Dorsoradial Ligament Reconstruction in Trapeziometacarpal Joint Arthritis

Background The main purpose of the study is to present the alternative novel surgical technique in treating patients with trapeziometacarpal (TMC) joint arthritis using dorsoradial ligament (DRL) reconstruction technique and report the clinical outcomes. Methods Patients who were diagnosed with TMC joint arthritis and underwent DRL reconstruction were evaluated. Visual analog pain score; Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) score; grip, tip pinch, tripod pinch, and key pinch strengths along with range of motion of the thumb; and Kapandji score were recorded in the preoperative period and at follow-up. Stress examination was also performed under a fluoroscope. Results Eleven patients were included in the study. Median follow-up time was 13 months. At follow-up, postoperative visual analog scale and QuickDASH score improved in all patients. Grip, tip pinch, tripod pinch, and key pinch strengths also improved. The range of motion and Kapandji score were slightly improved compared with the preoperative period except for the thumb metacarpophalangeal flexion. Two patients had numbness at the thumb and spontaneously recovered after 3 months. Conclusions According to recent evidence which proposed the importance of DRL in TMC joint stability, our DRL reconstruction technique may be an alternative treatment in treating patients presented with TMC joint arthritis. Further study with a longer follow-up period is needed.

Effect of Oral Choline Alfoscerate on Patients with Keratoconjunctivitis Sicca

Keratoconjunctivitis sicca (KCS) or dry eye is a disease characterized by ocular surface symptoms. This study aimed to investigate the effectiveness of oral choline alfoscerate (CA) administration as a treatment for KCS. The medical records of dry eye patients who were refractory to topical eyedrops and then took oral CA were reviewed. Results of tear break-up time (TBUT), fluorescein ocular surface staining score (FSS), and tear secretion by the Schirmer test (STT) were analyzed. The results of the ocular surface disease index (OSDI), visual analog pain score (VAS), reporting of the severity and frequency of symptoms, and the modified Standardized Patient Evaluation of Eye Dryness (SPEED) questionnaire were also analyzed. The records of 47 patients were analyzed for this study. The mean age was 62.8 ± 9.3 years, and the patients included 9 males and 38 females. TBUT, OSDI, and VAS significantly improved after CA administration compared to before (p < 0.05, paired t-test). After CA administration, symptom frequency and impact on life improved (p < 0.05, paired t-test). No significant change in photophobia or FSS was identified. In conclusion, oral CA administration was effective in improving tear stability and alleviating symptoms of KCS.

Revision of a Medial UKA to a Kinematic Aligned TKA: Comparison of Operative Complexity, Postoperative Alignment, and Outcome Scores to a Primary TKA

Revision of a medial unicompartmental knee arthroplasty (UKA) to a mechanically aligned total knee arthroplasty (MA TKA) is inferior to a primary TKA; however, revision with kinematic alignment (KA) has not been well studied. The present study determined whether patients revised with KA had a higher use of revision components, different postoperative alignment, and different clinical outcome scores from patients with a primary KA TKA. From 2006 to 2017, all patients suitable for a revision of a failed medial UKA to a TKA and a primary TKA were treated with KA. Reasons for the revision performed in ten females and six males at a mean age 67 ± 8 years included progression of osteoarthritis in the lateral hemi-joint (n = 6), aseptic loosening (n = 4), unremitting medial pain without loosening (n = 4), and insert wear (n = 2). Patients with a revision were matched 1:3 with a control cohort treated with a primary KA TKA. Revisions were performed with primary components without augments, stem extensions, or bone grafts. Seven postoperative alignment parameters of the limb and components were comparable to the control cohort (p > 0.05). At a mean follow-up of 5 years (1–10), implant survival was 100%, and the revision/primary group clinical outcome scores were 39/43 points for the Oxford Knee Score (OKS), 2.2/1.0 cm for the Visual Analog Pain Score, and 12/7 points for the Western Ontario and McMaster Universities Osteoarthritis Index score. When compared with primary KA TKA, surgeons that revise a failed medial UKA to a TKA with use of KA can expect similar operative complexity, comparable postoperative alignments, and a mean OKS of 39 points, which is higher than the mean 27 to 30 point range reported for revision of a failed UKA to a TKA with the use of MA.

Percutaneous Treatment of Unstable Scaphoid Waist Fractures

Background: Percutaneous techniques have been described for the treatment of nondisplaced scaphoid fractures, although less information has been reported about outcomes for unstable, displaced fractures. The aim of this study was to evaluate the union and complication rates following manual closed reduction and percutaneous screw placement for a consecutive series of unstable, displaced scaphoid fractures. Methods: A total of 28 patients (average age, 27 years; 22 male/6 female) were treated for isolated unstable displaced scaphoid waist fractures. Closed reduction and percutaneous headless, compression screw fixation was successfully performed in 14 patients (average age, 32 years; 10 male/4 female), and the remaining 14 patients required open reduction. Patients who underwent percutaneous treatment were followed for radiographic fracture union and clinical outcomes. Results: Thirteen of 14 fractures (93%) had clinical and radiographic evidence of bone union at an average of 2.8 months postoperatively. Average visual analog pain score at the time of union was 0.9. The average Quick Disability of the Arm, Shoulder, and Hand score at 2.5 years follow-up (range, 1.5-8.3 years) was 9.6 (range, 0.0-27.3). Complications included 1 case of nonunion and 1 case of intraoperative Kirschner wire breakage. Conclusions: Manual closed reduction followed by percutaneous headless, compression screw fixation was possible in 50% of patients who presented with acute unstable, displaced scaphoid fractures. This technique appears to be a safe and effective method when a manual reduction is possible, and it may offer a less invasive option when compared with a standard open technique.

Estimation of the Contribution of Norketamine to Ketamine-induced Acute Pain Relief and Neurocognitive Impairment in Healthy Volunteers

Background The N-methyl-D-aspartate receptor antagonist ketamine is metabolized in the liver into its active metabolite norketamine. No human data are available on the relative contribution of norketamine to ketamine-induced analgesia and side effects. One approach to assess the ketamine and norketamine contributions is by measuring the ketamine effect at varying ketamine and norketamine plasma concentrations using the CYP450 inducer rifampicin. Methods In 12 healthy male volunteers the effect of rifampicin versus placebo pretreatment on S-ketamine-induced analgesia and cognition was quantified; the S-ketamine dosage was 20 mg/h for 2 h. The relative ketamine and norketamine contribution to effect was estimated using a linear additive population pharmacokinetic-pharmacodynamic model. Results S-ketamine produced significant analgesia, psychotropic effects (drug high), and cognitive impairment (including memory impairment and reduced psychomotor speed, reaction time, and cognitive flexibility). Modeling revealed a negative contribution of S-norketamine to S-ketamine- induced analgesia and absence of contribution to cognitive impairment. At ketamine and norketamine effect concentrations of 100 ng/ml and 50 ng/ml, respectively, the ketamine contribution to analgesia is -3.8 cm (visual analog pain score) versus a contribution of norketamine of +1.5 cm, causing an overall effect of -2.3 cm. The blood-effect site equilibration half-life ranged from 0 (cognitive flexibility) to 11.8 (pain intensity) min and was 6.1 min averaged across all endpoints. Conclusions This first observation that norketamine produces effects in the opposite direction of ketamine requires additional proof. It can explain the observation of ketamine-related excitatory phenomena (such as hyperalgesia and allodynia) upon the termination of ketamine infusions.

Use of percutaneous kyphoplasty to treat painful vertebral compression fractures (VCF) in solid tumors

e20568 Background: Vertebral compression fractures are a major source of morbidity in metastatic carcinoma. Kyphoplasty involves inflation of a balloon for painful kyphotic deformity restoring the vertebral body to its original height and creating a cavity for percutaneous injection of polymethylmethacrylate (PMMA). Contraindications include epidural spinal cord compression. Although it is FDA approved for cancer-associated VCF most of the data is in the myeloma population. Methods: We retrospectively assessed by electronic medical records the safety and efficacy of kyphoplasties performed by the orthopedic spine service in a single institution between 12/03 and 2/08. We identified those patients who had kyphoplasty as the only spine procedure and excluded those patients with incomplete documentation of pain scores. Comparison was made between patients selected for pathologic compression fractures and benign compression fractures secondary to trauma or osteoporosis. Results: Review of 447 consecutive orthopedic spine cases identified 40 kyphoplasty patients, 30 of which met the inclusion criteria - 21 with benign compression fractures secondary to osteoporosis/trauma and 9 with malignant disease (3 breast CA, 2 lung, 1 cervix, 1 RCC, 2 myeloma). 49 kyphoplasties and 23 concurrent spine biopsies were performed in this group. Median age was in the cancer group was 55 (37–81) vs. 68(41–93) in benign group. One patient had prior radiation in the cancer group. The average preoperative visual analog pain score was 7 (range 3–9) and postoperative pain score was 2.0 (0–9) in the cancer group. The average preoperative visual analog pain score 6.8 (0–9) and post-operative score was 0.8 (0–4) in the benign group. Most procedures did not require general anesthesia. There were no reported PMMA extravasations, and no hematologic or neurologic complications in either group. Conclusions: Kyphoplasty provided marked pain relief in patients with VCF secondary to solid tumors and myeloma. The results are comparable to non-cancer population in safety and efficacy, and are feasible in selected cancer patients with pain due to pathologic compression fractures. [Table: see text]

Extracorporeal Shockwave Therapy for the Treatment of Achilles Tendinopathies

Background: Extracorporeal shockwave therapy has been shown to be effective in the treatment of chronic tendon pathology in the elbow, shoulder, and plantar fascia. This prospective study examines the efficacy of extracorporeal shockwave therapy in the treatment of chronic Achilles tendon disorders. Methods: Twenty-three patients (23 feet) were treated with extracorporeal shockwave therapy for Achilles tendinosis, insertional tendonitis, or both. Indications for treatment were a minimum of 6 months of conservative care, and a visual analog pain score &gt; 5. The mean follow-up was 20 months (range, 4–35 months). Results: Ninety-one percent (14 patients) were satisfied or very satisfied (23 patients) with treatment. Eighty-seven percent (20 patients) stated that extracorporeal shockwave therapy improved their condition, 13% (3 patients) said it did not affect the condition, and none stated that it made them worse. Eighty-seven percent (20 patients) stated they would have the procedure again if given the choice. Four months after extracorporeal shockwave therapy, the mean visual analog score for morning pain decreased from 7.0 to 2.3, and activity pain decreased from 8.1 to 3.1. Conclusion: High-power extracorporeal shockwave therapy is safe, noninvasive, and effective, and it has a role in the treatment of chronic Achilles tendinopathy. (J Am Podiatr Med Assoc 98(6): 466–468, 2008)

Percutaneous vertebroplasty and/or kyphoplasty is an effective and safe treatment for painful vertebral compression fractures in multiple myeloma (MM)

7610 Background: Painful vertebral compression fractures are a major source of morbidity in MM. Vertebroplasty involves percutaneous injection of polymethylmethacrylate (PMMA) into a vertebral body, while kyphoplasty involves inflation of a balloon for painful kyphotic deformity prior to stabilization with PMMA. Methods: We assessed safety and efficacy of 100 vertebroplasties and/or kyphoplasties in 81 consecutive myeloma patients between 12/2000 and 2/2005. Results: Median age was 63 (range 32–84), with 29% having prior radiotherapy to the vertebra treated. Contraindications included epidural compression of neural elements and failure to localize a symptomatic level. Kyphoplasty was preferred if kyphosis of > 20 degrees contributed to pain, or if the posterior vertebral cortex was disrupted so that controlled delivery of bone cement was difficult. Vertebroplasty was performed when vertebral collapse was either slight or so severe that insertion of balloon device was not possible, or if patient could not tolerate the general anesthesia required for kyphoplasty. The median preoperative visual analog pain score (0–10) was 8(range 2–10); the median postoperative pain score was 3 (range 0–10) (p < 0.01). There were no significant complications . Conclusions: Percutaneous vertebroplasty and kyphoplasty provided rapid and marked pain relief. These procedures are safe and feasible and represent the treatment of choice in selected MM patients with severe refractory pain due to pathologic compression fractures. No significant financial relationships to disclose.

The Modified Lapidus Procedure for Hallux Valgus: A Clinical and Radiographic Analysis

Background: Historically, the modified Lapidus procedure has been considered technically challenging, with high rates of complications, including nonunion and malunion. The purpose of this study was to review the clinical and radiographic results of this technique for the treatment of hallux valgus associated with first ray hypermobility, specifically examining patient satisfaction and the incidence of complications. Methods: We retrospectively reviewed the results of the modified Lapidus procedure in 32 patients (38 feet). Evaluation included preoperative and postoperative questionnaires, physical examination, and radiographs. Results: Complete clinical data was available for 29 patients (35 feet) and complete radiographic data for 29 patients (34 feet). Average age at surgery was 54 (range 27 to 84) years. Average followup was 42 months (range 29 to 93) months. Average preoperative visual analog pain score was 7.2 and postoperative 2.3 ( p < 0.001). Average preoperative AOFAS Hallux MTP-IP Score was 44.8 and postoperative 87.3 ( p < 0.001). Average preoperative intermetatarsal (IM) angle was 16 degrees, and the hallux valgus (HV) angle was 34 degrees. Postoperatively, the average IM angle was 6 degrees, the HV angle 11 degrees. There were no cases of nonunion or malunion. Complications included symptomatic hallux varus in two, recurrence of hallux valgus deformity in one, deep venous thrombosis in one, and failure of fixation in one patient. Twenty-four percent of patients (7 of 29) noted the subjective sensation of midfoot stiffness and 34% (10 of 29) noted forefoot stiffness. None of these patients thought that the stiffness was a disability. Ninety percent of patients (26 of 29) were satisfied with their foot function, and 86% (25 of 29) were satisfied with the cosmetic appearance of their foot. Conclusions: The modified Lapidus procedure results in a satisfactory clinical outcome in most patients. With meticulous operative technique, rigid internal fixation, and strict postoperative weightbearing restrictions, successful union can be achieved and complications can be minimized. Care should be taken to avoid hallux varus, and patients need to be counseled regarding a potentially long convalescent period and possible postoperative stiffness.

Minimum Local Analgesic Doses of Ropivacaine, Levobupivacaine, and Bupivacaine for Intrathecal Labor Analgesia

Background Doses for intrathecal opioid-local anesthetic mixtures have been arbitrarily chosen. The aim of this study was to compare the analgesic efficacies of intrathecal ropivacaine, levobupivacaine, and bupivacaine for labor analgesia and to determine the analgesic potency ratios for these three drugs. For this purpose, the authors used the up-down sequential allocation model, which estimates the minimum local analgesic dose for intrathecal local anesthetic. Methods Ninety-seven nulliparous term parturients in spontaneous labor, requesting combined spinal-epidural analgesia, were randomly allocated to one of three groups to receive 0.25% spinal ropivacaine, levobupivacaine, or bupivacaine. The initial dose of the local anesthetic drug was chosen to be 2.5 mg, and the testing interval was set at 0.25 mg. The subsequent doses were determined by the response of the previous parturient. Efficacy was accepted if the visual analog pain score decreased to 10 mm or less on a 100-mm scale within 30 min. The minimum local analgesic dose was calculated using the method of Dixon and Massey. Results The intrathecal minimum local analgesic dose was 3.64 mg (95% confidence interval, 3.33-3.96 mg) for ropivacaine, 2.94 (2.73-3.16) mg for levobupivacaine, and 2.37 (2.17-2.58) mg for bupivacaine. The relative analgesic potency ratios were 0.65 (0.56-0.76) for ropivacaine:bupivacaine, 0.80 (0.70-0.92) for ropivacaine:levobupivacaine, and 0.81 (0.69-0.94) for levobupivacaine:bupivacaine. There were significant trends (P &lt;/= 0.021) for greater motor block with bupivacaine and levobupivacaine. Conclusions This study suggests a potency hierarchy of spinal bupivacaine &gt; levobupivacaine &gt; ropivacaine.