Treatment of osteoarthritis of the knee (nonarthroplasty)

The clinical practice guideline was explicitly developed to include only treatments less invasive than knee replacement (ie, arthroplasty). Patients with symptomatic osteoarthritis of the knee are to be encouraged to participate in self-management educational programs and to engage in self-care, as well as to lose weight and engage in exercise and quadriceps strengthening. The guideline recommends taping for short-term relief of pain as well as analgesics and intra-articular corticosteroids, but not glucosamine and/or chondroitin. Patients need not undergo needle lavage or arthroscopy with débridement or lavage. Patients may consider partial meniscectomy or loose body removal or realignment osteotomy, as conditions warrant. Use of a free-floating interpositional device should not be considered for symptomatic unicompartmental osteoarthritis of the knee. Lateral heel wedges should not be prescribed for patients with symptomatic medial compartmental osteoarthritis of the knee. The work group was unable either to recommend or not recommend the use of braces with either valgus- or varus-directing forces for patients with medial unicompartmental osteoarthritis; the use of acupuncture or of hyaluronic acid; or osteotomy of the tibial tubercle for isolated symptomatic patellofemoral osteoarthritis.

Venous thromboembolism--prophylactic and therapeutic practice guideline

BACKGROUND

Pharmacological prophylactic anticoagulation in many countries, including South Africa, is under-prescribed, which unfortunately results in unacceptable morbidity and mortality in a substantial number of patients.

METHOD

The Southern African Society of Thrombosis and Haemostasis reviewed the available literature as well as guidelines from other societies. Specialties represented on the committees included anaesthetics, cardiology, clinical haematology, critical care, gynaecology, haematopathology, internal medicine, neurology, orthopaedic surgery, pulmonology and vascular surgery. A draft document was produced, which was revised by consensus agreement. To avoid local bias, the guidelines were adjudicated by recognised independent international external experts. RESULTS AND CONCLUSION. A concise, practical guideline for thrombo-prophylaxis and treatment in medical and surgical patients has been produced for South African conditions. These guidelines will hopefully lead to improved anticoagulation practice in this country, which we believe will directly benefit patient outcomes.

Testicular metastasis found in a patient with previous large bowel tumour

Epididymo-testicular metastasis arising from a colonic primary neoplasm is exceptionally rare. We present two cases, one where the ipsilateral intrascrotal metastasis was evidence of recurrence 3 years after colonic surgery, and the other where the contralateral epididymo-testicular metastasis was the initial presentation.

Bevacizumab for recurrent malignant gliomas: efficacy, toxicity, and patterns of recurrence

BACKGROUND

Bevacizumab, a humanized monoclonal antibody against vascular endothelial growth factor, may have activity in recurrent malignant gliomas. At recurrence some patients appear to develop nonenhancing infiltrating disease rather than enhancing tumor.

METHODS

We retrospectively reviewed 55 consecutive patients with recurrent malignant gliomas who received bevacizumab and chemotherapy to determine efficacy, toxicity, and patterns of recurrence. Using a blinded, standardized imaging review and quantitative volumetric analysis, the recurrence patterns of patients treated with bevacizumab were compared to recurrence patterns of 19 patients treated with chemotherapy alone.

RESULTS

A total of 2.3% of patients had a complete response, 31.8% partial response, 29.5% minimal response, and 29.5% had stable disease. Median time to radiographic progression was 19.3 weeks. Six-month progression-free survival (PFS) was 42% for patients with glioblastoma and 32% for patients with anaplastic glioma. In 23 patients who progressed on their initial therapy, bevacizumab was continued and the concurrent chemotherapy agent changed. In no case did the change produce a radiographic response, but two patients had prolonged PFS of 20 and 31 weeks. Recurrence pattern analysis identified a significant increase in the volume of infiltrative tumor relative to enhancing tumor in bevacizumab responders.

CONCLUSIONS

Combination therapy with bevacizumab and chemotherapy is well-tolerated and active against recurrent malignant gliomas. At recurrence, continuing bevacizumab and changing the chemotherapy agent provided long-term disease control only in a small subset of patients. Bevacizumab may alter the recurrence pattern of malignant gliomas by suppressing enhancing tumor recurrence more effectively than it suppresses nonenhancing, infiltrative tumor growth.

Results of polyaxial locked-plate fixation of periarticular fractures of the knee. Surgical technique

BACKGROUND

Locked-plate fracture-fixation techniques and designs continue to evolve. Polyaxial locking plates that allow screw angulation and end-point locking have become available; however, there are no clinical data documenting their strength and efficacy, to our knowledge. The purpose of this study was to evaluate the clinical performance of a variable-axis locking plate in a multicenter series of periarticular fractures about the knee.

METHODS

Between 2003 and 2005, fifty-four patients with a total of fifty-six fractures were treated with a polyaxial locked-plate fixation system (DePuy, Warsaw, Indiana). There were twenty male patients and thirty-four female patients with a mean age of fifty-seven years. There were twenty-five distal femoral fractures and thirty-one proximal tibial fractures. Twelve of the fractures were open. Clinical and radiographic data, including changes in alignment, hardware breakage, or other mechanical complications of the device, were retrospectively reviewed. Function was assessed with use of the Knee Society scores. One patient with a bilateral fracture died less than three months postoperatively, and two patients were lost to follow-up prior to union. Fifty-two fractures in fifty-one patients were followed to union or for a minimum of six months; the mean duration of follow-up was nine months (range, six to twenty-five months).

RESULTS

Forty-nine (94%) of the fifty-two fractures united. There were no mechanical complications. Most importantly, there was no evidence of varus collapse as a result of polyaxial screw failure. There were three deep infections and one aseptic nonunion. No plate fractured, and no screw cut out.

CONCLUSIONS

The variable-axis locking plates performed well, with a high rate of fracture union and no evidence of varus collapse due to failure of the polyaxial screw fixation, in a series of complex fractures about the knee. Complication rates were similar to those for historical controls treated with fixed-trajectory locking plates. Polyaxial locking plates offer more fixation versatility without an apparent increase in mechanical complications or loss of reduction.

Experience gained by basic surgical trainees in varicose vein surgery over a 15 year period - has it changed?

OBJECTIVE

The aim of this study was to see if the training provided for Basic Surgical Trainees (BST's) by one consultant vascular surgeon has changed over a 15-year period.

METHOD

From a computerized database we have a 15-year record of varicose vein operations identifying the first and second surgeon. We have analysed cases involving the BST and those in which the consultant operated alone. In such instances training opportunities were lost.

RESULTS

No change was found in the total number of cases performed, the number of operations carried by the BST as the first surgeon, or the cases performed by the consultant operating alone. The number of operations performed by a BST annually correlated positively with the total number of cases. A BST was named as first surgeon in 39% of cases (632/1622).

CONCLUSION

This study has shown no definite evidence to support the view that training in varicose vein surgery has deteriorated.

Severe asthma in adults: what are the important questions?

The term severe refractory asthma (SRA) in adults applies to patients who remain difficult to control despite extensive re-evaluation of diagnosis and management following an observational period of at least 6 months by a specialist. Factors that influence asthma control should be recognized and adequately addressed prior to confirming the diagnosis of SRA. This report presents statements according to the literature defining SRA in order address the important questions. Phenotyping SRA will improve our understanding of mechanisms, natural history, and prognosis. Female gender, obesity, and smoking are associated with SRA. Atopy is less frequent in SRA, but occupational sensitizers are common inducers of new-onset SRA. Viruses contribute to severe exacerbations and can persist in the airways for long periods. Inflammatory cells are in the airways of the majority of patients with SRA and persist despite steroid therapy. The T(H)2 immune process alone is inadequate to explain SRA. Reduced responsiveness to corticosteroids is common, and epithelial cell and smooth muscle abnormalities are found, contributing to airway narrowing. Large and small airway wall thickening is observed, but parenchymal abnormalities may influence airway limitation. Inhaled corticosteroids and bronchodilators are the mainstay of treatment, but patients with SRA remain uncontrolled, indicating a need for new therapies.

Clinical response to persistent, low-level beta-glucuronidase expression in the murine model of mucopolysaccharidosis type VII

Mucopolysaccharidosis type VII (MPS VII) is a lysosomal storage disease caused by beta-glucuronidase (GUSB) deficiency. This disease exhibits a broad spectrum of clinical signs including skeletal dysplasia, retinal degeneration, cognitive deficits and hearing impairment. Sustained, high-level expression of GUSB significantly improves the clinical course of the disease in the murine model of MPS VII. Low levels of enzyme expression (1-5% of normal) can significantly reduce the biochemical and histopathological manifestations of MPS VII. However, it has not been clear from previous studies whether persistent, low levels of circulating GUSB lead to significant improvements in the clinical presentation of this disease. We generated a rAAV2 vector that mediates persistent, low-level GUSB expression in the liver. Liver and serum levels of GUSB were maintained at approximately 5% and approximately 2.5% of normal, respectively, while other tissue ranged from background levels to 0.9%. This level of activity significantly reduced the secondary elevations of alpha-galactosidase and the levels of glycosaminoglycans in multiple tissues. Interestingly, this level of GUSB was also sufficient to reduce lysosomal storage in neurons in the brain. Although there were small but statistically significant improvements in retinal function, auditory function, skeletal dysplasia, and reproduction in rAAV-treated MPS VII mice, the clinical deficits were still profound and there was no improvement in lifespan. These data suggest that circulating levels of GUSB greater than 2.5% will be required to achieve substantial clinical improvements in MPS VII.

Are doctors working the EWTD night shift pattern less tired?

The introduction of the European Working Time Directive (EWTD) has resulted in shift pattern rotas that include a week of night shifts. The EWTD was introduced to reduce the number of hours worked per week and consequently ensure that tired doctors were not treating patients. A week of night shifts allows rotas to meet the EWTD requirements while providing night-time cover with regular interspersed rest periods, which seems an advantage over the now largely redundant on-call system.

Results of polyaxial locked-plate fixation of periarticular fractures of the knee

BACKGROUND

Locked-plate fracture-fixation techniques and designs continue to evolve. Polyaxial locking plates that allow screw angulation and end-point locking have become available; however, there are no clinical data documenting their strength and efficacy, to our knowledge. The purpose of this study was to evaluate the clinical performance of a variable-axis locking plate in a multicenter series of periarticular fractures about the knee.

METHODS

Between 2003 and 2005, fifty-four patients with a total of fifty-six fractures were treated with a polyaxial locked-plate fixation system (DePuy, Warsaw, Indiana). There were twenty male patients and thirty-four female patients with a mean age of fifty-seven years. There were twenty-five distal femoral fractures and thirty-one proximal tibial fractures. Twelve of the fractures were open. Clinical and radiographic data, including changes in alignment, hardware breakage, or other mechanical complications of the device, were retrospectively reviewed. Function was assessed with use of the Knee Society scores. One patient with a bilateral fracture died less than three months postoperatively, and two patients were lost to follow-up prior to union. Fifty-two fractures in fifty-one patients were followed to union or for a minimum of six months; the mean duration of follow-up was nine months (range, six to twenty-five months).

RESULTS

Forty-nine (94%) of the fifty-two fractures united. There were no mechanical complications. Most importantly, there was no evidence of varus collapse as a result of polyaxial screw failure. There were three deep infections and one aseptic nonunion. No plate fractured, and no screw cut out.

CONCLUSIONS

The variable-axis locking plates performed well, with a high rate of fracture union and no evidence of varus collapse due to failure of the polyaxial screw fixation, in a series of complex fractures about the knee. Complication rates were similar to those for historical controls treated with fixed-trajectory locking plates. Polyaxial locking plates offer more fixation versatility without an apparent increase in mechanical complications or loss of reduction.