3D打印个性化导航模板在全膝关节置换术中的临床效果

目的探讨3D打印个性化导航模板在全膝关节置换术中应用的临床效果。方法选取本院2015年7月～2017年12月收治的行全膝关节置换术患者中选取46例,随机分为观察组和对照组各23例。对照组给予常规截骨器械治疗,观察组给予3D打印个性化导航模板治疗。对比两组临床效果,并观察术前术后患者膝关节功能评分、疼痛程度以及下肢力线、膝关节活动度变化情况。结果观察组治疗总有效率高于对照组(P<0.05);两组术后HSS评分较术前均有所提高,VAS评分较术前均有所降低,且观察组术后HSS评分较对照组更高,VAS评分较对照组更低,差异有统计学意义(P<0.05);两组术后下肢力线较术前均有所降低,膝关节活动度较术前均有所提高,且观察组术后下肢力线较对照组更低,膝关节活动度较对照组更高,差异有统计学意义(P<0.05)。结论接受全膝关节置换术治疗的患者可应用3D打印个性化导航模板,能够提高手术治疗效果,改善患者预后。     

Venous Thromboembolism (VTE) Prophylaxis for Hip and Knee Arthroplasty: Changing Trends

Venous thromboembolism (VTE) has been identified as an immediate threat to patients undergoing major orthopedic procedures such as total hip arthroplasty (THA) and total knee arthroplasty (TKA). Given the known dangers of VTE, arthroplasty surgeons are sensitive to the need for VTE thromboprophylaxis. However, the modalities of thromboprophylaxis used to minimize the risks to patients have been variable. Clinical practice guidelines have been published by several professional organizations, while some hospitals have established their own protocols. The 2 most popular guidelines are those published by the Academy of Orthopaedic Surgeons (AAOS) and American College of Chest Physicians (ACCP), both from North America. Prior to 2012, these recommendations varied depending on underlying definitions, methodology, and goals of the 2 groups. For the first time, both groups have similar recommendations that focus on minimizing symptomatic VTE and bleeding complications. The key to determining the appropriate chemoprophylaxis for patients is to balance efficacy of a prophylactic agent, while being safe in regards to bleeding complications. However, a multimodal approach that focuses on early postoperative mobilization and the use of mechanical prophylaxis, in addition to chemoprophylaxis, is essential.     

全膝关节置换术后的康复治疗要点与相关研究

康复治疗对人工膝关节置换术后的临床效果至关重要，是术后膝关节功能能够达到预期效果的重要措施。肌力训练、关节活动度训练、本体觉训练及行走步态训练是术后康复治疗最重要的内容。为最大限度地恢复膝关节功能，综合康复训练必不可少，包括各种主动肌力训练增加膝关节伸、屈肌力；早期持续被动膝关节活动度训练增加关节活动度；本体感觉训练改善膝关节的运动控制能力、姿势校正及平衡维持能力；行走步态训练矫正异常行走步态等。     

Clinical and radiological outcomes of dynamic cervical implant arthroplasty: A 5-year follow-up

BACKGROUNDDynamic cervical implant (DCI) stabilization has been reported to have satisfactory clinical and radiological results with short- and mid-term follow-up in the treatment of cervical degenerative disc disease. However, few reports about the clinical and radiological outcome with more than 5-year follow-up exist.AIMTo investigate the long-term clinical and radiological results of DCI arthroplasty.METHODSA total of 40 patients who received DCI arthroplasty were consecutively reviewed from May 2010 to August 2015. Visual analogue scale (VAS), neck disability index (NDI) score, Japanese Orthopaedic Association (JOA) score, and SF-36 items were used to assess neural function rehabilitation. Static and dynamic radiographs and 3-dimentional computed tomography were used to evaluate the radiological outcomes.RESULTSThe scores of neck/arm VAS, NDI, JOA, and 8-dimensions of SF-36 were significantly improved at the 1-mo follow-up (P < 0.05) and maintained until the last follow-up (P < 0.05). The range of motion (ROM) of C2-C7, functional spinal unit (FSU), upper/lower adjacent level, C2-C7 lateral bending, and FSU lateral bending decreased at the 1-mo follow-up (P < 0.05), whereas they increased to the preoperative level at the later follow-up intervals (P > 0.05), except the ROM of FSU lateral bending (P < 0.05). The C2-C7 alignment and FSU angle kept more lordotic at the last follow-up (P < 0.05). The intervertebral height increased significantly at the 1-mo follow-up (P < 0.05) and decreased at later follow-ups (P > 0.05). At the last follow-up, 12 (26.1%) segments developed heterotopic ossification.CONCLUSIONDCI arthroplasty is a safe and effective non-fusion technique to treat cervical degenerative disc disease in long-term follow-up.     

Comprehensive Assessment of Long-term Effects of Reducing Intake of Energy Phase 2 (CALERIE Phase 2) screening and recruitment: Methods and results

The Comprehensive Assessment of the Long-term Effects of Reducing Intake of Energy Phase 2 (CALERIE) study is a systematic investigation of sustained 25% calorie restriction (CR) in non-obese humans. CALERIE is a multicenter (3 clinical sites, one coordinating center), parallel group, randomized controlled trial. Participants were recruited, screened, and randomized to the CR or control group with a 2:1 allocation. Inclusion criteria included ages 21–50 years for men and 21–47 years for women, and a body mass index (BMI) of 22.0 ≤ BMI < 28.0 kg/m². Exclusion criteria included abnormal laboratory markers, significant medical conditions, psychiatric/behavioral problems, and an inability to adhere to the rigors of the evaluation/intervention schedule. A multi-stage screening process (telephone screen and 3 in-clinic visits) was applied to identify eligible participants. Recruitment was effective and enrollment targets were met on time. 10,856 individuals contacted the clinical sites, of whom 9787 (90%) failed one or more eligibility criteria. Of the 1069 volunteers who started the in-clinic screening, 831 (78%) were either ineligible or dropped. 238 volunteers were enrolled (i.e., initiated the baseline evaluations), 220 were randomized, and 218 started the assigned intervention (2% from the first screening step). This study offered lessons for future multi-center trials engaging non-disease populations. Recruitment strategies must be tailored to specific sites. A multi-disciplinary screening process should be applied to address medical, physical, and psychological/behavioral suitability of participants. Finally, a multi-step screening process with simple criteria first, followed by more elaborate procedures has the potential to reduce the use of study resources.     

Continuous Passive Motion (CPM) in Rehabilitation Following Total Knee Arthroplasty: A Randomised Controlled Trial

Abstract

Objective: Continuous passive motion (CPM) has been shown to increase the amount of knee flexion in knee patients at the acute care hospital. Changing postoperative management leads to shorter hospitalisation periods. The objective of the present randomised controlled trial was to assess whether there is additional benefit in CPM use during such a short hospitalisation period.

Design: Forty patients undergoing total knee arthroplasty were randomly allocated to either a group receiving CPM in addition to physical therapy or a group receiving physical therapy alone. Both programmes were delivered during a 5-day postoperative period on an inpatient basis, starting on the first day after surgery. Main outcome measures were mobility and function; secondary measures included muscle strength, pain, satisfaction and length of hospital stay.

Results: The results indicate a significant difference in function score, pain and strength between the CPM group and the control group. Four days after surgery, the CPM group scored an average of 56 points on the Hospital for Special Surgery scale (HSS), versus 45 points in the control group (P = 0.005).

Conclusions: The results indicate that, in addition to an improved range of motion, a protocol including CPM seems to have a favourable effect on pain and muscle strength in the first two weeks after surgery.     

Percutaneous ultrasound-guided treatment of shoulder tendon calcifications: Clinical and radiological follow-up at 6 months

IntroductionCalcific tendinitis of the shoulder is a common condition characterized by chronic pain and/or very painful acute episodes. Different treatments are used during painful flare-up, but they are often ineffective. US-guided percutaneous needle aspiration/lavage is proving to be an effective means for eliminating these calcifications.Materials and methodsWe treated 123 consecutive patients (mean age 48 years) with calcific tendinitis of the shoulder. Fifty-five patients had persistent symptoms requiring 2 or more treatments with lavage and intrabursal steroid infiltration. Before and after treatment, US studies were done independently by 2 radiologists with experience in musculoskeletal ultrasound. Results were concordant in over 90% of the cases. Constant Shoulder Scores were calculated before and 6 months after treatment. At 6 months, MRI was performed to identify impingement and/or bursitis.ResultsPost-treatment Constant scores were significantly improved in all 68 patients treated once (Group 1: mean scores 28.6 vs. 81.4) and in 52 of the 55 treated twice or more (Group 2: mean scores 34.1 vs. 71.1) (p < 0.0001 in both cases). Pretreatment Constant scores were similar in patients with and without shoulder impingement on MRI (31.2 vs. 30.9, respectively), but after treatment the impingement group’s scores were significantly higher (82.2 vs. 73.3, respectively; p < 0.001).ConclusionsUS-guided percutaneous needle aspiration/lavage is an effective and economic treatment for calcific tendinitis of the shoulder. Pretreatment MRI should be done to check for impingement since it is often associated with an incomplete response to the first treatment.     

Clinical effectiveness of prospidin in systemic lupus erythematosus (results of a 6-month follow-up)

The efficacy of the new Soviet antirheumatoid drug prospidin (the long-term treatment dose 1.4-6.0 g) was studied in 22 patients with significant lupus erythematosus (SLE). As a result of prospidin therapy administered for a month, 3 patients considerably improved and 19 patients improved. For 6 months the maintenance therapy was given to 15 patients. Considerable improvement was recorded in 4 and improvement in 9 patients. No effect was marked in one patient and one female patient died. The drug was tolerated well. No side effects requiring prospidin withdrawal were recorded. Prospidin exerted the most powerful effect with respect to lupoid nephritis, the articulation syndrome, and cytopenias. In accordance with the clinical improvement, the drug was established to return the immunological shifts common to SLE to normal. The drug may be viewed as a new basic agent for the treatment of SLE.     

Percutaneous transluminal angioplasty in the treatment of chronic mesenteric ischemia: results and 3 years of follow-up in 23 patients

Background: We evaluated the clinical efficacy of visceral angioplasty in the treatment of chronic mesenteric ischemia. Methods: Over a 14-year period, we performed percutaneous transluminal angioplasty of 41 occlusive diseases of visceral arteries founded by angiography in 23 patients with chronic mesenteric ischemia. All but one (fibrodysplasic) stenoses were atherosclerotic, and 13 were localized in the ostial tract. Clinical follow-up was evaluated at 2, 6, 12, 24, and 36 months (mean follow-up = 27 months). Results: Angioplasty demonstrated a residual stenosis of 30% or less in 37 procedures, for a technical success rate of 90%. Seventeen of 20 patients had symptom remission after the first treatment, for a short-term clinical success of 77%; two patients needed a reangioplasty after 2 months, and one was referred for aortomesenteric bypass. During a mean follow-up of 27 months (range = 2–36), the clinical success was 88%; 2/15 patients underwent successful repeat angioplasty at 24 and 36 months, for a 100% secondary long-term clinical success. Only two minor complications were encountered. Conclusion: Although surgical results are undoubtedly positive, visceral angioplasty is justified in relation to both the high surgical mortality and the low incidence of complications arising from visceral angioplasty. Received: 31 October 1996/Accepted after revision: 2 April 1997     

Noyes膝关节疾病:手术、康复训练与临床预后(第2版)

正膝关节是运动创伤发生最多的关节之一。近年来,运动健身成为新的社会风尚,运动相关膝关节损伤的发生率随之增高。本书由膝关节外科权威,来自辛辛那提运动医学与骨外科中心的Noyes博士主编。Noyes博士及其团队在结合大量研究成果及团队数十年临床实践经验的基础上,建立了多种膝     

Metformin in gestational diabetes: the offspring follow-up (MiG TOFU): body composition at 2 years of age

OBJECTIVE

In women with gestational diabetes mellitus, who were randomized to metformin or insulin treatment, pregnancy outcomes were similar (Metformin in Gestational diabetes [MiG] trial). Metformin crosses the placenta, so it is important to assess potential effects on growth of the children.

RESEARCH DESIGN AND METHODS

In Auckland, New Zealand, and Adelaide, Australia, women who had participated in the MiG trial were reviewed when their children were 2 years old. Body composition was measured in 154 and 164 children whose mothers had been randomized to metformin and insulin, respectively. Children were assessed with anthropometry, bioimpedance, and dual energy X-ray absorptiometry (DEXA), using standard methods.

RESULTS

The children were similar for baseline maternal characteristics and pregnancy outcomes. In the metformin group, compared with the insulin group, children had larger mid-upper arm circumferences (17.2 ± 1.5 vs. 16.7 ± 1.5 cm; P = 0.002) and subscapular (6.3 ± 1.9 vs. 6.0 ± 1.7 mm; P = 0.02) and biceps skinfolds (6.03 ± 1.9 vs. 5.6 ± 1.7 mm; P = 0.04). Total fat mass and percentage body fat assessed by bioimpedance (n = 221) and DEXA (n = 114) were not different.

CONCLUSIONS

Children exposed to metformin had larger measures of subcutaneous fat, but overall body fat was the same as in children whose mothers were treated with insulin alone. Further follow-up is required to examine whether these findings persist into later life and whether children exposed to metformin will develop less visceral fat and be more insulin sensitive. If so, this would have significant implications for the current pandemic of diabetes.The Metformin in Gestational diabetes (MiG) trial prospectively compared pregnancy outcomes in women with gestational diabetes mellitus (GDM) randomized to either metformin (plus supplemental insulin as required) or insulin treatment. The primary outcome, a composite of neonatal complications, was not significantly different between the treatment arms (1). Secondary outcomes, including body anthropometry at birth, were also not different between the treatment arms.Metformin crosses the placenta in significant amounts, so although neonatal outcomes are reassuring, it is important to examine longer term outcomes, such as body composition in childhood (2). It is known that offspring of women with diabetes have an increased fat mass at birth but not an increase in fat-free mass (FFM) (3). An explanation of this finding may be that because of continued exposure to nutrient excess in utero, the subcutaneous fat stores become overloaded and, thus, the fetus develops leptin and insulin resistance and deposits excess nutrients as ectopic fat (4). Reduced insulin sensitivity has been demonstrated in cord blood of infants exposed to maternal hyperglycemia (5). In a similar manner, infants of obese women, who are also exposed to nutrient excess, have an increased fat mass at birth and have been shown to be insulin resistant (6). It is possible that metformin exposure in utero might lead to improved insulin action in the fetus, resulting in a metabolically healthier pattern of growth, with more subcutaneous fat stores developing and less ectopic fat (4,7,8).The aim of The Offspring Follow-Up (TOFU) study at 2 years of age was to compare body composition in children of women who participated in the MiG trial and, in particular, to compare measures of adiposity. Our hypothesis was that children whose mothers had been randomized to metformin treatment would have reduced central adiposity compared with children whose mothers had been randomized to insulin.     

Healthy Beginnings Trial Phase 2 study: follow-up and cost-effectiveness analysis

BackgroundIn 2007, we commenced the Healthy Beginnings Trial (HBT) Phase 1 study, which is the first randomised controlled trial (RCT) to test the effectiveness of an early childhood obesity intervention in children aged up to 2 years. The results were promising with significant improvements in infant feeding practices and a lower mean body mass index (BMI). The aims of this proposed Phase 2 study are to determine if the early intervention will lead to a lower mean BMI, lower screen time, improved dietary behaviours and demonstrated cost-effectiveness of the intervention, in children aged 3½ and 5 years.Methods/designIn Phase 1 of HBT 667 families participated in the RCT. No further intervention will be carried out in HBT Phase 2. In this study the intervention and control groups will be compared for children's outcomes at ages 3½ and 5 years. Primary outcome measures will be 1) BMI, 2) selected dietary measures using a validated survey tool, and 3) physical activity and screen time using a new generation of tri-axial accelerometers. Intention to treat principles will be used in the analysis. Multiple imputation will be used to impute outcomes for subjects lost to follow-up. A cost-effectiveness analysis (CEA) and cost-utility analysis for both HBT Phase 1 and 2 will also be conducted.DiscussionThis is the first time that a home-based early intervention strategy has been implemented to prevent the development of childhood obesity and obesity-conducive behaviours. The results of this trial will ascertain whether early intervention during the first 2 years of life is effective and cost-effective in preventing childhood overweight and obesity at 3½ and 5 years old.     

Continuous Passive Motion After Total Knee Arthroplasty: A Systematic Review and Meta-analysis of Associated Effects on Clinical Outcomes

ObjectiveTo evaluate the efficacy of continuous passive motion (CPM) after total knee arthroplasty (TKA) and whether the use of CPM is related to improved clinical and functional outcomes.Data SourcesA systematic MEDLINE search via Web of Science, Cochrane Library, and PubMed databases was conducted.Study SelectionEnglish-language articles published between January 2000 and May 2018 reporting the related clinical outcomes of CPM after TKA were included. A total of 3334 titles and abstracts were preliminarily reviewed, of which 16 studies were included according to the eligibility criteria.Data ExtractionTwo different reviewers were selected to perform the study extraction, independent of each other. If there were any disagreements regarding the final list of studies, the third reviewer reviewed the list as an arbitrator for completeness.Data SynthesisA total of 16 trials with 1224 patients were included. The pooled results revealed that use of CPM did not show a statistically significant improvement of postoperative knee range of motion (ROM) except for middle-term passive knee extension and long-term active knee flexion ROM. Also, CPM therapy did not show a significant positive effect on the functional outcomes. No significant reduction in length of stay (LOS) and incidence of adverse events (AEs) was identified.ConclusionAmong patients undergoing TKA, neither the ROM nor the functional outcomes could be improved by CPM therapy. Moreover, the risk of AEs and LOS could not be reduced by application of CPM. The current available evidence suggested that this intervention was insufficient to be used routinely in clinical practice.     

The sclerotic line: Why it appears under knee replacements (a study based on the Oxford Knee)

BackgroundRadiolucent lines and sclerotic margins are often seen on knee radiographs taken a year or longer after knee replacement surgery. Histology has shown that the radiolucent zone is predominantly fibrocartilage and the sclerotic margin is lamellar bone. The reasons for their existence are not clearly understood.MethodsA three-dimensional finite element model of the medial half of the proximal 75 mm of a tibia implanted with a knee replacement was created and run over 365 iterations simulating 1 year of in vivo post implant remodelling. After each iteration, new material properties were calculated for all elements of the model using established bone remodelling and tissue differentiation rules. For comparison with patient anteroposterior radiographs, “synthetic anteroposterior radiographs” were generated by reverse calculating radiographic densities from material properties of the model after 365 iterations. Von Mises stress of elements in the bone where the sclerotic line is usually seen were calculated after 365 iterations. These values were compared with the same entities assuming no remodelling.FindingsThe mean von Mises stress in the sclerotic region was higher when remodelling was assumed than when not, suggesting that the presence of the soft tissue (radiolucent line) increased the stress in the underlying bone.InterpretationThe sclerotic line is caused by the stiffening of bone due to the relatively larger loads seen by the bone just beneath the soft tissue (radiolucent line) adjoining knee replacements.     

Management of tuberculous constrictive pericarditis and tuberculous pericardial effusion in Transkei: results at 10 years follow-up

BACKGROUND: Tuberculous pericarditis is common in Transkei (Eastern Cape). Two randomized trials showed benefits at two years for prednisolone in patients with constrictive pericarditis, and open drainage plus prednisolone in patients with pericardial effusion. AIM: To see whether the advantages of prednisolone and open drainage were maintained up to 10 years. DESIGN: Follow-up of randomized, double-blind, placebo-controlled trials. METHODS: All 383 patients (143 constriction, 240 effusion) received the same anti-tuberculosis chemotherapy. They were randomized to prednisolone or placebo for the first 11 weeks, and were followed-up over 10 years. Among the 240 with effusion, 122 were also randomized to immediate open surgical drainage of pericardial fluid versus pericardiocentesis as required. Adverse outcomes were: death from pericarditis, pericardiectomy, repeat pericardiocentesis, and subsequent open drainage. RESULTS: The 10-year follow-up rate was 96%. In constriction patients, adverse outcomes occurred in 19/70 (27%) prednisolone vs. 28/73 (38%) placebo (p = 0.15), deaths from pericarditis being 2 (3%) vs. 8 (11%), respectively (p = 0.098, Fisher's exact test). In effusion patients, adverse outcomes occurred in 14/27 (52%) with neither drainage nor prednisolone, vs. 4/29 (14%) drainage and prednisolone, 4/35 (11%) drainage and placebo, and 6/31 (19%) prednisolone and no drainage (p = 0.08 for interaction). Drainage eliminated the need for repeat pericardiocentesis. In the 176 with effusion and no drainage, adverse outcomes occurred in 17/88 (19%) prednisolone vs. 35/88 (40%) placebo patients (p = 0.003), with repeat pericardiocentesis 20 (23%) placebo vs. 9 (10%) prednisolone (p = 0.025). In a multivariate survival analysis (stratified by type of pericarditis), prednisolone reduced the overall death rate after adjusting for age and sex (p = 0.044), and substantially reduced the risk of death from pericarditis (p = 0.004). At 10 years, the great majority of surviving patients in all treatment groups were either fully active or out and about, even if activity was restricted. DISCUSSION: In the absence of a clear contraindication, a corticosteroid should be used in addition to antituberculosis chemotherapy in the management of patients with tuberculous pericarditis.     

Prevalence and Predictors of Symptom Resolution and Functional Restoration in the Index Knee After Knee Arthroplasty: A Longitudinal Study

Objectives

To determine the prevalence of a 1- to 2-year postsurgical pain-free state and pain plus symptom-free state as well as functional restoration after knee arthroplasty (KA) and to identify predictors of these outcomes.