300x166.jpg" mce_src="http://usmorthopedic.blog.com/files/2009/10/pa060267-300x166.jpg" alt="external fixation for wound inspection" width="300" height="166" /></a>external fixation was apply, two pins on the femur bone and two pins on the tibia bone. there are two wounds on the anterior aspect of upper half leg. The wound is measuring 5x3cm and 5x4cm. There is bleeding, no slough, granulation tissue present, slope well-defined edge. There is no maculous pin-site infection.</p> <p>2. Fracture associated with nerve and vessel damage.<br />3. Severely comminuted and unstable fracture<br />4. Non-union where dead or sclerotic fracture fragment can be excised and fragments brought together by fixator<br />5. Fracture of pelvic which cannot be held by other method<br />6. Infected fracture<br />7. Severe multiple injuries</p> <h4>Complications</h4> <p>1. Damage to soft tissue structures.<br />Surgeon must familiar with the anatomy and the 'safe corridor' to prevent injured to the nerves and vessels.</p> <p>2. Overdistraction.<br />Fragments of the bone must come to contact for union to be occur. If there is no contact between of the fragments, union may be delayed or prevented.</p> <p>3. Pin-track infection.<br />This is rare but is the most complicated. Therefore, meticulous pin-site care is essential. If infection is occur, administered of antibiotics must be immediate.</p>Dr. K.M. Liauhttp://www.blogger.com/profile/05374546719213574530noreply@blogger.com2tag:blogger.com,1999:blog-6155132192235818010.post-76994340344571370082009-10-12T02:57:00.000-07:002009-10-12T03:00:28.899-07:00Type 2 Diabetes Mellitus and its related foot complications in Malaysia<div id="content" class="pad"><!--end menu--> <div class="alert-box entry"> </div><!--end alert-box--> <div class="post" id="post-5135"> <div class="post-header"> <h2><a href="http://usmorthopedic.blog.com/2009/08/28/diabetic-mellitus/" rel="bookmark" title="Permanent Link to Type 2 Diabetes Mellitus and its related foot complications in Malaysia"><br /></a></h2></div><!--end meta--> <div class="entry clear"> <p>Incidence of Type 2 Diabetes Mellitus in Malaysia:</p> <p>In Malaysia, the First National Health and Morbidity Survey (NHMS 1) conducted in 1986 reported a prevalence of diabetes mellitus of 6.3% [1]. In the Second National Health and Morbidity Survey (NHMS 2) in 1996, the prevalence had risen to 8.3% [2]. The prevalence of diabetes had increased drastically to 14.9 per cent in 2006 for the same age group; an increase of 80% based on the Third National Health and Morbidity Survey 2006 (NHMS 3) [3]. Currently, it is estimated that one out of eight Malaysians aged 30 years and above has diabetes, which amounts to over 1.6 million adults in Malaysia. The World Health Organisation (WHO) has estimated that in 2030, Malaysia would have a total number of 2.48 million diabetics compared to 0.94 million in 2000 - a 164% increase.</p> <p>Incidence of foot related complications:</p> <p>Foot ulceration associated with infection is one of the leading causes of hospitalization patients with diabetes mellitus. Approximately 15% of all patients with diabetes will develop a foot or leg ulceration at some time during the course of their disease.[1-3]</p> <p>Several population-based studies report an annual incidence of diabetic foot ulceration in the range of 2% to 3% in patients with either Type 1 or Type 2 diabetes, while the prevalence varies between 4% and 10%</p> <p>Numerous risk factors for diabetic foot ulceration have been ascertained. Aside from the major factors of neuropathy, ischemia, pressure (trauma), and infection, multiple other contributory factors interact to produce foot lesions. Intrinsic risk factors include metabolic or biologic characteristics that may or may not be causally related to diabetes but do contribute to the aetiology of ulceration.</p> <p>Symptom of diabetes:</p> <p>48% of patients above the age of 30 years old are not aware that they have diabetic. The majority are asymptomatic. Patients should be aware of common symptoms of diabetes which include polyuria (increased frequency of urination), polydipsia (increased thrist), easily tired and sudden unexplained weight loss [4].</p> <p>Classification diabetic foot complications<br />Diabetic Foot Problems are best classified according to King’s Classification [5].<br />Stage 1: Normal<br />Stage 2: High Risk<br />Stage 3: Ulcerated<br />Stage 4: Cellulitic Stage<br />Stage 5: Necrotic<br />Stage 6: Major Amputation</p> <div id="attachment_5136" class="wp-caption aligncenter" style="width: 162px;"><a rel="attachment wp-att-5136" href="http://usmorthopedic.blog.com/?attachment_id=5136"><img class="size-full wp-image-5136" src="http://usmorthopedic.blog.com/files/2009/08/asd.png" alt="asd" width="152" height="152" /></a><p class="wp-caption-text">Post Ray’s amputation+ incision and drainage</p></div> <div id="attachment_5137" class="wp-caption aligncenter" style="width: 312px;"><a rel="attachment wp-att-5137" href="http://usmorthopedic.blog.com/?attachment_id=5137"><img class="size-full wp-image-5137" src="http://usmorthopedic.blog.com/files/2009/08/ase.png" alt="The surgical wound located at the dorsal surface of the right foot. The wound bed consists of granulation tissues and slough. This is not a well-healing wound. " width="302" height="227" /></a><p class="wp-caption-text">The surgical wound located at the dorsal surface of the right foot. The wound bed consists of granulation tissues and slough. This is not a well-healing wound. </p></div> <p><strong>Investigations</strong></p> <p>Glycosylated hemoglobin level must be taken to obtain information of the patient’s glucose control over the past 3 months. This investigation is based on the fact that in the normal 120 day life span of the red blood cell, excess glucose molecules will react with hemoglobin, forming glycosylated hemoglobin. In individuals with poorly controlled diabetes, the level of glycosylated hemoglobins will be elevated.</p> <p>Plain radiograph of foot and ankle can also be taken to make sure there is no involvement of bone to rule out osteomyelitis.</p> <p>Doppler ultrasound also is significant to investigate the peripheral circulation of foot to prevent ischemia.</p> <p><strong>Diabetic Foot Care Treatment</strong></p> <p><strong>Self-Care at Home</strong></p> <p>A person with diabetes should do the following:</p> <ul type="disc"><li><strong>Foot examination:</strong> Examine your feet daily and also after any trauma, no matter how minor, to your feet. Report any abnormalities to your physician. Use a water-based moisturizer every day (but not between your toes) to prevent dry skin and cracking. Wear cotton or wool socks. Avoid elastic socks and hosiery because they may impair circulation.</li></ul> <ul type="disc"><li><strong>Eliminate obstacles:</strong> Move or remove any items you are likely to trip over or bump your feet on. Keep clutter on the floor picked up. Light the pathways used at night - indoors and outdoors.</li></ul> <ul type="disc"><li><strong>Toenail trimming: </strong>Always cut your nails with a safety clipper, never a scissors. Cut them straight across and leave plenty of room out from the nailbed or quick. If you have difficulty with your vision or using your hands, let your doctor do it for you or train a family member how to do it safely.</li></ul> <ul type="disc"><li><strong>Footwear:</strong> Wear sturdy, comfortable shoes whenever feasible to protect your feet. To be sure your shoes fit properly, see a podiatrist (foot doctor) for fitting recommendations or shop at shoe stores specializing in fitting people with diabetes. Your endocrinologist (diabetes specialist) can provide you with a refferel<span style="color: rgb(0, 0, 0);"> to a podiatrist ororthopedist who may also be an excellent resource for finding local shoe stores. If you have flat feet, bunions, or hammertoes, you may need prescription shoes or shoe inserts.</span></li></ul> <ul type="disc"><li><strong>Exercise:</strong> Regular exercise will improve bone and joint health in your feet and legs, improve circulation to your legs, and will also help to stabilize your blood sugar levels. Consult your physician prior to beginning any exercise program.</li></ul> <ul type="disc"><li><strong>Smoking:</strong> If you smoke any form of tobacco, quitting can be one of the best things you can do to prevent problems with your feet. Smoking accelerates damage to blood vessels, especially small blood vessels leading to poor circulation, which is a major risk factor for foot infections and ultimately amputations.</li></ul> <ul type="disc"><li><strong>Diabetes control: </strong>Following a reasonable diet, taking your medications, checking your blood sugar regularly, exercising regularly, and maintaining good communication with your physician are essential in keeping your diabetes under control. Consistent long-term blood sugar control to near normal levels can greatly lower the risk of damage to your nerves, kidneys, eyes, and blood vessels.</li></ul> <p><strong> </strong></p> <p><strong> </strong></p> <p><strong>Medical Treatment</strong></p> <ul type="disc"><li><strong>Antibiotics: </strong>If the doctor determines that a wound or ulcer on the patient’s feet or legs is infected, or if the wound has high a risk of becoming infected, such as a cat bite, antibiotics will be prescribed to treat the infection or the potential infection. It is very important that the patient take the entire course of antibiotics as prescribed. Generally, the patient should see some improvement in the wound in two to three days and may see improvement the first day. For limb-threatening or life-threatening infections, the patient will be admitted to the hospital and given IV antibiotics. Less serious infections may be treated with pills as an outpatient The doctor may give a single dose of antibiotics as a shot or IV dose prior to starting pills in the clinic or emergency department.</li></ul> <ul type="disc"><li><strong>Referral to wound care center:</strong> Many of the larger community hospitals now have wound care centers specializing in the treatment of diabetic lower extremity wounds and ulcers along with other difficult-to-treat wounds. In these multidisciplinary centers, professionals of many specialties including doctors, nurses, and therapists work with the patient and their doctor in developing a treatment plan for the wound or leg ulcer. Treatment plans may include surgical debridement of the wound, improvement of circulation through surgery or therapy, special dressings, and antibiotics. The plan may include a combination of treatments.</li></ul> <ul type="disc"><li><strong>Referral to podiatrist or orthopedic surgeon: </strong>If the patient has bone-related problems, toenail problems,<span style="color: rgb(0, 0, 0);"><span style="text-decoration: underline;">corn and callus </span></span><span style="color: rgb(0, 0, 0);">hammertoes</span>, bunions, flat feet, heel spurs, arthritis, or have difficulty with finding shoes that fit, a physician may refer you to one of these specialists. They create shoe inserts, prescribe shoes, remove calluses and have expertise in surgical solutions for bone problems. They can also be an excellent resource for how to care for the patient’s feet routinely.</li></ul> <ul type="disc"><li><strong>Home health care:</strong> The patient’s doctor may prescribe a home health nurse or aide to help with wound care and dressings, monitor blood sugar, and help the patient take antibiotics and other medications properly during the healing period.</li></ul> <p>References</p> <p>1. National Health and Morbidity Survey 1986</p> <p>2. National Health and Morbidity Survey 1996</p> <p>3. National Health and Morbidity Survey 2006</p> <p>4. Mafauzy M. <em>Diabetes Mellitus in Malaysia.</em> Medical Journal of Malaysia. 2006.</p> <p>5. Edmonds ME and Foster AVM. Managing the diabetic foot, 2nd ed. (Blackwell, London, 2005).</p> <p>Malaysia endocrine and metabolic society,Ministry of health,acdemic of medicine malaysia,Persatuan diabetic malaysia.</p></div></div></div>Dr. K.M. Liauhttp://www.blogger.com/profile/05374546719213574530noreply@blogger.com4tag:blogger.com,1999:blog-6155132192235818010.post-57088201347093684162009-09-12T06:33:00.000-07:002009-09-12T06:36:46.842-07:00Bionic brain chips could overcome paralysis<p class="infuse">By <i>Sunny Bains</i></p><p class="infuse"><br /></p><p class="infuse">A MONKEY sits on a bench, wires running from its head and wrist into a small box of electronics. At first the wrist lies limp, but within 10 minutes the monkey begins to flex its muscles and move its hand from side to side. The movements are clumsy, but they are enough to justify a rewarding slug of juice. After all, it shouldn't be able to move its wrist at all.</p> <p class="infuse">A nerve connection in the monkey's upper arm had previously been blocked with an anaesthetic that prevented signals travelling from its brain to its wrist, leaving the muscles temporarily paralysed. The monkey was only able to move its arm because the wires and the black box bypassed the broken link.</p> <p class="infuse">The monkey was in <a href="http://depts.washington.edu/pbiopage/people_fac_page.php?fac_ID=12" target="nsarticle">Eberhard Fetz's lab at the University of Washington in Seattle</a>. The experiment, performed last year, was the first demonstration of a new treatment that might one day cure paralysis, which is typically caused by a broken connection in the spinal cord. Though much work has focused on using stem cells to regrow damaged nerve fibres, some researchers believe that an electronic bypass like this is equally viable.</p> <p class="infuse">The idea is to implant electronic chips in the relevant regions of the brain to record neural activity. Then a decoder deciphers the neural chatter, often from thousands of neurons, to figure out what the brain wants the body to do. These messages must then be relayed - ideally wirelessly - to electrodes that deliver a pulse of electricity to stimulate the muscles into action. Such "brain chips" are already restoring hearing to the deaf and vision to the blind, and helping to stave off epileptic fits, so the idea isn't as far-fetched as it might sound <a href="http://www.newscientist.com/article/mg20327232.300-bionic-brain-chips-could-overcome-paralysis.html?full=true#bx272323B1">(see "Bionic medicine")</a>.</p> <p class="infuse">Every step of progress in tackling paralysis has been hard won. One of the early demonstrations that it may be possible emerged in 2003, when <a href="http://www.eecs.berkeley.edu/%7Ecarmena/" target="nsarticle">José Carmena</a>, then at Duke University in Durham, North Carolina, successfully created an interface between brain and machine that allowed his lab monkeys to play a computer game using only their minds.</p> <p class="infuse">To gain a juice reward, the monkeys had to move a cursor - initially with a joystick - to hit a target on the computer screen. Beforehand, Carmena and his colleagues had implanted several chips throughout the parietal and frontal lobes of the monkeys' brains - regions known to plan and control movement. Each chip held up to 64 electrodes, which recorded the firing of the surrounding neurons as the monkeys manipulated the joystick.</p> <p class="infuse">Once the system had successfully decoded the chatter from the monkeys' neurons, the program stopped responding to the joystick's movement altogether and relied solely on the monkeys' thoughts to control the cursor. Eventually even the animals worked this out and stopped holding the joysticks as they completed the task (<a href="http://www.plosbiology.org/article/info:doi/10.1371/journal.pbio.0000042" target="nsarticle"><i>PLoS Biology</i>, vol 1, p 42</a>).</p> <p class="infuse">Manipulating a cursor on a computer screen is one thing, but whether such brain chips could translate the more complicated tasks of daily life remained an open question until 2004, when <a href="http://www.cyberkinetics.com/people.html" target="nsarticle">John Donoghue</a> and colleagues from Cyberkinetics in Providence, Rhode Island, implanted a 100-electrode chip in the brain of a 25-year-old man known as MN, who had been left paralysed from the neck down by a knife wound.</p> <p class="infuse">Over the subsequent nine months, MN successfully used this BrainGate chip to open emails, operate a television and even control a robotic arm (<a href="http://www.nature.com/nature/journal/v442/n7099/abs/nature04970.html" target="nsarticle"><i>Nature</i>, vol 442, p 164</a>). It was a promising step, but the technology was far from perfect. "Although BrainGate1 worked well in many ways, at times the control was not satisfactory," says Donoghue. And by the end of the trial, fluids from the brain had degraded the chip. The team are now solving these problems, and earlier this year announced the start of a clinical trial for an improved version of the chip.</p> <div class="quotebx bxbg"><div class="quoteopen"><div class="quoteclose"> <div class="quotebody lowlight"> <quote><quotetext>With a chip implanted in his brain, a paralysed man was able to open emails, operate the TV and even control a robotic arm</quotetext></quote> </div> </div></div></div> <p class="infuse">The ultimate hope for many paralysed people, of course, is to regain movement in their own limbs. Until Fetz's experiment last year, no one had successfully used an implant to bridge a broken connection between the brain and the body. Trials of functional electrical stimulation (FES), in which implanted electrodes directly stimulate muscles into action, <a href="http://www.newscientist.com/article/mg18124364.000-we-can-rebuild-them.html">had hinted that this might be possible</a>. But these impulses had been activated by external triggers, such as a switch controlled by one of the patient's healthy limbs, and not directly by brain signals.</p> <p class="infuse">Not only did Fetz's work demonstrate that the electronics could descramble neural signals and relay appropriate instructions to the limbs using FES, he also showed that the brain makes the <a class="infusionLink" omd="zodJump('http://widgets.zibb.com/images/_jump.gif?tag=InfusionJS&url=http%3A%2F%2Fwww.newscientistjobs.com%2F&gsid=job&entitytypeid=kw&lid=http://www.newscientistjobs.com/&title=job&intref=infusion&variantName=job&zodid=96')" alt="job" href="http://www.newscientistjobs.com/">job</a> easier than one might expect. Although the motor neurons that connected to the chip did not naturally control the wrist, in a short time they adapted to the task and controlled complex actions (<a href="http://www.nature.com/nature/journal/v456/n7222/full/nature07418.html" target="nsarticle"><i>Nature</i>, vol 456, p 639</a>). "All neurons could be used equally well for control regardless of their original association to movement," says team member <a href="http://faculty.washington.edu/ctmoritz/main/" target="nsarticle">Chet Moritz</a>.</p><p class="infuse">That could have an important implication for humans hoping to use similar implants in the future. "It underscores the impressive flexibility of the brain in learning to adapt to novel connections, which may play a key role in allowing neural prostheses to be adopted by patients," he says.</p> <p class="infuse">So could the same approach work in humans? There seem to be no fundamental obstacles, and Donoghue plans to test the proposition in the new BrainGate trials, using his chip to control a limb using FES. If successful, it will represent a milestone in the development of such treatments.</p> <p class="infuse">Direct electrical stimulation of muscles using FES is unlikely to be the final solution, however. This direct approach uses a relatively powerful electric current applied to large areas of tissue, producing fairly clumsy movements. A more elegant method, some claim, is to send the impulse along the existing healthy nerves. That would require smaller local currents, delivered with greater precision, to finer regions of the muscle tissue, which should allow more subtle control.</p> <h3 class="crosshead">Coordination</h3> <p class="infuse">As a bonus, nerve stimulation could simplify some of the demands placed on a brain chip. That's because for many rhythmic activities, such as breathing, walking and crawling, the brain simply sends a command signal and it is the spinal cord's in-built systems that orchestrate the fine movements of each muscle. So if the healthy sections of a damaged spinal cord have retained their ability to control movement, the electronic chip could transmit the brain signal around the broken connection but leave the muscular orchestration to the spinal cord. In this case, a brain chip would just beam the message to a second device implanted in the spine below the break, which would then stimulate the spinal cord.</p> <div class="quotebx bxbg"><div class="quoteopen"><div class="quoteclose"> <div class="quotebody lowlight"> <quote><quotetext>The chips could simply transmit the information around the break, leaving the undamaged sections of the spinal cord to orchestrate the muscles</quotetext></quote> </div> </div></div></div> <p class="infuse">That could "dramatically simplify the control signals needed from the brain", says Moritz, since for these repetitive tasks the brain chip would just decode and transmit an umbrella command. Such simplification should make the chips less likely to fail - an important consideration when the only way to replace the chips is through invasive surgery - and also reduce their power consumption.</p> <p class="infuse">Using this principle in 2002, <a href="http://www.ualberta.ca/%7Evmushahw/" target="nsarticle">Vivian Mushahwar</a>, now at the University of Alberta in Edmonton, Canada, plugged four electrodes into a cat's spinal cord and delivered signals that mimicked the brain's command to walk. Sure enough, the cat made stepping motions.</p> <p class="infuse">Simply relaying the messages across a break in this way would not help the worst injuries, however, in which the spinal cord has lost its ability to coordinate muscles. In these cases, to minimise the size of the brain chip, and the burden placed on it, the muscular orchestration would need to come from either the chip implanted in the spinal cord, or an external device that communicates wirelessly with the chips in the brain and the spine.</p> <p class="infuse">Calculating exactly which nerves to stimulate and in what pattern is no easy task, but the first demonstration of an artificial "central pattern generator" was reported last year, when Mushahwar and colleagues at Johns Hopkins University in Baltimore, Maryland, successfully tested such a chip on a cat. With coordination coming solely from an external CPG chip connected to a handful of electrodes that stimulated the cat's spine, the animal was able to walk (<a href="http://ieeexplore.ieee.org/stamp/stamp.jsp?tp=&arnumber=4660348&isnumber=4660291" target="nsarticle"><i>IEEE Transactions on Biomedical Circuits and Systems</i>, vol 2, p 212</a>). In this experiment, the team were simply testing the CPG's ability to orchestrate movement as an alternative to FES, so the trigger came from a manual switch and not the cat's brain. The next hurdle will be to use the CPG in conjunction with a neural chip.</p> <p class="infuse">While this CPG chip only dealt with the action of walking, in humans an additional external chip might also offload some of the processing from the brain chip for non-repetitive motions like clenching a fist or raising a hand. The brain doesn't necessarily produce an umbrella command for all of these movements, so the neural implant would still need to detect a more complicated signal, but the external chip could at least perform some of the processing to decode and relay these comands to the relevant electrodes.</p> <p class="infuse">For many patients, technology like this would only solve half the problem, however. Paralysed people who have lost feeling as well as movement in their limbs would need two-way systems to pass sensations back to their brain. This information could come from artificial sensors, but ideally the chip would read sensations from existing nerves and relay them to chips that stimulate the areas of the brain that process tactile information.</p> Although work has been slower in this area, there's good evidence it will one day be possible. Carmena, for instance, who is now at the University of California, Berkeley, recently stimulated a rat's brain to feel sensations from some "virtual whiskers", causing it to move as if its own whisker's had really brushed against an object. Similar technology could one day relay tactile information to the human brain.<br /><br /><p class="infuse">If these advances in brain-chip capability are to be exploited, the researchers still need to ensure that the chips are safe and durable. Biocompatibility, for instance, is a huge challenge, because tissue in the brain can react badly to an implant, killing off the very neurons that the electronics are trying to connect to. Recent efforts suggest a coating of growth hormones might mitigate this problem, while others have shown chips that slowly exude stem cells might also work.</p> <p class="infuse">Then there's the problem of powering the devices. Most existing implants - like cochlear implants, for example - are connected to a battery outside the head that can be replaced regularly. The electrodes in the spine and limbs could be powered this way, but it's less practical for a chip deep within the skull. Instead, such chips will need to be recharged by electromagnetic fields generated by a device outside the head, so power consumption will have to be minimal.</p> <p class="infuse">One solution might be to offload the more difficult processing to a portable computer outside the body, before passing the information back to the chips that stimulate the nervous system. In this way, Reid Harrison at the University of Utah in Salt Lake City has produced a neural chip that uses just 8 milliwatts. That's less than the "standby" LED on the front of a TV set.</p> <h3 class="crosshead">Security risks</h3> <p class="infuse">All the pieces are gradually coming together, but whatever happens it will be a long time before these chips can become a mainstream treatment: the US Food and Drug Administration requires as much as 10 years of animal testing before a chip can be deemed safe enough to be implanted in human brains. That means the latest technology, such as chips that stimulate tactile sensations in the brain, will need extensive testing before clinical trials can begin.</p> <p class="infuse">Yet even once the technology has proven itself, the social issues surrounding the treatment will need to be solved. Take the question of security, for example. Last year, a team of researchers successfully hacked into a heart pacemaker and defibrillator through the wireless communication that allows doctors to adjust its performance. Although the device wasn't implanted in anyone at the time, it raised the possibility that hackers could disrupt a patient's treatment <a href="http://www.newscientist.com/article/mg19726485.300-pacemakers-can-be-hijacked-by-radio.html">(<i>New Scientist</i>, 22 March 2008, p 23)</a>.</p> <p class="infuse">To make matters worse, there is currently no obvious way of protecting a defibrillator or pacemaker from a hacker without inhibiting a doctor from accessing it during an emergency. Since neural prostheses will rely so heavily on wireless links to communicate between the different components, the risk to these chips may be even greater.</p> <p class="infuse">Perhaps most perplexing is the question of legal responsibility. If someone wearing a neural prosthesis were to punch someone, who is to blame? The action may have been deliberate, in which case the patient is to blame, or the chip may have been malfunctioning and the responsibility would lie with the manufacturer. Discovering where the truth lay would be no easy task. The law has had trouble catching up with the self-parking <a class="infusionLink" omd="zodJump('http://widgets.zibb.com/images/_jump.gif?tag=InfusionJS&url=http%3A%2F%2Fwww.newscientist.com%2Ftopic%2Fmotoring-tech&gsid=car&entitytypeid=kw&lid=http://www.newscientist.com/topic/motoring-tech&title=car&intref=infusion&variantName=car&zodid=96')" alt="car" href="http://www.newscientist.com/topic/motoring-tech">car</a>, never mind an electronically controlled limb gone wild.</p> <div class="artbx bxbg"> <h3 id="bx272323B1">Bionic medicine</h3> <p><b>Paralysis is not the only condition that can be treated with chips in the brain</b></p> <p><b>Deafness</b></p> <p>The cochlear implant has been commercially available for many years. It detects sound and creates a signal that is fed directly into the auditory nerve. In this way, damaged portions of the ear can be bypassed entirely.</p> <p><b>Blindness</b></p> <p>Retinal prostheses are being tested in blind people who lack the ability to turn light signals into neural signals. They can be plugged into the brain either at the retina itself, the optic nerve, or even the visual cortex.</p> <p><b>Parkinson's disease</b></p> <p>Some people with Parkinson's are implanted with deep brain stimulation systems that can prevent some of the shaking that is characteristic of the disease. Though the surgery carries risks, a new study shows that people gained more than 4.5 "good" hours a day using the devices (<i>The Journal of the American Medical Association</i>, vol 301, p 63).</p> <p><b>Epilepsy</b></p> <p>Devices known by some as "brain pacemakers" send regular electrical pulses to parts of the brain associated with the condition, helping to prevent the neurons from firing in the patterns associated with seizures.</p> </div> <p><i>Sunny Bains is a science journalist based in London</i></p>Dr. K.M. Liauhttp://www.blogger.com/profile/05374546719213574530noreply@blogger.com0tag:blogger.com,1999:blog-6155132192235818010.post-76910434798584979822009-09-12T00:41:00.000-07:002009-09-12T00:42:46.666-07:00Diabetic foot team lowers rate of major amputations<p class="artTitle"><br /></p> <p class="deckLine">Incidence of major diabetic foot amputations decreased 41% in 10 years. </p> <i>By </i><span class="p12"><i>Gina Brockenbrough</i></span><br /><cite>ORTHOPAEDICS TODAY EUROPE</cite> 2009; 12:17 <p>Norwegian investigators discovered a significant decrease in the incidence of diabetic foot amputations in one town 10 years after the establishment of a diabetic foot team at the city’s only hospital. </p> <p>“We have registered a 41% decrease in major diabetic amputations,” Eivind Witsø, MD, said during his presentation at the 10th EFORT Congress. “The decrease reflects the improved quality of the prevention and treatment of diabetic foot ulcers and a general improvement in public health.” </p> In a previous study of patients with diabetes in the city of Trondheim, Norway, Witsø and his colleagues identified a rate of 4.4 lower extremity amputations per 1,000 patients each year between 1994 and 1997 — a rate he considered high.<br /><br /> <p class="artTitle">Diabetic foot team lowers rate of major amputations</p> <p class="deckLine">Incidence of major diabetic foot amputations decreased 41% in 10 years. </p> <i>By </i><span class="p12"><i>Gina Brockenbrough</i></span><br /><cite>ORTHOPAEDICS TODAY EUROPE</cite> 2009; 12:17 <p>Norwegian investigators discovered a significant decrease in the incidence of diabetic foot amputations in one town 10 years after the establishment of a diabetic foot team at the city’s only hospital. </p> <p>“We have registered a 41% decrease in major diabetic amputations,” Eivind Witsø, MD, said during his presentation at the 10th EFORT Congress. “The decrease reflects the improved quality of the prevention and treatment of diabetic foot ulcers and a general improvement in public health.” </p> <p>In a previous study of patients with diabetes in the city of Trondheim, Norway, Witsø and his colleagues identified a rate of 4.4 lower extremity amputations per 1,000 patients each year between 1994 and 1997 — a rate he considered high. </p><center><hr /><span style="color: gray;">advertisement<br /><object border="0" height="280" vspace="10" width="336"><param name="movie" value="images/banners/Delphi_336x280_0903.swf"><embed src="http://www.orthosupersite.com/images/banners/Delphi_336x280_0903.swf" height="280" width="336"></embed></object> </span><hr /></center> <h4>Diabetic foot team </h4> <p>In response, the investigators established the Trondheim Diabetic Foot Team as part of the orthopaedic surgery department at St. Olav’s University Hospital. The team consisted of an orthopaedic surgeon, nurse, podiatrist, prosthetist and orthotist, and focused on preventative care and early treatment. </p> <p>The investigators compared the incidence of diabetic amputations from 1994 to 1997 with information from 2004 to 2007. </p> <table align="RIGHT" border="0" cellpadding="5" cellspacing="5" width="100"> <tbody> <tr> <td align="center"> <p class="caption"><img src="http://www.orthosupersite.com/images/content/OTI/200909/Witso.jpg" alt="Eivind Witso, MD" border="1" height="90" vspace="3" width="70" /><br /><b>Eivind Witsø</b></p></td> </tr> </tbody> </table> <h4>Amputations </h4> <p>The investigators found that the overall incidence of diabetic amputations per 1,000 patients with diabetes per year significantly decreased from 4.4 to 2.8 in 10 years. </p> <p>Although they found that the incidence of minor diabetic amputations also decreased, the difference was not statistically significant. </p> <p>Witsø said the study revealed no significant difference in the number of vascular interventions performed on patients with diabetes during the decade. He also noted that the diabetic foot team screened nearly 750 patients and performed nearly 6,000 consultations between 1996 and 2006. </p> <h4>A global trend? </h4> <p>During the paper discussion, co-moderator Per Kjaersgaard-Andersen, MD, asked Witsø if there has been a global decrease in the incidence of diabetic amputation. </p> <p>“No, it’s not a global observation,” Witsø responded. He noted that while some countries have seen a decrease, diabetic foot amputation remains a major problem in other nations. He added that other researchers have observed a decline in diabetic amputations due to preventative care and an increase in vascular interventions. </p> <p>“Perhaps this is one of the first studies that has shown a decrease in amputations that cannot be explained by an increase in vascular interventions,” Witsø said. </p> <blockquote><b>For more information: </b> <ul><li>Per Kjaersgaard-Andersen, MD, heads the Section for Hip and Knee Replacement, Department of Orthopaedics, Vejle Hospital, DK-7100 Vejle, Denmark; +45-7940-5716; e-mail: <a href="mailto:pka@dadlnet.dk">pka@dadlnet.dk</a>. He has no direct financial interest in any products or companies mentioned in this article.</li><li> Eivind Witsø, MD, can be reached at St. Olav’s University Hospital, Norwegian University of Science, Gate 17, N-7006 Trondheim, Norway, 7030; +47-738-68000; e-mail: <a href="mailto:eivind.witso@stolav.no">eivind.witso@stolav.no</a>. He has no direct financial interest in any products or companies mentioned in this article.</li></ul> <p><b> Reference: </b></p> <ul><li>Eivind W, Arne L, Stian L. Forty percent decrease in the incidence of diabetic amputations in 10 years. Paper F197. Presented at the 10th EFORT Congress. June 3-6, 2009. Vienna.</li></ul></blockquote> <br /><input id="gwProxy" type="hidden"><!--Session data--><input onclick="jsCall();" id="jsProxy" type="hidden"><div id="refHTML"></div>Dr. K.M. Liauhttp://www.blogger.com/profile/05374546719213574530noreply@blogger.com3tag:blogger.com,1999:blog-6155132192235818010.post-38530304894297717042009-09-01T07:06:00.001-07:002009-09-01T07:06:34.607-07:00Pine Bark Study Shows Further Progress Against Osteoarthritis<div align="center"><b><span style="font-size:130%;"><br /></span></b></div><br />A new study on pine bark as an osteoarthritis treatment showed Pycnogenol reduced osteoarthritis (OA) symptoms by 56% and provided pain relief. In the study, held at Italy’s Chieti-Pescara University, 156 patients with knee OA received 100 milligrams of Pycnogenol or placebo daily for three months and were evaluated using a number of tools. Patients were permitted to continue taking their choice of pain medication provided they recorded every tablet in a diary for later evaluation. Results indicated Pycnogenol, an antioxidant plant extract from the bark of the French maritime pine tree, was an effective OA treatment and provided OA pain relief. In addition, the Pycnogenol group also: <ul><li>• Experienced a 55% improvement in joint pain.</li><li>• Reduced pain medication use by 58%.</li><li>• Had a 63% improvement in gastrointestinal complications.</li><li>• Reduced stiffness by 53%.</li><li>• Improved physical function scores by 57%.</li><li>• Enhanced overall well being by 64%.</li></ul>“The results of this study are significant as they clearly demonstrate the clinical action of Pycnogenol on OA and management of symptoms,” said Gianni Belcaro, a lead researcher of the study. “The use of Pycnogenol may reduce costs and side effects of anti-inflammatory agents and offer a natural alternative solution to people suffering from OA.”Dr. K.M. Liauhttp://www.blogger.com/profile/05374546719213574530noreply@blogger.com2tag:blogger.com,1999:blog-6155132192235818010.post-72096689729986396552009-09-01T07:00:00.000-07:002009-09-01T07:03:27.963-07:00Bio-Spacers<span class="title">The Bio-Spacers Range from Orthopaedic Innovation Limited</span><br /><br />The Bio-Spacers range from Orthopaedic Innovation Limited, a member of the Medsmart Solutions family, are innovative and highly effective devices designed to help overcome arthroplastic infections, whilst maintaining mobility and the quality of life for the patient.<br /><br /><br /><img src="file:///C:/DOCUME%7E1/User/LOCALS%7E1/Temp/moz-screenshot-8.jpg" alt="" /><img src="file:///C:/DOCUME%7E1/User/LOCALS%7E1/Temp/moz-screenshot-9.jpg" alt="" /><a onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}" href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhp23vLBb7-diOxOW7CzVD1SQ4gmwrgLNGhJij-MVNZU1PYeXi1acD8QMfQ3AEzXA1bPZQI8t0O-QZqGQQcSq_BrclHbv3PcWeYvIndusdPRBYYlopkHZMD1F0Tu1T2bP1MBWJ5PjTa/s1600-h/Bio+spacer.jpg"><img style="margin: 0px auto 10px; display: block; text-align: center; cursor: pointer; width: 283px; height: 398px;" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhp23vLBb7-diOxOW7CzVD1SQ4gmwrgLNGhJij-MVNZU1PYeXi1acD8QMfQ3AEzXA1bPZQI8t0O-QZqGQQcSq_BrclHbv3PcWeYvIndusdPRBYYlopkHZMD1F0Tu1T2bP1MBWJ5PjTa/s400/Bio+spacer.jpg" alt="" id="BLOGGER_PHOTO_ID_5376499027575766722" border="0" /></a><br /><br /><br />These temporary, implantable devices, which incorporate Gentamicin, are used to provide a replacement for a joint prosthesis which has been removed as a result of a septic process. They release antibiotic into the surrounding tissues to help the treatment of infected total joint replacement and facilitate successful re-implantation of the definitive prosthesis.<br /><br /><br /><br />Our range of Bio-Spacers are made from O-I Bone Cement and the Hip Spacer is reinforced with a Stainless Steel (316L) insert to enhance strength. All our spacers feature highly polished surfaces to prevent lesions to joint surfaces and various models and sizes are available. O-I Bio-spacers’ key features are: <ul><li>Maintenance of joint space, mobilisation and limb length (Partial weight- bearing and functional use of the limb must be assessed on an individual patient basis).</li><li>Effective in-situ release of high local antibiotic dosage with reduced systemic effects.</li><li>Homogeneous distribution of antibiotic in the cement.</li><li>Implantable with bone cement.</li><li>Improved quality of life between surgeries.</li><li>Eventual easier re-implantation of the definitive prosthesis.</li><li>Shorter hospitalisation.</li><li>Lower costs per treatment.</li><li>Improved recovery index.</li></ul>http://www.orthopaedicinnovation.com/Dr. K.M. Liauhttp://www.blogger.com/profile/05374546719213574530noreply@blogger.com1tag:blogger.com,1999:blog-6155132192235818010.post-180912485556134242009-09-01T06:35:00.000-07:002009-09-01T06:39:21.490-07:00Interferon Regulator Factor-8<p class="artTitle">Orthopaedics Today<br /></p><p class="artTitle">Researchers identify protein involved in causing osteoporosis, arthritis </p> <br />1<sup>st</sup> on the web (August 31, 2009)<p>Investigators at the Hospital for Special Surgery in New York, along with several collaborators, reported that a gene called interferon regulator factor-8 (IRF-8) plays an important role in the development of diseases such as rheumatoid arthritis, osteoporosis and periodontitis (gum disease). </p><p>The study, which appeared online Aug. 30 ahead of print in the journal <cite>Nature Medicine</cite>, could lead to new treatments, according to the authors. </p><p>“The study doesn't have immediate therapeutic applications, but it does open a new avenue of research that could help identify novel therapeutic approaches or interventions to treat diseases such as periodontitis, rheumatoid arthritis or osteoporosis,” Baohong Zhao, PhD, lead author of the study and a research fellow in the Arthritis and Tissue Degeneration Program at the Hospital for Special Surgery, said in a press release.<br /></p><p><br /></p><p>Zhao initiated the study while working in the laboratory led by Masamichi Takami, PhD, and Ryutaro Kamijo, PhD, at Showa University, Tokyo, where much of the work was performed. Zhao completed the study and extended the work to human cells during the past year at the Hospital for Special Surgery while working with Lionel Ivashkiv, PhD. </p><p>Specifically, the researchers discovered that downregulation of IRF-8 increases the production of cells called <a href="http://www.orthosupersite.com/searchResults.asp?condition222=any&searchStr=osteoclasts&condition=any&x=2&y=4" target="New">osteoclasts</a> that are responsible for breaking down bone. Enhanced development of osteoclasts can create canals and cavities that are hallmarks of diseases such as periodontitis, osteoporosis and rheumatoid arthritis. </p><p>Previous researchers have spent time identifying genes that are upregulated during enhanced development of osteoclasts, such as NFATc1, but few studies have identified genes that are downregulated in the process, according to the press release. </p><p>To fill this knowledge gap, the researchers used microarray technology to conduct a genome-wide screen to identify genes that are downregulated during the formation of osteoclasts. They found that expression of IRF-8 was reduced by 75% in the initial phases of osteoclast development. The researchers then genetically engineered mice to be deficient in IRF-8 and gave the animals X-rays and CT scans to analyze IRF-8's influence on bone. </p><p>They found that the mice had decreased bone mass and severe osteoporosis. Experiments demonstrated that this was due not to a decreased number of osteoblasts but rather due to an increased number of osteoclasts. The researchers concluded that IRF-8 suppresses the production of osteoclasts. </p><p>Tests in human cells confirmed these findings, Zhao noted. </p><p>“This is the first paper to identify that IRF-8 is a novel key inhibitory factor in osteoclastogenesis [production of osteoclasts],” Zhao said in the press release. “We hope that the understanding of this gene can contribute to understanding the regulatory network of osteoclastogenesis and lead to new therapeutic approaches in the future.” </p>Dr. K.M. Liauhttp://www.blogger.com/profile/05374546719213574530noreply@blogger.com0tag:blogger.com,1999:blog-6155132192235818010.post-12933801985034006892009-08-31T06:35:00.000-07:002009-08-31T06:36:46.620-07:00Reduced BMD in adults with very low birth weight may lead to osteoporosis, related fractures<p class="artTitle"><br /></p> <br />Orthopaedics Today<br /><br />1<sup>st</sup> on the web (August 28, 2009)<p>Individuals who had a <a href="http://www.orthosupersite.com/searchResults.asp?condition222=any&searchStr=low+birth+weight&condition=phrase&x=29&y=15" target="New">very low birth weight</a> (VLBW) had significantly less bone mineral density (BMD) at the adult age when they should normally reach peak bone mass compared to same-aged adults born at term, Finnish researchers found. </p><p>In the Helsinki Study of Very Low Birth Weight Adults, a multidisciplinary cohort study designed to see if health problems in VLBW babies persist into adulthood, Petteri Hovi, MD, and colleagues evaluated 144 adults between 18.5 and 27.1 years old born in the greater Helsinki area between 1978 and 1985 with VLBW. They compared the group’s skeletal health to 139 adults matched for age, gender and birth hospital. </p><p>Hovi and colleagues defined VLBW babies as those whose birth weight was less than 3.31 pounds.<br /></p><p><br /></p><p>The researchers determined each participant’s BMD using dual-energy X-ray absorptiometry. They calculated Z scores representing the participants’ lower lumbar spine and hip BMD, defining reduced BMD as a Z score of -1.0 units or less. </p><p>The study group’s average Z score for the lower lumbar spine was -0.51 unit (95% CI: 0.28-0.75); the average femoral neck Z score was -0.56 unit (95% CI: 0.34-0.78) for areal BMD. After adjusting for the shorter adult height and less intense level of exercise practiced in the VLBW group, the differences remained statistically significant, according to a press release. </p><p>“Furthermore, 44% of the VLBW participants, but only 26% of the term-born participants, had a lumbar spine Z score of -1.0 or less,” study editor Tom W.J. Huizinga, of Leiden, Netherlands, wrote in his summary of the findings. </p><p>Hovi and colleagues said in their abstract, “This finding may predict symptomatic <a href="http://www.orthosupersite.com/sectionContent.asp?sid=49" target="New">osteoporosis</a> and increased fracture rates.” </p><p>In addition, increased vigilance in osteoporosis prevention may be warranted in VLBW children who become adults with low BMD, they noted. </p><p>Researchers said the main limitations of the study were the final cohort may not be representative of the original cohort of individuals born in Helsinki-area hospitals; comparisons they made were only internal; and they measured BMD just once, which reduced the chances of associating lower BMD with other possible causes, such as delayed skeletal maturing in the VLBW group. </p><blockquote><p><b>Reference:</b></p><ul><li>Hovi P, Andersson S. Järvenpää A-L, et al. Decreased bone mineral density in adults born with very low birth weight: A cohort study. <cite>PloS Med</cite>. 2009;6(8):e1000135. DOI: 10.1371/journal.pmed.1000135. </li></ul></blockquote>Dr. K.M. Liauhttp://www.blogger.com/profile/05374546719213574530noreply@blogger.com0tag:blogger.com,1999:blog-6155132192235818010.post-1703691040981010092009-08-31T06:27:00.000-07:002009-08-31T06:34:18.264-07:00Orthopedic study suggests knee extensor strength plays a part in keeping osteoarthritis at bayOrthopaedics Today<br /><br />1<sup>st</sup> on the web (August 27, 2009)<p>Researchers exploring factors that affect the risk of developing symptomatic<span style="text-decoration: underline;"><span style="font-weight: bold;"></span></span> knee osteoarthritis in a multicenter study found that women with the strongest thigh muscles developed the condition less often than women with weaker knee extensor strength. </p><p>According to findings from the Multicenter Knee Osteoarthritis Study, funded by the U.S. National Institute on Aging, men with stronger thigh muscles were only slightly more protected from developing symptomatic OA than those with weaker muscles. Furthermore, thigh muscle strength was not helpful for predicting radiographic OA in women or men, the investigators noted in their study, which appears online today in <cite>Arthritis Care & Research</cite>. </p><p>“These findings suggest that targeted interventions to reduce risk for symptomatic knee OA could be directed toward increasing knee extensor strength,” co-investigator Neal A. Segal, MD, MS, from the department of orthopedics and rehabilitation at the University of Iowa, said in a press release.<br /></p><p><br /></p><p>Segal and colleagues studied the knees of 3,026 men and women 50 to 79 years old. They measured study participants’ thigh muscle strength with a dynamometer and determined their H:Q ratio, an indication of the balance of strength between hamstrings and quadriceps. </p><p>Investigators followed subjects 30 months using knee radiographs and telephone interviews to establish baseline OA, pain and other knee symptoms with the goal of determining whether knee extensor strength was a predictor of radiographic or symptomatic knee OA. </p><p>To draw their conclusions, they took into account the participants’ height, weight, body mass index, femoral neck bone mineral density and self-assessed level of physical activity. </p><p>At the end of their study, investigators reported that 7.1 % of men and 9.9% of women developed radiographic knee OA, compared to 7.8% of men and 10.1% of women who had signs of symptomatic OA. “H:Q ratio was not predictive of symptomatic knee OA in either men or women,” they wrote in their results. </p><p>The lack of hip abductor strength assessments in the analysis was one of the study limitations, the researchers noted in the press release. </p><p>“Study of hip abductor strength, which is important for control of the knee joint, may be useful in a more comprehensive study of risk for OA of the knee,” Segal said in the release. </p><blockquote><p><b>Reference: </b></p><ul><li>Segal NA, Torner JC, Felson D, et al. Effect of thigh strength on incident radiographic and symptomatic knee osteoarthritis in a longitudinal cohort. <cite>Arthritis Care Res</cite>. Published online Aug. 27, 2009 (DOI 10.1002/art). </li></ul></blockquote>Dr. K.M. Liauhttp://www.blogger.com/profile/05374546719213574530noreply@blogger.com1tag:blogger.com,1999:blog-6155132192235818010.post-3283118978540460152009-08-25T08:54:00.001-07:002009-08-25T08:54:24.437-07:00Limb-sparing surgery and amputation provide similar quality of life for patients with bone cancer<p class="artTitle"><br /></p> <br />1<sup>st</sup> on the web (August 11, 2009)<p>Limb-sparing surgery, an alternative to amputation for <a href="http://www.orthosupersite.com/searchResults.asp?condition222=any&searchStr=bone+and+soft+tissue+sarcomas&condition=phrase&x=5&y=10" target="New">bone and soft tissue sarcomas</a> of the lower limb, may not provide much or even any additional benefit to patients compared to amputation, according to a new review. </p><p>Researchers who conducted the analysis, which was posted yesterday in the online edition of <cite>Cancer</cite>, recommend that patients and physicians should rethink the pros and cons of both <a href="http://www.orthosupersite.com/searchResults.asp?condition222=any&searchStr=limb-sparing+surgery&condition=phrase&x=2&y=10" target="New">limb-sparing surgery</a> and <a href="http://www.orthosupersite.com/searchResults.asp?condition222=any&searchStr=amputation&condition=any&x=16&y=15" target="New">amputation</a> before making a final decision. </p><p>To compare the costs and benefits of limb-sparing surgery with amputation in these patients with cancer, researchers Ronald Barr, MD, MB, ChB, of McMaster University in Hamilton, Ontario, and Jay Wunder, MD, MSc, of Mount Sinai Hospital and the University of Toronto, reviewed all published papers on limb-sparing surgery that also measured patients’ functional health and quality of life. </p><center><hr /><span style="color: gray;">advertisement<br /><object border="0" vspace="10" width="336" height="280"><param name="movie" value="images/banners/JJ_336x280_0903.swf"><embed src="http://www.orthosupersite.com/images/banners/JJ_336x280_0903.swf" width="336" height="280"></embed></object> </span><hr /></center><p>According to a press release, the researchers found that while limb-sparing surgery is generally as effective as amputation in removing the patient’s cancer, it tends to be associated with more early and late complications. Studies also show that, particularly for patients with lower limb bone sarcomas, limb salvage does not provide a better quality of life to patients than amputation, according to the press release. </p><p>In the press release, Wunder said most studies have found that the differences in disability between amputation and limb-sparing patients are smaller than expected. Many revealed no significant differences in psychological health and quality of life between patients who underwent amputations and those who had limb-sparing surgery. However, there appear to be greater advantages to limb-sparing surgery over amputation for higher surgical sites in the lower limb, such as the hip. </p><p>Some studies have compared the costs of amputation vs. limb-sparing surgery. “Up front” surgical costs, the duration of rehabilitation and the need for revisions are all greater for limb-sparing surgery. However, amputation carries greater longer-term costs related to artificial limb manufacture, maintenance and replacement, the researchers said in the press release. </p><p>The authors say additional research is needed to provide a thorough comparison of amputation and limb-sparing surgery in different types of patients with bone and soft tissue sarcomas. </p><p>“Future studies that include function, health-related quality of life, economics and stratification of patients by age will be useful contributions to decision-making … by patients, health care providers and administrators,” Wunder said in the press release. </p><blockquote><p><b>Reference: </b></p><ul><li>Barr R, Wunder J. Bone and soft tissue sarcomas are often curable – But at what cost? A call to arms (and legs). <cite>Cancer</cite>. Advance preview published on Aug. 10. 10.1002/cncr.24458. </li></ul></blockquote>Dr. K.M. Liauhttp://www.blogger.com/profile/05374546719213574530noreply@blogger.com0tag:blogger.com,1999:blog-6155132192235818010.post-41501770378895833702009-08-25T08:52:00.001-07:002009-08-25T08:52:59.361-07:00Promising results seen with minimally invasive repair of Achilles tendon ruptures<p class="artTitle"><br /></p> <p class="deckLine">Surgeon cautions that device may not benefit tendon rupture cases with frayed ends.</p> <i>By </i><span class="p12"><i>Gina Brockenbrough</i></span><br /><cite>ORTHOPEDICS TODAY</cite> 2009; 29:42 <p>DENVER — With minimally invasive surgical repair of Achilles tendon ruptures, surgeons look to obtain the advantages of open repair techniques while avoiding the problems of wound complications and infections. </p> <p>At the <a href="http://www.orthosupersite.com/setContent.asp?setID=425" target="new">American Orthopaedic Foot and Ankle Society’s 24th Annual Meeting</a>, Eric M. Bluman, MD, PhD, discussed the results of minimally invasive repair techniques and highlighted the outcomes of repairs using a minimally invasive Achilles tendon suture device (Achillon, Integra). </p> <p>“I think that minimally invasive repairs have shown promising results in case series and limited level I studies,” Bluman said. “Obviously, more level I studies are needed, and I think that we need to show caution in using [the Achillon] technique. It may be particularly difficult to use in ruptures in which the tendon ends are frayed or in very distal ruptures where tendon material in which to put your sutures in is limited.” </p><center><hr /><span style="color: gray;">advertisement<br /><a href="http://www.orthosupersite.com/clickHandler.asp?bid=3731&scope=Foot%20and%20Ankle" target="bnrWindow" nofollow=""><img src="http://www.orthosupersite.com/images/banners/Cipka_336x280_0908.gif" alt="Cipka" border="0" vspace="10" width="336" height="280" /></a></span><hr /></center> <h4>Tendon suture device </h4> <p>Although his presentation focused on minimally invasive repairs, Bluman use nonoperative treatment for Achilles tendon ruptures when indicated and open repair on occasion. Regarding surgical methods, “I began questioning how I could justify the assault on the posterior tissues in the ankle, when there are methods to obtain repairs with much less invasive methods,” he said. </p> <p>The minimally invasive repair technique he uses is aided by the Achillon device. The technique uses a 2-cm vertical incision that allows for direct visualization of tendon apposition. It also maintains all the sutures deep to the peritenon, Bluman said. “One of the nice things about the vertical incisions is it is easily converted into an open approach if needed.” </p> <table align="right" border="0" cellpadding="5" cellspacing="5" width="210"> <tbody><tr> <td bgcolor="#e9f6ff"> <p class="caption"><img src="http://www.orthosupersite.com/images/content/OT/200905/Achilles.jpg" alt="Achilles tendon" border="1" vspace="3" width="200" height="163" /><br /><b>Image showing the scar</b> left after a minimally invasive Achilles tendon rupture repair.</p> <p class="source" align="right">Image: Bluman EM</p></td> </tr> </tbody></table> <p>Bluman said he has used the technique on many patients, 11 of whom have a minimum 1-year follow-up. “All are back to their pre-rupture activity level,” he said. “These are active duty military people and active retirees. All patients are satisfied and would have the procedure again.” </p> <p>Comparing the uninjured side to the contralateral limb using dynamometry showed no significant difference, he said. He noted no wound problems, infections, re-ruptures, sural nerve injuries or adhesions were seen. </p> <h4>No infections, nerve injuries </h4> <p>A study by the device’s inventor reported on 83 patients whose tendons were repaired using the Achillon device showed no infections and no sural nerve injuries, Bluman said. “They did have three re-ruptures which they attributed to noncompliance of the patients, and all of their patients did eventually return to previous function.” </p> <p>He also cited an independent study performed by Calder, and colleagues which corroborated the results with the device in 25 patients. The investigators found no infections, wound dehiscence, sural nerve injuries or re-ruptures and reported good functional results. </p> <p>Although totally percutaneous techniques reduce infection and wound dehiscence rates to 0%, “There have been reports of increased rates of sural nerve injury as high as 17% in some cases,” Bluman said. “There is an inability to directly visualize tendon apposition as well.” Sural nerve injuries have been shown to be due to lassoing of the nerve with the suture in percutaneous cases. </p> <p>In a study comparing percutaneous and open repair, Lim and colleagues found two adhesions, two re-ruptures and a 21% infection rate in the open repair group. In the percutaneous cohort, they had one re-rupture, one sural neuropathy and had three cases of wound puckering. “This study was limited in that no dynamometry was done and only subjective outcome measures were used for evaluation,” Bluman said. </p> <blockquote><b>For more information: </b> <ul><li>Eric M. Bluman, MD, PhD, can be reached at Madigan Army Medical Center, Orthopaedic Surgery, 9040 A. Fitzsimmons Fr., Tacoma, WA 98431; 253-968-1581; e-mail: <a href="mailto:emb43@cornell.edu">emb43@cornell.edu</a>. He receives miscellaneous non-income support from DePuy. </li></ul> <b> Reference: </b> <ul><li>Bluman EM. Minimally invasive surgical repair of the Achilles tendon rupture. Presented at the American Orthopaedic Foot and Ankle Society 24th Annual Summer Meeting. June 26-28, 2008. Denver.</li></ul></blockquote>Dr. K.M. Liauhttp://www.blogger.com/profile/05374546719213574530noreply@blogger.com0tag:blogger.com,1999:blog-6155132192235818010.post-31628852913758052652009-08-25T08:39:00.000-07:002009-08-25T09:47:06.042-07:00Total Hip Replacement and Hip Resurfacing Surgery<span style="font-size:78%;"><u><span style="color: rgb(0, 128, 128);">Source: http://www.bananarepublican.info/Hip_Surface_Replacement.htm</span></u></span><b><u><span style="color: rgb(0, 128, 128);font-size:180%;" ><br /><br />Background </span></u></b> <p><span style="color: rgb(128, 0, 0);">Hip replacement surgery has been around since the early 1960s.<span style=""> </span>Sir John Charnley experimented in the early 1950s, and he used a small (22 mm) stainless steel ball on a stem in 1962 that he inserted into the femur (hip) bone to replace the femoral head (ball).<span style=""> </span>He then inserted a high-density plastic socket to replace the acetabular (socket) side of the hip joint.<span style=""> </span>Both were secured with a self-curing acrylic polymer known as bone cement.<span style=""> </span></span></p> <div align="center"> <center> <center> </center><table border="0" cellpadding="5" cellspacing="10" width="622" height="46"> <tbody><tr> <td width="622" height="46"> <p align="left"><b><u><span style="color: rgb(0, 128, 128);font-size:130%;" ><a name="THR"></a></span><span style="color: rgb(0, 128, 128);font-size:180%;" >Total Hip Replacements</span></u></b></p> <p><span style="color: rgb(128, 0, 0);">Today, the modular balls are made of a cobalt-chrome metal alloy or a ceramic material, and some of the components are press-fit and do not require bone cement.<span style=""> </span>The procedure remains basically the same: (1) the femur bone is amputated to remove the femoral head; (2) the femoral canal is reamed-out for insertion of the stem; (3) an acetabular socket is affixed to the socket side of the hip; and (4) the ball joint is inserted into the acetabular socket.<span style=""> </span>This is known as a total hip replacement, or more correctly, total hip arthroplasty (THA).</span></p></td> <td width="622" height="46"> <p align="center"><a href="http://www.bananarepublican.info/images/THRdevice.jpg" target="_blank"><img src="http://www.bananarepublican.info/images/THRdevice.jpg" border="0" width="176" height="236" /></a></p> <p align="center"><i><span style="font-size:78%;">image from <a href="http://www.wmt.com/" target="_blank">www.wmt.com</a></span></i></p> <p align="center"><i><span style="color: rgb(0, 128, 128);font-size:100%;" >(Click on image to enlarge)</span></i></p></td> </tr> </tbody></table> </center> </div> <div align="center"> <center> <center> </center><table border="0" cellpadding="5" cellspacing="10" width="622" height="46"> <tbody><tr> <td align="center" valign="middle" width="622" height="46"> <p align="center"><a href="http://www.bananarepublican.info/images/THRwoCEMENT.gif" target="_blank"><img src="http://www.bananarepublican.info/images/THRwoCEMENT.gif" border="0" width="190" height="212" /></a></p> <p align="center"><i><span style="font-size:78%;">image from <a href="http://www.jri-oh.com/" target="_blank">www.jri-oh.com</a></span></i></p> <p align="center"><i><span style="color: rgb(0, 128, 128);font-size:100%;" >(Click on image to enlarge)</span></i></p></td> <td align="center" valign="middle" width="622" height="46"> <p align="center"><a href="http://www.bananarepublican.info/images/THRwoCement.jpg" target="_blank"><img src="http://www.bananarepublican.info/images/THRwoCement.jpg" border="0" width="155" height="218" /></a></p> <p align="center"><i><span style="font-size:78%;">image from <a href="http://www.jri-oh.com/" target="_blank">www.jri-oh.com</a></span></i></p> <p align="center"><i><span style="color: rgb(0, 128, 128);font-size:100%;" >(Click on image to enlarge)</span></i></p></td> </tr> </tbody></table> </center> </div> <div align="center"> <center> <center> </center><table border="0" cellpadding="5" cellspacing="10" width="622" height="46"> <tbody><tr> <td width="622" height="46"> <p class="MsoNormal"><span style="color: rgb(128, 0, 0);">The acetabular socket used in THA is normally lined with a high molecular weight polyethylene (sometimes the liner is ceramic).<span style=""> </span>A metal or ceramic ball is attached to the stem and rotates within the socket.<span style=""> </span>Fine particulate debris is produced from the wearing process of the ball against the liner that leads to tissue reaction.<span style=""> </span>The body’s immune system attacks the debris, and consequently, attacks the adjacent bone supporting the THA device, leading to bone loss and a loosening of the device.<span style=""> </span>This bone loss is known as <a href="http://www.gentili.net/thr/osteolys.htm" target="_blank"> osteolysis</a>.<span style=""> </span>To lessen the amount of wear, a small ball (approximately 30 mm) is used; however, the small size of the ball makes the joint less stable and increases the <a href="http://rothmaninstitute.com/patienteducation/joint/hip/thr-dislocation.htm" target="_blank"> risk of dislocation</a> in certain circumstances. </span></p> <p class="MsoNormal"><span style="color: rgb(128, 0, 0);">The loosening of the THA device requires revision surgery in which a larger diameter stem must be inserted in the femoral canal.<span style=""> </span>Depending on the age and activity of the patient, multiple revision surgeries may be necessary throughout a patient’s life.<span style=""> </span>A young (under 60), active individual can expect only 10 – 15 years before needing revision surgery.<span style=""> </span>Revision surgery can be complex and costly.<span style=""> </span>The lifespan of a THA device is clocked in miles rather than years.</span></p> <p class="MsoNormal"><span style="color: rgb(128, 0, 0);">(<b>Note:</b> <a href="http://www.wmt.com/" target="_blank">Wright Medical Technology, Inc.</a> has developed a <a target="_blank" href="http://www.wmt.com/Downloads/ConserveTotalBrochure.pdf">large femoral head</a> using metal-on-metal technology (see Hip Surface Replacement below) that reduces the risk of dislocations and osteolysis in THRs. The large head THR has received FDA approval and is actively being marketed.)</span></p> </td> </tr> </tbody></table> </center> </div> <div align="center"> <center> <center> </center><table border="0" cellpadding="5" cellspacing="10" width="622" height="46"> <tbody><tr> <td width="622" height="46"><b><u><span style="color: rgb(0, 128, 128);font-size:130%;" ><a name="hip surface"></a></span><span style="color: rgb(0, 128, 128);font-size:180%;" >Hip Surface Replacements</span></u></b> <p class="MsoNormal"><span style="color: rgb(128, 0, 0);">Although it was experimented with and attempted in the 1960s, metal-on-metal “resurfacing” of the femur and acetabulum was abandoned because of loosening of the fittings.<span style=""> </span>With the refinement of acrylic fixation and its very successful use with the THA stem, interest in hip resurfacing was renewed, and it was subsequently used in several countries in the 1970s. (See <a href="http://www.jri-oh.com/hipsurgery/Surface.asp" target="_blank">History of Hip Resurfacing</a>.)<span style=""> </span><o:p> </o:p> </span></p> <p class="MsoNormal"><span style="color: rgb(128, 0, 0);">Resurfacing has the advantage of preserving the femoral bone stock (and marrow contained in the femur). It also has the advantage of easy future revision to THA if it becomes necessary.<span style=""> </span>Since the femur is persevered and not amputated in the initial hip surface replacement surgery, it is available to support a THA stem should revision become necessary.<span style=""> </span>Maintaining the integrity of the femur bone also aids in the mechanical transfer of weight and stress in a more natural manner.<span style=""> </span>Where THA patients often experience thigh pain, recipients of hip surface replacements avoid that particular discomfort.</span></p></td> </tr> </tbody></table> </center> </div> <div align="center"> <center> <center> </center><table border="0" cellpadding="5" cellspacing="10" width="622" height="46"> <tbody><tr> <td width="622" height="46"> <p align="center"><a href="http://www.bananarepublican.info/images/HipSurf.gif" target="_blank"><img src="http://www.bananarepublican.info/images/HipSurf.gif" border="0" width="180" height="210" /></a></p> <p align="center"><i><span style="font-size:78%;">image from <a href="http://www.jri-oh.com/" target="_blank">www.jri-oh.com</a></span></i></p> <p align="center"><i><span style="color: rgb(0, 128, 128);font-size:100%;" >(Click on image to enlarge)</span></i></p></td> <td width="622" height="46"> <p align="center"><a href="http://www.bananarepublican.info/images/HipSurf.jpg" target="_blank"><img src="http://www.bananarepublican.info/images/HipSurf.jpg" border="0" width="225" height="216" /></a></p> <p align="center"><i><span style="font-size:78%;">image from <a href="http://www.jri-oh.com/" target="_blank">www.jri-oh.com</a></span></i></p> <p align="center"><i><span style="color: rgb(0, 128, 128);font-size:100%;" >(Click on image to enlarge)</span></i></p></td> </tr> </tbody></table> </center> </div> <div align="center"> <center> </center><center> </center><table border="0" cellpadding="5" cellspacing="10" width="622" height="46"> <tbody><tr> <td width="622" height="46"> <p align="left"><span style="color: rgb(128, 0, 0);">Using a metal acetabular socket as well as a metal cap over the femur head (metal-on-metal) eliminates the polyethylene debris produced in THA.<span style=""> </span>The metal wear debris from a hip surface replacement produces smaller particles than polyethylene wear debris.<span style=""> </span>The inflammatory response to metal debris is considerably less than that from polyethylene debris.<span style=""> </span>It is believed that the body can partially dissolve and expel metal since it is a naturally occurring substance in the body.<span style=""> </span>There is concern by some of the toxicity of metal, but there is currently no definitive evidence that metal ions cause cancer.<span style=""> </span>Since a metal surface does not wear as readily as a polyethylene lining, a larger ball (approximately 38-51 mm) can be used that adds stability to the joint and reduces the danger of dislocation.<o:p> </o:p></span></p> </td> <td width="622" height="46"> <p align="center"><a href="http://www.bananarepublican.info/images/conserve.jpg" target="_blank"><img src="http://www.bananarepublican.info/images/conserve.jpg" border="0" width="138" height="145" /></a></p> <p align="center"><a href="http://www.bananarepublican.info/images/cnsrvplus.jpg" target="_blank"><img src="http://www.bananarepublican.info/images/cnsrvplus.jpg" border="0" width="199" height="126" /></a></p> <p align="center"><i><span style="font-size:78%;">images from <a href="http://www.wmt.com/" target="_blank">www.wmt.com</a> & <a href="http://www.jri-oh.com/" target="_blank">www.jri-oh.com</a></span></i></p> <p align="center"><i><span style="color: rgb(0, 128, 128);font-size:100%;" >(Click on images to enlarge)</span></i></p></td> </tr> </tbody></table> </div> <center> </center> <table border="0" cellpadding="5" cellspacing="10" width="622" height="46"><tbody><tr> <td width="622" height="46"> <p class="MsoNormal"><span style="color: rgb(128, 0, 0);">The surgery time for hip surface replacement is slightly longer than that for THA.<span style=""> </span>The attachment of the acetabular socket is basically the same.<span style=""> </span>It is press-fitted and does not require bone cement.<span style=""> </span>The attachment of the cobalt-chrome cap requires a more precise alignment, and it takes slightly longer to fit.<span style=""> </span>The hole for the pin insertion must be aligned and drilled, and the dome of the femoral head must be ground and shaped to fit the cap.<span style=""> </span>Some bone cement is used to affix the cap, but the interior surface of both the cap and the socket is such that bone grows into the relief surface to grip the device.<o:p> (See the <a href="http://www.bananarepublican.info/Hip_Resurfacing_Videos.htm" target="_blank">video clips of hip resurfacing surgery</a>.) </o:p> </span></p> </td> </tr> <tr> <td align="center" width="622" height="46"> <p align="left"><i><span style="color: rgb(0, 0, 0);font-size:85%;" >The following images are from an Instructional Lecture delivered at an International Symposium in Fukuoka, Japan on March 16, 1996 by Harlan C. Amstutz, Peter Grigoris, and Frederick J. Dorey entitled "Evolution and future of surface replacement of the hip." Journal of Orthopaedic Science. J Orthop Sci (1998) 3:169-186.</span></i></p> <center> <p><a href="http://www.bananarepublican.info/images/SURGERY2.jpg" target="_blank"><img src="http://www.bananarepublican.info/images/SURGERY2.jpg" border="0" width="160" height="144" /></a> <a href="http://www.bananarepublican.info/images/SURGERY4.jpg" target="_blank"><img src="http://www.bananarepublican.info/images/SURGERY4.jpg" border="0" width="192" height="143" /></a> <a href="http://www.bananarepublican.info/images/SURGERY6.jpg" target="_blank"><img src="http://www.bananarepublican.info/images/SURGERY6.jpg" border="0" width="208" height="143" /></a></p> </center> <p align="left"><i><span style="color: rgb(0, 0, 0);font-size:85%;" > Superimposed hemisurface. Pin centering guide. Cylindrical reamer.</span></i></p> <center> <p><a href="http://www.bananarepublican.info/images/SURGERY8.jpg" target="_blank"><img src="http://www.bananarepublican.info/images/SURGERY8.jpg" border="0" width="142" height="196" /></a> <a href="http://www.bananarepublican.info/images/SURGER12.jpg" target="_blank"><img src="http://www.bananarepublican.info/images/SURGER12.jpg" border="0" width="212" height="147" /></a> <a href="http://www.bananarepublican.info/images/SURGER10.jpg" target="_blank"><img src="http://www.bananarepublican.info/images/SURGER10.jpg" border="0" width="191" height="149" /></a></p> </center> <p align="left"><i><span style="color: rgb(0, 0, 0);font-size:85%;" >Saw cutoff guide and oscillating saw. Chamfered reamer. Femoral head bone preparation.</span></i></p> <p align="center"><i><span style="color: rgb(0, 128, 128);font-size:100%;" >(Click on images to enlarge)</span></i></p></td> </tr> <tr> <td width="622" height="46"> <p class="MsoNormal"><span style="color: rgb(128, 0, 0);"><a href="http://www.bananarepublican.info/Risks_&_Complications.htm" target="_blank">Risks</a> involved in the hip surface replacement surgery are the same as the risks involved in any major surgery.<span style=""> </span>Risks specific to the hip surface replacement involve the potential for cracking in the neck of the femur bone due to the drilling of the guide hole through the neck for the support pin in the metal cap, and also a negative reaction of the femur head to dislocation and being reshaped to fit the metal cap leading to the development of avascular necrosis (bone death)--often referred to as AVN--due to a disruption of blood circulation to the femur head and neck (see <a href="http://www.bananarepublican.info/AVN.htm" target="_blank">AVN Risk</a>).<span style=""> </span>In such instances, a THA could easily be performed to correct the problem.<o:p> </o:p> </span></p> <p class="MsoNormal"><span style="color: rgb(128, 0, 0);">Hip surface replacement in the United States has been pioneered by Harlan C. Amstutz, M.D. at the <a href="http://www.jri-oh.com/" target="_blank">Joint Replacement Institute</a> in Los Angeles, CA.<span style=""> For years, a </span>hip surface replacement in the United States has been labeled an “investigative device” by the Food and Drug Administration (FDA). The longest study has been conducted by <a href="http://www.wmt.com/" target="_blank">Wright Medical Technology, Inc.</a> under the product name of CONSERVE ® Plus Total Resurfacing Hip System.<span style=""> The </span>clinical trials have proceeded for a number of years, and they are nearing their end.<span style=""> </span>They have involved nine surgeons across the country in California, Florida, Texas, Maryland, North Carolina, Ohio, and in the Pacific Northwest.<span style=""> </span><a href="http://www.corin.co.uk/" target="_blank">Corin Medical, Ltd.</a> of the United Kingdom has also begun an FDA study in the United States using the Cormet 2000 device.</span></p><p class="MsoNormal"><b><span style="color: rgb(128, 0, 0);"><i><a href="http://www.bananarepublican.info/Files/MMSAjbjs.pdf" target="_blank">Click here</a> </i>to read the 2-6 year follow up report of the first 400 </span></b><span style="color: rgb(128, 0, 0);"><b> CONSERVE ® Plus</b></span> <b><span style="color: rgb(128, 0, 0);"> hips.</span></b></p><p class="MsoNormal"><span style="color: rgb(128, 0, 0);">In Europe, the Birmingham Hip Surface Replacement System (BHR) has been in use for many years. Smith & Nephew Inc., manufacturer of the BHR, applied for FDA approval, and perhaps due to the long record of use in Europe, they obtained FDA premarket approval to begin commercial distribution of their device in the United States on May 9, 2006 (see <a href="http://www.bananarepublican.info/Files/FDA_Approval_Letter.pdf" target="_blank">FDA approval letter</a> and <a href="http://www.bananarepublican.info/New%20Device%20Approval%20-%20Birmingham%20Hip%20Resurfacing%20%28BHR%29%20System%20-%20P040033.htm" target="_blank">FDA announcement</a>). Because the BHR was not previously used in the United States, the number of American surgeons qualified to use it was limited due to the fact that they had all been participating in the Wright and Corin studies; however, that is destined to change with the FDA approval obtained by Smith & Nephew. </span></p></td></tr></tbody></table>Dr. K.M. Liauhttp://www.blogger.com/profile/05374546719213574530noreply@blogger.com2tag:blogger.com,1999:blog-6155132192235818010.post-13441490748965062572009-08-25T08:27:00.000-07:002009-08-25T08:28:13.365-07:00Hospital for Special Surgery lays claim to being the oldest U.S. orthopedic hospital<p class="artTitle"><br /></p> <p class="deckLine">The 162-bed hospital is known for achievements in sports medicine, joint replacement and research.</p> <i>By </i><span class="p12"><i>Susan M. Rapp</i></span><br /><cite>ORTHOPEDICS TODAY</cite> 2009; 29:58 <p>The 146-year history of Hospital for Special Surgery is rich with clinical, research and educational accomplishments that have improved how orthopedic medicine is practiced. </p><img src="http://www.orthosupersite.com/images/content/OT/200907/OTPioneers.gif" alt="Pioneers" align="left" border="0" vspace="5" width="112" height="115" hspace="5" /> <p>In 1863, Hospital for Special Surgery (HSS) in New York began as the Hospital for the Ruptured and Crippled in a philanthropic effort to provide medical care to injured Civil War soldiers and needy city residents. It has been led by 11 surgeons-in-chief and now has 85 full-time orthopedic surgeons who performed 24,000 orthopedic procedures in 2008, including more than 7,366 joint replacements, according to current HSS Surgeon-in-Chief Thomas P. Sculco, MD. </p> <p>The list of musculoskeletal medicine pioneers from HSS reads like a who’s who of orthopedic innovation: Harlan C. Amstutz, MD, Albert Burstein, PhD, John N. Insall, MD, Chitranjan S. Ranawat, MD, Peter S. Walker, PhD, and Russell E. Warren, MD, among others. </p> <p> “The many strong physician contributors at HSS over the years are typified by how well they integrated excellent patient care with critical review and analysis of clinical results and applied, basic science,” said Douglas W. Jackson, MD, Chief Medical Editor of <cite>Orthopedics Today</cite>. </p> <table align="center" border="0" cellpadding="5" cellspacing="5" width="210"> <tbody><tr> <td bgcolor="#e9f6ff"> <p class="caption"><img src="http://www.orthosupersite.com/images/content/OT/200907/ot0709sculcoF1.jpg" alt="Hospital for Special Surgery" border="1" vspace="3" width="400" height="235" /><br /><b>Hospital for Special Surgery (HSS)</b> is an independent, free-standing orthopedic hospital that is closely affiliated with a medical center and the Weill Cornell Medical College for conducting musculoskeletal research. </p> <p class="source" align="right">Images: Hospital for Special Surgery</p></td> </tr> </tbody></table> <h4>Leading the way </h4> <p>“We are the oldest orthopedic hospital, certainly in the United States and probably in the world,” Sculco said. </p> <p>HSS was founded by the first surgeon-in-chief, James Knight, MD, whose interest in orthopedics was limited to designing and constructing braces for children’s congenital deformities. </p> <p>Eventually HSS’ focus shifted entirely to the treatment and rehabilitation of the musculoskeletal system for patients locally and around the world, which remains the mission of the 162-bed hospital. HSS also has </p> <h4>Surgical innovation </h4> <p>An early HSS pioneer, Virgil P. Gibney, MD, became the second surgeon-in-chief in 1887 and held the position 40 years. He instituted changes in the work performed at the hospital and wrote about hip surgery. </p> <p>“Virgil Gibney was responsible for establishing the first orthopedic residency,” in the 1890s, Sculco told <cite>Orthopedics Today</cite>. </p> <p> “He put the hospital on the map as a surgical hospital,” said David B. Levine, MD, Director of HSS Alumni Affairs.</p> <table align="center" bgcolor="#e9f6ff" border="0" cellpadding="5" cellspacing="0" width="420"> <tbody><tr valign="top"> <td> <p class="caption"><img alt="James Knight, MD" src="http://www.orthosupersite.com/images/content/OT/200907/ot0709sculcoF2.jpg" border="1" width="200" height="272" hspace="3" /><br /><b>The first HSS Surgeon-in-Chief James Knight, MD,</b> founded the hospital in 1863 at his home in lower Manhattan. He was a general physician rather than an orthopedic surgeon.</p></td> <td> <p class="caption"><img alt="John Marshall, MD" src="http://www.orthosupersite.com/images/content/OT/200907/ot0709sculcoF4.jpg" border="1" vspace="3" width="200" height="257" /><br /><b>The late John Marshall, MD,</b> a physician at HSS, is credited with launching sports medicine as an academic discipline. </p> </td> </tr> </tbody></table> <h4>Gibney’s leadership </h4> <p>Gibney was the first president of the American Orthopaedic Association. </p> <p>Under Philip D. Wilson Sr., MD, who became the fifth surgeon-in-chief in 1935, the hospital changed its name to The Hospital for Special Surgery, moved to its current site and affiliated with Weill Cornell Medical College. In 1996, HSS dropped “The” from the beginning of its name. </p> <p>“Wilson, Sr. had the vision to make it a very specialized institution and improve its research and academic mission,” Sculco said. </p> <p>Wilson was AAOS president in 1934. His son, Philip D. Wilson Jr., MD, was the eighth surgeon-in-chief and AAOS president in 1972.</p> <h4>Knee arthroplasty </h4> <p>Wilson Jr. bridged the gap between engineering and biomechanics, according to Sculco. </p> <p>“He created an environment here in the late 1960s and early 1970s for the design and development of implants with surgeons collaborating closely with engineers and basic scientists. To a large extent, that still goes on today.” </p> <p>The joint arthroplasty research work performed by engineers like Walker and Burstein exemplifies that collaboration, yielding the duo-condylar knee developed in 1971. In 1973 Walker broached the concept of the cemented cruciate-sacrificing total condylar knee prosthesis that improved on other available designs. </p> <p>Burstein and Insall developed the first posterior stabilized knee prosthesis in 1979 and in 1989 an updated version was marketed. </p> <h4>Subspecialization </h4> <p>In the 1970s, “[Wilson, Jr.] reorganized the orthopedic department into subspecialties and anatomic regions,” Levine said. “He was way ahead of his time.” </p> <p>Specialty clinics for treating groups of patients with similar problems followed. </p> <p>Sculco said this change at HSS mainly influenced what happened nationally and started the trend toward subspecialization. More importantly, Wilson, Jr. created an environment where individual doctors and researchers could flourish. </p> <p>The research accomplishments at HSS are as strong as its clinical areas with work underway in tendon and ligament repair, soft tissue healing, osteolysis, spine, sports medicine, cartilage repair, osteoarthritis and other areas. The hospital has a strong commitment to registries and has several, including a prospective total joint replacement registry with data on nearly 13,000 patients and one containing more than 20,000 retrieved implants. </p> <table align="center" border="0" cellpadding="5" cellspacing="5" width="210"> <tbody><tr> <td bgcolor="#e9f6ff"> <p class="caption"><img src="http://www.orthosupersite.com/images/content/OT/200907/ot0709sculcoF3.jpg" alt="Brace shop" border="1" vspace="3" width="400" height="284" /><br /><b>Workers at the HSS brace shop</b> are shown working in the early 1900s. Bracing was a large component of treatments at the hospital. More recently, orthopedic implants were fabricated on-site at the hospital. </p> </td> </tr> </tbody></table> <h4>Retrieval program </h4> <p>Timothy Wright, PhD, Director of the Department of Biomechanics started the HSS retrieval program in 1977 with Burstein. </p> <p>The research and biomechanics programs Walker had in place when Wright joined HSS in 1976 were unmatched in the world. About then, they started collaborating with the engineering department at Cornell University’s main campus, which provided valuable resources for computer modeling, biomechanical studies and related research, Wright said. </p> <p>“That collaboration has been really vital and continues today,” he told <cite>Orthopedics Today</cite>. </p> <h4>Collaboration </h4> <p>Internal collaboration between surgeons like Ranawat, Insall and Allan E. Inglis, MD, also spawned many successful concepts. </p> <p>“If you look at modern total knee replacements some 30 years later, about half the market consists of posterior stabilized knees. Insall and Burstein developed that concept originally. That was a big stepping stone because it took an implant that did all the right things — it resurfaced bone so the pain went away and was well-fixed — and assured patients of something close to normal function and a larger range of motion,” Wright said, noting that nothing remotely like it was being done elsewhere. </p> <h4>Translational research </h4> <p>Another HSS achievement: digitizing radiographs and CT scans so they could be stored on computers and manipulated. “We were at the forefront of computer-aided design of implants,” Wright said. </p> <p>Currently, HSS biomechanics researchers are investigating areas including tissue engineering and bone adaptation that will no doubt impact the orthopedic therapies of the future. Wright said researchers at HSS thrive because they can focus solely on the musculoskeletal system. </p> <p>“It is a wonderful environment to do translational research that exists to go not just from bench top to bed, but more importantly, from bed to bench top and then back to the bed,” he said. </p> <table align="center" border="0" cellpadding="5" cellspacing="5" width="210"> <tbody><tr> <td bgcolor="#e9f6ff"> <p class="caption"><img src="http://www.orthosupersite.com/images/content/OT/200907/ot0709sculcoF5.jpg" alt="Scoliosis" border="1" vspace="3" width="400" height="272" /><br /><b>HSS made its name</b> early on by treating children for scoliosis and other deformities, which was a common reason for the establishment of many orthopedic hospitals. </p> </td> </tr> </tbody></table> <h4>On the field </h4> <p>HSS boasts an early sports medicine specialty practice started by John Marshall, MD, which Warren, surgeon-in-chief emeritus, greatly expanded. HSS physicians are team physicians or associate team physicians for six major New York-area professional sports teams. </p> <p>“I have valued the published results and teachings of John Marshall. He impacted sports medicine by making it more of an academic discipline,” Jackson said. </p> <p>In terms of academics, HSS has 40 residents and a large multi-national orthopedic fellowship program, with at least one fellow working with each service and multiple fellows working with the larger ones. </p> <p>“Our fellowship program has been very successful. It spawns research and interaction between our faculty, fellows and researchers which generates research studies,” Sculco said.</p> <blockquote> <b>For more information: </b> <ul><li> Douglas W. Jackson, MD, can be reached at Memorial Orthopedic. Surgical Group, 2760 Atlantic Ave., Long Beach, CA 90806; 562-424-6666; e-mail: <a href="mailto:jacksondw@aol.com" target="new">jacksondw@aol.com</a>. </li><li> David B. Levine, MD, can be reached at HSS, 535 E. 70th St., New York, NY 10021; 212-606-1555; e-mail: <a href="mailto:LevineDB@hss.edu" target="new">LevineDB@hss.edu</a>. </li><li> Thomas P. Sculco, MD, can be reached at HSS, Belaire Building, 2nd Floor, 525 East 71st St., New York, NY 10021; 212-606-1475; e-mail: <a href="mailto:sculcot@hss.edu" target="new">sculcot@hss.edu</a>. </li><li> Timothy Wright, PhD, can be reached at HSS, Caspary Research Building, 541 East 71st St., New York, NY 10021, 212-606-1093; e-mail: <a href="mailto:wrightt@hss.edu" target="new">wrightt@hss.edu</a>. </li></ul></blockquote>Dr. K.M. Liauhttp://www.blogger.com/profile/05374546719213574530noreply@blogger.com0tag:blogger.com,1999:blog-6155132192235818010.post-43117682934094383202009-08-25T08:26:00.000-07:002009-08-25T08:27:01.473-07:00Consider femoral morphology, bone quality in selecting patients for hip resurfacing<p class="deckLine">Patients who seek hip resurfacing want to lead an active lifestyle without limitations, surgeon says.</p> <i>By </i><span class="p12"><i>Gina Brockenbrough</i></span><br /><cite>ORTHOPEDICS TODAY</cite> 2009; 29:10 <p>The indications for total hip resurfacing are narrow, and careful patient selection and surgical technique are crucial to obtaining good outcomes. </p> <p>At <a href="http://www.othawaii.com/" target="_new"><cite>Orthopedics Today</cite> Hawaii</a> 2009, Section Chair Thomas P. Schmalzried, MD, discussed the indications for <a href="http://www.orthosupersite.com/searchResults.asp?condition222=any&searchStr=hip+resurfacing&condition=phrase&x=28&y=13" target="_new">hip resurfacing</a> and presented tips on performing the procedure. </p> <p>“The indications have been refined,” Schmalzried said. “There is no need for any new comer to repeat the learning curve. The patients have higher activity and break the no-restriction policy, and are at actually higher survivorship than total hip in the at-risk patient.” </p><center><hr /><span style="color: gray;">advertisement<br /><object border="0" vspace="10" width="336" height="280"><param name="movie" value="images/banners/JJ_336x280_0903.swf"><embed src="http://www.orthosupersite.com/images/banners/JJ_336x280_0903.swf" width="336" height="280"></embed></object> </span><hr /></center> <h4>Indications </h4> <p>The results of the procedure are due to the quality of the starting material, he said. If the walls of the acetabular component are less than 4 mm thick, the amount of acetabular reaming is similar to that for a conventional total hip component, and the operation is conservative on the acetabular and femoral side. </p> <p>“There are differences on the femoral side,” Schmalzried said. “The offset of the femur after resurfacing surgery is just like it was before. You cannot change the offset. You cannot improve the offset.” </p> <p>He also noted that the procedure can lengthen limbs up to 1 cm. </p> <p>He has narrower indications for resurfacing than total hip replacement (THR). “My indications are those patients who are at an increased risk for failure with a total hip, [have a] good proximal femur or a femoral deformity or device that would complicate or difficult putting a total hip in,” Schmalzried said. </p> <table align="right" border="0" cellpadding="5" cellspacing="5" width="210"> <tbody><tr> <td bgcolor="#e9f6ff"> <p class="caption"><img src="http://www.orthosupersite.com/images/content/OT/200908/ThomasSchmalzried_Hawaii09.jpg" alt="Thomas P. Schmalzried, MD" border="1" vspace="3" width="250" height="287" /><br /><b>Thomas P. Schmalzried, MD,</b> discussed the indications for hip resurfacing and presented tips on performing the procedure at the <cite>Orthopedics Today</cite> Hawaii 2009 meeting.</p> <p class="source" align="right">Image: Beadling L, <cite>Orthopedics Today</cite></p></td> </tr> </tbody></table> <h4>Patient selection </h4> <p>He cited research by Harlan C. Amstutz, MD, which reported a higher risk of femoral-side failure after metal-on-metal surface replacement in women, patients with smaller component sizes, large femoral defects, relative varus positioning and older patients. Large men with osteoarthritis had the highest survivorship rates, because they had denser bone and larger areas of fixation, Schmalzried said. </p> <p>He said surgeons should consider resurfacing because patients are living longer and harder. </p> <p>“In the eyes of many of our patients, it is not longevity,” Schmalzried said. “It is lifestyle. They are unaccepting of disability. They seek early intervention and they do not want any restrictions. They are actually more concerned about having the big spike put in their femur than the resection of the head.” </p> <h4>THR limits </h4> <p>Some surgeons emphasize the limitations of THR, making resurfacing an even more attractive option for patients. </p> <p>“To some degree, the medical community has created a poor image for total hips,” Schmalzried said. </p> <p>Recent studies have also indicated that resurfacing maintains bone, and that patients have better outcomes with earlier intervention. Schmalzried attributed the good outcomes of resurfacing to the patients. </p> <p>“The resurfacing patients are, on average, more active than total hip replacement patients,” he said. “There are at least three studies that have seen that.” He also highlighted differences between the attitudes of patients undergoing resurfacing and THR. “The patients seek resurfacing because they intend to have a vigorous lifestyle and not accept any limitations,” Schmalzried said. </p> <h4>Tips </h4> <p>Schmalzried obtains AP, frog lateral and Johnston lateral views to perform the procedure. </p> <p>“You are really resurfacing around the neck,” Schmalzried said. “You are not really resurfacing the head, so you want to make sure that you understand what is going on at the head-neck junction and translate those landmarks on the radiograph into your operation. Do not get this confused with small incision surgery. When you are first starting to do this, make a reasonable skin incision.” In addition, surgeons should avoid high lateral open angles and increased anteversion. </p> <p>He uses femoral suction to get a dry interface for the cement. “Retrieval studies have indicated that aberrations in cementing are a consistent finding in short-term failures,” Schmalzried said. </p> <p>Surgeons can also convert the procedure to a total hip if there is a femoral-side failure. </p> <p>“In terms of operative time and blood loss, it is very similar to the primary total hip,” he said.</p> <blockquote><b>For more information: </b> <ul><li>Thomas P. Schmalzried, MD, medical director, Joint Replacement Institute, can be reached at 2200 W. Third St., Los Angeles, CA 90057, 213-484-7600; e-mail: <a href="mailto:schmalzried@earthlink.net" target="_new">schmalzried@earthlink.net</a> He has a consulting and research relationship with DePuy, a Johnson & Johnson company, and Stryker Corp.</li></ul> <p> <b>Reference: </b></p> <ul><li>Schmalzried TP. Update on total hip resurfacing. Presented at <a href="http://www.orthosupersite.com/setContent.asp?setID=520" target="_new"><cite>Orthopedics Today</cite> Hawaii 2009</a>. Jan. 11-14, 2009. Kohala Coast, Hawaii. </li></ul></blockquote>Dr. K.M. Liauhttp://www.blogger.com/profile/05374546719213574530noreply@blogger.com1tag:blogger.com,1999:blog-6155132192235818010.post-30396975150687620622009-08-25T08:21:00.000-07:002009-08-25T08:22:26.978-07:00Hip and back fractures increase mortality rates in people older than 50 years<p class="artTitle"><br /></p> <br />1<sup>st</sup> on the web (August 6, 2009)<p>Vertebral and hip fractures are associated with an increased mortality rate in individuals over the age of 50, according to a study published this week in the <cite>Canadian Medical Association Journal</cite>. </p><p>According to the 5-year study, approximately 25% of people who develop a <a href="http://www.orthosupersite.com/searchResults.asp?condition222=any&searchStr=hip+fracture&condition=phrase&x=21&y=14" target="New">hip fracture</a> and 16% who develop a <a href="http://www.orthosupersite.com/searchResults.asp?condition222=any&searchStr=spine+fracture&condition=phrase&x=18&y=10" target="New">spine fracture</a> past the age of 50 will die within 5 years, according to a press release. </p><p>The research was part of the Canadian Multicentre Osteoporosis Study and consisted of 2,187 men and 5,566 women. It differs from previous studies in that the group of participants involved was representative of the general population, researchers said in the press release. Individuals were recruited via telephone lists based on postal code areas. </p><center><hr /><span style="color: gray;">advertisement<br /><a href="http://www.orthosupersite.com/clickHandler.asp?bid=3733&scope=Trauma" target="bnrWindow" nofollow=""><img src="http://www.orthosupersite.com/images/banners/MTJR_336x280_0908.gif" alt="MTJR" border="0" vspace="10" width="336" height="280" /></a></span><hr /></center><p>“Hip fractures may have long-lasting effects that result in eventual death by signaling or actually inducing a progressive decline in health,” co-investigator George Ioannidis, PhD, wrote in the study. “Our results also showed that vertebral fracture was an independent predictor of death.” </p><p>The authors concluded that interventions such as osteoporosis medications, fall prevention strategies, hip protectors and enhanced rehabilitation after fracture must be introduced to improve mobility and strength. </p><p>In a related commentary, Maureen C. Ashe, PhD, BScPT, wrote that cognitive impairment and dementia are major risk factors for fractures, but patients with these conditions are often difficult to recruit and are thus underrepresented. </p><p>“If this was the case in this Canadian cohort (and it most likely was), the mortality data may contain ‘healthy volunteer bias’ and the population mortality rates may even be higher than reported by Ioannidis and his colleagues,” she wrote. </p><blockquote><p><b>For more information: </b></p><ul><li>George Ioannidis, PhD, is a health research methodologist with McMaster University in Hamilton, Ontario. He can be reached at 501-25 Charlton Ave. East, Hamilton, ON L8N 1Y2; e-mail: g.ioannidis@sympatico.ca. </li></ul></blockquote><blockquote><p><b>Reference: </b></p><ul><li>Ioannidis G, Papaioannou A, Hopman WM, et al. Relation between fractures and mortality: Results from the Canadian Multicentre Osteoporosis Study. <cite>Can Med Assoc J</cite>. Aug. 4, 2009. DOI:10.1503/cmaj.081720</li></ul></blockquote><p> <br /></p>Dr. K.M. Liauhttp://www.blogger.com/profile/05374546719213574530noreply@blogger.com0tag:blogger.com,1999:blog-6155132192235818010.post-18511858785658859932009-08-25T08:16:00.000-07:002009-08-25T08:18:53.349-07:00Purified stem cell group shows greater levels of Type II collagen<p class="artTitle"><br /></p> <i>By </i><span class="p12"><i>Gina Brockenbrough</i></span><br />1<sup>st</sup> on the web (May 29, 2009)<p>MIAMI — Subpopulations of human <a href="http://www.orthosupersite.com/searchResults.asp?condition222=any&searchStr=mesenchymal+stem+cells&condition=phrase&x=26&y=20" target="New">mesenchymal stem cells</a> (MSCs) may have varying potential for chondrogenic expression, according to a study presented here. </p><p>To determine if a purified subpopulation of MSCs would lead to a more uniform differentiation of cells into chondrocytes, Charles C. Secretan, MD, and his colleagues investigated the CD44 cell surface receptor which is believed to play a role in cartilage matrix generation and homoeostasis. </p><p>They reported their findings at the <a href="http://www.orthosupersite.com/setContent.asp?setID=610" target="New">8th World Congress of the International Cartilage Repair Society</a>, here. </p><p>After culturing and isolating MSCs, the investigators used flow cytometry to detect the surface antigens in the population. They then created the following three groups of cells using a fluorescence-activated cell sorter: </p><ul><li>a CD44-positive population; </li><li>a CD44-negative population; and, </li><li>a mixed or native population. </li></ul><p>They used real-time polymerase chain reaction to quantify and compare the Type I collagen, Type II collagen and aggrecan content in the stem cell-derived chondrocytes in each group. </p><p>The investigators discovered significantly greater Type II collagen expression in the CD44-positive population compared to the mixed and CD44-negative groups. The CD44-positive group also showed significantly greater aggrecan expression than the mixed population. </p><p>However, the investigators found no significant difference in the aggrecan expression between the CD44-positive and negative groups. All of the groups showed high levels of Type I collagen, Secretan said. </p><p>“Human MSC populations isolated from the bone marrow [are] heterogeneous,” he said during his presentation. “There does appear to be subpopulations in human mesenchymal stem cells with functional and differential capabilities, and a CD44 purified mesenchymal stem cell population did show an enhanced ability to produce more Type II collagen and aggrecan [compared to a mixed population].” </p><blockquote><p><b>Reference:</b> </p><ul><li>Secretan CC, Bater J, Bagnall KN, et al. Isolation of a subpopulation of human mesenchymal stem cells with enhanced chondrogenic potential. #9.2.5. Presented at the 8th World Congress of the International Cartilage Repair Society. May 23-26, 2009. Miami. </li></ul></blockquote>Dr. K.M. Liauhttp://www.blogger.com/profile/05374546719213574530noreply@blogger.com0tag:blogger.com,1999:blog-6155132192235818010.post-6420661173251948072009-08-25T08:15:00.001-07:002009-08-25T08:16:10.133-07:00Scientists closer to making implantable bone material for orthopedics<p class="artTitle"><br /></p> <br />1<sup>st</sup> on the web (July 28, 2009)<p>Researchers are closer to understanding how to grow replacement bones using <a href="http://www.orthosupersite.com/searchResults.asp?condition222=any&searchStr=stem+cell+technology&condition=phrase&x=31&y=13" target="New">stem cell technology</a>, according to research published Sunday in the journal <cite>Nature Materials</cite>. </p><p>Scientists from Imperial College London compared the bone-like material grown from three different, commonly used, clinically relevant cell types and discovered significant differences between the qualities of bone-like material that these can form, according to a press release. </p><p>Among these discoveries: Bone-like materials that were grown from bone cells in mouse skull and mouse bone marrow stem cells successfully mimicked many of the hallmarks of real bone, including stiffness. The investigators also found that the bone-like material grown from mouse embryonic stem cells was much less stiff and complex in its mineral composition when compared to the other materials. </p><p>The scientists suggest that further research is now needed to explore the implications of these results for different stem cell therapies. </p><p>Researchers used laser-based Raman spectroscopy and multivariate statistical analysis techniques, which enabled them to compare and analyze data about the growth of different cell populations and understand the detailed chemical make-up of live cells as they grew. They also used a nano-indenter and high resolution electron microscopy, which allowed them to probe the samples so they could understand how stiff the bone-like materials were and what their structure was at a microscopic level. </p><p>“Our study provides an important insight into how different cell sources can really influence the quality of bone that we can produce,” Molly Stevens, a professor with the Institute of Biomedical Engineering at Imperial College London, said in the press release. “It brings us one step closer to developing materials that will have the highest chance of success when implanted into patients.” </p><blockquote><p><b>Reference: </b></p><ul><li>Gentleman E, Swain RJ, Evans ND, et al. Comparative materials differences revealed in engineered bone as a function of cell-specific differentiation. <cite>Nat Mater</cite>. July 26, 2009. </li></ul></blockquote><blockquote><p><b>For more information:</b> </p><ul><li><a href="http://www3.imperial.ac.uk/newsandeventspggrp/imperialcollege/newssummary/news_27-7-2009-10-48-41?newsid=71344/" target="New">www.imperial.ac.uk</a> </li></ul></blockquote>Dr. K.M. Liauhttp://www.blogger.com/profile/05374546719213574530noreply@blogger.com0tag:blogger.com,1999:blog-6155132192235818010.post-15275903665444441042009-08-25T08:13:00.000-07:002009-08-25T08:15:06.289-07:00NY surgeon survives lightning strike and discovers a surprising musical ability<p class="artTitle"><br /></p> <p class="deckLine">Anthony D. Cicoria, MD, has gained notoriety from his near-death experience and music-filled dreams.</p> <i>By </i><span class="p12"><i>Susan M Rapp</i></span><br /><cite>ORTHOPEDICS TODAY</cite> 2009; 29:52 <p>The first CD of music written and performed by orthopedic surgeon Anthony D. Cicoria, MD, a novice piano composer, contains 27 minutes and 44 seconds of haunting themes, pensive melodies, sudden crescendos and peaceful interludes that should appeal to many listeners. </p> <p>However, most will likely listen a little closer to this CD released last year once they learn Cicoria did not get to where he is today musically, which includes playing sold-out concerts, by practicing or studying composition. </p> <p align="justify">Cicoria became a pianist and composer by accident. </p><center><hr /><span style="color: gray;">advertisement<br /><a href="http://www.orthosupersite.com/clickHandler.asp?bid=3733&scope=Special%20Features" target="bnrWindow" nofollow=""><img src="http://www.orthosupersite.com/images/banners/MTJR_336x280_0908.gif" alt="MTJR" border="0" vspace="10" width="336" height="280" /></a></span><hr /></center> <h4>Near-death experience </h4> <p>In 1994 Cicoria was struck by lightning and suffered cardiac arrest. The way he tells it, he briefly died, saw himself dead on the ground in an out-of-body experience and, for some unknown reason he is still grappling with, lived to tell his amazing story. </p> <p>With this new “life” came an implausible change in a man who worked 10- to 12-hour-days as the only orthopedist in Chenango County, N.Y., and enjoyed life raising his three children, but had little time for much else. </p> <p>“It was just a few weeks afterwards when I started to have a craving to hear classical piano music,” Cicoria told <cite>Orthopedics Today</cite>. </p> <p>The craving was so strong he felt compelled to drive nearly an hour to the closest large music store and purchase a CD of Chopin piano music. He soon acquired a piano. </p> <p>“And that’s how it all started,” according to Cicoria. </p> <table align="center" border="0" cellpadding="5" cellspacing="5" width="210"> <tbody><tr> <td bgcolor="#e9f6ff"> <p class="caption"><img src="http://www.orthosupersite.com/images/content/OT/200908/ot0809cicoriaF1.jpg" alt="Anthony D. Cicoria, MD" border="1" vspace="3" width="400" height="281" /><br /><b>Cicoria is the only orthopedist in his county</b>. He must fit his piano practicing, composing and performances into his busy surgical and office schedule.</p> <p class="source" align="right">Images: Cicoria AD </p></td> </tr> </tbody></table> <h4>Music in dreams </h4> <p>Cicoria eventually learned to play the piano studying on his own and later starting lessons in 1998 with Sandra McKane, who was trained at the Julliard School. </p> <p>After the accident, pieces of complex music started coming to him in dreams or emerged when he was playing other composer’s works, haunting him until he could get them notated, which he did with special computer software and help from McKane and others. </p> <p>Now when Cicoria writes, “The music comes and unfolds,” he said. </p> <h4>Publicized case </h4> <p>Cicoria admitted that dealing with this new musical component of his life over the past 15 years has not been easy, especially at first. </p> <p>“Somehow, I had deluded myself into thinking the only reason I had survived had something to do with this music. I really became a bit of a fanatic about it,” he said. </p> <p>Cicoria connected in 2006 with world-famous neurologist Oliver Sacks, MD, FRCP, who helped him gain insight into the possible causes of his unusual new musical abilities. After that meeting, Cicoria’s story was widely covered by the media, including a BBC television feature and a piece by Sacks published in <cite>The New Yorker</cite> in 2007. </p> <p>Cicoria has since heard from others who underwent equally unusual experiences and from some who claim his music healed their chronic pain or affected them in other positive ways. </p> <h4>Wake-up call </h4> <p>Fortunately, there were few physical sequelae from the lightning strike. </p> <p>“I had a burn on my face where [the lightning bolt] went in and on my foot where it came out, so I had gotten hit pretty hard. Although for a week afterwards I was pretty fuzzy, it eventually cleared,” he said. </p> <p>Immediately following the lightning strike, “I was not sure what it all meant other than the fact it was kind of a wake-up call.” </p> <p>Tests showed no changes to Cicoria’s brain that might account for his new-found music ability, however Sacks developed theories about what happened. “He thinks there had to have been some rewiring of my brain because I had a presumed cardiac arrest,” Cicoria said. </p> <table align="center" border="0" cellpadding="5" cellspacing="5" width="210"> <tbody><tr> <td bgcolor="#e9f6ff"> <p class="caption"><img src="http://www.orthosupersite.com/images/content/OT/200908/ot0809cicoriaF2.jpg" alt="Cicoria playing piano" border="1" vspace="3" width="400" height="260" /><br /><b>After surviving a lightning strike</b>, Anthony D. Cicoria, MD, suddenly wanted to play the piano and started composing music. He now urges his children and others to follow their passions in life because they will always lead to happiness. </p> </td> </tr> </tbody></table> <h4>Musical gene </h4> <p>Before 1994, Cicoria’s musical interest pretty much consisted of listening to rock and roll. “There was not much of anything else,” he said. His formal music training included a year of piano lessons when he was 7 years old which he disliked. </p> <p>“There must be some sort of a music gene in the family. One of Dr. Sacks’ speculations is this gene was there in the brain and the lightning has allowed it to be expressed,” Cicoria said. </p> <p>Before all the publicity emerged, Cicoria said he was reticent about discussing his experiences. “It almost sounds a little bit on the fringe of reality. It is not exactly the kind of thing you want to portray as a physician and surgeon.” </p> <p>“Until Sacks took it out of the closet, it was my private little story and my private quest for music. All of a sudden it was everywhere. Perhaps it was supposed to be that way. That is why I have got to laugh and say it has taken on a life of its own, because had it been left up to me it would still be in the drawer. It would be between me and my muse, whatever that is.” </p> <p>With more concerts scheduled and a symphony, two concertos and other pieces in the works, Cicoria is far from locking his talents away. He hopes to eventually transition to where music is the centerpiece of his life, but “I also do not see myself just quitting orthopedics either. It will be an interesting next 5 to 10 years.”</p> <blockquote><b>For more information: </b> <ul><li>Anthony D. Cicoria, MD, can be reached at P.O. Box 271, Norwich, NY 13815; 607-337-4700; e-mail: <a href="mailto:tcicoria@yahoo.com" target="_new">tcicoria@yahoo.com</a>. </li></ul> <p align="justify"><b>References:</b> </p> <ul><li><a href="http://cdbaby.com/cd/drtonycicoria" target="_new">http://cdbaby.com/cd/drtonycicoria</a> </li><li>Sacks O. A neurologist’s notebook: A bolt from the blue: Where do sudden passions come from? <cite>The New Yorker</cite>. 2007; Jul 23:38-42. </li></ul></blockquote><table style="background-color: rgb(233, 242, 236);" cellpadding="0" cellspacing="0" width="650"><tbody><tr><td valign="top" width="650" height="1"><br /></td></tr><tr><td><br /></td></tr></tbody></table>Dr. K.M. Liauhttp://www.blogger.com/profile/05374546719213574530noreply@blogger.com0tag:blogger.com,1999:blog-6155132192235818010.post-17745512796980947842009-08-25T08:12:00.001-07:002009-08-25T08:12:21.864-07:00Hyaline-like tissue seen in defects treated with stem cells and platelet rich plasma<p class="artTitle"><br /></p> <p class="deckLine">Analysis showed a higher relation between Collagen I and II after stem cell treatments.</p> <i>By </i><span class="p12"><i>Gina Brockenbrough</i></span><br /><cite>ORTHOPEDICS TODAY</cite> 2009; 29:28 <p>MIAMI — Treating chondral defects with mesenchymal stem cells delivered in a scaffold with platelet-rich plasma may result in repair tissue with properties more similar to normal hyaline cartilage than the repair tissue seen in controls, the use of scaffolds alone or loading scaffolds with stem cells alone. </p> <p>“The treatment of full-thickness chondral defects with a collagen scaffold, mesenchymal stem cells compromised to the chondrocyte lineage and platelet rich plasma shows promising results,” Alex Vaisman, MD, said during his presentation at the <a href="http://www.orthosupersite.com/setContent.asp?setID=610" target="_new">8th World Congress of the International Cartilage Repair Society</a>. “Nevertheless, none of the treatment groups healed with normal hyaline cartilage.” </p> <img src="http://www.orthosupersite.com/images/content/OT/200907/ICRS-06_OT.jpg" alt="ICRS" align="left" border="1" vspace="5" width="200" height="90" hspace="5" /> <p>To evaluate the properties of repair tissue created after treating full-thickness chondral defects of the knee with a bi-layer collagen scaffold embedded with autologous mesenchymal stem cells (MSCs) induced to chondrocyte differentiation and platelet-rich plasma (PRP), Vaisman and his colleagues created 20 mm<sup>2</sup> acute full-thickness chondral defects in 36 femoral condyles of adult male New Zealand White rabbits. </p> <p>They randomly assigned the rabbits to the following four groups: </p> <ul><li> Group 1 in which the lesion was left untreated; </li><li> Group 2 in which surgeons implanted a scaffold without MSCs or PRP; </li><li> Group 3 in which a scaffold containing MSCs was implanted; and </li><li> Group 4 in which a scaffold contained MSCs and PRP. </li></ul> <p>The investigators sacrificed the rabbits after 6 months. They evaluated the femoral condyles macroscopically, histologically using hematoxylin-eosin and Toluidine Blue staining, and molecularly using quantitative real-time polymerase chain reaction of Collagen II/I and aggrecan/versican. </p> <h4>Evaluation </h4> <table align="right" border="0" cellpadding="5" cellspacing="5" width="210"> <tbody><tr> <td bgcolor="#e9f6ff"> <p class="caption"><img src="http://www.orthosupersite.com/images/content/OT/200907/ot0709vaismanF1.jpg" alt="Rabbit knee with a scaffold" border="1" vspace="3" width="200" height="240" /><br /><b>A rabbit knee with a scaffold</b> containing mesenchymal stem cells and platelet-rich plasma.</p> <p class="source" align="right">Image: Vaisman A</p></td> </tr> </tbody></table> <p>Using macroscopy, the investigators discovered fibrous tissue without bony exposure in the control group. </p> <p>“Groups 2 and 3 showed a hypertrophic, soft, irregular tissue covering the whole lesion,” Vaisman said. “Group 4 has similar- to normal-hyaline cartilage.” </p> <p>Histology revealed that all of the groups had some fibrocartilage, but the investigators found no significant difference among the groups. </p> <p>“However, groups 3 and 4 had a slightly more similar appearance to hyaline cartilage than the other groups,” Vaisman said. </p> <p>Upon molecular analysis, the investigators discovered that groups 3 and 4 had a significantly higher relation between Collagen II and I compared to the other groups. </p> <p>Alan J. Nixon, MD, a co-moderator of the session, noted that PRP can contain a variety of growth factors. “Do you know what you used for PRP?” Nixon asked. “Did you assay what factors were in that?” </p> <p>Vaisman said that the investigators did not assess which growth factors were in the PRP or determine the concentrations of these growth factors.</p> <blockquote> <b>For more information: </b> <ul><li> Alan J. Nixon, MD, can be reached at Cornell University, College of Veterinary Medicine, C3-187 VMC, Ithaca, NY 14853; 607-253-3224; e-mail: <a href="mailto:ajn1@cornell.edu" target="new">ajn1@cornell.edu</a>. </li><li> Alex Vaisman, MD, can be reached at Orthopaedic Surgery Unit, Clínica Alemana de Santiago, and Faculty of Medicine, Universidad del Desarrollo, P.O. Box 3737, Santiago, Chile; (56-2) 210-11 11, 212-97 00; e-mail: <a href="mailto:avaisman@alemana.cl" target="new">avaisman@alemana.cl</a>. They have no direct financial interest in any companies or products mentioned in this article. </li></ul> <p align="justify"> <b>Reference: </b></p> <ul><li> Vaisman A, Figueroa D, Calvo R, et al. Treatment of full-thickness chondral defects with a collagen scaffold, mesenchymal stem cells compromised to the chondrocyte lineage and platelet rich plasma. Paper #9.2.7. Presented at the 8th World Congress of the International Cartilage Repair Society. May 23-26, 2009. Miami. </li></ul></blockquote>Dr. K.M. Liauhttp://www.blogger.com/profile/05374546719213574530noreply@blogger.com0tag:blogger.com,1999:blog-6155132192235818010.post-17885433948469304562009-08-25T08:10:00.001-07:002009-08-25T08:10:53.718-07:00Navigation-assisted bone tumor surgery may lead to better resection, function<p class="artTitle"><br /></p> <p class="deckLine">Investigators from Korea found a mean registration error of less than 1 mm with navigation surgery.</p> <i>By </i><span class="p12"><i>Gina Brockenbrough</i></span><br /><cite>ORTHOPEDICS TODAY</cite> 2009; 29:35 <p>Performing <a href="http://www.orthosupersite.com/searchResults.asp?condition222=any&searchStr=bone+tumor+resection&condition=phrase&x=28&y=14" target="_new">bone tumor resection</a> using a navigation system can improve the accuracy of the surgical resection and help preserve limb function, according to researchers from Korea. </p> <p>“Under navigated guidance, three-dimensional anatomy of the tumor and the surrounding normal tissue can be visualized during surgery,” Hwan-Seong Cho, MD, said during his presentation at the <a href="http://www.orthosupersite.com/setContent.asp?setID=539" target="_new">American Academy of Orthopaedic Surgeons annual meeting</a>. “Precise control of the resection margin is possible, enabling us to achieve the resection margin determined preoperatively. In selected patients, this technique can be helpful in increasing the accuracy of surgical resection and in reducing the functional impairment.” </p> <h4>Malignant bone tumors </h4> <p>Cho and his colleagues studied patients with a total of 11 primary bone tumors or solitary bone metastases who underwent bone tumor resection and joint preservation limb surgery using a navigation system at Seoul National University College of Medicine since 2005. Preoperatively, the patients had malignant fibrous histiocytoma of bone, high-grade chondrosarcomas, Ewing’s sarcomas, osteosarcomas, and solitary bone metastases from rectal or thyroid cancers. </p> <p>Surgeons used a navigation system during four internal hemipelvectomies, two partial sacrotomies and five joint preserving limb salvage procedures. They performed joint preserving limb surgery if the following conditions were met: </p> <table align="right" border="0" cellpadding="5" cellspacing="5" width="210"> <tbody><tr> <td bgcolor="#e9f6ff"> <p class="caption"><img src="http://www.orthosupersite.com/images/content/OT/200908/ot0809choF1.jpg" alt="Lobulated lesion" border="1" vspace="3" width="250" height="188" /><br /><b>A T2-weighted spin-echo axial image</b> shows a lobulated lesion with a high signal intensity confined to right sacral ala.</p> <p class="source" align="right">Images: Cho HS</p></td> </tr> </tbody></table> <ul><li> the tumor was located in the metaphyseal region; </li><li>the preoperative chemotherapy was estimated to be effective as evidenced by imaging studies; and </li><li>the remaining epiphysis was expected to be more than 1 cm long after tumor resection with a 1 cm- to 2 cm-surgical margin.</li></ul> <p>The navigation system took a mean time of almost 51 minutes to set-up, and the investigators followed the patients for a mean of 18.5 months. </p> <h4> Accuracy </h4> <p>The investigators discovered that the mean registration error was less than 1 mm. </p> <p>“The distances from the tumor to the resection margins on the pathologic examination were in accordance with those of the preoperative plans,” Cho said. The patients had a mean Musculoskeletal Tumor Society functional score of 28 points, and the investigators found no cases of local recurrence at the latest follow-up. </p> <h4>Soft tissues, blood loss </h4> <p>During the paper discussion, audience member Lawrence R. Menendez, MD, asked if the investigators used navigation to measure the surgical margins during the soft tissue resection. </p> <p>“I used the navigation system for only the osteotomy,” Cho said. “For the soft tissue resection, I use conventional methods.” </p> <p>Menendez noted that navigation has been used for soft tissue procedures in other fields such as neurosurgery. </p> <p>Cho replied, “But, in the soft tissue sarcoma, we cannot technically attach the dynamic reference base.” </p> <p>Another audience member asked if the investigators noticed a difference in blood loss during tumor resection when using navigation.</p> <p>“I did not compare the blood loss between the conventional method and the navigation use, but I guess that there is no big difference,” Cho said.</p> <table align="center" bgcolor="#e9f6ff" border="0" cellpadding="5" cellspacing="0" width="420"> <tbody><tr valign="top"> <td> <p class="caption"><img alt="Dynamic reference-base" src="http://www.orthosupersite.com/images/content/OT/200908/ot0809choF2.jpg" border="1" vspace="3" width="250" height="220" hspace="3" /><br /><b>A dynamic reference-base</b> was fixed to the spinous process of L5. Tumor resection with wide margin was performed under navigation guidance.</p></td> <td> <p class="caption"><img alt="L5/sacral nerve roots" src="http://www.orthosupersite.com/images/content/OT/200908/ot0809choF3.jpg" border="1" vspace="3" width="260" height="220" hspace="3" /><br /><b>The tumor was excised</b> with an adequate surgical margin as planned and L5 nerve root and sacral nerve roots could be preserved. </p> </td> </tr> </tbody></table> <blockquote><b>For more information: </b> <ul><li>Hwan-Seong Cho, MD, can be reached at Kyungpook National University College of Medicine, 200 Dongduk-ro Jung-gu, Daegu, 700-721, South Korea; 82-53-420-6322; e-mail: <a href="mailto:mdchs111@snu.ac.kr" target="_new">mdchs111@snu.ac.kr</a>. He receives research or institutional support from Aesculap/B. Braun and Smith & Nephew.</li><li>Lawrence R. Menendez, MD, is the Director of Orthopaedic Oncology at the University of Southern California University Hospital. He can be reached at 1520 San Pablo St., Suit e 2000, Los Angeles, CA 90033; 323-442-5830; e-mail: <a href="mailto:menendez@usc.edu" target="_new">menendez@usc.edu</a>. Neither source has any financial interest in any products or companies mentioned in this article. </li></ul> <p align="justify"><b> Reference: </b></p> <ul><li>Cho HS, Han I, Oh JH, et al. Bone tumor resection under navigation guidance. Paper #469. Presented at the <a href="http://www.orthosupersite.com/setContent.asp?setID=539" target="_new">American Academy of Orthopaedic Surgeons 76th Annual Meeting</a>. February 25-28, 2009. Las Vegas.</li><li>Cho HS, Kang HG, Kim HS, Han I. Computer-assisted sacral tumor resection. A case report.<cite> J Bone Joint Surg (Am)</cite>. 2008;90(7):1561-1566. </li><li>Cho HS, Oh JH, Han I, Kim HS. Joint-preserving limb salvage surgery under navigation guidance. <cite>J Surg Oncol</cite>. 2009 Mar 27. [Epub ahead of print] </li></ul></blockquote>Dr. K.M. Liauhttp://www.blogger.com/profile/05374546719213574530noreply@blogger.com1tag:blogger.com,1999:blog-6155132192235818010.post-29041110988307916622009-08-25T08:09:00.000-07:002009-08-25T08:10:00.985-07:00Doctor traveling with fellows quarantined 7 days in Hong Kong after H1N1 exposure<p class="artTitle"><br /></p> <p class="deckLine">He spent 2 days on a hospital infectious disease ward and then was confined to a camp.</p> <i>By </i><span class="p12"><i>Susan M Rapp</i></span><br /><cite>ORTHOPEDICS TODAY</cite> 2009; 29:24 <p>At the height of recent worldwide concern over the spread of influenza A, H1N1, a U.S. orthopedic surgeon was quarantined in a hospital and camp in Hong Kong for 7 days after a passenger on his overseas flight developed H1N1, or swine flu. </p> <p>One day after arriving in Hong Kong, health authorities contacted Alvin H. Crawford, MD, FACS, an <cite>Orthopedics Today</cite> Editorial Board section editor, to alert him a situation was developing related to a sick passenger on his flight. </p> <h4>Extra caution </h4> <p>“The Asian countries are in sort of a heightened state of alert because of their previous experience with SARS,” he told <cite>Orthopedics Today</cite> after returning from his trip. </p><center><hr /><span style="color: gray;">advertisement<br /><a href="http://www.orthosupersite.com/clickHandler.asp?bid=3733&scope=Special%20Features" target="bnrWindow" nofollow=""><img src="http://www.orthosupersite.com/images/banners/MTJR_336x280_0908.gif" alt="MTJR" border="0" vspace="10" width="336" height="280" /></a></span><hr /></center> <p>Crawford was traveling to Asia to mentor three spine surgeons considered to be the best and brightest of the Scoliosis Research Society (SRS) candidate members. They were participating in the SRS Traveling Fellowship Program, a trip that included stops in Hong Kong, Beijing, Tokyo, Singapore and Seoul. </p> <table align="right" border="0" cellpadding="5" cellspacing="5" width="210"> <tbody><tr> <td bgcolor="#e9f6ff"> <p class="caption"><img src="http://www.orthosupersite.com/images/content/OT/200908/ot0809CrawfordF1.jpg" alt="Alvin H. Crawford, MD" border="1" vspace="3" width="200" height="344" /><br /><b><cite>Orthopedics Today</cite> Editorial Board Section Editor Alvin H. Crawford, MD</b>, was required to wear a surgical mask and identification badge at all times when quarantined in a Hong Kong camp due to a swine flu scare. He is pictured here after his daily physical examination and Tamiflu shot. </p> <p class="source" align="right">Images: Crawford AH </p></td> </tr> </tbody></table> <p>Part of his journey involved a Detroit-to-Tokyo flight, prior to landing in Hong Kong. </p> <p>“I was made aware in Hong Kong there was a passenger on the flight from Detroit to Tokyo who had come down with swine flu,” Crawford said. </p> <p>They told him the three-row rule was in effect and he was not seated within three rows of the ill person. He then lectured at the Chinese University and had taken an excursion and came in contact with many people. </p> <p>Crawford felt his risk of contracting or spreading H1N1 was low, but later Hong Kong health authorities told him a passenger sitting in front of him also developed H1N1. </p> <p>Although he did not have a fever or other symptoms, the Hong Kong authorities made him aware that he would have to undergo an examination and testing, he said. He was taken to Princess Margaret Hospital and kept in isolation on the infectious disease ward for 2 days under observation, undergoing testing and starting a course of Tamiflu (oseltamivir phosphate, Roche). All of Crawford’s tests came back negative; however, that was not the resolution of the issue. He was confined and his young traveling companions continued on their trip to Beijing without him. </p> <h4>Quarantine camp </h4> <p>He was then transferred to a camp near the mainland China border for the remainder of his quarantine, where he was assigned a bungalow, was required to wear a mask, picked up his meals at a canteen, and was observed to ensure he took his flu medication daily. Socialization with others quarantined at the camp was discouraged. </p> <p>He spent his time there cruising the Internet, reading everything he could find and practicing the clarinet. </p> <p>Crawford contacted the U.S. State Department and a colleague in Hong Kong — a friend of the Minister of Health — for assistance, but those efforts failed to shorten his quarantine time. </p> <p>Upon release 5 days later, he received a certificate stating he had been quarantined and treated for H1N1, but even with that Crawford was concerned he might get stopped when he flew to Japan to connect with the traveling fellows because 10-day quarantines were in effect there. His choices were to risk further quarantine in Japan, if another passenger came down with the flu, or head back to Cincinnati. </p> <p>“I elected to re-join the group,” he said. “I went to Tokyo and met up with the group and encountered no further problems,” Crawford said. </p> <p>The traveling fellows told him one hospital they were scheduled to visit in Beijing and another in Hong Kong were closed to foreign visitors due to the H1N1 situation. </p> <p>Crawford, who ran a hospital orthopedic department for 28 years, feels he probably has a greater appreciation for how these kinds of administrative issues impact the practice of medicine. </p> <table align="center" border="0" cellpadding="5" cellspacing="5" width="210"> <tbody><tr> <td bgcolor="#e9f6ff"> <p class="caption"><img src="http://www.orthosupersite.com/images/content/OT/200908/ot0809CrawfordF2.jpg" alt="H1N1 quarantine" border="1" vspace="3" width="500" height="340" /><br /><b>Part of the 7-day quarantine</b> for H1N1 exposure included time at a camp on Hong Kong’s border near mainland China. Workers are shown here between performing exams and giving Tamiflu shots to detainees.</p> </td> </tr> </tbody></table> <p>“I knew there was possibly little risk in terms of contamination, but realized it was a government decision made on a bureaucratic level. Once you mentally process and resolve that, it becomes a little easier,” he said. “The H1N1 story is by no means over and its worldwide impact has yet to be determined.” </p> <p>Crawford’s chief concern during his ordeal remained his responsibility to mentor the fellows and introduce them to key people at each stop of the trip. </p> <p>“Fortunately, only one leg of the trip was interrupted.”</p> <blockquote><b>For more information: </b> <ul><li>Alvin H. Crawford, MD, can be reached at Cincinnati Children’s Hospital Medical Center, Division of Pediatric Orthopaedic Surgery, 3333 Burnet Ave., Building C, MLC #2017, Cincinnati, OH 45229-3026; 513-636-4787; e-mail: <a href="mailto:alvin.crawford@cchmc.org" target="_new">alvin.crawford@cchmc.org</a>. </li></ul></blockquote>Dr. K.M. Liauhttp://www.blogger.com/profile/05374546719213574530noreply@blogger.com0tag:blogger.com,1999:blog-6155132192235818010.post-32890709486397767322009-08-25T08:08:00.000-07:002009-08-25T08:09:08.968-07:00Students embed stem cells in sutures to enhance healing<p class="artTitle"><br /></p> <br />1<sup>st</sup> on the web (August 10, 2009)<p>Johns Hopkins biomedical engineering students have demonstrated a practical way to embed a patient's own <a href="http://orthosupersite.com/searchResults.asp?condition222=any&searchStr=adult+stem+cells&condition=phrase&x=16&y=9">adult stem cells</a> in the surgical thread that doctors use to repair serious orthopedic injuries such as ruptured tendons. </p><p>The students’ goal is to enhance healing and reduce the likelihood of re-injury without changing the surgical procedure itself. </p><p>The project team – 10 undergraduates sponsored by Bioactive Surgical Inc. – won first place in the recent Design Day 2009 competition conducted by the university's Department of Biomedical Engineering. In collaboration with orthopedic physicians, the students have begun testing the stem cell–bearing sutures in an animal model, paving the way for possible human trials within about five years. </p><p>"Using sutures that carry stems cells to the injury site would not change the way surgeons repair the injury," said Matt Rubashkin, the student team leader, in a release. “We believe the stem cells will significantly speed up and improve the healing process. And because the stem cells will come from the patient, there should be no rejection problems." </p><p>The corporate sponsor, Bioactive Surgical, developed the patent-pending concept for a new way to embed stem cells in sutures during the surgical process. The company then enlisted the student team to assemble and test a prototype to demonstrate that the concept was sound. The undergraduates performed this work during the yearlong Design Team course, required by the school's Biomedical Engineering Department. </p><p>As envisioned by the company and the students, a doctor would withdraw bone marrow containing stem cells from a patient's hip while the patient was under anesthesia. The stem cells would then be embedded in the novel suture through a quick and easily performed proprietary process. The surgeon would then stitch together the ruptured Achilles tendon or other injury in the conventional manner but using the sutures embedded with stem cells. </p><p>At the site of the injury, the stem cells are expected to reduce inflammation and release growth factor proteins that speed up the healing, enhancing the prospects for a full recovery and reducing the likelihood of re-injury. The team's preliminary experiments in an animal model have yielded promising results, indicating that the stem cells attached to the sutures can survive the surgical process and retain the ability to turn into replacement tissue, such as tendon or cartilage. </p><p>"These students have demonstrated an amazing amount of initiative and leadership in all aspects of this project, including actually producing the suture and designing the ensuing mechanical, cell-based and animal trials," said Lew C. Schon, MD, one of the inventors of the technology, in a release. “The students exceeded all expectations. They have probably cut at least a year off of the development time of this technology, and they are definitely advancing the science in this emerging area.” </p><blockquote>For more information: <ul><li>Lew C. Schon, MD, is an assistant professor of orthopedic surgery in the Johns Hopkins School of Medicine. He can be reached at 3333 N. Calvert Street Johnston Prof. Building, Suite 400 Baltimore, MD 21218; (800)-571-9820; e-mail: <a href="mailto:lschon@gcoa.net" target="_new">lschon@gcoa.net</a>. </li></ul></blockquote>Dr. K.M. Liauhttp://www.blogger.com/profile/05374546719213574530noreply@blogger.com0tag:blogger.com,1999:blog-6155132192235818010.post-82325306185128110582009-08-25T08:04:00.001-07:002009-08-25T08:04:50.649-07:00Tendon reconstruction is recommended for treating ankle instability<p class="artTitle"><br /></p> <p class="deckLine">Long-term problems, multiple re-injuries may impede ligament reconstructions.</p> <i>By </i><span class="p12"><i>Nicholas A. Abidi, MD</i></span><br /><cite>ORTHOPEDICS TODAY</cite> 2008; 28:88 <p>Ankle instability is probably one of the most common sports injuries that we see each day in the United States: some 27,000 per day. It was the most common reason for a trip to the emergency room at one point and typically it is an inversion mechanism. </p> <table align="left" border="0" cellpadding="5" cellspacing="0" width="90"> <tbody><tr> <td> <p class="caption" align="center"><img src="http://www.orthosupersite.com/images/content/OT/200806/abidi.jpg" alt="Nicholas A. Abidi, MD" border="1" vspace="4" width="70" height="90" /><br /><b>Nicholas A. Abidi</b></p> </td> <td><br /></td></tr></tbody></table> <p>Overall, if it is instability and ankle sprain, what is the big deal? Our goal in nonoperative and operative treatment should be to prevent the occurrence of sprains, since they have been shown in the literature and in our practices to prevent the long-term development of arthritis in many cases. </p> <p>I used to perform the Broström-Gould procedure. I had pretty good results with that in the first 5 or 6 years in practice and I am happy with that. But as I thought about long-term problems after 3 to 5 years of following these patients, I realized I could not reconstruct the ligaments effectively in many patients in the middle of surgery, and I didn’t necessarily have an alternative other than some nonanatomic tendon reconstructions. </p><p>I surveyed Canadian surgeons several years ago and they recently told me that because of the long waiting list for patients there, many of the surgeons have switched to tendon reconstruction procedures because they determined that the Broström-Gould didn’t always give good long-term results. </p><p>Many have also told me that they have to make this decision intraoperatively based on the quality of the tissue, and that they have to justify using anchors because the cost of implants or tendon grafts limits their use in their provinces. </p><h4>Athletic population </h4><p>I use tendon reconstruction in people who have failed bracing and are athletes. Many of them have more than 10 years of ankle instability as well as hyperextension, patellofemoral, elbow and shoulder issues. I have a highly athletic patient population, being near a military base on the West Coast, and I noticed that when I looked at the older series with the Broström-Gould technique that most patients had several reinjuries. Many patients obviously will have more reoccurring instability at 3 to 5 years, and I couldn’t explain it other than that their tissues had given up. Reconstructions were the same every time, and in the end, adding the Gould modifications didn’t make it a true anatomic reconstruction </p><p>I thought about how there are so many papers are going back to the 1960s that talk about ligament construction and how that progressed to interest in tendon reconstruction. The patients were unsatisfied with their ligament reconstructions. </p><p>There are many types of ankle ligament reconstructions, not all necessarily anatomic, and many downfalls, too. There are about 25 types of Christian-Snook procedures that cross the subtalar joint as many as three times, they were not anatomic and they were very stiff — perhaps worse than a fusion sometimes. </p><p>The Evans reconstruction that is an augmentation has been shown to create subtalar joint arthritis over the long term. The Colville procedure is not really anatomic because it keeps the peroneus brevis tendons attached and has limited inversion in some patients at long-term. </p><h4>Anatomic reconstruction </h4><p>Now switch to anatomic reconstruction. Coughlin and Younger are both high-volume surgeons and their papers are being published on using tendon graft with interference anchors in the heel and in the neck of the talus, where it maintains the 105° axis. The theory behind it is that the tendons are less likely to attenuate with time as much as the ligaments do. </p><p>Using anchors permits early motion. In the Broström-Gould approach, we were casting for 4 to 6 weeks, which led to its own morbidity and relied upon scar tissue in the procedures, which is sometimes relying on wishful thinking. In many cases, I found attenuation at long-term follow-up. </p><p>There are more recent anatomic ligament reconstructions. I try to avoid the ones using gracilis autograft from the knee because I think the graft is a bit bulky and requires accessing the medial knee for an ankle procedure. Nevertheless, investigators have found outstanding results in that they had one recurrence at the most in a large series of patients. </p><h4>Technique </h4><p>At the time I was doing the Colville procedure, I had a patient with no peroneus brevis ligament to reconstruct … only a peroneus longus and severe instability. So I took a strip of that and discovered that the length was perfect to reconstruct the ankle. The results were outstanding. I look forward to advancing the procedure by using it on other patients who I can study, using a linear incision along the course of the fibula that to see if it works as well. </p><p>I run a linear incision along the course of the fibula but above the superior retinaculum to about one-third of the peroneus longus, and remove it with a tendon stripper. I attach the graft to the origin of the calcaneofibular ligament (CFL) underneath the peroneal tendons through a tunnel in the fibula and then down to the anterior talofibular ligament (ATFL) and anchor it into the neck of the talus with an interference anchor. We then pull up the capsule, which we peeled off of the distal fibula, and suture it back to the fibula. We may supplement it with the Gould modification in high-demand patients. It is not necessarily as tight or as a solid as a primary Brostrum, but it closes the capsule and prevents impinging tissue. </p><p>Postoperative rehabilitation begins with nonweight-bearing for 2 weeks and then weight-bearing with a walker for 2 weeks, leg splints for 2 weeks and no long-term mobilization. For physical therapy, there are six to 12 physical therapy sessions. </p><p>I have entered patients who have chronic ankle instability with functional and demonstrable MRIs and variable demands into a new study. Most are of a high-performance military population on a military base, and quite a few are recreational athletes in our area. We used validated instruments prospectively with 30 patients and hope to finish collecting the data soon and validate that. So far, the SF12 scores improved in the physical and mental components. </p><h4>Zero recurrance </h4><p>The thing that I really noticed when I’ve talked to people who have used this procedure is that the incidence of recurrent injury in patients is flat zero. These guys are jumping over brick walls and jumping out of helicopters. The patients can swim, run marathons, participate in triathlons and return to regular full-service duty after the reconstruction, and they get back quickly. </p><p>They said that when they turned their ankle didn’t sprain, so that was a good thing. The downside seems to be numbness, which seems to go along with the Broström procedure and similar incisions as well. The worst of the patients had stiffness in the first 3 months. We mobilized them with cortisone to get them moving, and they seem to be doing pretty well in 6 months. </p><p>In summary, I found the Broström-Gould procedure sometimes to be less filling, while the anatomic tendon reconstruction to taste great. But, if you look at the overall evidence-based literature, essentially when you look at the comparison trials that were done with the older techniques and not these, there are no evidence-based comparison studies at level 2 or level 1 instances that compare these types of reconstructions, and some have to be done. </p> <blockquote><b>For more information: </b> <ul><li>Nicholas A. Abidi, MD, can be reached at Santa Cruz Orthopaedic Institute, 1505 Soquel Drive, Suite 12, Santa Cruz, CA 95065; 831-475-4024; e-mail: <a href="mailto:nabidi@comcast.net">nabidi@comcast.net</a>. He has no direct financial interest in any product or company mentioned in the article. </li></ul><p> <b>Reference:</b> </p> <ul><li>Abidi NA. Tendon reconstruction. Presented as part of the Ankle Instability Debate at the 38th Annual Winter Meeting of the American Orthopaedic Foot and Ankle Society. March 8, 2008. San Francisco. </li></ul></blockquote>Dr. K.M. Liauhttp://www.blogger.com/profile/05374546719213574530noreply@blogger.com0tag:blogger.com,1999:blog-6155132192235818010.post-69679286327439010882009-08-25T07:59:00.000-07:002009-08-25T08:00:20.407-07:00Atraumatic Bilateral Femur Fracture in Long-Term Bisphosphonate Use<p class="artTitle"><br /></p> <i>By </i><span class="p12"><i>Maria S. Goddard, MD; </i></span><span class="p12"><i>Kristoff R. Reid, MD; </i></span><span class="p12"><i>James C. Johnston, MD; </i></span><span class="p12"><i>Harpal S. Khanuja, MD</i></span><br /><cite>ORTHOPEDICS </cite>2009; 32:607 <h4>Abstract</h4> <p>Postmenopausal women with osteoporosis are commonly treated with the bisphosphonate class of medications, one of the most frequently prescribed medications in the United States. In the past 4 years, reports have been published implying that long-term bisphosphonate therapy could be linked to atraumatic femoral diaphyseal fractures. </p> <p>This article presents a case of a 67-year-old woman who presented with an atraumatic right femur fracture. She had a medical history notable for use of the bisphosphonate alendronate for 16 years before being switched to ibandronate for 1 year before presentation. She had sustained a similar fracture on the contralateral side 3 years previously. </p> <p>This case report, in addition to a review of the literature, shows that use of the bisphosphonate class of medications for an extended period of time may result in an increased susceptibility to atraumatic femoral diaphyseal fractures. Some studies have suggested that the reason may be the mechanism of action of bisphosphonates, resulting in decreased bone turnover and remodeling. Studies have not shown if the entire class of medications produce a similar result, but patients who have been treated with any bisphosphonate for an extended period of time should be considered at risk. In patients who have already sustained a femoral diaphyseal fracture, imaging of the contralateral side should be performed to identify cortical thickening as an early sign of fracture risk. Patients should also be questioned about thigh pain. </p><center><hr /><span style="color: gray;">advertisement<br /><object border="0" vspace="10" width="336" height="280"><param name="movie" value="images/banners/JJ_336x280_0903.swf"><embed src="http://www.orthosupersite.com/images/banners/JJ_336x280_0903.swf" width="336" height="280"></embed></object> </span><hr /></center> <p><img src="http://www.orthosupersite.com/images/layout/hrule.gif" align="bottom" width="600" height="1" /></p> <p>Postmenopausal women with osteoporosis are commonly treated with the bisphosphonate class of medications. In 2006, approximately 22 million prescriptions for this medication were written in the United States (National Prescription Audit Plus 2006; IMS Health, Norwalk, Connecticut). However, since 2005, reports have been published indicating that long-term bisphosphonate therapy could be linked to atraumatic low-energy femoral shaft fractures.<sup>1-7</sup> This article presents a case of a 67-year-old woman with a history of sequential bilateral atraumatic femur fractures after long-term use of bisphosphonates. </p> <h4>Case Report </h4> <p>A 67-year-old woman presented to the emergency department with a spontaneous right femoral diaphyseal fracture. There was no history of trauma and she denied antecedent pain. A review of her medical history revealed that she had sustained a left femoral diaphyseal fracture under similar circumstances 3 years previously, which had been treated with intramedullary nailing. In that earlier injury, she reported a feeling of “giving way” before falling. She had no risk factors for pathologic fractures. She was a nonsmoker and did not take corticosteroids. She had a distant history of hormone replacement therapy before 1985 to prevent osteoporosis. She began taking alendronate 70 mg per week in 1991 for osteopenia and was switched to ibandronate 150 mg monthly in 2007 for a more convenient dosing regimen. In addition, her past medical history included degenerative thoracolumbar scoliosis. </p> <p>Radiographs of the pelvis, right hip, and right femur revealed a displaced diaphyseal fracture at the proximal and middle one-third right femoral junction. There was evidence of osteopenia in the metaphyseal regions (Figure 1). Given her previous history of fracture on the contralateral side and a lack of risk factors for spontaneous fractures, a magnetic resonance imaging scan without contrast was obtained to exclude a pathologic fracture. It showed no evidence of a bone lesion or other abnormality. A review of the records from her previous fracture showed no radiographic evidence of an underlying malignancy to explain that injury. </p> <p>On the day of admission, she underwent cephalomedullary rod fixation. There were no postoperative complications, and she was discharged after 5 days. Pathologic analysis of bone fragments removed during the procedure showed bony trabeculae and hyaline cartilage with no evidence of granulomas or tumors. </p> <p>At 6-month follow-up, the patient reported minimal pain at the fracture site. She was ambulating with a cane and maintained full range of motion. Radiographs showed the intramedullary rod in place with evidence of callus formation and a visible fracture line (Figure 2). Because of signs of delayed union, dynamization was performed by removing the distal interlocking screw. She has elected to discontinue use of any type of bisphosphonate medication since her second fall. Conventional radiographs at 1-year follow-up showed that the fracture had healed completely (Figure 3). </p> <table align="center" bgcolor="#e9f6ff" border="0" cellpadding="5" cellspacing="0" width="380"> <tbody><tr valign="top"> <td><img src="http://www.orthosupersite.com/images/content/obj/0908/goddard_fig1.jpg" alt="Figure 1: The characteristic fracture pattern of cortical thickening and a unicortical beak" border="1" width="180" height="262" /></td> <td><img src="http://www.orthosupersite.com/images/content/obj/0908/goddard_fig2a.jpg" alt="Figure 2A: Callus formation and visible fracture line" border="1" width="180" height="262" /></td> </tr> <tr valign="top"> <td><img src="http://www.orthosupersite.com/images/content/obj/0908/goddard_fig2b.jpg" alt="Figure 2B: Callus formation and visible fracture line" border="1" width="180" height="262" /></td> <td><img src="http://www.orthosupersite.com/images/content/obj/0908/goddard_fig3.jpg" alt="Figure 3: A completely healed fracture" border="1" width="180" height="262" /></td> </tr> <tr valign="top"> <td colspan="2"> <p class="caption"><b>Figure 1:</b> Preoperative conventional AP radiograph showing the characteristic fracture pattern of cortical thickening and a unicortical beak. <b>Figure 2:</b> Postoperative conventional AP (A) and lateral (B) radiographs taken 4 months after injury, showing callus formation and visible fracture line. <b>Figure 3:</b> Postoperative radiograph at 1-year follow-up visit showing a completely healed fracture.</p> </td> </tr> </tbody></table> <h4>Discussion </h4> <p>Some studies have suggested that long-standing bisphosphonate use may be a risk factor for atraumatic femoral shaft fractures.<sup>1-8</sup> It is believed that bisphosphonates inhibit the normal bone remodeling cycle, thus limiting native repair and leading to the accumulation of microfractures, which places a patient at an increased risk for long-bone fractures.<sup>8,9</sup> In a dual-center study, Odvina et al<sup>8</sup> examined the bone biopsy results from 9 patients treated with alendronate for 3 to 8 years for osteoporosis or osteopenia; those authors proposed that the mechanism behind this paradoxical increased incidence of femoral shaft fractures is severe suppression of bone turnover by bisphosphonates. They confirmed this theory histologically as a decrease in the osteoclastic and osteoblastic surfaces and identified a reduction or lack of tetracycline labeling, indicating diminished mineralized bone.<sup>8</sup> All patients, including those who were given estrogen therapy, had decreased bone formation and no double-tetracycline labeling. </p> <p>Because bisphosphonates bind to bone and are slowly released during bone resorption,<sup>10</sup> it may take several years for any detrimental effect to become evident. For example, alendronate has a half-life of 10.9 years,<sup>11</sup> and therefore could be present in the body long after therapy is stopped. One study has shown that, after taking alendronate for 5 years, the biochemical markers of bone turnover remained suppressed for at least 3 years after its discontinuation.<sup>12</sup> Using a pharmacokinetic model with a dose of 10 mg per day, Rodan et al<sup>13</sup> found that the amount of alendronate retained in bone after 10 years of treatment was approximately 75 mg per 2 kg of mineral. </p> <p>Our patient, who sustained sequential bilateral femoral diaphyseal fractures within a 3-year period, had been treated with bisphosphonates (alendronate and ibandronate) for osteopenia for more than 16 years. Given similar mechanisms without substantial trauma and no other risk factors for these fractures, the long-term use of bisphosphonates is implicated. </p> <p>Alendronate has been the bisphosphonate most commonly used and has been implicated in most of the reported cases of atraumatic femur fractures. It is likely a class effect, that is, an effect related to bisphosphonates in general rather than to a specific medication. It is likely that other bisphosphonates will result in more complications as their use increases. Using a rat model, Yang et al<sup>14</sup> showed that high levels of the bisphosphonate pamidronate lowered the bone mineral density and mechanical strength of the femur. In addition, they also found that there was reduced healing and callus formation after fracture in femurs with a high intraosseous concentration of pamidronate. They suggested that severe suppression of bone turnover also occurs with bisphosphonates other than alendronate, in high concentrations and over time. </p> <p>Ott<sup>15</sup> recommended that treatment with bisphosphonates be stopped after 5 years and that patients that require additional fracture protection be given parathyroid hormone. The rationale for this timeframe is to allow adequate time for fracture prevention while minimizing the risks of severe suppression bone turnover. A more recent study by Sebba<sup>16</sup> suggested a medication holiday of 1 year to reduce the fracture risk from long-term uninterrupted use because there is no reduction of the protective benefit during that time. Some studies have shown that discontinuation of alendronate after this time period does not diminish the protective effect for vertebral fractures.<sup>10</sup> It is important to define the minimal duration of treatment needed for osteoporosis to reduce the side effects of these medications. </p> <p>One study has shown that treatment with estrogen replacement in combination with bisphosphonates resulted in greater levels of suppression of bone turnover than use of the latter alone.<sup>17</sup> Although our patient had a distant history of estrogen use, it was not concomitant with her bisphosphonate therapy. </p> <p>Atraumatic femoral diaphyseal fractures occurring in long-term bisphosphonate use have similar characteristics: a simple transverse pattern, unicortical beak, and cortical hypertrophy.<sup>3-6</sup> The fracture pattern in our patient was similar to that described in other studies<sup>3-6</sup>; it appears to be pathognomonic for a femoral fracture in long-term bisphosphonate use. In a case series of 17 patients on alendronate therapy with subtrochanteric insufficiency fractures, Kwek et al<sup>3</sup> found that all patients experienced prodromal pain and that all had similar radiographic fracture patterns. These patterns included a transverse fracture with lateral pattern, which they described as simple with thick cortices. In a 5-year retrospective review of 70 patients with low-energy femoral fractures, Neviaser et al<sup>5</sup> found that of 25 patients being treated with alendronate, 19 (76%) had a simple, transverse fracture with a unicortical beak in an area of cortical hypertrophy. Only 1 patient of the remaining 45 who were not treated with alendronate in this study had these radiographic findings. </p> <p>To our knowledge, a bilateral fracture in association with bisphosphonate use over an extended period of time has been reported in only 1 other case.<sup>1</sup> In that study, Cheung et al<sup>1</sup> showed suppressed bone turnover in their patient by using a double-tetracycline-labeled bone biopsy of the anterior superior iliac spine. Goh et al<sup>2</sup> examined 9 patients who sustained subtrochanteric insufficiency fractures while on alendronate and found hypertrophy of the cortex on the contralateral side in 3 patients, implying a risk for bilateral fracture development. </p> <p>Since our patient’s follow-up, we have identified 2 other patients with atraumatic fractures after bisphosphonate therapy for several years, 1 of whom had evidence of a cortical stress reaction on the opposite side. For patients presenting with a low-energy subtrochanteric or diaphyseal femur fracture and a history of long-term bisphosphonate treatment, we recommend that such medications be considered a part of the underlying abnormality. Attention should also be paid to patients who have been treated with bisphosphonates for a long time who report thigh pain because this symptom might be an early indication of an impending fracture. We also recommend that patients on bisphosphonate therapy who have already had a femoral fracture should undergo one-time imaging of the contralateral side to identify any cortical thickening. If thickening is identified, consideration should be given to a medication holiday or termination of the bisphosphonate therapy. This decision should be made in conjunction with the physician who prescribed the medication. </p> <p>It seems clear that in certain patients, chronic use of bisphosphonates predisposes them to low-energy or atraumatic long bone fractures. Undoubtedly, these medications are beneficial for the prevention of vertebral compression and other osteoporotic fractures,<sup>18,19</sup> and the discontinuation of bisphosphonates should be discussed with the patient’s primary physician. Additional pathophysiology studies are needed to identify patients who are at risk for this major complication. </p> <h4>References </h4> <ol><li>Cheung RKH, Leung KK, Lee KC, Chow TC. Sequential non-traumatic femoral shaft fractures in a patient on long-term alendronate. <cite>Hong Kong Med J</cite>. 2007; 13(6):485-489. </li><li>Goh SK, Yang KY, Koh JSB, et al. Subtrochanteric insufficiency fractures in patients on alendronate therapy. A caution. <cite>J Bone Joint Surg Br</cite>. 2007; 89(3):349-353. </li><li>Kwek EBK, Goh SK, Koh JSB, Png MA, Howe TS. An emerging pattern of subtrochanteric stress fractures: a long-term complication of alendronate therapy? <cite>Injury</cite>. 2008; 39(2):224-231. </li><li>Lenart BA, Lorich DG, Lane JM. Atypical fractures of the femoral diaphysis in postmenopausal women taking alendronate. <cite>N Engl J Med</cite>. 2008; 358(12):1304-1306. </li><li>Neviaser AS, Lane JM, Lenart BA, Edobor-Osula F, Lorich DG. Low-energy femoral shaft fractures associated with alendronate use. <cite>J Orthop Trauma</cite>. 2008; 22(5):346-350. </li><li>Sayed-Noor AS, Sjoden GO. Subtrochanteric displaced insufficiency fracture after long-term alendronate therapy—a case report. <cite>Acta Orthop</cite>. 2008; 79(4):565-567. </li><li>Schneider JP. Should bisphosphonates be continued indefinitely? An unusual fracture in a healthy woman on long-term alendronate. <cite>Geriatrics</cite>. 2006; 61(1):31-33. </li><li>Odvina CV, Zerwekh JE, Rao DS, Maalouf N, Gottschalk FA, Pak CYC. Severely suppressed bone turnover: a potential complication of alendronate therapy. <cite>J Clin Endocrinol Metab</cite>. 2005; 90(3):1294-1301. </li><li>Visekruna M, Wilson D, McKiernan FE. Severely suppressed bone turnover and atypical skeletal fragility. <cite>J Clin Endocrinol Metab</cite>. 2008; 93(8):2948-2952. </li><li>Black DM, Schwartz AV, Ensrud KE, et al. Effects of continuing or stopping alendronate after 5 years of treatment. The Fracture Intervention Trial Long-term Extension (FLEX): a randomized trial. <cite>JAMA</cite>. 2006; 296(24):2927-2938. </li><li>Khan SA, Kanis JA, Vasikaran S, et al. Elimination and biochemical responses to intravenous alendronate in postmenopausal osteoporosis. <cite>J Bone Miner Res</cite>. 1997; 12(10):1700-1707. </li><li>Ensrud KE, Barrett-Connor EL, Schwartz A, et al. Randomized trial of effect of alendronate continuation versus discontinuation in women with low BMD: results from the Fracture Intervention Trial long-term extension. <cite>J Bone Miner Res</cite>. 2004; 19(8):1259-1269. </li><li>Rodan G, Reszka A, Golub E, Rizzoli R. Bone safety of long-term bisphosphonate treatment. <cite>Curr Med Res Opin</cite>. 2004; 20(8):1291-1300. </li><li>Yang KH, Won JH, Yoon HK, Ryu JH, Choo KS, Kim JS. High concentrations of pamidronate in bone weaken the mechanical properties of intact femora in a rat model. <cite>Yonsei Med J</cite>. 2007; 48(4):653-658. </li><li>Ott SM. Editorial: long-term safety of bisphosphonates. <cite>J Clin Endocrinol Metab</cite>. 2005; 90(3):1897-1899. </li><li>Sebba A. Osteoporosis: how long should we treat? <cite>Curr Opin Endocrinol Diabetes Obes</cite>. 2008; 15(6):502-507. </li><li>Bone HG, Greenspan SL, McKeever C, et al. Alendronate and estrogen effects in postmenopausal women with low bone mineral density. Alendronate/Estrogen Study Group. <cite>J Clin Endocrinol Metab</cite>. 2000; 85(2):720-726. </li><li>Black DM, Cummings SR, Karpf DB, et al. Randomised trial of effect of alendronate on risk of fracture in women with existing vertebral fractures. Fracture Intervention Trial Research Group. <cite>Lancet</cite>. 1996; 348(9041):1535-1541. </li><li>Bone HG, Hosking D, Devogelaer JP, et al. Ten years’ experience with alendronate for osteoporosis in postmenopausal women. <cite>N Engl J Med</cite>. 2004; 350(12):1189-1199.</li></ol> <h4>Authors</h4> <p>Drs Goddard, Reid, Johnston, and Khanuja are from the Department of Orthopedic Surgery, The Johns Hopkins University, Baltimore, Maryland. </p> <p>Drs Goddard, Reid, Johnston, and Khanuja have no relevant financial relationships to disclose. </p> <p>Correspondence should be addressed to: Harpal S. Khanuja, MD, c/o Elaine P. Henze, BJ, ELS, Medical Editor and Director, Editorial Services, Department of Orthopedic Surgery, Johns Hopkins Bayview Medical Center, 4940 Eastern Ave, #A6765, Baltimore, MD 21224-2780. </p> <p>DOI: 10.3928/01477447-20090624-27 </p>Dr. K.M. Liauhttp://www.blogger.com/profile/05374546719213574530noreply@blogger.com1