Patellofemoral joint arthroplasty: patient selection,surgical technique and outcomes

Isolated patellofemoral arthritis is an increasingly recognized entity, and is usually associated with previous patellofemoral dysplasia or instability. Patellofemoral arthroplasty (PFA) has evolved significantly in recent years, both in terms of implant design and importantly in the understanding of appropriate patient selection. This review outlines the indications and investigations for PFA, provides a brief history of the development of contemporary implants, and presents the clinical outcomes for the prostheses most commonly used in the UK. In addition, it provides a detailed surgical technique for implantation of an onlay implant, with tips on how to optimize patellofemoral biomechanics and thus achieve a consistently good outcome.     

Part II: presentation,diagnosis, classification,treatment, and prevention of stress fractures in female athletes

ABSTRACT

Objectives: Stress fractures (SFx) occur as the result of repetitive loads over short periods of time, which leads to micro-damage of the bone through cortical resorption, ultimately leading to fracture. They are a common injury in female athletes and often cause significant morbidity. The goal of this study is to review the presentation, diagnosis, classification, treatment, and prevention of SFx in female athletes.

Results: A thorough history, physical exam, and appropriate imaging can facilitate early diagnosis of stress fracture (SFx) and faster resolution of symptoms with more conservative management. The female athlete triad is an especially important factor that contributes to the increased risk of SFx in females. The continuum of stress injuries ranges from mild microfailure to complete fracture, which has resulted in the development of newer grading schemas through MRI and radiographic findings. Stress fractures are also classified as low- or high-risk according to anatomic location, as blood supply and applied forces at different locations affect the likelihood of fracture propagation, displacement, delayed union, or non-union.

Conclusions: The ability to screen for at-risk athletes is paramount in preventing SFx. Recognition and prompt treatment of the female athlete triad requires a multidisciplinary approach in order to restore energy balance, correct menstrual irregularities, and improve bone health. This review provides a basis for understanding how to identify and treat stress fractures, which may allow treating physicians to diagnose this condition earlier and minimize any associated morbidity.     

Barriers and characteristics for successful transition to adult healthcare for individuals with cerebral palsy: a systematic review

Abstract

Background: Cerebral palsy (CP) is a common childhood disability. However, these individuals are now living longer lives, participating in adult roles, and seeking healthcare services. The transition from pediatric to adult healthcare for adolescents with CP is a challenging yet significant time. Adolescents experience several barriers during transition.

Objectives: To utilize the environmental and personal dimensions of the ICF model in order to explore barriers when transitioning to adulthood as well as discuss characteristics and physical therapy implications needed to succeed within transition.

Methods: Electronic searching of PubMed, CINAHL, ERIC, Scopus, ProQuest, and the Cochrane Library databases was concluded on January 9, 2019 for studies including transition between pediatric and adult healthcare in individuals diagnosed with CP. Two independent reviewers agreed upon inclusion, eligibility, and quality assessment of each study using the Mixed-Methods Appraisal Tool (MMAT).

Results: Seven studies were included in the systematic review. Results for each study were separated based on the personal and environmental contextual factors of the ICF model and solutions to the barriers were then discussed.

Conclusions: Research has provided proposed solutions to select barriers, however, other barriers have yet to be addressed. More research is needed to address these barriers and provide a model program that can be implemented within the healthcare systems to promote a successful transition for adolescents with CP from pediatric to adult services.     

Hippocampal and parahippocampal volumes vary by sex and traumatic life events in children

BackgroundChildhood trauma is reliably associated with smaller hippocampal volume in adults; however, this finding has not been shown in children, and even less is known about how sex and trauma interact to affect limbic structural development in children.MethodsTypically developing children aged 9 to 15 years who completed a trauma history questionnaire and structural T₁-weighted MRI were included in this study (n = 172; 85 female, 87 male). All children who reported 4 or more traumas (n = 36) composed the high trauma group, and all children who reported 3 or fewer traumas (n = 136) composed the low trauma group. Using multivariate analysis of covariance, we compared FreeSurfer-derived structural MRI volumes (normalized by total intracranial volume) of the amygdalar, hippocampal and parahippocampal regions by sex and trauma level, controlling for age and study site.ResultsWe found a significant sex × trauma interaction, such that girls with high trauma had greater volumes than boys with high trauma. Follow-up analyses indicated significantly increased volumes for girls and generally decreased volumes for boys, specifically in the hippocampal and parahippocampal regions for the high trauma group; we observed no sex differences in the low trauma group. We noted no interaction effect for the amygdalae.LimitationsWe assessed a community sample and did not include a clinical sample. We did not collect data about the ages at which children experienced trauma.ConclusionResults revealed that psychological trauma affects brain development differently in girls and boys. These findings need to be followed longitudinally to elucidate how structural differences progress and contribute to well-known sex disparities in psychopathology.     

Systematic review of enhanced recovery after gastro-oesophageal cancer surgery

Introduction

Fast track methodology or enhanced recovery schemes have gained increasing popularity in perioperative care. While evidence is strong for colorectal surgery, its importance in gastric and oesophageal surgery has yet to be established. This article reviews the evidence of enhanced recovery schemes on outcome for this type of surgery.

Methods

A systematic literature search was conducted up to March 2014. Studies were retrieved and analysed using predetermined criteria.

Results

From 34 articles reviewed, 18 eligible studies were identified: 7 on gastric and 11 on oesophageal resection. Three randomised controlled trials, five case-controlled studies and ten case series were identified. The reported protocols included changes to each stage of the patient journey from pre to postoperative care. The specific focus following oesophageal resections was on early mobilisation, a reduction in intensive care unit stay, early drain removal and early (or no) contrast swallow studies. Following gastric resections, the emphasis was on reducing epidural anaesthesia along with re-establishing oral intake in the first three postoperative days and early removal of nasogastric tubes.In the papers reviewed, mortality rates following fast track surgery were 0.8% (9/1,075) for oesophageal resection and 0% (0/329) for gastric resection. The reported morbidity rate was 16.5% (54/329) following gastric resection and 38.6% (396/1,075) following oesophageal resection. Length of stay was reduced in both groups compared with conventional recovery groups in comparative studies.

Conclusions

The evidence for enhanced recovery schemes following gastric and oesophageal resection is weak, with only three (low volume) published randomised controlled trials. However, the enhanced recovery approach appears safe and may be associated with a reduction in length of stay.     

Exaggerated Exercise Blood Pressure Response and Future Cardiovascular Disease

Exaggerated blood pressure (BP) response to exercise predicts future hypertension. However, there is considerable lack of understanding regarding the mechanism of how this abnormal response is generated, and how it relates to the future establishment of cardiovascular disease. The authors studied 82 healthy male volunteers without cardiovascular risk factors. The participants were categorized into two age‐matched groups depending on their exercise systolic BP (ExSBP) rise after 3 minutes of exercise using a submaximal step test: exaggerated ExSBP group (hyper‐responders [peak SBP ≥180 mm Hg]) and low ExSBP responder group (hypo‐responders [peak SBP <180 mm Hg]). Forearm venous occlusion plethysmography and intra‐arterial infusions of acetylcholine (ACh), N^G‐monomethyl‐L‐arginine (L‐NMMA), sodium nitroprusside (SNP), and norepinephrine (NE) were used to assess vascular reactivity. Proximal aortic compliance was assessed with ultrasound, and neurohormonal blood sampling was performed at rest and during peak exercise. The hyper‐responder group exhibited a significantly lower increase in forearm blood flow (FBF) with ACh compared with the hypo‐responder group (ΔFBF 215% [14] vs 332.3% [28], mean [standard error of the mean]; P<.001), as well as decreased proximal aortic compliance. The vasoconstrictive response to L‐NMMA was significantly impaired in the hyper‐responder group in comparison to the hypo‐responder group (ΔFBF −40.2% [1.6] vs −50.2% [2.6]; P<.05). In contrast, the vascular response to SNP and NE were comparable in both groups. Peak exercise plasma angiotensin II levels were significantly higher in the hyper‐responder group (31 [1] vs 23 [2] pg/mL, P=.01). An exaggerated BP response to exercise is related to endothelial dysfunction, decreased proximal aortic compliance, and increased exercise‐related neurohormonal activation, the constellation of which may explain future cardiovascular disease.

Atherosclerotic vascular disease is the major cause of death in Western societies. There is evidence suggesting that endothelial dysfunction occurs early and is the precursor to atheroma formation. Indeed, children and young adults with a family history of cardiovascular disease who may have a genetic predisposition to these diseases have been reported to have impaired endothelial function.¹, ² Importantly, endothelial dysfunction in the coronary circulation predicts future cardiac adverse events.³ Most, if not all, cardiovascular risk factors are associated with endothelial dysfunction, and risk factor modification leads to improvement in vascular function.Since the process of atherosclerosis begins early in life,⁴ and endothelial dysfunction contributes to atherogenesis and precedes the development of morphological vascular changes, it is important to detect early functional structural changes.⁵ Indeed, for the cardiovascular disease burden to be reduced, primary prevention measures may be best targeted at individuals without overt vascular diseases, but with demonstrable endothelial dysfunction. There is, however, no simple method of assessing vascular endothelial function. We have previously shown that in hypertensive patients an exaggerated blood pressure (BP) response to a simple three‐minute exercise step test predicted the presence and degree of endothelial dysfunction, but these patients already had cardiovascular risk factors, thus limiting the applicability of the test to those with established atherosclerotic disease.⁶ On the other hand, it has been suggested that an exaggerated BP response to exercise occurring in patients with normal resting BP is predictive of risk for new‐onset hypertension.⁷ However, the mechanism(s) associated with exaggerated BP and by extension, contributing to future hypertension, remain poorly understood. We therefore set out to explore whether exaggerated exercise BP responses may be a surrogate marker of overall vascular health in healthy young men without cardiovascular risk factors. We also sought to explore the mechanism(s) behind the genesis of exaggerated BP responses during exercise and their relationship to future cardiovascular disease.     

P21 Design and operation of a human breath freshness panel

Objective  Practical treatment of halitosis requires tongue cleaning since volatile sulphur compounds (VSC) seems mainly to be from the tongue coating. From this point of view, mechanical tools such as tongue brushes or scrapers have been developed. However, approaches by chemical tongue cleaning have not been reported. Thus we developed tablets containing protease from kiwifruits, which could resolve tongue coating, and assessed the effects of the protease tablet to control tongue coating.
Methods  Crossover studies and double blind experiments were designed using volunteers with informed consent. The trial was done twice per volunteer, that is, they had a tablet with or without the addition of protease from kiwifruits (test and placebo) with intervening washout periods of at least 2 weeks. The degree of change in tongue coating was evaluated visually using a tongue coating score which consisted of an area component (0–3) and a thickness component (0–3). An image analyzer was also used to measure the changing in actual area of coating.
Results  The average value of the tongue coating scores after taking a test tablet (11.4 ± 5.2) was significantly smaller ( P  < 0.01) than before taking the tablet (18.8 ± 7.0). Image analyzer measurements also showed significant reduction ( P  < 0.01) of tongue coating by taking test tablet. On the other hand, a placebo tablet showed no significant effects in both analyses.
Conclusions  This study indicated that taking protease tablets could reduce tongue coating. We are planning further clinical trials that can show reduced VSC concentrations in mouth air with decreasing tongue coating.     

Two years oral use of chlorhexidine in man

Possible changes in the structure of human oral mucosa resulting from exposure to chlorhexidine were examined in biopsy specimens of palatal and gingival mucosa obtained from three groups of young adults who had rinsed for more than 1 year (a) once or (b) twice daily with 0.2 % chlorhexidine solution or (c) with a placebo mouthwash. Specimens were quenched in liquid nitrogen and cryostat sectioned perpendicular to the epithelial surface. Sections stained with hematoxylin and eosin were used to assess the degree of keratinization of epithelia and to measure the width of the stratum corneum. Sections treated with buffered alkaline solutions were used to expand and count the number of layers of cells in the stratum corneum.
All specimens examined showed evidence of keratinization and, in keeping with previous reports, palatal specimens were more frequently orthokeratinized than gingival specimens. Mean width of the stratum corneum of gingival specimens was approximately 13 μ m and of palatal specimens, 23 μ m. The mean number of layers of cells in the stratum corneum of the gingiva was approximately 10 and of the palate, approximately 12. Differences in the degree of keratinization and thickness of the stratum corneum between gingival and palatal specimens was statistically significant, but no statistically significant differences were found between the chlorhexidine-exposed and non-chlorhexidine-exposed palatal tissue in keratinization, layers of cells or thickness of the stratum corneum. Neither was there any statistical difference in the same parameters for the gingival specimens. The methods employed did not therefore detect any changes in the normal structure of keratinizing oral epithelia as a result of prolonged daily exposure to chlorhexidine.