Shortening Scarf osteotomy for correction of severe hallux valgus. Does shortening affect the outcome?

BackgroundTranslation and shortening of Scarf osteotomy allows correction of severe hallux valgus deformity. Shortening may result in transfer metatarsalgia.AimTo evaluate outcome of patients undergoing shortening Scarf osteotomy for severe hallux valgus deformities.Materials and MethodsFifteen patients (20 feet, mean age 58 years) underwent shortening Scarf osteotomy for severe hallux valgus deformities. Outcomes were pre and postoperative AOFAS scores, IM and HV angles, patient satisfaction.ResultsMean follow-up was 25 months (range 22–30). The IM angle improved from a median of 18.60 (range 13.4–26.20) preoperatively to 9.70 (range 8.0–13.70) postoperatively (8.9; 95% CI = 7.6–10.3; p < 0.001). The HV angle improved from a mean of 43.2 (range 27.4–68.2) preoperatively to 13.6 (range 3.0–37.4) postoperatively (29.6; 95% CI = 26.1–33.2; p < 0.001).The median AOFAS score improved from 29.2 (range 14–60) preoperatively to 82.2 (range 55–100) postoperatively (53.0; 95% CI = 48.0–58.5; p < 0.001). All patients rated their satisfaction as either satisfied or very satisfied. None had symptoms of transfer metatarsalgia at final follow-up. All osteotomies united.ConclusionsShortening Scarf osteotomy is a viable option for treating severe hallux valgus deformities with no transfer metatarsalgia.     

The extended posterolateral approach for split depression lateral tibial plateau fractures extending into the posterior column: 2 years follow up results of a prospective study

ObjectiveTo prospectively study the outcome of surgically treated split depression lateral tibial plateau fractures extending into the posterior column using the extended posterolateral approach.MethodsTwenty-one patients with split depression lateral tibial plateau fractures (AO: 41-B3) with extension into the posterior column were treated with open reduction and internal fixation through an extended posterolateral approach with osteotomy of the fibular neck ± Gerdy tubercle. Follow up radiographs was assessed for quality of articular reduction and limb axis. Functional assessment was performed at last follow up using the Tegner–Lysholm score. Complications pertaining to the surgical approach were recorded.ResultsThe approach was performed in 15 patients with a fibular neck osteotomy alone and 6 patients required a Gerdy's tubercle osteotomy also. All fractures and osteotomies had united. Anatomical articular reduction was achieved in 16 patients. Radiological limb alignment was restored in all patients except for a reversed posterior slope in 1 patient. Arthritic changes were seen in 3 patients. The mean Tegner–Lysholm score was 87.3 (range: 76–95) at last follow up. No specific complications related to the surgical approach like common peroneal nerve injury and lateral instability of the knee was encountered.ConclusionThe extended posterolateral approach offers excellent exposure posterior to the fibular head to perform articular reduction and fixation achieving satisfactory radiological and functional results in split depression lateral tibial plateau fractures extending into the posterior column.     

Bunionette deformity corrected with “shortening” scarf osteotomy of the fifth metatarsal: mid-term results of a 34-cases

BackgroundThe aim of this study was to evaluate the clinical and radiological outcomes (in mid-term) after “shortening” scarf osteotomy of the fifth metatarsal for the treatment of bunionette deformity.MethodsWe retrospectively reviewed the functional score — American Orthopaedic Foot and Ankle Society (AOFAS) Lesser Toe Metatarsophalangeal-Interphalangeal Scale, radiographic results — 4th/5th intermetatarsal angle, varus angle of the 5th metatarsophalangeal joint and complications in a consecutive series of 34 feet (27 patients) with bunionette. Nine males and 18 females (mean age: 45 years) were included in the study. Three males and four females were operated bilaterally The patients were operated on between 2004 and 2015, and evaluated during 2017.ResultsThe average AOFAS score improved from 59.4 to 93 at a mean follow-up of 7.2 years. The 4th/5th intermetatarsal angle and varus angle of the 5th metatarsophalangeal joint decreased from 13.9°/19.5° preoperatively to 6°/5.9° at final follow-up. No neurovascular damage was recorded. Complications arose in five feet (14.7%): delayed union (n = 1), early infection (n = 1), distal screw migration (n = 1), asymptomatic non-union (n = 1), transverse metatarsalgia (n = 1). The osteotomy healed within less than three months except twoo (delayed union, non-union). Three feet needed additional surgery: screw removal (n = 2), Weil osteotomy of 2nd–4th metatarsals (n = 1).Conclusions“Shortening” scarf osteotomy is an acceptable, but not complication-free, treatment option for the bunionette deformity and offers promising results in the mid-term.     

Comparison of prognostic models for burn patients: A retrospective nationwide registry study

BackgroundPrognostic burn index (PBI) is a unique model utilized to predict mortality of burn patients in Japan. In contrast, other prediction models are rarely used in Japan, and their accuracy and predictive value are unknown. The present study aimed to compare commonly used burn prediction models and determine the appropriate model for mortality prediction in Japanese burn patients.MethodsJapanese burn patients registered in the nationwide burn registry of Japanese Society for Burn Injury between April 1, 2011 and March 31, 2019 were reviewed retrospectively. The prognostic performance of PBI was compared with Baux score, revised Baux score, abbreviated burn severity index (ABSI), Ryan score and Belgian outcome in burn injury score (BOBI). The primary outcome was in-hospital mortality.ResultsThe study included 7911 acute burn patients. The overall mortality rate was 10.7%, the median age was 52 (interquartile range, 26–72) years, and the median % total body surface area was 7% (interquartile range, 3%–17%). The areas under the receiver operating characteristic curve for PBI, Baux score, ABSI, revised Baux score, Ryan score, and BOBI were 0.940 (95% confidence interval [CI]: 0.931–0.948), 0.943 (95% CI: 0.934–0.951; p = 0.002), 0.945 (95% CI: 0.937–0.953; p = 0.058), 0.946 (95% CI: 0.937–0.953; p = 0.002), 0.859 (95% CI: 0.846–0.870; p < 0.001), and 0.896 (95% CI: 0.885–0.905; p < 0.001), respectively.ConclusionAlthough the performance of PBI was good, it was not superior to the Baux score, revised Baux score, and ABSI. These three scores have a high prognostic accuracy. Hence, they are considered as alternative burn prognostic scores in Japan. The Baux score was an optimal prognostic model for patients with burns in Japan.     

Scarf osteotomy for the treatment of moderate to severe hallux valgus: Analysis of predictors for midterm outcomes and recurrence

BackgroundControversies remain regarding the predictors for outcomes and recurrence after scarf osteotomy for hallux valgus deformity.MethodsSixty-two patients (70 feet) underwent scarf osteotomy for hallux valgus deformity. The radiological angles, tibial sesamoid position, articular congruence, demographics, comorbidities, AOFAS, VAS and SF-12 scores, and the postoperative compliance were tested as predictors for outcomes and recurrence.ResultsAfter a mean 38 ± 15.4 months follow-up, all of the radiological angles, the total AOFAS, PCS-12 and VAS scores significantly improved (all P < 0.001). Preoperative MCS-12 was directly related to the total postoperative AOFAS score (P = 0.003). A higher number of cardiovascular risk factors negatively affected the postoperative total AOFAS score, VAS and PCS-12 (β = −3.42, P = 0.030; β = 0.262, P = 0.022; β = −0.181, P = 0.025, respectively). The BMI influenced postoperative PCS-12 (β = −0.244, P = 0.002). Preoperative HVA was directly related to postoperative DMAA (P = 0.002) and tibial sesamoid position (P = 0.005). Preoperative joint incongruence and postoperative noncompliance were associated with recurrence (P = 0.043 and P = 0.035, respectively).ConclusionsSatisfactory results can be expected after scarf osteotomy. Higher BMI and number of cardiovascular risk factors, and low mental status should be carefully considered when counselling patients for this procedure. Adherence to postoperative care instructions influences deformity recurrence.     

Outcomes of MPFL reconstruction with tibial tubercle transfer for recurrent patellar instability with high grade trochlear dysplasia in Indian population

BackgroundPatellar instability is a painful condition which affects the quality of life and mobility of young individuals. The aim of this study is to observe the results of medial patello-femoral ligament reconstruction with hamstring autograft along with a modified Fulkerson osteotomy, for recurrent instability of patella with high-grade trochlear dysplasia in Indian population.Materials & methodsWe conducted a prospective observational study of 26 knees (21 patients) who attended our outpatient department from June 2014 to February 2019, with recurrent instability of the patella and high-grade trochlear dysplasia. All knees were treated with MPFL reconstruction with hamstring autograft and modified Fulkerson osteotomy.ResultsThe mean follow-up period was 30 months (range: 24–50). The mean Lysholm scores improved from 49.9 (range: 30–63) preoperatively to 82.5 (range: 51–100) (p < 0.05), Kujala scores from 55.5 (36–67) to 85.9 (55–100) and International Knee Documentation Committee (IKDC) scores from 50.2 (31.6–62.3) to 82.9 (54.7–98.3) (p < 0.05) at 2 years follow-up. TT-TG distance decreased from 21.2 mm (18–25) to 11.6 mm (10–13) (p < 0.05) and patellar tilt angle decreased from 24.2° (18°-35°) to 7.2° (5°-10°) (p < 0.05). One knee had superficial skin infection in immediate post-operative period. Three knees had postoperative stiffness, which improved on manipulation under anesthesia. Six knees had implant irritation from the osteotomy screws which were removed after bony union was achieved. Functional scores were low in two knees due to patello-femoral pain, but they did not have recurrent instability.ConclusionMPFL reconstruction with tibial tubercle transfer gives good functional outcomes in 92.3% patients with recurrent patellar instability, associated with high-grade trochlear dysplasia in Indian population.     

Youngswick osteotomy for treatment of moderate hallux rigidus: Thirteen years without arthrodesis

PurposeThe purpose of this study was to evaluate the need for first metatarsophalangeal joint (MTPJ) arthrodesis as a measure of the Youngswick osteotomy survival, or any other secondary procedures in the long term follow up in patients with stage II and III hallux rigidus.MethodsWe retrospectively evaluated 61 patients with stage II and III hallux rigidus who had undergone Youngswick osteotomy and analyzed their outcomes in the long term using first metatarsophalangeal arthrodesis as an end point. The candidates for inclusion underwent clinical and radiographic evaluation, including the Foot and Ankle Outcome Score (FAOS).ResultsMean follow-up time was 54.8 months. All patients had improved their FAOS, with all achieving postoperative scores >75 points at the final follow up (P < 0.05). Although 49 % (P < 0.05) of the patients depicted worsening of the radiological aspect of the MTPJ, over the long time, no patient needed a first MTPJ arthrodesis.ConclusionOur results show satisfying long-term outcomes with regard to function, pain relief, and patient satisfaction of the Youngswick osteotomy in grade II as well as grade III hallux rigidus that sustained over the follow up period; even in patients followed up for over 13 years.Level of evidenceIII.     

Instability of the extensor digitorum tendons in Jaccoud arthropathy assessed by semi-dynamic MRI of the metacarpophalangeal joints

PurposeThe purpose of this study was to test the hypothesis that Jaccoud arthropathy (JA) in patients with systemic lupus erythematosus (SLE) is associated with instability of the extensor digitorum (ED) tendons during flexion of the metacarpophalangeal (MCP) joints by comparing the position of the ED tendons between SLE patients with JA and control subjects on hand MRI obtained with flexed and extended MCP joints.Materials and methodsThirty-two hands of SLE patients with JA (13 women and 3 men; mean age, 50.0 ± 12.2 [SD] years; age range: 26–68 years) and 24 hands of sex- and age-matched control subjects (20 women and 4 men; mean age, 50.1 ± 13.0 [SD] years; age range: 24–68 years) were included in the study. Axial spin echo T1-weighted MRI images of the second to fifth MCP joints in flexion and in extension were obtained. Two radiologists (R1 and R2) separately measured the amplitude and assessed the direction of the displacement of the ED tendons with respect to the midline at the level of each MCP joint. Statistical analysis included two-way ANOVA with random effects to assess differences in amplitude and Fisher–Freeman–Halton exact test to assess differences in direction with P-values < 0.0083 and < 0.0063 considered as statistically significant respectively.ResultsAmplitude of the displacement of the ED tendons was statistically significantly greater in SLE patients with JA than in control subjects in flexion for both readers (median 58°, 95% confidence interval [CI]: 50°–65° vs. 20°, 95% CI: 16°–24°; P < 0.0001 for R1 and 54°, 95% CI: 47°–61° vs. 25°, 95% CI: 22°–28°; P < 0.0001 for R2) and in extension for one reader (17°, 95% CI: 15°–20° vs. 14°, 95% CI: 11°–16°; P = 0.0048 for R1 and 20°, 95% CI: 15°–25° vs. 16°, 95% CI: 12°–18°; P = 0.0292 for R2). Ulnar deviation of the ED tendons was statistically significantly more frequent in SLE patients with JA than in control subjects in flexion and in extension for both readers (P < 0.0001).ConclusionJA is associated with instability of the ED tendons in patients with SLE best depicted when MCP joints are flexed.     

Arthroscopic deepening trochleoplasty for chronic anterior knee pain after previous failed conservative and arthroscopic treatment. Report of two cases

PurposeA proportion of patients having years of chronic anterior knee pain(AKP) that have not responded to non-operative modalities. Trochlear dysplasia have been found to be a cause for AKP. By restoring the anatomy with a trochleoplasty procedure the patellofemoral joint is unloaded. This study is a prospective 2 year follow-up study, based on two cases with chronic AKP for several years and having severe trochlear dysplasia and both were successfully treated by arthroscopic deepening trochleoplasty.MethodsCase one was a 46 year old women with chronic anterior knee pain (AKP). Imaging showed lateral trochlear inclination angle of 2°, trochlear asymmetry 0.36, central height 81% and medial height 83%. Thepreoperative Kujala score was 70 and Knee injury and Osteoarthritis Outcome Score (KOOS) subscale for pain was 67. Case two was a 26 year old man troubled by AKP and knee knee joint effusion for >8 years without any instability in the history. Imaging showed lateral trochlear inclination angle of 6°, trochlear asymmetry 0.25, central height 76% and medial height 78%. The preoperative Kujala score was 49 and KOOS subscale for pain was 72.ResultsThe postoperative Kujala score was for case one 82 and for case two 81. The postoperative KOOS subscale for pain was for case one 89 and for case two 92. Improvement in the KOOS subscale for sport and recreational activities and quality of living were also found.ConclusionThis is the first case report to demonstrate that patient having had years of chronic AKP and trochlear dysplasia can be successfully treated by arthroscopic trochleoplasty.     

Safety and efficacy of adipose-derived mesenchymal stem cells for knee osteoarthritis: A systematic review and m-analysis

ObjectiveThis research aimed to study the safety and efficacy of adipose-derived mesenchymal stem cells (ADMSCs) for knee osteoarthritis (OA).MethodsWe used six databases to search for records and then screened them for eligibility. In both randomized and non-randomized studies, the risk of bias was assessed. The data were then retrieved and used in single-arm and double-arm analyses using Comprehensive Meta-Analysis (CMA) Version 3.0 and RevMan Version 5.3, respectively.ResultsBased on the study's inclusion criteria, we included 15 studies with a total of 463 patients. According to our single-arm analyses, there was a significant improvement in quality of life (QOL) among the three dose subgroups (high, medium, and low doses), as measured by SF-36 scores after a year of follow-up [low dose: mean (M) = ?23.99; 95% confidence interval (CI) [?31.49 to ?16.49]; P < 0.001; medium dose: M = ?15.96; 95% CI [?23.5 to ? 8.42]; P < 0.001; high dose: M = ?19.31; 95% CI [?28.02 to ?10.59], P < 0.001] and the knee injury and osteoarthritis outcome score (KOOS) QOL sub-score after six months following ADMSCs injection in the low-dose group (M = 24.9; 95% CI [4.3 to 45.6]; P < 0.05). Moreover, after three months of follow-up, we detected significant pain reduction as measured by the numeric pain rating scale (NPRS), with no significant difference between the low and medium doses (low dose: M = ?3.12; 95% CI [?5.09 to ?1.14]; P < 0.01; medium dose; M = ?2.17; 95% CI [?3.13 to ?1.21]; P < 0.001). However, after a year, the results were no longer significant. Despite finding no significant difference between them after 6 and 12 months post-treatment in the Visual Analogue scale (VAS) scale and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) total score, double-arm analyses revealed significant pain reduction in the ADMSCs group over the control after 12 months as estimated by the WOMAC pain sub-score (mean difference (MD) = ?1.85, 95% CI [?3.55, ?0.15], P < 0.05). After six months, the low dosage group's knee functions and activity levels improved significantly, as determined by the WOMAC physical function and stiffness subscales (M = ?23.79; 95% CI [?38.43 to ?9.16]; P = 0.001; M = ?10.25; 95% CI [?17.31 to ?2.59]; P < 0.01, respectively), as well as the KOOS scores after a year (P < 0.01 for all KOOS subscales). In the ADMSCs injections group, there were no serious adverse effects [event rate (ER) = 0.11; 95% CI [0.03–0.3]; P = 0.001].ConclusionIn the present single-arm meta-analysis, ADMSCs were associated with significant reduction in pain and improvement in QOL and knee functions in patients with knee OA. However, double arm analyses did not confirm these positive findings, which may be returned to the small sample size of included patients. Therefore, to introduce ADMSCs into clinical practice and establish guidelines for their use, more randomized controlled clinical trials with large sample sizes and long-term follow-ups are needed.     

Outcomes of medial patellofemoral ligament reconstruction and tibial tubercle osteotomy in syndromic adolescents with patellar dislocation

BackgroundTreatment of congenital and habitual dislocation of the patella in syndromic adolescents can be difficult due to accompanying soft-tissue and/or osseous abnormalities often present in the knee. The aim of this study was to report the results of surgical treatment of congenital and habitual patellar dislocation with medial patellofemoral ligament (MPFL) reconstruction and tibial tubercle osteotomy (TTO) in adolescents with an underlying syndrome.MethodsSyndromic adolescent patients with congenital or habitual patellar dislocation treated with MPFL reconstruction and TTO between 2005 and 2019 with a minimum of one year of follow-up were identified. Demographic, clinical, radiographic, and surgical data were recorded, and any complications were noted. Kujala and Lysholm scores were used to quantitate knee function.ResultsSeventeen knees in 11 patients met the criteria for inclusion. The mean age at operation was 14.8 years (range, 13.3–18.3 years). Patients were identified as having Ehlers-Danlos (four), Down (two), trichorhinophalangeal (one), McCune-Albright (one), Klippel-Feil (one), and generalized joint hypermobility (two) syndromes. The mean follow-up was 2.2 years for each individual knee (range, 1–5.9 years). The mean Kujala score increased from 56 ± 10 preoperatively to 86 ± 6 at the most recent postoperative visit (p < 0.001). The mean Lysholm score increased from 53 ± 10 preoperatively to 85 ± 7 at the most recent postoperative visit (p < 0.001). Knee flexion increased significantly from 117° ± 15° preoperatively to 154° ± 13° postoperatively (p < 0.001). However, knee extension was no different pre- and postoperatively (4° ± 8° vs. 1° ± 4°, respectively, p = 0.2).ConclusionsCongenital and habitual patellar dislocation in adolescent-aged patients with an underlying syndromic diagnosis can be successfully treated with MPFL reconstruction combined with TTO.     

Arterial endofibrosis in endurance athletes: Prospective comparison of the diagnostic accuracy of intra-arterial digital subtraction angiography and computed tomography angiography

PurposeTo prospectively compare the diagnostic capabilities of computed tomography angiography (CTA) to those of digital subtraction angiography (DSA) in endurance athletes with suspicion of arterial endofibrosis.Materials and methodsForty-five athletes (39 men, 6 women; median age: 30 years, interquartile range: 23–42 years) prospectively underwent DSA and CTA without (n = 5) or with (n = 40) electrocardiogram gating. DSA was interpreted by a single expert (experience of 15 years). CTA was independently interpreted by three other readers (experience of 5–8 years). Readers assessed the presence and degree of stenoses on iliac and femoral arteries and the overall diagnosis (negative, uncertain, positive) of endofibrosis at the limb level. Sensitivities and specificities of DSA and CTA were estimated at the limb level using histological findings and long-term follow-up as reference, and compared using the McNemar test.ResultsFor diagnosing and quantifying stenoses, concordance between DSA and CTA was moderate-to-good for common and external iliac arteries, moderate for lateral circumflex arteries and poor-to-moderate for the other branches of the deep femoral artery. It was good for all readers for the overall diagnosis of endofibrosis. After long-term follow-up (median, 95 months; interquartile range: 7–109 months), DSA sensitivity and specificity were respectively 88.6% (39/44; 95% confidence interval [CI]: 76–95%) and 75% (24/32; 95% CI: 57.9–86.7%); CTA sensitivity and specificity were respectively 88.6% (39/44; 95% CI: 76–95%; P > 0.99) and 84.4% (27/32; 95% CI: 68.2–93.1%; P = 0.51), 86.3% (38/44; 95% CI: 73.3–93.6%; P > 0.99) and 75% (24/32; 95% CI: 57.9–86.7%; P > 0.99), and 84.1% (37/44; 95% CI: 70.6–92.1%; P = 0.68) and 75% (24/32; 95% CI: 57.9–86.7%; P > 0.99) for the three readers.ConclusionCTA shows performances similar to those of DSA in predicting the long-term diagnosis of endofibrosis in endurance athletes with suggestive symptoms.     

Predictors of response to anti-TNF therapy in RA patients with moderate or high DAS28 scores

ObjectivesTo identify the clinical factors predicting a good clinical response to anti-TNF therapy in rheumatoid arthritis (RA) patients entered in the LORHEN registry after 5 years of treatment with anti-TNF agents and divided into two groups on the basis of their baseline DAS28 scores (moderate > 3.2–5.1 [MDA] and high > 5.1 [HDA]).MethodsDisease activity at baseline and after 12 months was assessed using the DAS28, and response was evaluated using the EULAR improvement criteria.ResultsThe study involved 1300 patients with established RA: 975 with HDA and 325 with MDA. After a mean 36-month, 29.6% of the patients had a DAS28 score of less or equal to 2.6 (HDA 25.8% vs. MDA 43.0%; P < 0.001) and were considered to be in remission. A higher probability of a good EULAR response in patients with HDA was associated with male gender (F vs. M – OR 0.45, 95% CI 0.26–0.78; P: 0.004), lower age at the start of treatment (OR 0.98, 95% CI 0.96–0.99; P: 0.002), the absence of comorbidities (OR 0.18, 95% CI 0.06–0.52; P: 0.002) or no previous use of corticosteroids (OR 1.92, 95% CI 1.14–3.22; P: 0.015) and the use of adalimumab vs. infliximab (OR 2.21, 95% CI 1.37–3.57; P 0.001); in patients with MDA, the probability of a good EULAR response was associated with male gender (F vs. M – OR 0.39, 95% CI 0.17–0.90; P: 0.027).ConclusionsWith the exception of male gender, the factors predicting a good EULAR response are different in patients with MDA and those with HDA.     

Diagnosis of postoperative recurrence of Crohn disease with MR-enterography: Value of diffusion-weighted imaging

PurposeTo compare the diagnostic capabilities of MR enterography (MRE) using contrast-enhanced (CE) sequences with those of MRE using diffusion-weighted (DW) imaging for the diagnosis of postoperative recurrence at the neo-terminal ileum and/or anastomosis after ileocolonic resection in patients with Crohn disease (CD), and to clarify the role of additional DW imaging to CE-MRE in this context.Material and methodsForty patients who underwent ileal resection for CD, and both endoscopy and MRE within the first year after surgery were included. There were 21 men and 19 women, with a mean age of 38 years ± 12 (SD) years (range: 18–67 years). MRE examinations were blindly analyzed independently by one senior (R1) and one junior (R2) radiologist for the presence of small bowel postoperative recurrence at the anastomotic site. During a first reading session, T2-, steady-state- and DW-MRE were reviewed (DW-MRE or set 1). During a separate distant session, T2-, steady-state- and CE-MRE were reviewed (CE-MRE or set 2). Lastly, all sequences were analyzed altogether (set 3). Performances of each reader for the diagnosis of postoperative recurrence were evaluated using endoscopic findings as the standard of reference (Rutgeerts score ≥ i2b).ResultsFifteen patients out of 40 (37.5%) had endoscopic postoperative recurrence at the anastomotic site. Sensitivity for the diagnosis of postoperative recurrence was 73% (95% CI: 51–96%) for R1 and 67% (95% CI: 43–91%) for R2 using set 1, and 80% (95% CI: 60–100%) for both readers using set 2. There was no significant differences in sensitivity between reading set 1 and reading set 2, for either R1 or R2 (R1, P  > 0.99; R2, P = 0.48). Specificity was 96% (95% CI: 88–100%) for both readers using set 1 or using set 2. Reading set 3 yielded an area under the ROC curve (AUC) of 0.93 (95% CI: 0.84–1) versus 0.89 (95% CI: 0.75–1) with set 1 (P = 0.18) and versus 0.89 (95% CI: 0.78–1) with set 2 (P = 0.21). No significant differences in AUC were found between set 1 or 2 and set 3 (P = 0.18), nor between set 1 and 2 (P = 0.76). Accuracies were 88% (95% CI: 74–95%) and 85% (95% CI: 71–93%) for DW-MRE for R1 and R2, respectively; 90% (95% CI: 77–96%) for CE-MRE for both readers; and 93% (95% CI: 80–97%) and 88% (95% CI: 74–95%) for R1 and R2 with set 3, respectively.ConclusionDW-MRE has diagnostic capabilities similar to those of CE-MRE for the diagnosis of postoperative recurrence of CD at the anastomotic site.     

Oncological outcomes of laparoscopic nephroureterectomy with pluck method for distal ureter resection

ObjectiveTo report the oncologic outcomes of upper tract urothelial carcinoma treated with laparoscopic nephroureterectomy and pluck method for distal ureter resection.Materials and methodsBetween May 2004 and November 2015, 118 patients with upper urinary tract urothelial carcinoma received laparoscopic radical nephroureterectomy with endoscopic bladder cuff excision at our institution. The medical records were reviewed retrospectively for clinical and pathological results. Cox regression analyses were performed on factors related to oncological outcomes.ResultsThe median follow-up was 26 months. Bladder recurrence was found in 27 patients (22.9%), extravesical retroperitoneal recurrence in four patients (3.4%), and metastases in 17 patients (14.4%). Multivariate analyses showed that male sex was associated with higher bladder recurrence [odds ratio (OR) = 2.2; 95% confidence interval (CI), 1.02–4.78; p = 0.045)], tumor size had significant correlation with locoregional recurrence (OR = 1.29; 95% CI, 1.07–3.43; p = 0.029), tumor stage was significantly correlated with subsequent metastasis (OR = 2.08; 95% CI, 1.21–3.56; p = 0.008) and overall survival (OR = 1.84; 95% CI, 1.06–3.22 ; p = 0.031), and tumor size correlated significantly with cancer-specific survival (OR = 2.57; 95% CI, 1.16–5.72; p = 0.021).ConclusionsTumor size and tumor stage were significantly associated with survival (cancer-specific and overall survival) in patients receiving nephroureterectomy with pluck method.     

Does perceived injustice correlate with pain intensity and disability in orthopaedic trauma patients?

IntroductionIndividuals who experience musculoskeletal trauma may construe the experience as unjust and themselves as victims. Perceived injustice is a cognitive construct comprised by negative appraisals of the severity of loss as a consequence of injury, blame, injury-related loss, and unfairness. It has been associated with worse physical and psychological outcomes in the context of chronic health conditions. The purpose of this study is to explore the association of perceived injustice to pain intensity and physical function in patients with orthopaedic trauma.MethodsA total of 124 orthopaedic trauma patients completed the Injustice Experience Questionnaire (IEQ), the PROMIS Physical Function Computer Adaptive Testing (CAT), the PROMIS Pain Intensity instruments, the short form Patient Health Questionnaire for depression (PHQ-2), the short form Pain Self-Efficacy Questionnaire (PSEQ-2), and the short form Pain Catastrophizing Scale (PCS-4) on a tablet computer. A stepwise linear regression model was used to identify the best combination of predictors explaining variance in PROMIS Physical Function and PROMIS Pain Intensity.ResultsThe IEQ was associated with PROMIS Physical Function (r = −0.36; P < 0.001) and PROMIS Pain Intensity (r = 0.43; P < 0.001). In multivariable analysis, however, Caucasian race (β = 5.1, SE: 2.0, P = 0.013, 95% CI: 1.1–9.2), employed work status (β = 5.1, SE: 1.5, P = 0.001, 95% CI: 2.1–8.2), any cause of injury other than sports, mvc, or fall (β = 7.7, SE: 2.1, P < 0.001, 95% CI: 3.5–12), and higher self-efficacy (PSEQ-2; β = 0.93, SE: 0.23, P < 0.001, 95% CI: 0.48–1.4) were selected as part of the best model predicting variance in PROMIS Physical Function. Only a higher degree of catastrophic thinking (PCS-4; β = 1.2, SE: 0.12, P < 0.001, 95% CI: 0.99 to 1.5) was selected as important in predicting higher PROMIS Pain Intensity.ConclusionPerceived injustice was associated with both physical function and pain intensity in bivariate correlations, but was not deemed as an important predictor when assessed along with other demographic and psychosocial variables in multivariable analysis. This study confirms prior research on the pivotal role of catastrophic thinking and self-efficacy in reports of pain intensity and physical function in patients with acute traumatic musculoskeletal pain.     

There is still a care gap in osteoporosis management for patients with rheumatoid arthritis

ObjectivesTo assess compliance rates with the current Canadian osteoporosis guidelines and whether the Fracture Risk Assessment Tool score in patients with rheumatoid arthritis correlated with the likelihood of receiving osteoporosis treatment and having a bone mineral density test.MethodsCharts of serial outpatients with rheumatoid arthritis were reviewed to collect bone mineral density test data and patients’ use of calcium, vitamin D, and osteoporosis treatment. Odds ratios (OR) were calculated to determine if a higher Fracture Risk Assessment Tool score increased the likelihood of osteoporosis treatment or having a bone mineral density test.ResultsUsing the Fracture Risk Assessment Tool, the 10-year risk of major osteoporotic fracture was high in 92 (12.5%), moderate in 216 (29.3%), and low in 429 (58.2%) patients. Compared to those at low risk, patients identified as high risk were more likely to receive osteoporosis treatment (OR 16.31, 95% CI 9.45–28.13, P < 0.001); calcium (OR 3.89, 95% CI 2.43–6.25, P < 0.001); vitamin D (OR 3.46, 95% CI 2.12–5.64, P < 0.001); and to have had a bone mineral density test (OR 10.22, 95% CI 5.50–18.96, P < 0.001). Among 124 patients currently taking prednisone, half (46.8%) were prescribed a bisphosphonate.ConclusionsAlthough compliance with current osteoporosis guidelines remains low among all patients with rheumatoid arthritis, higher risk patients were more likely to have a bone mineral density test and receive treatment for osteoporosis, as indicated by the clear dose response seen along the 10-year fracture risk from low to high-risk groups.     

Prediction of intra-hospital mortality after severe trauma: which pre-hospital score is the most accurate?

PurposeComputing trauma scores in the field allows immediate severity assessment for appropriate triage. Two pre-hospital scores can be useful in this context: the Triage-Revised Trauma Score (T-RTS) and the Mechanism, Glasgow, Age and arterial Pressure (MGAP) score. The Trauma Revised Injury Severity Score (TRISS), not applicable in the pre-hospital setting, is the reference score to predict in-hospital mortality after severe trauma. The aim of this study was to compare T-RTS, MGAP and TRISS in a cohort of consecutive patients admitted in the Trauma system of the Northern French Alps(TRENAU).Materials and methodsFrom 2009 to 2011, 3260 patients with suspected severe trauma according to the Vittel criteria were included in the TRENAU registry. All data necessary to compute T-RTS, MGAP and TRISS were collected in patients admitted to one level-I, two level-II and ten level-III trauma centers. The primary endpoint was death from any cause during hospital stay. Discriminative power of each score to predict mortality was measured using receiver operating curve (ROC) analysis. To test the relevancy of each score for triage, we also tested their sensitivity at usual cut-offs. We expected a sensitivity higher than 95% to limit undertriage.ResultsThe TRISS score showed the highest area under the ROC curve (0.95 [CI 95% 0.94–0.97], p < 0.01). Pre-hospital MGAP score had significantly higher AUC compared to T-RTS (0.93 [CI 95% 0.91–0.95] vs 0.86 [CI 95% 0.83–0.89], respectively, p < 0.01). MGAP score < 23 had a sensitivity of 88% to detect mortality. Sensitivities of T-RTS < 12 and TRISS < 0.91 were 79% and 87%, respectively.Discussion/conclusionPre-hospital calculation of the MGAP score appeared superior to T-RTS score in predicting intra-hospital mortality in a cohort of trauma patients. Although TRISS had the highest AUC, this score can only be available after hospital admission. These findings suggest that the MGAP score could be of interest in the pre-hospital setting to assess patients’ severity. However, its lack of sensitivity indicates that MGAP should not replace the decision scheme to direct the most severe patients to level-I trauma center.     

Computer-aided diagnosis system for characterizing ISUP grade ≥ 2 prostate cancers at multiparametric MRI: A cross-vendor evaluation

PurposeTo assess the performance of a computer-aided diagnosis (CADx) system trained at characterizing International Society of Urological Pathology (ISUP) grade ≥ 2 peripheral zone (PZ) prostate cancers on multiparametric magnetic resonance imaging (mpMRI) examinations from a different institution and acquired on different scanners than those used for the training database.Patients and methodsPreoperative mpMRIs of 74 men (median age, 65.7 years) treated by prostatectomy between 2014 and 2017 were retrospectively selected. One radiologist outlined suspicious lesions and scored them using Prostate Imaging-Reporting and Data System version 2 (PI-RADSv2); their CADx score was calculated using a classifier trained on an independent database of 106 patients treated by prostatectomy in another institution. The lesions’ nature was assessed by comparison with prostatectomy whole-mounts. Diagnostic accuracy was estimated with areas under receiver operating characteristic curves (AUCs). Sensitivity and specificity were calculated using a CADx threshold (≥0.21) that yielded 95% sensitivity in the training database, and a PI-RADSv2 ≥ 3 threshold.ResultsA total of 127 lesions (PZ, n = 104; transition zone [TZ], n = 23) were described. In PZ, CADx and PI-RADSv2 scores had similar AUCs for characterizing ISUP grade ≥ 2 cancers (0.78 [95% confidence interval (CI): 0.69–0.87] vs. 0.74 [95%CI: 0.62–0.82], respectively) (P = 0.59). Sensitivity and specificity were respectively 89% (95%CI: 82–97%) and 42% (95%CI: 26–58%) for the CADx score, and 97% (95%CI: 93–100%) and 37% (95%CI: 22–52%) for the PI-RADSv2 score. In TZ, both scores showed poor specificity.ConclusionIn this external cohort, the CADx and PI-RADSv2 scores showed similar performances in characterizing ISUP grade ≥ 2 cancers.