Anabolic steroids after total knee arthroplasty. A double blinded prospective pilot study

Background: Total knee arthroplasty is reported to improve the patient’s quality of life and mobility. However loss of mobility and pain prior to surgery often results in disuse atrophy of muscle. As a consequence the baseline functional state prior to surgery may result in poorer outcome “post surgery” and extended rehabilitation may be required. The use of anabolic steroids for performance enhancement and to influence muscle mass is well established. The positive effects of such treatment on bone and muscle could therefore be beneficial in the rehabilitation of elderly patients. The purpose of this study was to investigate the effects of small doses of Nandrolone decanoate on recovery and muscle strength after total knee replacement and to establish the safety of this drug in multimorbid patients. Methods: This study was designed as a prospective double blind randomized investigation. Five patients (treatment group) with a mean age of 66.2 (58-72), average BMI of 30.76 (24.3-35.3) received 50 mg nandrolone decanoate intramuscular bi-weekly for 6 months. The control group (five patients; mean age 65.2, range 59-72; average BMI 31.7, range 21.2-35.2) was injected with saline solution. “Pre-operatively” and “post-operatively” (6 weeks, 3,6,9 and 12 months) all patients were assessed using the knee society score (KSS), isokinetic strength testing and functional tests (a sit-to-stand and timed walking tests). In addition, a bone density scan was used preoperatively and 6 month postoperatively to assess bone mineral density. Results: Whilst the steroid group generally performed better than the placebo group for all of the functional tests, ANOVA failed to reveal any significant differences. The steroid group demonstrated higher levels of quadriceps muscle strength across the postoperative period which reached significance at 3 (p = 0.02), 6 (p = 0.01), and 12 months (p = 0.02). There was a significant difference for the KSS at 6 weeks (p = 0.02), 6 (p = 0.02) and 12 month (p = 0.01). The steroid group demonstrated a reduction in the amount of bone mineral density at both the femur and lumbar spine from “pre-” to “post-surgery”, however, these results did not reach significance (p < 0.05) using one-way ANOVA. Conclusions: This project strongly suggests that the use of anabolic steroids result in an improved outcome as assessed by the KSS and significantly increases extensor strength. No side effects were seen in either the study or control group. Trial Registration Number: Regional Health District: Register No. 03.05 Human Research Ethics Committee University: Clearance Number: 04/03-1

Accuracy of acetabular cup positioning using imageless navigation

Background: Correct placement of the acetabular cup is a crucial step in total hip replacement to achieve a satisfactory result and remains a challenge with free-hand techniques. Imageless navigation may provide a viable alternative to free-hand technique and improve placement significantly. The purpose of this project was to assess and validate intra-operative placement values for both inclination and anteversion as displayed by an imageless navigation system to post-operative measurement of cup position using high resolution CT scans

Medial gastrocnemius flap for reconstruction of the extensor mechanism of the knee following high-energy trauma. A minimum 5 year follow-up

The purpose of this study was to assess the medium-term results of reconstruction of the extensor mechanism using the medial gastrocnemius while also providing soft tissue coverage.This retrospective review consisted of a consecutive series of four patients (age 28-40 years) with complex high energy traumatic injuries to lower extremity including both soft tissue loss and disruption of the knee extensor mechanism. The medial gastrocnemius rotational flap was used to reconstruct the patellar tendon and restore soft tissue coverage simultaneously. Range of motion and extensor lag; functional recovery was judged by return to work and sports activity. Validated measures included the Oxford Knee Score, Knee Injury and Osteoarthritis Outcome Score, and the modified Cincinnati Score.At the final follow up was 61.5 (57-66) months after reconstruction, the mean SF 12 physical component score ranged from 21.7 to 56.8 with a median of 55.3; the mental component from 42.8 to 60.7 with a median of 58.6. The KSS knee score ranged from 50 to 78 with a median of 68; the function score from 65 to 90 with a median of 85. The Oxford knee score ranged from 22 to 45 with a median of 33.5. The KOOS ranged from 28 to 82.7 with a median of 73.7 and the modified Cincinnati score from 38 to 82 with a median of 76.5. Knee range of motion ranged from 0 to 120°. Of the four patients three returned to working fulltime in their profession and returned to sports, including mountain biking and fitness training.For severe traumatic knee injuries with the combination of soft tissue defects and disruption of the extensor mechanism, the medial gastrocnemius flap provides an excellent reconstructive option to address both problems simultaneously. The results of this small case series support the use of this limb salvage technique

Subacromial Decompression in Patients With Shoulder Impingement With an Intact Rotator Cuff: An Expert Consensus Statement Using the Modified Delphi Technique Comparing North American to European Shoulder Surgeons

Purpose: To perform a Delphi consensus for the treatment of patients with shoulder impingement with intact rotator cuff tendons, comparing North American with European shoulder surgeon preferences. Methods: Nineteen surgeons from North America (North American panel [NAP]) and 18 surgeons from Europe (European panel [EP]) agreed to participate and answered 10 open-ended questions in rounds 1 and 2. The results of the first 2 rounds were used to develop a Likert-style questionnaire for round 3. If agreement at round 3 was ≤60% for an item, the results were carried forward into round 4. For round 4, the panel members outside consensus (>60%, <80%) were contacted and asked to review their response. The level of agreement and consensus was defined as 80%. Results: There was agreement on the following items: impingement is a clinical diagnosis; a combination of clinical tests should be used; other pain generators must be excluded; radiographs must be part of the workup; magnetic resonance imaging is helpful; the first line of treatment should always be physiotherapy; a corticosteroid injection is helpful in reducing symptoms; indication for surgery is failure of nonoperative treatment for a minimum of 6 months. The NAP was likely to routinely prescribe nonsteroidal anti-inflammatory drugs (NAP 89%; EP 35%) and consider steroids for impingement (NAP 89%; EP 65%). Conclusions: Consensus was achieved for 16 of the 71 Likert items: impingement is a clinical diagnosis and a combination of clinical tests should be used. The first line of treatment should always be physiotherapy, and a corticosteroid injection can be helpful in reducing symptoms. The indication for surgery is failure of no-operative treatment for a minimum of 6 months. The panel also agreed that subacromial decompression is a good choice for shoulder impingement if there is evidence of mechanical impingement with pain not responding to nonsurgical measures. Level of evidence: Level V, expert opinion

Fellowship exit examination in orthopaedic surgery in the commonwealth countries of Australia, UK, South Africa and Canada. Are they comparable and equivalent? A perspective on the requirements for medical migration

International migration of healthcare professionals has increased substantially in recent decades. In order to practice medicine in the recipient country, International Medical Graduates (IMG) are required to fulfil the requirements of their new countries medical registration authorities. The purpose of this project was to compare the final fellowship exit examination in Orthopaedic Surgery for the UK, Australia, Canada and South Africa. The curriculum of the Australian Orthopaedic Association (SET) was selected as a baseline reference. The competencies and technical modules specified in the training syllabus, as well as the specifics of the final fellowship examination as outlined in SET, were then compared between countries. Of the nine competencies outlined in SET, the curricula of the UK, South Africa and Canada were all compatible with the Australian syllabus, and covered 97.7%, 86% and 93%, respectively, of all competencies and sub-items. The final fellowship examinations of Australia, South Africa and the UK were all highly similar in format and content. The examination in Canada was substantially different, and had two written sessions but combined the oral and clinical component into a structured OSCE using standardized patients and the component included unmanned stations. There were no significant differences for completion certificate of training and/or board certification observed between these countries. The results of this study strongly suggest that core and technical competencies outlined in the training and education curriculum and the final fellowship examination in Orthopaedic Surgery in Australia, South Africa and the UK are compatible. Between country reciprocal recognition of these fellowship examinations should not only be considered by the relevant Colleges, but should also be regulated by the individual countries health practitioner registration boards and governing bodies.http://tandfonline.com/loi/zmeo20hj2018Orthopaedic Surger

Temporary incapacitation rates and permanent loss of medical license in commercial airline pilots

INTRODUCTION : the purpose of this study was to report the temporary loss of medical license and pilot incapacitations in the United Arab Emirates from 2018–2021. METHOD : the General Civil Aviation Authority database was searched for all reported temporary suspensions of license between 2018–2021 and the ICD-10 codes were extracted. RESULTS: a total of 1233 incapacitations was reported with a mean license suspension of 148.4 ± 276.8 d. the mean days of suspension for the various medical specialties were 115.2 ± 188.4 for musculoskeletal conditions (N = 392), 189.3 ± 324.8 for medicine (N = 335), 101.6 ± 231.4 for surgery, 109.4 ± 223.5 for urology (N = 93), 90.3 ± 128.7 for ophthalmology (N = 68), 385.6 ± 594.3 for psychiatry (N = 61), 150.4 + 285.9 for eNt (N = 59), 419.4 ± 382.6 for obstetrics and gynecology (N = 30), and 44.9 + 39 for dermatology (N = 21). Permanent suspensions were as follows: total N = 100 (8.1%), musculoskeletal N = 13 (3.3%), medicine N = 37 (11%), surgery N = 10 (5.7%), urology N = 10 (10.7%), ophthalmology N = 2 (2.9%), psychiatry N = 20 (32.8%), ENt N = 1 (1.7%), obstetrics and gynecology N = 4 (13.1%), and dermatology N = 3 (14.3%). DISCUSSION : Musculoskeletal conditions are the most common reason for temporary loss of medical license followed by medical and surgical conditions. the least common reason was dermatological conditions. the longest period of incapacitation was associated with psychiatric conditions followed by medical and ENT conditions. the annual calculated temporary incapacitation rate was 2.8% and the permanent suspension rate was 0.25%.https://www.asma.org/journalhj2023Orthopaedic Surger

Functional and psychological outcomes of delayed lower limb amputation following failed lower limb reconstruction

The purpose of this study was to evaluate the functional and psychological outcomes of patients who underwent delayed lower limb amputation following failed limb salvage surgery.This retrospective, descriptive study evaluated functional outcomes using the Sickness Impact Profile (SIP) and Short Form-36 (SF-36) in 12 patients. Inclusion criteria included patients who underwent limb reconstruction and delayed amputation between July 2006 and December 2014, with an age range between 18 and 80 years of age, the ability to ambulate independently, a time interval between the last salvage procedure and amputation greater than six months, and a minimum follow-up of 24 months. Patients were contacted via telephone by the principal investigator and both the Sickness Impact Profile (SIP) and Short Form-36 (SF-36) were completed. Descriptive analysis (means and standard deviation) was used to determine outcomes for both SIP and SF-36 health profiles.Ten patients who had amputations following failed reconstruction (2006-2014) with a mean age of 53±10years were interviewed. Six patients had a SIP 10 points. The main deficit on the SF-36 was in the physical component. The SF-36 scores demonstrated a mean score of 40.8±11.5 for the physical component, and 57.4±7.9 for the mental component. Three patients returned to work after amputation and continued performing their pre-injury duties as farmers. Three other patients returned to work, but were allocated to administrative duties. Two patients were pensioners at the time of their injuries, and the only female patient was a housewife. One patient went into early retirement.The results of this study strongly suggest that delayed amputation following failed limb salvage surgery can still result in good and satisfactory outcomes in the majority of patients and achieves results similar to early amputation and limb reconstruction techniques

Pilots after shoulder surgery and rehabilitation in a dedicated musculoskeletal rehabilitation unit of a major airline returned to work earlier when compared to standard rehabilitation by external providers

PURPOSE : The purpose of this study was to compare the time to return to work (RTW) for pilots who underwent shoulder surgery and underwent rehabilitation within a dedicated musculoskeletal rehabilitation (MSK) unit of a major airline to a group of pilots who had standard rehabilitation and to calculate cost savings. METHODS : The database of Emirates Airline was searched for all ICD-10 codes relating to shoulder pathology. Pilots who had shoulder surgery between January 2017 and June 2021 were included. Pilots who had previous shoulder surgery, underwent fracture surgery, joint replacement, revision surgery, or conservative treatment were excluded. The time between suspension and reinstatement of their license was defined as RTW. Cost savings were calculated on the basis of the median salary and rosterable fraction of a commercial airline pilot. RTW compared between a group undergoing rehabilitation in the MSK unit and a group receiving standard rehabilitation by external providers. Group allocation for either attending MSK unit or standard rehabilitation occurred randomly and according to the individual pilots preferences. RESULTS : The MSK unit treated 36 pilots (36 males/0 females, mean age 45.4 ± 9.4), and 18 pilots (17 males/1 female, mean age 50.3 ± 7.3) were treated by external physical therapist providers. Patients treated by the MSK unit returned to work at a mean of 85.3 ± 32.8 days, and patients treated by external providers returned to work at a mean of 117.9 ± 42.5days (P = .02). The cost savings for pilots treated by the MSK unit were calculated to be $27,948 USD per patient. CONCLUSIONS : The results of this study showed that pilots’ after shoulder surgery RTW times range between 85 to 118 days. Rehabilitation in a dedicated MSK unit reduced the return to flying duties by 39$27,948 USD per pilot.https://www.sciencedirect.com/journal/arthroscopy-sports-medicine-and-rehabilitationhj2023Orthopaedic Surger

Platelet-rich plasma versus corticosteroids for the treatment of plantar fasciitis : a systematic review and meta-analysis

Please read abstract in the article.https://journals.sagepub.com/home/ajshj2022Orthopaedic Surger