Revision Total Knee Arthroplasty: Infection should be Ruled Out in All Cases

We hypothesized that some aseptic revision total knee arthroplasty failures are indeed caused by occult infection. This prospective study recruited 65 patients undergoing revision total knee arthroplasty. The mean follow-up period was 19 months. Collected synovial fluid was analyzed by Ibis T5000 biosensor (Abbott Molecular Inc, Ill; a multiplex polymerase chain reaction technology). Cases were considered as infected or aseptic based on the surgeon\u27s judgment and Ibis findings. Based on Ibis biosensor, 17 aseptic cases were indeed infected that had been missed. Of these 17 cases, 2 developed infection after the index revision. A considerable number of so-called aseptic failures seem to be occult infections that were not adequately investigated and/or miscategorized as aseptic failure. We recommend that all patients undergoing revision arthroplasty be investigated for periprosthetic joint infection. Copyright © 2012 Elsevier Inc. All rights reserved

The mathematical relationship among normal patellar dimensions, to find the pre-diseased patellar thickness in different populations

Whether resurfacing or not resurfacing the patella during total knee arthroplasty (TKA) still is a challenge to orthopedic surgeons. A significant reason for this controversy is the far from perfect outcomes of both techniques, resulting from inadequate knowledge of normal patellar dimensions in a diseased one. The primary purpose of the current study is to find the pre-diseased patellar dimensions and the ethnic differences in patellar dimensions. We measured the patella\u27s dimensions on 927 normal young adult knee MRIs from seven different ethnicities. Besides comparing the dimensions between sexes, ages, and sides, we analyzed the differences among ethnic groups. The average thickness was 25.12±2.33 mm; the average width was 44.57±4.32 mm, the average articular surface length was 32.69±3.75 mm, with significant gender, age, and ethnic differences. There were also significant differences in dimensions among ethnic groups, except for between the Indians and Far Eastern Asians and between the Arabs and North Africans. We could also find a robust mathematical relationship between the patella\u27s width, length, and thickness. The ethnic differences in patellar dimensions found in this study can help optimize surgical technique and implant designs for patellar resurfacing. The mathematical equation will help the surgeons find the normal, pre-diseased patella thickness to prevent over-or understuffing during the patellar resurfacing

Which method is best for the induction of labour?: A systematic review, network meta-analysis and cost-effectiveness analysis

Background: More than 150,000 pregnant women in England and Wales have their labour induced each year. Multiple pharmacological, mechanical and complementary methods are available to induce labour. Objective: To assess the relative effectiveness, safety and cost-effectiveness of labour induction methods and, data permitting, effects in different clinical subgroups. Methods: We carried out a systematic review using Cochrane methods. The Cochrane Pregnancy and Childbirth Group’s Trials Register was searched (March 2014). This contains over 22,000 reports of controlled trials (published from 1923 onwards) retrieved from weekly searches of OVID MEDLINE (1966 to current); Cochrane Central Register of Controlled Trials (The Cochrane Library); EMBASE (1982 to current); Cumulative Index to Nursing and Allied Health Literature (1984 to current); ClinicalTrials.gov; the World Health Organization International Clinical Trials Registry Portal; and hand-searching of relevant conference proceedings and journals. We included randomised controlled trials examining interventions to induce labour compared with placebo, no treatment or other interventions in women eligible for third-trimester induction. We included outcomes relating to efficacy, safety and acceptability to women. In addition, for the economic analysis we searched the Database of Abstracts of Reviews of Effects, and Economic Evaluations Databases, NHS Economic Evaluation Database and the Health Technology Assessment database. We carried out a network meta-analysis (NMA) using all of the available evidence, both direct and indirect, to produce estimates of the relative effects of each treatment compared with others in a network. We developed a de novo decision tree model to estimate the cost-effectiveness of various methods. The costs included were the intervention and other hospital costs incurred (price year 2012–13). We reviewed the literature to identify preference-based utilities for the health-related outcomes in the model. We calculated incremental cost-effectiveness ratios, expected costs, utilities and net benefit. We represent uncertainty in the optimal intervention using cost-effectiveness acceptability curves. Results: We identified 1190 studies; 611 were eligible for inclusion. The interventions most likely to achieve vaginal delivery (VD) within 24 hours were intravenous oxytocin with amniotomy [posterior rank 2; 95% credible intervals (CrIs) 1 to 9] and higher-dose (≥ 50 μg) vaginal misoprostol (rank 3; 95% CrI 1 to 6). Compared with placebo, several treatments reduced the odds of caesarean section, but we observed considerable uncertainty in treatment rankings. For uterine hyperstimulation, double-balloon catheter had the highest probability of being among the best three treatments, whereas vaginal misoprostol (≥ 50 μg) was most likely to increase the odds of excessive uterine activity. For other safety outcomes there were insufficient data or there was too much uncertainty to identify which treatments performed ‘best’. Few studies collected information on women’s views. Owing to incomplete reporting of the VD within 24 hours outcome, the cost-effectiveness analysis could compare only 20 interventions. The analysis suggested that most interventions have similar utility and differ mainly in cost. With a caveat of considerable uncertainty, titrated (low-dose) misoprostol solution and buccal/sublingual misoprostol had the highest likelihood of being cost-effective. Limitations: There was considerable uncertainty in findings and there were insufficient data for some planned subgroup analyses. Conclusions: Overall, misoprostol and oxytocin with amniotomy (for women with favourable cervix) is more successful than other agents in achieving VD within 24 hours. The ranking according to safety of different methods was less clear. The cost-effectiveness analysis suggested that titrated (low-dose) oral misoprostol solution resulted in the highest utility, whereas buccal/sublingual misoprostol had the lowest cost. There was a high degree of uncertainty as to the most cost-effective intervention

GIANT CELL TUMOR OF THE VERTEBRA SIMULATING VERTEBRA PLANA

A case of g iant cell tumor of t he vertebra simulat ing vert ebra plana was reported . t he d i agnos i s o f t he vertebra plana should not be confirmed by t he history of the patient and radiologica l manifestation alone . it can onlybe confirmed by biopsy ."nBone l esions of the spine i s one of the most di fficul t problems t o diagnosis and t r eat . Spinal tumors a r e either primary or metastatic . Ilos t bone tumors of the spine i n t he first two decade of l i f e are primary and benign;where as a majority of the bone lesions in old people ar e me tast at1,c and rna I 1' 9n ant . 5- 11 The rnaI1' 9~ant Lee Ss 1i 0ns 0f t h e Sp1' - ne can wi t hout very great risk be excl uded f r om diagnostic considerati on in chi ldren and adoles cence (She r r a r d . 1969) 12 . From 34 casps of bone l esions of the spine and the pelvis i n the f irst two decade of l i f e, reported by Thommes on and 1 3 , Paulsen (1967) ni ne were histiochtosis X, two anevr ysma l bone cyst,nine Ewi ng sar coma , two reticul um cell sar c ~ma. None were g i ant cel l tumor ."nGiant cell tumor of the spine is r a re; mo s t of t he report ed cases were in t he sacrum. J affe (1958) 17repor t ed only two c ases of giant cell t umo r, one of which o c c ur r e d in the por t e d s a c r um.Of the 218 cases of the g i an t ce l l tumor re6 by Goldenbe rg and Carnpbell( 1970) there were 13 cases of g i ant c e l l tumor o f the ver t ebra , one in the cervical r e g i o n , o ne in the l umbar spi ne , and e l e ven in t he sacrum. Of '08 giant ce l l t umors studied by Coley( 1960)4 ,one was i n the lumba r ver t ebra and one in the s a c rum. al In a r e view of 413 tumors i nc l uding t he spine(Cohen et 3 1964) tr.ere were sixteen cases o f g i ant c e l l tumor ,one  n the c e r vica l spine , one in the l umbar r e gion and f ourte61 n the sacrum. I n thi s a r t i c l e we are going to report a case of giant cel l t umor of the s i xth thor a ci c vertebra, r adiologically simul ating vert ebra plana

Induction of labor with titrated oral misoprostol solution versus oxytocin in term pregnancy: randomized controlled trial Indução do trabalho de parto por meio de solução oral titulada de misoprostol versus oxitocina em gestação a termo: estudo controlado randomizado

PURPOSE: To evaluate the effectiveness and the safety of orally administered misoprostol in comparison to intravenously infused oxytocin for labor induction in term pregnant women. METHODS: Between 2008 and 2010, a total of 285 term pregnant women whom were candidate for vaginal delivery were assessed for eligibility to enter the study. Twenty five patients were excluded for different reasons; and 260 included women were randomly assigned to one of the two groups according to the method of treatment, misoprostol or oxytocin. The misoprostol group received 25 µg every 2 hours for up to 24 hours for induction. The oxytocin group received an infusion of 10 IU which was gradually increased. The time from induction to delivery and induction to the beginning of the active phase and successful inductions within 12, 18, and 24 hours were recorded. The trial is registered at irct.ir, number IRCT2012061910068N1. RESULTS: Failure of induction, leading to caesarean section was around 38.3% in the oxytocin group and significantly higher than that of the misoprostol group (20.3%) (pOBJETIVO: Avaliar a eficácia e segurança do misoprostol administrado por via oral em comparação à infusão de oxitocina para a indução do trabalho de parto em gestantes a termo. MÉTODOS: Entre 2008 e 2010, um total de 285 gestantes a termo candidatas para parto vaginal foram avaliadas quanto à eligibilidade para inclusão no estudo. Vinte e cinco pacientes foram excluídas por várias razões, e as 260 mulheres incluídas foram divididas aleatoriamente em dois grupos de acordo com o método de tratamento, misoprostol ou oxitocina. O grupo tratado com o misoprostol recebeu 25 µg cada 2 horas durante um máximo de 24 horas para indução. O grupo tratado com oxitocina recebeu infusão de 10 UI, que foi aumentada gradativamente. O tempo a partir da indução até o início da fase ativa e as induções bem-sucedidas dentro de 12, 18 e 24 horas foram registrados. O ensaio foi registrado em irct.ir, número IRCT2012061910068N1. RESULTADOS: A falha de indução levando à necessidade de cesariana foi de aproximadamente 38.3% no grupo tratado com oxitocina, sendo significativamente maior em relação ao grupo tratado com misoprostol (20,3%) (p<0,001). Apesar da falha mais prevalente no grupo tratado com oxitocina, os intervalos médios entre indução e fase ativa e trabalho de parto nesse grupo foram ambos significativamente menores em relação ao grupo tratado com misoprostol (10,1±6,1 e 13,2±7,7 versus 12,9±5,4 and 15,6±5,1 horas, respectivamente, sendo ambos os p-valores <0,05). Complicações maternas e fetais foram comparáveis entre grupos, com exceção dos sintomas gastrointestinais, que foram encontrados mais frequentemente no grupo tratado com misoprostol (10,9 versus 3,9%, p=0,03). CONCLUSÕES: O misoprostol é droga segura e eficaz para a indução do parto, com poucas complicações. Falhas são menos observadas e cesáreas são indicadas menos frequentemente com o misoprostol em relação à oxitocina