Suboptimal outcomes after closed reduction and internal fixation of displaced femoral neck fractures in middle-aged patients: is internal fixation adequate in this age group?

BACKGROUND: There have been many studies regarding nongeriatric femoral neck fractures (FNFs), which included patients of a wide age range (between 20 and 60 years old). We aimed to determine whether internal fixation provided acceptable outcomes for middle-aged patients with displaced FNFs, and identify predictors of successful internal fixation. METHODS: A total of 117 patients, aged 50-60 years and who underwent closed reduction and unilateral internal fixation using cannulated screws, were included. The outcomes were classified as either "complications" (varus malunion, femoral neck shortening, non-union/early collapse, avascular necrosis, or arthroplasty during the follow-up) or "optimal outcomes" (no complications). Patients with displaced FNFs (Garden stages III-IV, n = 69) were categorized according to whether they experienced acceptable or unacceptable reduction. We evaluated whether patients' clinical characteristics could predict optimal outcomes. RESULTS: Patients with displaced FNFs generally experienced complications (84.1%). Twenty-two percent of patients experienced optimal outcomes when acceptable reduction was achieved. Patients with unacceptable reductions experienced complications. Optimal outcomes were positively associated with Pauwels' type II fracture (OR: 8.67, p = 0.025) and negatively associated with excessive alcohol consumption (p = 0.045). CONCLUSIONS: Compared with the younger age group, complication rates are higher in middle-aged patients with displaced FNFs treated using cannulated screws. If internal fixation is to be used for a displaced FNF, patient selection is essential. Care must be taken to avoid selecting patients with excessive alcohol consumption, while successful internal fixation may be more likely for patients with Pauwels' type II fracture.

Eight weeks of esomeprazole therapy reduces symptom relapse, compared with 4 weeks, in patients with Los Angeles grade A or B erosive esophagitis.

BACKGROUND & AIMS: There is disagreement over the ideal duration of initial proton pump inhibitor (PPI) therapy for gastroesophageal reflux disease, and whether prolonged therapy increases healing of the esophagitis and prevents symptom relapse. We performed a multicenter, prospective, randomized, controlled study to compare the efficacies of 4 weeks vs 8 weeks of PPI therapy in reducing reflux symptoms and preventing symptom relapse in patients with Los Angeles grade A or B erosive esophagitis. METHODS: Consecutive patients with symptomatic Los Angeles grade A or B erosive esophagitis were assigned randomly to groups given daily esomeprazole (40 mg) for 4 weeks (n = 207) or 8 weeks (n = 201) as their initial treatment. Patients with complete symptom resolution were switched to on-demand therapy until the end of week 20. All patients underwent follow-up endoscopy at the end of week 20. Symptom relapse was defined as 2 or more episodes of troublesome reflux symptoms per week or ingestion of PPI for more than 7 days within 4 weeks, owing to reflux symptoms. RESULTS: The 4-week and 8-week groups had comparable rates of complete symptom resolution (77.9% vs 82.1%). However, the cumulative 12-week incidence of symptom relapse was higher for the 4-week group than for the 8-week group (62.5% vs 47.8%; difference, 14.7%; 95% confidence interval, 3.7%-25.7%; P = .009). No significant difference was observed between groups in the proportions of patients with sustained healing at the end of week 20 (49.6% vs 40.9%; P = .160). CONCLUSIONS: Prolonging PPI therapy from 4 weeks to 8 weeks does not appear to increase the rate of complete symptom resolution in patients with mild erosive esophagitis. However, 8 weeks of PPI therapy reduces symptom relapse, compared with 4 weeks, in patients with Los Angeles grade A or B erosive esophagitis. ClinicalTrials.gov number: NCT01874535.

Clinical significance of postdecompression facet joint effusion after minimally invasive decompression for degenerative lumbar spinal stenosis.

STUDY DESIGN: A retrospective case series study. OBJECTIVE: To investigate the clinical significance of postdecompression facet effusion (PDFE) after microendoscopic decompressive laminotomy (MEDL). SUMMARY OF BACKGROUND DATA: The facet joint effusion noted on magnetic resonance imaging was considered as an indicator of degeneration of the facet joints and segmental instability. PDFE occurring after MEDL might imply postdecompression segmental instability. Its clinical significance has not yet been clarified. MATERIALS AND METHODS: From 2005 to 2010, 165 patients with degenerative lumbar spinal stenosis (average age: 64.5, average follow-up: 25.8 mo) who received MEDL were reviewed. We investigated the incidence of PDFE with preoperative and repetitive magnetic resonance imaging at 6 months postoperatively. The clinical data and treatment courses were reviewed. The treatment outcomes were evaluated with Oswestry Disability Index and Japanese Orthopedic Association scores. RESULTS: The incidence of PDFE was 17.0% (n=28), which was significantly higher in patients receiving multilevel decompression and patients with scoliosis or spondylolisthesis. The intensity of low back pain was similar between patients with and without PDFE, but "mechanical" low back pain was only noted in patients with PDFE. Of the 28 patients with PDFE, only 9 symptomatic patients required invasive treatment (5 facet joint steroid injection, 3 revision MEDL, and 1 spinal fusion). Although the postoperative Oswestry Disability Index and Japanese Orthopedic Association scores were significantly worse these 9 patients, the final outcomes were good. Progression of spondylolisthesis was noted in 2 patients without PDFE but no patients with PDFE during the follow-up period. CONCLUSIONS: The relatively high incidence of PDFE after MEDL suggests that injury to the integrity of facet joint is inevitable during decompression of the stenosis, even using minimally invasive techniques. However, the overall stability is well preserved with very rare progression of spondylolisthesis. Most patients with PDFE are asymptomatic. The prognosis of PDFE is very good. Spinal fusion is rarely indicated.

Muscle torque in total knee arthroplasty: comparison of subvastus and midvastus approaches.

The subvastus and midvastus approaches are two of the most commonly performed quadriceps preserving approaches for total knee arthroplasty (TKA), which can hasten functional recovery and rehabilitation. However, there has not been sufficient investigation with respect to a quantitative comparison between the two approaches in terms of muscle strength. To compare outcomes with respect to muscle strength between these two approaches, quadriceps and hamstring muscle torques of 20 patients who underwent primary TKA with the subvastus (SV) approach and 10 patients who received the midvastus (MV) approach were measured after surgery. The median age of patients in the SV group (68 years, range 53-77 years) was significantly different that the median age of patients in the MV group (61 years, range 50-73 years) (P = 0.0141). There was no significant difference in patient weight, height, or postoperative duration before muscle testing between the SV and MV groups. There were no significant differences in peak muscle torque or hamstring/quadriceps (H/Q) ratio between the groups. We thus conclude peak muscle torque and H/Q ratios were not statistically different with the SV or MV approach, therefore functional outcome is comparable.

Idiopathic osteonecrosis of the third metacarpal head.

Osteonecrosis of the metacarpal head is a rare disease entity and there are only a few isolated case reports in the literature. No single modality of treatment can be recommended as ideal. In this report, we describe a patient who presented with changes resembling avascular necrosis at the third metacarpal head of the right hand. It presented as a 2-week history of sudden onset of pain in the region of the right third metacarpophalangeal joint with limitation of flexion. We treated the 51-year-old male patient by curettage, debridement and multiple drilling. At 1-year follow-up, the patient was symptom-free and showed improved range of motion of the metacarpophalangeal joint (0 to 80 degrees). He returned to his original work 2 weeks after the operation without limitation of daily activities. This report presents a new operative treatment that improved the functional outcome of osteonecrosis of the metacarpal head.

Avulsion fracture of the extensor carpi ulnaris due to roller injury.

Avulsion fractures of the radial wrist extensor from the metacarpal base are rare injuries, and have previously been reported in only a few papers. Although 2 cases of closed rupture of the extensor carpi ulnaris (ECU) were mentioned in 1 report, no case of avulsion fracture of the ECU from its insertion was found in the literature. We recently encountered such a case. The patient, a machine operator, suffered multiple fractures of his forearm, wrist and hand when his left hand was caught in a machine roller. He immediately underwent emergency operation, during which we found the avulsed bone fragment from the ECU insertion. This fragment was retracted to the ECU groove of the ulna, and was located beside the fracture fragment of the ulnar styloid on X-ray. The avulsed fragment was reattached to the base of the fifth metacarpal with Kirschner wires and wire loop, and the patient returned to work 4 months after the operation.

The Frequencies of Gastroesophageal and Extragastroesophageal Symptoms in Patients with Mild Erosive Esophagitis, Severe Erosive Esophagitis, and Barrett's Esophagus in Taiwan.

Background. Gastroesophageal reflux disease (GERD) may present with gastroesophageal and extraesophageal symptoms. Currently, the frequencies of gastroesophageal and extragastroesophageal symptoms in Asian patients with different categories of GERD remain unclear. Aim. To investigate the frequencies of gastroesophageal and extragastroesophageal symptoms in patients with mild erosive esophagitis, severe erosive esophagitis, and Barrett's esophagus of GERD. Methods. The symptoms of symptomatic subjects with (1) Los Angeles grade A/B erosive esophagitis, (2) Los Angeles grade C/D erosive esophagitis, and (3) Barrett's esophagus proven by endoscopy were prospectively assessed by a standard questionnaire for gastroesophageal and extragastroesophageal symptoms. The frequencies of the symptoms were compared by Chi-square test. Result. Six hundred and twenty-five patients (LA grade A/B: 534 patients; LA grade C/D: 37 patients; Barrett's esophagus: 54 patients) were assessed for gastroesophageal and extragastroesophageal symptoms. Patients with Los Angeles grade A/B erosive esophagitis had higher frequencies of symptoms including epigastric pain, epigastric fullness, dysphagia, and throat cleaning than patients with Los Angeles grade C/D erosive esophagitis. Patients with Los Angeles grade A/B erosive esophagitis also had higher frequencies of symptoms including acid regurgitation, epigastric acidity, regurgitation of food, nausea, vomiting, epigastric fullness, dysphagia, foreign body sensation of throat, throat cleaning, and cough than patients with Barrett's esophagus. Conclusion. The frequencies of some esophageal and extraesophageal symptoms in patients with Los Angeles grade A/B erosive esophagitis were higher than those in patients with Los Angeles grade C/D erosive esophagitis and Barrett's esophagus. The causes of different symptom profiles in different categories of GERD patients merit further investigations.

Extraskeletal osteochondroma of the foot.

Extraskeletal osteochondroma, an infrequently encountered benign lesion, is described in 1 patient who presented with a slow-growing, relatively painful mass on the dorsal side of his right foot, in the 3rd toe web. Radiographs and magnetic resonance imaging studies demonstrated a radio-opaque extraskeletal mass. Excision biopsy revealed a well-defined and lobulated, firm, calcified, extraskeletal mass, which was easily enucleated. Histologic examination revealed mature chondroid tissues with bland-looking chondrocytes and ossified tissues. The diagnosis of an extraskeletal osteochondroma should be considered when a discrete ossified mass is localized in the soft tissues of the distal extremities. A case of pathologically proven extraskeletal osteochondroma is presented together with clinical, radiologic, and magnetic resonance imaging findings, and a literature review.

Effectiveness evaluation of bar code implementation in hospital -- an illustration of out-patient pharmacy information system.

We implement a bar code medication system in a region hospital in out-patient pharmacy. We record the data before and after this system on-line. To compare the data, we find this system makes the medication error going down. The clinical professionals spend less time when using this system then before. The bar code interface is easily and friendly.

Posterolateral fusion using laminectomy bone chips in the treatment of lumbar spondylolisthesis.

We retrospectively reviewed the outcome of posterolateral fusion (PLF) in 136 patients with lumbar spondylolisthesis (LS), who had undergone posterior decompression laminectomy with foraminotomy and PLF using laminectomy bone chips as bone graft, with reduction of the slipped vertebra with transpedicle screws, between 1993 and 2003. Diagnosis of LS was confirmed by plain lumbar radiography, with computed tomography (CT) scan or magnetic resonance imaging (MRI) studies performed to confirm an associated condition, such as ruptured disc and spinal stenosis. The outcome of spinal fusion was good with 129 (94.85%) patients attaining solid fusion, while failed fusion was noted in seven (5.15%) patients. None of our patients complained of excessive postoperative wound pain. Additionally, no complications, such as wound infection, were encountered. Proper decortication of the posterior paravertebral gutters with an osteotome and removal of all soft tissues from the laminectomy bone chips are significant factors contributing to the successful outcome of the laminectomy bone chips in PLF. The fusion rate obtained with this type of autogenous bone graft is comparable to that of the iliac bone crest autogenous graft; hence, it is a good substitute for the iliac crest bone autogenous graft in performing PLF in treating lumbar spondylolisthesis.

Developing a camera-phone-based drug barcode reader and support system.

The Food and Drug Administration (FDA) published a rule that require certain human drug and biological product labels to have a linear bar code, to help reduce the number of medication errors. This paper descripts a software support system for care givers and patients to identify the barcode use a camera phone. It is an economical and effective way if we can create software to help people to identify the barcode and show the information they need just on their phone.

Application of graphical relational representation techniques in healthcare website: taking SARS website information query and representation as an example.

In this study, the website information in the SARS period was taken as the example. By setting attributes of information of each article, the relations between articles are established. The relation,presented by an interacted graphic interface based on SVG language, could very with users query. The results show that the new approach could help users to find and understand the contents and relationship among different information source more efficiently.